Pharmacologic profile and efficacy of venlafaxine

Venlafaxine is a structurally novel phenylethylamine agent with antidepressant properties. The preclinical profile suggests that it will be as effective as the tricyclic antidepressants (TCAs) with few significant effects on the neuroreceptors that mediate many of the side effects common with the TCAs. Venlafaxine has been studied in more than 2500 patients in clinical trials; its efficacy has been evaluated in more than 700 venlafaxine-treated patients in six placebo-controlled trials (five in out-patients and one in in-patients). These studies used a wide range of doses (25-375 mg/day) and different dose regimens (t.i.d. and b.i.d). The results of these studies clearly establish that venlafaxine is significantly more effective than placebo. In the two studies that used doses of 375 mg/day, a significant difference from placebo was observed on the Montgomery- Asberg Depression Rating Scale (MADRS) at the earliest time points assessed, after 4 days of treatment in the in-patient study and after 1 week of treatment in the out-patient study. Venlafaxine also appears to be as effective as some reference antidepressants. A positive dose-response effect has been demonstrated with doses of up to 375 mg/day, with a minimum effective dose of 75 mg/day.

[Cerebral blood flow and post-TIA depression]

OBJECT

This study tries to evaluate the hypothesis of an association between severity of post-stroke depression and reduced cerebral blood flow (SPECT Xenon-133).

METHOD

37 patients in the fourth week of post-stroke evolution with RDS criteria of major depression (N = 20) and non-depressed patients (N = 17) were compared in regard to following parameters: values of cerebral blood flow (SPECT Xenon-133), localization of brain lesion (CT Scanner) and quantitative measurement of mood (HDRS, MARDS, BDI), functional ability (Barthel, Karnofsky), cognitive function (MMSE, WPT) and neurological function (Orgogozo's Scale).

RESULTS

Post-stroke major depression is more frequent (NS) in left and anterior lesions. We also demonstrated a significant association between total brain hypoperfusion and 1) severity of post-stroke depression, 2) severity of neurologic and functional impairments.

CONCLUSION

these results suggest a relationship between mood and cerebral perfusion following stroke.

Mirtazapine is more effective than trazodone: a double-blind controlled study in hospitalized patients with major depression

Two hundred hospitalized patients with DSM-III diagnosis of moderate to severe major depressive episode were randomized to receive mirtazapine or trazodone for 6 weeks in a double-blind trial. The dosages were 24-72 mg/day for mirtazapine and 150-450 mg/day for trazodone. The improvement on all depression rating scales used was generally greater for mirtazapine, with statistically significant differences over trazodone in the Hamilton Psychiatric Rating Scale for Depression total score and two subscores (the Bech melancholia factor and retardation factor), the Brief Psychiatric Rating Scale total score, the General Psychiatric Impression Global Assessment Scale, the Beck score and responder rates. Mirtazapine was well tolerated, while the trazodone-treated patients experienced somnolence more frequently, particularly during the first 2 weeks of treatment. Furthermore, postural symptoms were a clinical problem in 6% of the trazodone-treated patients. In this trial, mirtazapine showed significant clinical advantages over trazodone in terms of overall efficacy and tolerability.

Detection of expanded CAG repeats in bipolar affective disorder using the repeat expansion detection (RED) method

Genetic factors are of major aetiological importance in Bipolar Affective Disorder (BPAD type I and II). The exact mode of inheritance of BPAD is unknown, but the recent demonstration of anticipation suggests that dynamic mutations could be involved in the clinical expression of the disease. We have used the repeat expansion detection (RED) method to test whether the anticipation in BPAD could be explained by the presence of expanded trinucleotide repeat sequences. Using a (CTG)10 oligonucleotide a significantly higher number of expanded CAG repeats were found in the genomic DNA of two independent samples of unrelated BPAD patients of Swedish and Belgian ancestry as compared with normal controls. The difference in repeat number was more consistent if data of the two samples of patients was pooled. In this study a CAG trinucleotide repeat expansion was associated for the first time with a major psychiatric disorder. It is possible that the CAG trinucleotide repeat expansion is involved in the clinical expression of BPAD and that it is the molecular basis explaining the phenomenon of anticipation observed in this disorder.

