Zur Rolle kortikolimbischer affektregulatorischer Mechanismen bei der Therapie depressiver Erkrankungen

 

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Zusammenfassung

Die Komplexität der affektiven Erkrankungen zugrunde liegenden Pathomechanismen erschwert den therapeutischen Zugang zu diesen Störungen. Während die medikamentöse Therapie depressiver Erkrankungen bisher hauptsächlich auf die Beeinflussung monoaminerger Neurotransmittersysteme zielte, mehren sich Hinweise, dass auch bisher weniger beachtete Regelkreise für die Affektregulation bei depressiven Störungen bedeutsam sind. Hierzu zählen insbesondere kortikolimbische, sog. top-down-Regulationsmechanismen, die bei depressiven Erkrankungen in engem Zusammenhang stehen mit negativen Prädiktionen und der damit verbundenen Beeinflussung der Wahrnehmung depressiver Menschen. Neuroanatomische und neurophysiologische Korrelate derartiger Prozesse konnten lange Zeit meist nur hypothesengeleitet beschrieben werden. Inzwischen bestätigen bildgebende Verfahren die Vermutung, dass top-down-Mechanismen bei der auf Vergangenheit und Erinnerung bezogenen Affektregulation depressiver Menschen beteiligt sind und dass sich diese auch durch psychotherapeutische Verfahren oder medikamentöse stimmungsstabilisierende Ansätze (wie z. B. die Augmentation mit Antikonvulsiva oder Neuroleptika der zweiten Generation) positiv beeinflussen lassen. Die Arbeit gibt einen kurzen Überblick über relevante Literatur und einen Ausblick auf die klinische Bedeutung der kortikolimbischen top-down-Regulation bei Depression.

Abstract

Complex functional mechanisms underlie the etiopathogenesis of affective disorders. However, therapeutic implications of new insights are still limited. From the neuropsychological perspective therapy focuses on limbic-cortical (bottom-up) processes whereas cortical-limbic regulatory systems (top-down) were rarely mentioned, although first evidence of their relevance was given in the 80ties, e. g. the use of GABAergic anticonvulsants in affective disorders. Meanwhile modern brain imaging studies support a pronounced role of cortical-limbic top-down mechanisms in the regulation of mood and the therapy of depression, e. g. the effects of cognitive behavioural therapy. The article briefly reviews relevant literature focusing on the neuropsychological hypothesis and the therapeutic implications of these and pharmacologic data. Psychotherapy as well as anticonvulsants appear to mainly affect cortico-limbic mechanisms compared to antidepressants which influence mostly limbic-cortical processes. The combination of both regulatory systems, e. g. the combination of antidepressants and anticonvulsants, appear to have synergistic effects. Such combinations may also be effective in low doses of each compound which does, furthermore, reduce the amount of unwanted side-effects. Studies combining classical antidepressants and mood-stabilizing medication (anticonvulsants and newer neuroleptics) should be performed to substantiate these findings.

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Prof. Dr. Detlef E. Dietrich

Abt. Klinische Psychiatrie und Psychotherapie, Medizinische Hochschule Hannover

30623 Hannover

Email: dietrich.detlef@mh-hannover.de