Effects of buspirone and alprazolam on the cognitive performance of normal elderly subjects

OBJECTIVE

To increase understanding of the potential in elderly persons for disability related to behavioral side effects of anxiolytic medications, cognitive and psychomotor effects of clinical doses of buspirone and a popular intermediate-acting benzodiazepine, alprazolam, were examined in carefully screened, healthy elderly subjects.

METHOD

Sixty subjects recruited through community organizations and newspaper advertisements and screened on the basis of history, physical examination, and laboratory studies were randomly assigned to one of three drug treatment groups. After 2 days of washout placebo, subjects were given 0.25 mg t.i.d. of alprazolam, 5 mg t.i.d. of buspirone, or placebo three times a day for a total of 14 days in a double-blind design. Behavioral assessments were completed beginning 1 hour after ingestion of medication on the second washout placebo day, day 1 of the treatment period, and day 14 of the treatment period. Tests included the continuous performance test, recall memory for word lists, digit-symbol substitution, retention of pictorial stimuli over 1 hour, the Profile of Mood States, and subjective ratings of mental status.

RESULTS

Buspirone did not affect reaction time, vigilance, psychomotor speed, or memory function. Alprazolam had minimal effects on vigilance, psychomotor speed, and memory on the first treatment day and had no effects after repeated doses.

CONCLUSIONS

Buspirone did not produce behavioral side effects that could lead to disability, and alprazolam had minimal side effects. Because the patients were carefully screened, it is unclear whether these medications in the doses used would have more side effects in less healthy elderly patients.

Relation of psychopathology in general medical inpatients to use and cost of services

The authors investigated the relation between psychopathology in medically ill inpatients and use and cost of medical care services. Of 455 medical inpatients, the Medical Inpatient Screening Test identified 27.9% as very depressed, 27.5% as very anxious, 20.2% as having cognitive dysfunction, and 8.6% as having high pain levels. Overall, the test identified 51% of the patients as having high levels of psychopathology or pain. These subjects had a 40% longer median length of hospital stay and 35% greater mean hospital costs than those with low levels of psychopathology or pain. Patients with greater psychopathology also had higher hospital charges, more procedures during hospitalization, and more discharge diagnoses but did not differ from the other patients in sex, race, age, diagnosis-related group (DRG) major diagnostic category, or DRG weight.

A prospective assessment of the Garren-Edwards Gastric Bubble and bariatric surgery in the treatment of morbid obesity

Morbid obesity is a serious medical hazard, and effective alternatives to surgery have been unsuccessful. In 1985, the Garren-Edwards Gastric Bubble (GEGB) was offered as an adjunct to dietary and behavioral therapy for weight loss treatment. The safety and efficacy of the GEGB were compared with bariatric surgery, the current standard for the treatment of morbid obesity. Fifty-seven patients received GEGB and 77 underwent bariatric surgery. GEGB patients were divided into two groups: those who attended group therapy and those who did not. This study showed that bariatric surgery was far more effective in reducing excess body weight during a 12-month period compared with the GEGB plus group therapy and the GEGB alone. The morbidity from bariatric surgery was greater than in the GEGB-treated groups, while the cost for uncomplicated cases for a year's treatment was comparable. It is concluded that the GEGB does not offer an effective alternative to bariatric surgery in the treatment of morbid obesity.

Neuropsychological effects of occupational exposure to cadmium

Neuropsychological functioning was measured in 31 male workers exposed to cadmium in a refrigerator coil manufacturing plant. Workers with high urinary cadmium levels performed less well than did those with low urinary cadmium levels on measures of attention, psychomotor speed, and memory. There were modest correlations between one of two biologic measures of cadmium exposure and neuropsychological performance. The neuropsychological impairments cannot readily be attributed to exposure to other neurotoxins, alcohol intake, CNS effects of renal dysfunction, or psychological distress. Cadmium body burden has previously been related to intelligence and school achievement of children; this study would appear to be the first to suggest that occupational exposure to cadmium is associated with cognitive impairment in adults. Cadmium interferes with several important nervous system functions, but the mechanisms of neurotoxicity remain uncertain.

