Determinants of serum brain-derived neurotrophic factor

BACKGROUND

Brain-derived neurotrophic factor (BDNF) belongs to the neurotrophin family of growth factors and affects the survival and plasticity of neurons in the adult central nervous system. The high correlation between cortical and serum BDNF levels has led to many human studies on BDNF levels in various populations, however knowledge about determinants that influence BDNF is lacking.

AIMS

To gain insight into the factors that influence BDNF levels in humans.

METHODS

In 1168 people aged 18 through 65, free of antidepressants and current psychiatric disease, from the Netherlands study of depression and anxiety four categories of determinants (sampling, sociodemographics, lifestyle indicators and diseases) were measured as well as BDNF level. We used univariate analyses as well as multivariate linear regression analyses in particular to determine which of the possible determinants significantly influenced serum BDNF levels.

RESULTS

The mean BDNF level was 8.98ng/ml (SD 3.1ng/ml) with a range from 1.56ng/ml through 18.50ng/ml. Our final multivariate regression analysis revealed that a non-fasting state of blood draw (β=-.067; p=.019), later measurement (β=-.065; p=.022), longer sample storage (β=-.082; p=.004) and being a binge drinker (β=-.063; p=.035) all resulted in attenuated BDNF levels. This was in contrast to smoking (β=.098; p=.001) and living in an urban area (β=.109; p<.001), which resulted in increased BDNF levels. Moreover we found that older subjects also had higher BDNF levels, but this only applied to women (β=.226; p<.001).

CONCLUSIONS

Future studies on serum levels of BDNF in humans should correct for the time of blood withdrawal, storage, urbanicity, age, sex, smoking status and food and alcohol intake.

[Can I have some sunshine to cheer me up? vitamin D deficiency and depression in the elderly]

Vitamin D deficiency is very common in the elderly, and the geriatric patient is probably at even greater risk. Vitamin D plays an important role in calcium homeostasis; recent studies point to a possible causal link between vitamin D deficiency and the development and severity of depression. In this article we focus on an 80-year-old patient with depression and severe vitamin D deficiency and give advice on the diagnosis and treatment of vitamin D deficiency. To supplement the current multidisciplinary guidelines on depression, we recommend routine testing of serum vitamin D level prior to confirming the diagnosis of depression in the elderly.

[Treatment of anxiety disorders in the elderly]

AIM

To collect empirical evidence concerning the effectiveness of the treatment of anxiety disorders in the elderly.

METHOD

Meta-analysis and randomised controlled trials.

RESULTS

Meta-analysis showed that cognitive behavioural therapy (CBT) was more successful than waiting-list control or active control as a treatment for older persons with anxiety disorders. In a direct comparison of the treatment of older persons with panic disorder (PD) both CBT an paroxetine were found to be more effective than waiting-list control. CBT was more successful in reducing avoidance behaviours in older persons with PD. Older persons with reported fewer and less severe agoraphobic cognitions than younger patients, but there was no difference between the severity of agoraphobic avoidance in older patients with PD and younger patients with PD.

CONCLUSION

There is sufficient empirical evidence to support the effectiveness of CBT in the treatment of older persons with anxiety disorders. In assessing the severity of PD in the elderly, one should carefully consider the severity of avoidance behaviours. Because no difference was found between the effectiveness of CBT and paroxetine for the treatment of PD in the elderly and because was more effective in reducing avoidance behaviours in older patients with PD than in younger patients with pd, there seems to be a slight preference for CBT in the case of older patients with PD. Older age is not associated with a poorer outcome of treatment with CBT.

The course of depressive symptoms in unipolar depressive disorder during electroconvulsive therapy: a latent class analysis

BACKGROUND

Research examining the course of depressive symptoms during electroconvulsive therapy (ECT) is relatively scarce.

OBJECTIVE

To classify patients according to the course of their depressive symptoms while receiving ECT.

METHODS

The sample consisted of 156 consecutive patients receiving ECT for unipolar depressive disorder. Depressive symptoms were measured weekly with the Montgomery-Asberg Depression Rating Scale. Latent class analysis was applied to identify distinct trajectories of symptom improvement.

RESULTS

We identified five classes of different trajectories (improvement rates) of depressive symptoms, i.e. fast improvement (39 patients), intermediate improvement (47 patients), slow improvement (30 patients), slow improvement with delayed onset (18 patients), and finally a trajectory with no improvement (20 patients). The course of depressive symptoms at the end of the treatment within the trajectories of intermediate improvement, slow improvement and slow improvement with delayed onset, was still improving and did not achieve a plateau.

CONCLUSION

The different courses of depressive symptoms during ECT probably contribute to mixed results of prediction studies of ECT outcome. Data suggest that for a large group of patients no optimal clinical endpoint can be identified, other than full remission or no improvement at all, to discontinue ECT.

