Lower dosages of phentermine-fenfluramine given in the afternoon: five cases with significant weight loss

Phentermine and fenfluramine are widely used in the treatment of obesity. Despite the fact that primary pulmonary hypertension and mitral valve insufficiency have been associated with fenfluramine use, many of these patients need medication to achieve weight loss. Small degrees of weight loss have been shown to significantly improve obesity-related medical conditions such as hypertension, hypercholesterolemia, and noninsulin-dependent diabetes mellitus. Current practice is to give phentermine and fenfluramine in the morning and afternoon. Doses for phentermine have ranged from 15 to 37.5 mg and for fenfluramine from 20 to 120 mg per day. We report five cases of severely obese women with medical complications who were treated with phentermine 8 mg twice per day (at 1:00 p.m. and 4:00 p.m.) and fenfluramine 20 mg per day (at 4:00 p.m.). Because many obese patients skip breakfast and eat more in the afternoon and evening, medication was dosed in order to cover these high-risk eating periods. Overall, these patients lost a mean of 22.4% of their initial weight (range 18.6% to 32.8%) over an average of 8.4 months (range 3.5 to 16 months). These cases suggest that short-term weight loss can be achieved with a low dose of fenfluramine when both medications are given in the afternoon to better target the eating patterns of obese subjects.

A placebo-controlled comparison of the antidepressant efficacy and effects on sexual functioning of sustained-release bupropion and sertraline

Sexual dysfunction, a frequently reported side effect of many antidepressants, may result in patient dissatisfaction and noncompliance with treatment regimens. This paper describes the results of the first placebo-controlled comparison of the efficacy, safety, and effects on sexual functioning of sustained-release bupropion (bupropion SR) and the selective serotonin reuptake inhibitor sertraline. This randomized, double-masked, double-dummy, parallel-group, multicenter trial enrolled 360 patients with moderate-to-severe recurrent major depression. Patients were treated with bupropion SR 150 to 400 mg/d, sertraline 50 to 200 mg/d, or placebo for up to 8 weeks. Patients' depression and sexual functioning were assessed at weekly or biweekly clinic visits; safety was assessed by regular monitoring of adverse events, vital signs, and body weight. Treatment groups were similar at baseline in terms of age, sex, and race, and most patients had a diagnosis of moderate uncomplicated depression. Patients treated with bupropion SR or sertraline showed similar improvements on all efficacy measures; both active treatments were superior to placebo in improving scores on all rating scales for depression at various time points. Significantly more patients treated with sertraline experienced orgasmic dysfunction throughout the study than did patients treated with bupropion SR or placebo (P < 0.001). Headache was the most frequently reported adverse event in all 3 treatment groups and occurred with similar frequency in each group (30% to 40%). Nausea (31%), diarrhea (26%), insomnia (18%), and somnolence (17%) occurred in significantly more patients in the sertraline group than in the bupropion SR group (18%, 7%, 13%, and 3%, respectively) and the placebo group (10%, 11%, 4%, and 6%, respectively). Dry mouth occurred more frequently with bupropion SR (19%) than with sertraline (14%) or placebo (12%), although the differences were not significant. Changes in vital signs were similar in all groups. Similar (small, but not statistically significant) decreases in mean body weight were seen in both the bupropion SR (-1.06 kg) and sertraline (-0.79 kg) groups, whereas the placebo group experienced a minor increase (0.21 kg). Although bupropion SR and sertraline were similarly well tolerated and effective in the treatment of depression, sertraline treatment was more often associated with sexual dysfunction and certain other adverse events compared with bupropion SR and placebo. Therefore, bupropion SR may be an appropriate choice as an antidepressant for the treatment of sexually active patients.

Recent advances in the pharmacotherapy of smoking

Since the 1996 publication of guidelines on smoking cessation from the Agency for Health Care Policy and Research and the American Psychiatric Association, several new treatments have become available, including nicotine nasal spray, nicotine inhaler, and bupropion hydrochloride. In addition, nicotine gum and patch have become available over-the-counter. This article reviews the published literature and US Food and Drug Administration and pharmaceutical company reports on these therapies. Based on this review, clinical logic, and experience, we conclude that pharmacotherapy should be made available to all smokers. All currently available therapies appear to be equally efficacious, approximately doubling the quit rate compared with placebo. Concomitant behavioral or supportive therapy increases quit rates and should be encouraged but not required. Combining patch with gum or patch with bupropion may increase the quit rate compared with any single treatment. Because patient characteristics predictive of success with a particular therapy are not yet known, the best treatment choice for an individual patient should be guided by the patient's past experience and preference and the product's adverse effect profile.