Amphetamine challenge test, response to treatment, and lateral ventricle size in schizophrenia

The hypothesis of two independent pathologies in schizophrenia proposed by Crow (1980) were tested. Two dimensions of the dopamine variable, namely, the behavioral response during the Amphetamine Challenge Test (ACT) and the response to neuroleptic treatment, were studied in a cohort of 19 subjects with a research diagnosis of schizophrenia (n = 18) or schizoaffective disorder (n = 1) in an acute inpatient setting. The size of the lateral ventricle was assessed by mesauring the ventricle-brain ratio (VBR) on the computerized tomographic brain scan. Patients who had greater symptom reduction with the neuroleptic treatment worsened more in their positive psychotic symptoms during the ACT. Those with larger VBRs showed less treatment responsiveness and no worsening during the ACT. The findings are supportive of Crow's hypothesis. The ACT has the potential to be an index of both Type I and Type II pathologies.

Denial and medical outcome in unstable angina

Denial may be adaptive during hospitalization for acute coronary disease. We studied the impact of denial in 48 patients referred to a tertiary care center for treatment of unstable angina. Using the Hackett-Cassem Denial Scale, we divided the group into 25 high deniers and 23 low deniers. The two groups were comparable in baseline demographic and social data, coronary risk factors, cardiac history, medical treatment, vital signs, and cardiac catheterization results (number of diseased vessels and ejection fraction). Compared to low deniers, high deniers had half as many episodes of angina during hospitalization (1.3 vs. 2.5; p less than 0.03, t = 2.2, df = 46) and were more likely to reach medical stabilization, i.e., pain free for 36 hr (92% vs. 65%, p less than 0.03, Fisher exact probability test). Intravenous nitroglycerin drips were also required less often in high deniers (32% vs. 78%, p = 0.002, Fisher exact). Two myocardial infarctions and one death occurred, all in low deniers. We conclude that denial independently predicts better medical outcome during acute hospitalization for unstable angina.

First admission young adult patients to a state hospital: relative risk for rapid readmission

High readmission rates by young adult patients to state hospitals represents a major service utilization problem for the public mental health system. By identifying those patients who have an increase risk for rapid readmission, effective community-based services could be developed to help reduce utilization of costly hospital services. A nonconcurrent prospective study of 210 first admission young adult patients admitted to a state hospital was conducted to ascertain the incidence of readmission within 180 days of discharge from the index admission (rapid readmission), and to establish relative risk for rapid readmission based on demographic, hospital utilization, and diagnostic variables. The cohort was partitioned into two subgroups: patients with no prior hospitalization, (NPH; N = 119), and patients with prior hospitalization, (PH; N = 91). Group comparisons revealed NPH patients had a lower readmission rate, had shorter hospital lengths of stay, and had a higher proportion on patients with personality or adjustment disorders. The relative risk for rapid readmission in the NPH patient group was greatest for nonwhite female patients (3.30) and for patients who had hospital length of stays between 4-15 days (1.76). In the PH patient group, the relative risk for rapid readmission was greatest for those patients with hospital length of stay less than 15 days (2.15). In both groups, patients with major mental illness were more likely to get readmitted. An association between hospital occupancy rate, the time of discharge from the index admission and readmission to the hospital, hospital length of stay, sex, race, or diagnostic category was not found.

Differences in CT findings within schizophrenics may be due to varying severity of the illness

The authors investigated the importance of severity and duration of illness in schizophrenia with regard to findings on computerised tomographic (CT) scans. Two groups are compared, one from a state hospital's chronic ward and the other group from a university hospital. They provide evidence to propose increased ventricular size is an indicator of severity of illness.

Who benefits from tricyclic antidepressants: a survey

To determine what patients are likely to benefit from treatment with a tricyclic antidepressant, the authors surveyed American researchers, teachers of psychiatry, general psychiatric practitioners, and foreign researchers. Areas of agreement were appreciable and can serve as an index of accepted community practice and as guidelines for teaching. Responses indicated that patients most likely to benefit from a tricyclic antidepressant are those with primary depression; early morning awakening; motor retardation; loss of appetite; weight loss; prior positive response to a tricyclic antidepressant; loss of interest in work or hobbies; sad, blue, or depressed feelings; improved mood in evening; and loss of interest in sex. Amitriptyline was preferred for agitated depressions, and imipramine was preferred for retarded depressions.

