In een vergrijzende bevolking neemt de prevalentie van psychogeriatrische patiënten toe. Die toename hangt onder meer samen met de met de leeftijd toenemende kwetsbaarheid van het brein. Deze beschouwing gaat over die samenhang.

In 1972 is door de Wereldgezondheidsorganisatie het begrip ‘psychogeriatrie’ omschreven als een tak van de psychiatrie die zieh bezig houdt met die psychische stoornissen die zieh voor het eerst op oudere leeftijd manifesteren en duidelijk oorzakelijk samenhangen met de maatschappelijke, geestelijke en lichamelijke veranderingen in de derde levensfase.

Our current understanding of the physiological mechanisms underlying depressive disorders is not only based on behavioral, neuroendocrine and pharmacological studies in depressed humans, but also on experimental studies in a wide variety of animal models of depression. Ideally, the two approaches should operate in close interaction, each providing additional information to the other approach. However, in practice the animal model approach seems to be rather independent from the human studies. In a critical evaluation of the available animal models of depression, Willner concluded that none of the models fulfilled the criteria of a sufficient face, construct and predictive validity. Although this evaluation was made ten years ago, we feel that the situation has improved very little since that time. Most animal models fail to sufficiently mimic both the etiology and the symptomatology of human depressive disorders. With respect to the etiology, stress and major life events are generally considered to be an important factor in the development of depression. Most of the animal models however use stressors which bear little or no relationship to the biology of the species, i.e. to the situations an animal may meet in its everyday life in a natural habitat. Moreover, these models do not pay attention to the temporal dynamics of the disease. In humans, the disease is characterized by its gradual onset, which is often preceded by symptoms of anxiety. Moreover, a relatively large number of patients suffers from recurrent episodes of depression, which tend to occur with decreasing intervals and increasing duration and severity. If we want to improve our knowledge of the causal mechanisms of depression, animal models which allow an experimental analysis of the temporal dynamics of the disease are essential.

An interactional model of brain function is postulated, in which activity and reactivity are basic properties of the central nervous system from the very beginning. Variability is an essential aspect of normal functioning. Primary or indiscriminate variability consists of the development of many strategies for the execution of motor acts. It is predominant during fetal age and infancy. Toddler age is characterized by secondary or adaptive variability, which reflects the ability to select the adequate strategy at the right moment. This is important for the development of proper planning of movement patterns and is a prerequisite for skill development. Recognition of the types and quality of variability helps to detect developmental disorders at an early age.

Memory complaints and altered states of consciousness with automatic behaviour of narcoleptic patients indicate cognitive dysfunctioning. Although more problems arise while performing attention tasks than memory tasks, the neuropsychological test inquiry doesn't indicate one particular neuropsychological function as consistently impaired. They often perform well because they compensate impaired wakefulness by an increased willingness to respond. Neurophysiological research indicates that the sometimes occurring cognitive dysfunction is associated with a waxing and waning between wakefulness and sleep. The increased psychopathology is partly a reflection of, partly a reaction to the symptoms. The impact of hypersomnia on psychosocial functioning is more important than that of epilepsy in epileptics. In severe cases smoking and driving should better be dissuaded.

Since the introduction of international psychiatric classification systems, systematic diagnostic methods have become available for personality disorders. Recent developments in the dimensional diagnostic approach of personality disorders have yielded relationships between this type of disorders and neurobiological processes including both monoaminergic and stress-hormonal systems. It is hypothesized that the pathogenesis of borderline personality disorders is related to an enhanced serotonergic tone in septo-hippocampal structures. Preliminary clinical data are suggestive for potential therapeutic effects of serotonin-modulating compounds in borderline personality disorders

Cognitive and behavioural processes may constitute a risk for onset and persistence of depression. People who become depressed frequently show enduring negative cognitions which predispose them to depression. In addition, interpersonal processes are supposed to contribute to the etiology and maintenance of depression. Depression-prone persons are presumed to display deficient or problematic social behaviours that elicit negative reactions in others, finally resulting in withdrawal by family and friends.