Neuropsychological deficits in psychotic versus nonpsychotic unipolar depression

A broad range of neuropsychological function was compared in samples of young adult unipolar depressed inpatients with and without psychotic features. Consistent with expectations, the psychotic depressive group demonstrated a broad range of deficit and had more impaired performances than the nonpsychotic group. Relevance of these data for hypotheses concerning psychotic depression as a unique diagnostic entity is discussed. In the context of previous research, the current findings suggest that accounting for individual differences in depression may clarify discrepancies between earlier studies of neuropsychological function in depression, and our understanding of the mechanisms by which depression influences cognition may be refined.

An open trial of bupropion for ADHD in adolescents with substance use disorders and conduct disorder

OBJECTIVE

Adolescents with conduct disorder (CD) and substance use disorders (SUD) have higher rates of comorbid attention-deficit/hyperactivity disorder (ADHD) than those without CD and SUD. Comorbid ADHD may contribute to more severe SUD. Treatment of ADHD may enhance effective treatment of substance abuse and behavior problems, yet there are few data regarding pharmacological treatment of ADHD in such youths.

METHOD

Pilot data are presented from a 5-week, open-label bupropian trial in 13 nondepressed adolescent boys in a residential treatment program focusing on substance and behavioral treatments. All had diagnoses of ADHD, CD, and SUD. Patients' doses were titrated to a maximum fixed daily dose of 300 mg of bupropion. The Conners Hyperactivity Index and Daydream Attention scores, along with Clinical Global Impressions Severity of Illness (CGI-S) ratings, were obtained at baseline and at the fifth week of treatment.

RESULTS

Subjects' mean Conners Hyperactivity Index score declined from 75.5 to 65.4 (p < .01, Wilcoxon signed rank test) (13% decline). The mean Daydream Attention score declined from 59.5 to 53.6 (p < .02, Wilcoxon signed rank test) (10% decline). Mean CGI-S declined from 4.9 to 3.0 (p < .002, Wilcoxon signed rank test) (39% decline).

CONCLUSIONS

These preliminary data suggest that bupropion may be a useful treatment for ADHD in adolescents with CD and SUD; they suggest the need for a controlled trial of bupropion in such youths.

Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD

A review of records was carried out to examine the results obtained when people with Attention Deficit Disorder (ADD) received 40 sessions of training that combined neurofeedback with the teaching of metacognitive strategies. While not a controlled scientific study, the results, including pre- and post-measures, are consistent with previously published research concerning the use of neurofeedback with children. A significant addition is that a description of procedures is included. The 111 subjects, 98 children (age 5 to 17) and 13 adults (ages 18 to 63), attended forty 50-min sessions, usually twice a week. Feedback was contingent on decreasing slow wave activity (usually 4-7 Hz, occasionally 9-11 Hz) and increasing fast wave activity (15-18 Hz for most subjects but initially 13-15 Hz for subjects with impulsivity and hyperactivity). Metacognitive strategies related to academic tasks were taught when the feedback indicated the client was focused. Some clients also received temperature and/or EDR biofeedback during some sessions. Initially, 30 percent of the children were taking stimulant medications (Ritalin), whereas 6 percent were on stimulant medications after 40 sessions. All charts were included where pre- and post-testing results were available for one or more of the following: the Test of Variables of Attention (TOVA, n = 76), Wechsler Intelligence Scales (WISC-R, WISC-III, or WAIS-R, n = 68), Wide Range Achievement Test (WRAT 3, n = 99), and the electroencephalogram assessment (QEEG) providing a ratio of theta (4-8 Hz) to beta (16-20 Hz) activity (n = 66). Significant improvements (p < .001) were found in ADD symptoms (inattention, impulsivity, and variability of response times on the TOVA), in both the ACID pattern and the full-scale scores of the Wechsler Intelligence Scales, and in academic performance on the WRAT 3. The average gain for the full scale IQ equivalent scores was 12 points. A decrease in the EEG ratio of theta/beta was also observed. These data are important because they provide an extension of results from earlier studies (Lubar, Swartwood, Swartwood, & O'Donnell, 1995; Linden, Habib, & Radojevic, 1996). They also demonstrate that systematic data collection in a private educational setting produces helpful information that can be used to monitor students' progress and improve programs. Because this clinical work is not a controlled scientific study, the efficacious treatment components cannot be determined. Nevertheless, the positive outcomes of decreased ADD symptoms plus improved academic and intellectual functioning suggest that the use of neurofeedback plus training in metacognitive strategies is a useful combined intervention for students with ADD. Further controlled research is warranted.