Borderline personality disorder: replication of MMPI profiles

The purpose of this study was to determine whether a particular MMPI profile is associated with borderline personality disorder (BPD). Forty-seven symptomatic volunteers who satisfied DSM-III criteria for borderline and/or schizotypal personality disorder were given the full MMPI. Concordance of MMPI profile for BDP confirmed the findings of four previous studies. Elevations were noted on F, D, PD, PA, PT, and SC. A subject's profile with this pattern is interpreted from item content as generally neurotic, dysthymic, socially withdrawn, suspicious, apathetic toward the future, affectively erratic, unable to anticipate the consequences of his or her own behavior, and unable to judge the social desirability of his or her own behavior. Correlations of the foregoing scales with a total BPD score ranged from .44 to .77, with a multiple R of .80 and a cross validity of .77. The accuracy of predicting actual BPD and non-BPD cases was 89%. Accordingly, the MMPI could be used as a coarse screen for BPD casefinding in that patients with the MMPI profiles above should be selected for more thorough diagnostic workup. In the future, the MMPI might be linked to other variables, such as drug response, to understand further the pathophysiology of BPD.

Schizophrenic symptoms and deterioration. Relation to computed tomographic findings

Thirty-two patients with a research diagnosis of chronic schizophrenia were studied using structured clinical scales for premorbid adjustment, clinical symptomatology, and social deterioration. By computed axial tomography (CAT), ventricle-brain ratio (VBR) and cortical atrophy were assessed. The relation between the clinical variables and CAT findings was assessed using linear correlation. CAT-based subgroups were compared using univariate analysis of variance. Previous findings of ventricular enlargement and cortical atrophy in some schizophrenics were replicated. Premorbid asociality and social deterioration were found to have a modest, positive relation with CAT findings but formal thought disorder had a negative relation to ventricle size. There was no relation between the negative symptoms and CAT measures. Within the CAT-positive group the presence of cortical atrophy appeared to be associated with a more severe illness compared with those with ventricular enlargement but the sample sizes were too small to obtain any significant differences.

Productive naming and memory in depression and Alzheimer's type dementia

Patients with mild to moderate dementia of the Alzheimer's type (DAT), patients with major depression, and normal controls completed tests of productive naming and verbal recall memory. Both depressed and DAT patients demonstrated reduced verbal fluency on productive naming tasks, indicating limited utility of such tasks in differential diagnosis. There was a stronger relationship between verbal fluency and memory in DAT patients than in depressed patients. The linguistic component as well as the requirement for cognitive speed may be important in explaining the deficit of DAT patients on productive naming tasks. In contrast, the speed component may be particularly important for depressed patients whose poor performance may reflect a motivational deficit.

Selective reminding procedure in depression and dementia

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal elderly control subjects were administered a verbal learning task using the selective reminding procedure. Depressed patients were impaired on total recall and the proportion of items retained from one trial to the next without reminding and did not benefit from imagery in retaining items over consecutive trials. The DAT patients were impaired on all measures derived from the test, including storage and recognition memory. With the exception of the ability to benefit from imagery, all of the measures distinguished depressed and mild DAT patients. These findings are consistent with deficient encoding in DAT and performance deficits as a function of effortful cognitive processing in depression.

Psychological factors predict symptoms of severe recurrent genital herpes infection

In a group of patients with severe recurrent genital herpes infection, we measured symptoms (pain and itching), psychological factors (depression, anxiety, somatisation, interpersonal sensitivity, and life change) and objective indices of disease (number of recurrences in the previous year, total number of recurrences, duration of recurrences, number of lesions per recurrence). Psychological factors were more predictive of pain and itching than were somatic indices, even after correcting for sex.

Selective reminding procedure in depression and dementia

Patients with mild dementia of the Alzheimer's type (DAT), patients with major depression, and normal elderly control subjects were administered a verbal learning task using the selective reminding procedure. Depressed patients were impaired on total recall and the proportion of items retained from one trial to the next without reminding and did not benefit from imagery in retaining items over consecutive trials. The DAT patients were impaired on all measures derived from the test, including storage and recognition memory. With the exception of the ability to benefit from imagery, all of the measures distinguished depressed and mild DAT patients. These findings are consistent with deficient encoding in DAT and performance deficits as a function of effortful cognitive processing in depression.