Manic-depressive illness and linkage reanalysis in the Xq27-Xq28 region of chromosome X

Inconsistent findings in X linkage studies of manic-depressive illness (MDI) have been ascribed to the presence of phenotypic uncertainties (incomplete penetrance), considerable variation in form and severity of MDI, and the likely presence of phenocopies (or false positives). In order to address some of these issues, previous X linkage data with colour blindness, glucose-6-phosphate dehydrogenase deficiency, and blood coagulation factor IX (F9) markers were reanalysed using a narrow and a broad definition of MDI. Our results confirm the X-linked hypothesis for MDI genetic transmission when controlling for diagnostic variation. The lod score (log of odds ratio) is reduced for a more conservative definition of the disease, but nevertheless remains significant. However, conclusive linkage between the MDI gene and the F9 gene in the Xq27 region is not maintained in our series. Our findings emphasize the need to reanalyse previous genetic data with more sophisticated diagnostic and statistical techniques.

Effects of early treatment of poststroke depression on neuropsychological rehabilitation

This study was made in an attempt to document the effects of early treatment of poststroke depression (including fluoxetine treatment) on neuropsychological rehabilitation (including cognitive function). Assessment measures used included the Schedule for Affective Disorders and Schizophrenia (SADS) and Research Diagnostic Criteria (RDC), as well as standard measures of severity of depression, functional ability, cognitive function, and neurological function. Thirty-seven patients with poststroke depression, treated with fluoxetine (n = 26) or nortriptyline (n =11), were compared with 11 poststroke depressed patients who received no depression treatment and 82 poststroke nondepressed patients who received no depression treatment. Our findings about the prevalence of depression (37%), more frequent with anterior lesion (p = .009) and left hemisphere lesion (not statistically significant), tend to confirm previous reports. Early treatment (4th week poststroke) with either fluoxetine or nortriptyline significantly improved the depressed patients' mood, neurological function, functional ability, and cognitive ability. A close relationship between appropriate early treatment (including fluoxetine treatment) of poststroke depression and improved neuropsychological rehabilitation (including cognitive improvement) is suggested by our findings. This is the first report, to our knowledge, of the beneficial effects of early antidepressant treatment on the cognitive function of poststroke depressed patients.

Linkage analysis of bipolar illness with X-chromosome DNA markers: a susceptibility gene in Xq27-q28 cannot be excluded

Transmission studies have supported the presence of a susceptibility gene for bipolar (BP) illness on the X-chromosome. Initial linkage studies with color blindness (CB), glucose-6-phosphate dehydrogenase (G6PD) deficiency, and the blood coagulation factor IX (F9) have suggested that a gene for BP illness is located in the Xq27-q28 region. We tested linkage with several DNA markers located in Xq27-q28 in 2 families, MAD3 and MAD4, that previously were linked to F9 and 7 newly ascertained families of BP probands. Linkage was also examined with the gene encoding the alpha 3 subunit of the gamma-amino butyric acid receptor (GABRA3), a candidate gene for BP illness located in this region. The genetic data were analyzed with the LOD score method using age-dependent penetrance of an autosomal dominant disease gene and narrow and broad clinical models. In MAD3 and MAD4 the multipoint LOD score data suggested a localization of a BPI gene again near F9. In the 7 new families the overall linkage data excluded the Xq27-q28 region. However, if the families were grouped according to their proband's phenotype BPI or BPII, a susceptibility gene for BPI disorder at the DXS52-F8 cluster could not be excluded.

Temporal glucose metabolism in borderline personality disorder

The pathophysiology of borderline personality disorder (BPD) is obscure. Underlying organic factors such as epilepsy are suspected because clinical characteristics of the syndrome are similar to some manifestations of patients with complex partial seizures (CPS). Positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) reveals hypometabolism in the area surrounding epileptic foci. To test the epilepsy hypothesis in BPD, we have explored 10 patients with BPD and compared them with 15 control subjects using PET with FDG. We conclude that PET provides no metabolic indication of temporal lobe epilepsy in BPD.