About 60% of human communication is non-verbal. An ethological approach may therefore contribute to reveal behavioural and cognitive vulnerability factors for depression onset or persistence. Various studies support this presumption: High levels of patients' observed behaviour indicating involvement in the interaction between depressives and clinicians at admission are related with persistence of depression.

In 1975 van den Burg and van den Hoofdakker hypothesized that depressed patients might be ‘overaroused.’ This suggestion is consistent not only with their seminal observations on the antidepressant effects of total sleep deprivation in depression, but with the short, fragmented, and shallow sleep of depressed patients, lowered arousal thresholds, hyperactivity of the hypothalamus-pituitary adrenal (HPA) axis, and elevated core body temperature commonly found in some patients during the sleep period.

Many of the dramatic seasonal changes that occur in animals are triggered by changes in the length of night. Changes in the duration of melatonin secretion, which usually occurs exclusively at night and therefore lasts longer in winter than in summer, often act as a chemical transducer of the effects of seasonal changes in night-length on animals' behavior and physiology. Cells in sites that regulate seasonal behaviors, such as those associated with breeding, appear to possess melatonin receptors and interval timing mechanisms that enable them to detect melatonin and measure the duration of the nightly interval when it is present. These sites then trigger changes that are appropriate for the season that is indexed by the measured length of the interval.

Sleep electroencephalography in depressed patients reveals many signs of disrupted sleep, like long sleep latency, frequent awakenings, reduced amounts of time spent in the sleep stages 3 and 4, and early morning wakefulness. Upon total deprivation of sleep for one night, many patients experience an unexpected alleviation of their depression, which usually lasts until the subsequent sleep period. Attempts have been made to explain these changes of mood to result from induced changes in sleep physiological mechanisms. Such attempts can roughly be categorized in two classes. One class of hypotheses concerns proposed disturbances in circadian sleep control (i.e. the timing of sleep is inappropriately controlled), the other class concerns postulated disrupted homeostatic sleep control (i.e. the intensity of sleep is inappropriately controlled). For both types of theoretical approaches data have been published which are consistent with the hypotheses as well as data which are not.

Seasonal affective disorder (SAD) is characterised by recurrent episodes in autumn and winter of depression, hypersomnia, augmented appetite with carbohydrate craving, and weight gain, and can be successfully treated with bright light. Circadian rhythm hypotheses (summarized in) have stimulated research into the pathophysiology of SAD, postulating that:

1. 1.The illness is a consequence of delayed phase position,

2. 2.It is correlated with diminished circadian amplitude, or

3. 3.It results from changes in the nocturnal duration between dusk and dawn e.g. of low core body temperature or melatonin secretion. Light is considered to act directly on the circadian pacemaker (‘Process C’) and not on sleep dependent processes (‘Process S’). Thus successful treatment of SAD must act via mechanisms within known retinohypothalamic pathways. Conversely, emergence of SAD symptoms may reflect inappropriate neurobiological response to decreasing daylength.

Light therapy (LT) has become increasingly popular in various countries around the world in the last decade. For instance, according to a recent survey carried out in Germany in 1992, 13% (n = 56) of all German psychiatric hospitals (n = 422) used LT for different treatment indications and another 8% indicated their interest to do so. Among university facilities LT is even more popular, with a percentage of 57%. Although the most frequently used treatment indication for LT is seasonal affective disorder (SAD) or its subsyndromal form (S-SAD) it is apparent that other forms of depression e.g. non-seasonal forms, either acute or chronic are also a target for this new treatment modality. There is a number of studies supporting the use of LT for SAD (for review), however there are just a few studies for non-seasonal depression or for the other treatment indications (for review).