Prevalence variations in psychotropic treatment of children

This study was undertaken to clarify several aspects of the estimation of prevalence of three commonly use pediatric psychotropic agents, namely, methylphenidate, desipramine, and imipramine. The study aims are threefold: (1) to show the variability of drug prevalence by comparing estimates from three data sources; (2) to show the misleading impression that can be created by reporting drug prevalence estimates based on counts of prescriptions rather than persons; (3) to show the utility of gender-by-age-specific prevalence of drug use as a marker for diagnosis. Two data sources that yield population-based prescription estimates were available: 1991 Medicaid administrative claims data for prescriptions from a mid-Atlantic state and 1991 prescription records of the northwest region of Kaiser Permanente, a staff-model health maintenance organization (HMO). Another source of data consists of the 1991 National Ambulatory Medical Care Survey, which records medication information reported during physician office visits. Data analysis consists of quantitative estimates of (1) drug prevalence from each source; (2) the ratio of prescription claims to persons; and (3) the proportion of drug use according to age and gender. Methylphenidate and desipramine prevalence had a twofold greater use among state Medicaid enrollees compared with HMO enrollees. Average claims-to-person ratios of 5:1 suggest better accuracy using persons with medication rather than prescription counts. Gender-by-age-specific prevalence rates showed that 75% of the drug use for desipramine among those less than 15 years old was found among males, whereas 75% of the desipramine use among those 15 or older was found among females, suggesting its use for the treatment of attention deficit-hyperactivity disorder among young males and for depression among older females. The variability of community physician decision making in pediatric psychopharmacology is better understood by observing drug prevalence rates from different settings. National sampling efforts should be undertaken to verify regional and setting-specific prevalence findings and to learn the reasons for their fluctuation.

Levels of intravenous drug misuse among clients prescribed oral dexamphetamine or oral methadone: a comparison

There has been a considerable increase in the number of intravenous amphetamine misusers during the last decade, and the development of effective treatment strategies for this high-risk group has become critical. The use of substitute prescribing is one option, but reservations have been expressed as to its demonstrated effectiveness in reducing injecting practice and associated risks. This study compares the effect of substitute prescribing on the injecting practices of two groups of intravenous drug misusers: 120 primary opiate misusers, prescribed oral methadone; and 60 primary amphetamine misusers, prescribed dexamphetamine elixir. The levels of intravenous drug misuse at time of discharge for the two groups was similar, with 67% of the opiate misusers and 70% of the amphetamine misusers having stopped injecting.

The use of an N-of-1 randomised clinical trial in resolving therapeutic doubt. The case of a patient with an 'attention disorder'

OBJECTIVE

To describe the use of an N-of-1 randomised clinical trial (N-of-1 RCT) in general practice as illustrated by the case of a 16 year old boy with a learning and attention problem whose parents were convinced that amphetamines were necessary.

DESIGN

The N-of-1 RCT with a double blind technique was used in which a single patient served as his own control in testing whether amphetamine had any advantage over placebo.

RESULTS

No difference was noted in the boy's teachers' behavioural assessment scores nor in his own self reported ability to concentrate when taking either amphetamine or placebo.

CONCLUSION

This study showed that this patient obtained no objective improvement from amphetamine and the result was well accepted by his parents. N-of-1 RCTs are a relatively easy technique for tackling any area of therapeutic doubt. They can help the thoughtful GP to feel 'more like a scientist and less like a quack'.

Reliability and validity of the SKAMP rating scale in a laboratory school setting

In children with attention deficit hyperactivity disorder (ADHD), the effects of methylphenidate were investigated in a pharmacodynamic comparison of placebo and the standard b.i.d. administration of methylphenidate. In each of these conditions, teachers completed ratings in classroom settings at times chosen to coincide with expected "peaks" and "troughs" of serum concentrations in the b.i.d. condition. Analyses of variance (ANOVAs) revealed the expected differences between the two conditions in the laboratory classroom setting using standard rating scales (Conners and the IOWA Conners) and a new rating scale (the SKAMP), which specifically measures the classroom manifestation of ADHD. The psychometric properties of the SKAMP were evaluated by calculating test-retest reliability and by calculating correlations with the standard rating scales to establish concurrent validity.

Amineptine in the treatment of amphetamine withdrawal: a placebo-controlled, randomised, double-blind study

Temporary inability to function without amphetamine and the experience of withdrawal syndrome enhance the tendency for repetitive use. The investigators proposed to examine the therapeutic effects of amineptine, an antidepressant with dopamine reuptake inhibition effect, for the treatment of amphetamine withdrawal. The 14-day study was carried out on a randomised, double-blind, placebo-controlled design. The authors assessed the severity of amphetamine withdrawal syndrome by using two measures and performed both end-point and intent-to-treat analyses. The results showed that amineptine helped relieve a depressed mood within one week and improved the general condition within 2 weeks. In conclusion, amineptine is effective in rapid relief of depressed mood and improves the general condition of patients with amphetamine withdrawal. Since the amphetamine withdrawal may last for several weeks, studies with longer duration should be conducted before incorporating amineptine into the clinical practice a of amphetamine withdrawal treatment.