TSH response to TRH and EEG sleep in non-bipolar major depression: a multivariate approach

The TSH response to TRH and selected sleep EEG variables were studied in a homogeneous sample of 280 non-bipolar major depressed inpatients (95 males and 185 females). The TSH response to TRH was blunted in 28% of the sample. delta max TSH was correlated negatively with age, Hamilton rating scale, Newcastle scale, percentage of wake, and positively with basal TSH, percentage of stage II, slow wave sleep, REM sleep and REM latency. delta max TSH was also lower in male patients and in patients suffering from an endogenous or a psychotic subtype of major depression. Basal TSH was only correlated negatively with the Newcastle score. In view of intercorrelations between all these variables, and because of the confounding effect of age, gender and severity on both the TSH response to TRH and sleep EEG variables, a multiple regression analysis was performed and demonstrated that basal TSH and gender were the two variables with the highest contribution to the delta max TSH variance, followed by age and the presence of psychotic symptoms. When controlling strictly for these significant effects, correlation with the severity or with the endogenous character of depression, and with sleep EEG parameters disappeared.

Frontal and parietal metabolic disturbances in unipolar depression

The authors investigated brain glucose utilization using positron emission tomography (PET) in 12 normal volunteers and 12 unipolar unmedicated depressed patients (six endogenous; six nonendogenous) following injection of [18F]fluoro-deoxyglucose (FDG). Compared by analyses of variance, absolute and relative regional glucose metabolic rates appeared different in depressed patients and control subjects, especially in parietal and frontal lobes. In patients with unipolar depression, metabolic rates were increased in the orbital part of the frontal lobe and decreased in a frontal dorsolateral area. The metabolic supero-basal gradient calculated in the frontal cortex was significantly lower in depressed patients than in normal subjects. Decreased glucose metabolism was also observed in the parietal cortex of depressed patients. No differences in glucose metabolic rates have been detected between endogenous and nonendogenous patients. No correlation has been found between the metabolic data and the Hamilton Rating Scale.

Multicompartmental study of fluorine-18 altanserin binding to brain 5HT2 receptors in humans using positron emission tomography

Serotoninergic type 2 (5HT2) receptors have been implicated in the regulation of many brain functions in humans and may play a role in several neurological and psychiatric diseases. Fluorine-18 altanserin has been proposed as a new radiotracer for the study of 5HT2 receptors by PET because of its high affinity for 5HT2 receptors (Ki: 0.13 nM) and its good specificity in in vitro studies. Dynamic PET studies were carried out in 12 healthy volunteers after intravenous injection of 0.1 mCi/kg [18F]altanserin. Ninety minutes after injection, we observed mainly cortical binding. Basal ganglia and cerebellum showed very low uptake and the frontal cortex to cerebellum ratio was about 3. To evaluate the quantitative distribution of this ligand in the brain, we used two different methods of data analysis: a four-compartment model was used to achieve quantitative evaluation of rate constants (K1 and k2 through k6) by non-linear regression, and a multiple-time graphical analysis technique for reversible binding was employed for the measurement of k1/k2 and k3/k4 ratios. Using both methods, we found significant differences in binding capacity (estimated by k3/k4 = Bmax/Kd) between regions, the values increasing as follows: occipital, limbic, parietal, frontal and temporal cortex. After correction of values obtained by the graphical method for the existence of non-specific binding, results generated by the two methods were consistent.

Biological markers as classifiers for depression: a multivariate study

1. Delta TSH, REM latency, 4 pm and 11 pm post-dexamethasone cortisol values were determined after a wash-out period in a group of 74 non-selected depressed patients who were diagnosed (according to RDC with the SADS) as follows: 46 definite and 10 probable MD, 4 minor and 14 intermittent depression. 2. These biological variables, as well as gender, age and basal TSH were introduced in a principal component analysis. The four first PC scores explaining up to 77% of the data set were further calculated for each patients and used in a cluster analysis. A three clusters solution was retained. 3. DST escape and increased TSH response to TRH each identified subgroups of depressed patients. Conversely, blunted TSH response or REM latency were inefficient to classify patients. 4. Thus, HPA hyperactivity characterized CL-I patients (n = 29). These were more severely depressed, displayed more endogenous features and were reported as being more anxious. 5. Increased TSH response to TRH identified CL-III, exclusively composed of female patients (n = 10) that displayed more apparent sadness and tended to be older. 6. In CL-II, the usual sex-ratio for depressive illness was reversed and patients (n = 35) exhibited the least HPA axis disturbances and the same rate of blunted TSH response than in CL-I. They were also less severely depressed, displayed less endogenous characteristics and were rated as more mood reactive. 7. These results suggest heterogeneity in biological disturbances in depression and further stress the importance for controlling age, gender and severity of illness in studies investigating biological markers in depression.