Since the description of SAD the prevalence of this disorder has been of particular interest. The more so, because early studies, indicated the correctness of the on theoretical grounds - expected interaction between latitude and prevalence rate of SAD. More eleborate prevalence studies, mainly in the USA indeed showed a positive correlation between prevalence rate and latitude. In Europe, only few studies have appeared. Although the results of most of these studies are preliminary and research-methods and criteria vary across studies, tentative conclusions are that the prevalence rates in Europe are considerably lower than in the USA, but that there is a similar trend in the direction of an increase of prevalence at higher latitudes.8"10 In the present study, the prevalence of SAD in the Netherlands is investigated.

The common treatment modalities for depression, i.e. pharmacotherapy and psychotherapy have the significant disadvantage of at least a three- to four-week time lag between initiation of treatment and amelioration of mood. Total sleep deprivation (TSD) in contrast, leads to an immediate antidepressant effect in 60% of the patients. However, it has gained only little clinical relevance as usually the improvement is only transient and almost regularly reversed by the next nights of sleep. A procedure preserving the antidepressive effect of sleep deprivation would therefore be of high clinical relevance.

Oince the discovery in the late 1950's of imipramine (Tofranil®), the first tricyclic antidepressant (TCA), and iproniazid, the first monoamine oxidase inhibitor (MAOI), many other TCAs and MAOIs, now being considered the classical antidepressants, have become available. Their effectiveness has been shown in numerous studies, although according to nowadays standards well designed studies (placebo-controlled, defined diagnostic groups, the use of standardized rating scales) with these compounds are relatively scarce.

From the early 1980's the so called modern antidepressants have been introduced: the selective serotonin re-uptake inhibitors (SSRIs), the reversible selective monoamine oxidase-A inhibitors (RIMAs) and a variety of other compounds. All these drugs have been registered after their effectiveness had been shown in well designed, placebo-controlled studies. In defining the efficacy of antidepressants, registration authorities consider two aspects important: statistical evidence and clinical relevance.

Although less undisputed in biological psychiatry than formerly, there are basically still two premisses which underly most hypotheses in biological depression research. These are deeply rooted in the medical way of thinking and have guided the construction of DSM-III. The first is that depressive symptoms and complaints cluster in one or more discrete syndromes, and the second is that these correspond to separate nosological entities, characterized by specific biological derangements and pathogenetic processes. Below a number of issues are raised which cast doubts on the validity of these premisses and on the progress made in pinpointing the derangements looked for.

Unequivocal results demonstrating a causal relationship between a disturbance in circadian rhythms and depression have not yet been reported (reviews). However, acute mood changes, such as the antidepressive effect of sleep deprivation, diurnal variations of mood and their interrelationship, are commonly put forward as evidence of the importance of circadian dysregulations in affective disorders. The purpose of the present study is to obtain more insight in the mechanisms underlying these mood changes. The results will be discussed in the context of a recently postulated non-chronobiological explanation.

Earlier studies have suggested that the relationship between diurnal variation of mood and the response to total sleep deprivation (TSD) is clear and unambiguous: improvement of mood during the day prior to TSD (a positive diurnal variation) is followed by a positive response (mood improvement) to TSD, while no improvement or deterioration of mood during the day prior to TSD (a negative diurnal variation) may result in no, or even a negative, TSD response (for references see Van den Hoofdakker). However, these conclusions were based on the results from cross-sectional studies, comparing single TSD effects across individuals. Comparison of sleep deprivation effects within individuals, however, revealed that the course of mood during the day prior to TSD is irrelevant for the TSD response. Accordingly, a favourable response to TSD appeared to be related to the patient's propensity to show diurnal mood variations per se, irrespective of their direction.

Since Rosenthal et al published their first study about the effects of light treatment on mood in patients suffering from winter depression, many research centres have become interested in the study and treatment of seasonal affective disorders (SAD), one of them being the department of Biological Psychiatry in Groningen. In 1987, we started the first experiments under the inspiring direction of Prof. Rudi van den Hoofdakker and hundreds of patients have participated in various investigations ever since.