A survey of psychiatrists' practices related to the use of tricyclic antidepressants

Four groups of psychiatrists were surveyed about their clinical practices in relation to the use of tricyclic antidepressants to determine if there is any unanimity about procedures. The four groups were U.S. experts in the pharmacotherapy of depression, faculty who taught the pharmacotherapy of depression in accredited departments of psychiatry, general psychiatrists in Virginia who treated depressions with drugs, and non-U.S. experts. The authors report on practices related to dosage buildup, side effects, concurrent medical conditions, blood level information, and maintenance on tricyclics. They found moderate to high consensus on most issues; exceptions were treatment of a patient with chronic hypertension and maintenance dosage and duration.

Alprazolam versus imipramine in depressed out-patients with neurovegetative signs

The purpose of this study was to compare the safety and efficacy of a relatively new antidepressant drug, alprazolam (a triazolobenzodiazepine) with imipramine in the treatment of 60 depressed symptomatic volunteers. Eligible patients were randomly assigned after a 1-week washout to one of the medications and followed for 6 treatment weeks. Contrary to the earlier report of Feighner et al. (1983), who found alprazolam superior to imipramine and placebo, but consistent with Rush et al. (1985) we find imipramine superior in efficacy to alprazolam on a variety of symptoms. Both the present study and Rush's study employed patients with signs indicative of response to tricyclics. Feighner's patients may have been the type who tend to be less responsive to tricyclics but may be more responsive to alprazolam. Some of our data also show that alprazolam may have a more advantageous effect in the early weeks of treatment but is overtaken in subsequent treatment weeks by imipramine.

Borderline and schizotypal personality disorders treated with low-dose thiothixene vs placebo

Fifty outpatients with borderline and/or schizotypal personality disorder were randomly allocated to thiothixene (Navane) or placebo treatment that was continued for 12 weeks. The mean daily dosage of thiothixene hydrochloride in the final week of the study was 8.7 mg, a lower dosage than is used in outpatient schizophrenics. Significant drug-placebo differences were found, regardless of diagnosis, on "illusions," "ideas of reference," "psychoticism," "obsessive-compulsive symptoms," and "phobic anxiety," but not on "depression." Thiothixene seems to have more than an antipsychotic effect. Since response to treatment studies are a means for reformulating diagnostic concepts, we suggest a subdiagnosis defined by those symptoms that are drug-responsive, some of which are not included in current diagnostic criteria. Patients with borderline and schizotypal disorder without the foregoing symptoms probably would not profit from thiothixene and might needlessly be placed at risk for adverse drug effects.

Posttraumatic stress disorder from pentaborane intoxication. Neuropsychiatric evaluation and short-term follow-up

Fourteen individuals briefly exposed to a toxic industrial compound, pentaborane, were evaluated for neuropsychiatric abnormalities four to 12 weeks after exposure. Results of physical, neurological, and routine laboratory evaluations were normal. Initial and persistent psychiatric symptoms, neuropsychological deficits, electroencephalographic changes, elevated central nervous system neurotransmitter levels, and ventricular brain ratios (computed tomographic scan) provide evidence of central nervous system damage. Seven patients met diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, ed 3, for posttraumatic stress disorder, and seven patients had neuropsychological test evidence of mild brain dysfunction. No statistically significant relationship was found between neuropsychiatric test results and psychiatric diagnoses. These results contradict previous literature that reports most symptom resolution within the first week after exposure to pentaborane. Results suggest that patients suffered a combination of organic brain insult and psychological trauma.

Brain ventricular size and CSF monoamine metabolites in an adolescent inpatient population

The cerebrospinal fluid monoamine metabolites, homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5HIAA), were compared with ventricle-brain ratios (VBRs) in a group of adolescent inpatients who were divided into psychotic and nonpsychotic groups. HVA, 5HIAA, and VBR did not differ significantly between the two groups. There were no significant relationships between these variables in the nonpsychotic group. Psychotic adolescents, however, displayed significant negative correlations between VBR and HVA, and between VBR and 5HIAA. The relationship between VBR and monoamine metabolites appears to occur in psychoses other than schizophrenia, is present early in the course of illness, and probably does not represent a dilutional effect.