The 24-hour profiles of cortisol, prolactin, and growth hormone secretion in mania

OBJECTIVE

To characterize sleep and the 24-hour profiles of cortisol, prolactin (PRL), and growth hormone (GH) secretion in mania.

METHODS

Blood was sampled at 15-minute intervals, and sleep was polygraphically recorded in eight unmedicated male patients with pure mania and the results compared with those from a group of 14 healthy age-matched controls. The circadian, sleep-related, and pulsatile hormonal variations were quantitatively characterized using specifically designed computer algorithms.

RESULTS

The manic state was associated with alterations of corticotropic activity and circadian rhythmicity partially overlapping those previously observed in acute endogenous depression, consisting of an elevation of nocturnal cortisol levels and an early timing of the nadir of the circadian variation. Sleep onset was delayed and the sleep period was reduced. A trend for short rapid eye movement latencies was apparent in the adult patients. Both the amount and the temporal organization of PRL and GH secretion were normal.

CONCLUSION

The manic state seems to be characterized by similar but less severe neuroendocrine and circadian abnormalities, compared with major depression.

[Genetics and manic-depressive psychosis: review and current findings]

The present article reviews the basic and recent findings of the genetics in manic-depressive illness. The different molecular genetic techniques that have been applied to this research field are presented. Results of linkage and association studies are discussed in regard to the main limitations of these approaches in psychiatric disorders. On the whole, linkage and association studies contributed to the localisation of some potentials vulnerability genes for manic-depression on chromosome X and 11 and more recently 18.

[Rhythm of paradoxical sleep in an adult]

Adults rarely present with rhythmic movement disorders in the Sleep Laboratory. We report the case of a 34 year-old woman, in good health, with a complaint of chronic body rolling during sleep and fatigue. Polysomnographic and video recordings showed head and body rhythmic movements, mainly during REM sleep. The contribution of severe psychopathology or neurological disorder was ruled out with personality testing, structured psychiatric interview and neurological examination with EEG, cerebral CT, MRI, and PET scans.

A rhythmic movement disorder in REM sleep: a case report

The case of a 34-year-old woman in good health with a complaint of diurnal fatigue and chronic repetitive rocking body movements during sleep is reported. Repeated polygraphic and video recordings during sleep allowed for a detailed analysis of rhythmic patterns of head and body rolling movements preferentially occurring during rapid eye movement sleep. The contribution of severe psychopathology or neurologic disorder was carefully examined and ruled out with personality testing, structured psychiatric interview, neurological examination with electroencephalogram, cerebral computerized tomography, magnetic resonance imaging and position emission tomography scans.

Effect of an antidiencephalon immune serum on pain and sleep in primary fibromyalgia

The results of a double-blind, randomized, therapeutical trial with SER282, an antidiencephalon immune serum (Serolab, Lausanne, Switzerland), in 36 women, aged 24-56 years, with primary fibromyalgia are presented. Treatment was ambulatory and consisted of either SER282 (20 mg/ml) or amitryptiline (AMI, 50 mg) or placebo (PL) over an 8-week treatment course. Clinical and sleep EEG polygraphic data were obtained at baseline and after 4 and/or 8 weeks of therapy. Compared to an important PL response and moderate analgesia with AMI, pain and associated symptoms improved moderately with SER282. In contrast, polysomnographic recordings showed that SER282 tended to promote stage 4 sleep, while AMI and PL had few--if any--effect on sleep. These results are discussed together with the clinical characteristics of the patients and the relations between pain, associated symptoms, and sleep parameters in our patient population.