Cognitive-behavioural therapy for late-life anxiety disorders: a systematic review and meta-analysis

OBJECTIVE

To examine and estimate the efficacy of cognitive-behavioural therapy (CBT) for late-life anxiety disorders.

METHOD

A systematic review and meta-analysis of randomized controlled trials comparing CBT with i) a waiting-list control condition and ii) an active control condition controlling for non-specific effects in patients aged over 60 years and suffering from an anxiety disorder. The main outcome parameter of individual studies, i.e. effect on anxiety, was pooled using the standardized mean difference (SMD).

RESULTS

Seven papers fulfilled the inclusion criteria, including nine randomized controlled comparisons for 297 patients. Anxiety symptoms were significantly more reduced following CBT than after either a waiting-list control condition [SMD = -0.44 (95 CI: -0.84 -0.04), P = 0.03] or an active control condition [SMD = -0.51 (95 CI: -0.81, -0.21), P<0.001]. Additionally, CBT significantly alleviated accompanying symptoms of worrying and depression.

CONCLUSION

Cognitive-behavioural therapy is efficacious for the treatment of late-life anxiety disorders.

Consequences of a benzodiazepine discontinuation programme in family practice on psychotropic medication prescription to the participants

BACKGROUND

Whether long-term benzodiazepine users who participate in a family practice-based benzodiazepine discontinuation programme substitute benzodiazepines by other psychotropics is not clear.

OBJECTIVE

To evaluate the impact of a benzodiazepine discontinuation programme on non-benzodiazepine psychotropic prescription in family practice.

METHODS

In family practices in the Netherlands, 2425 long-term benzodiazepine users participated in a two-step benzodiazepine discontinuation programme. The programme started with a discontinuation letter (Step 1). Subjects unable to stop (N = 1707) were offered participation in Step 2, a three-group randomized trial with a taper procedure with group psychotherapy, a taper without psychotherapy and usual care. Only 156 subjects agreed to participate. The comparison group consisted of 1821 long-term users from family practices not participating in the programme. The main outcome was the change in prescription of non-benzodiazepine psychotropic medication from baseline (3 months before the start of the programme) till 21 months after the start of the programme. Four logistic regression models were performed concerning antidepressant prescription in the follow-up.

RESULTS

Only antidepressants were prescribed in relevant numbers. The prescription of antidepressants was not related to the programme. (P-value of experimental versus control group varied between 0.18 and 0.85 in the four models). The most important predictor of antidepressant prescription in follow-up was baseline antidepressant prescription [odds ratio (OR): 67.2; 95% confidence interval (95% CI): 49.8-90.7]. Subjects, of whom the prescription of benzodiazepines had been discontinued completely, had been prescribed less antidepressants (OR: 0.8; 95% CI: 0.6-1.0).

CONCLUSION

An effective benzodiazepine reduction programme was not accompanied by a substitute use of other psychotropics.

The absence of benzodiazepine craving in a general practice benzodiazepine discontinuation trial

This study aimed to assess benzodiazepine craving longitudinally and to describe its time course by means of the Benzodiazepine Craving Questionnaire (BCQ). Subjects were long-term benzodiazepine users participating in a two-part treatment intervention aimed to reduce long-term benzodiazepine use in general practice in The Netherlands. Four repeated measurements of benzodiazepine craving were taken over a 21-month follow-up period. Results indicated that (1) benzodiazepine craving severity decreased over time, (2) patients still using benzodiazepines experienced significantly more severe craving than patients who had quit their use after one of the two interventions, and (3) the way in which patients had attempted to quit did not influence the experienced craving severity over time, however, (4) patients who had received additional tapering off, on average, reported significantly more severe craving than patients who had only received a letter as an incentive to quit. Although benzodiazepine craving is prevalent among (former) long-term benzodiazepine users during and after discontinuation, craving severity decreases over time to negligible proportions. Self-reported craving can be longitudinally monitored and quantified by means of the BCQ.

Predictors of discontinuation of benzodiazepine prescription after sending a letter to long-term benzodiazepine users in family practice

BACKGROUND

Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently.

OBJECTIVE

To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation.

METHODS

Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months.

RESULTS

A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time <24 hours were predictive of complete discontinuation in the short (6 months) and long term (21 months). Multiple agent use at baseline, use of antidepressants at 6 months and benzodiazepine type (anxiolytic/hypnotic) at baseline predicted relapse. Attendance at an evaluation consultation 3 months after the letter was sent was not predictive of discontinuation or relapse.

CONCLUSIONS

Amount of baseline use and duration of use are the main determinative characteristics of successful discontinuation. The discontinuation letter intervention is suitable for use with a broad group of long-term benzodiazepine users in family practice and can be used as a first step within a stepped care approach to decrease long-term benzodiazepine use.

Long-term outcome of two forms of randomised benzodiazepine discontinuation

About two-thirds of long-term users of benzodiazepines in the population are able to discontinue this drug with the aid of supervised programmes for tapering off. Little is known about the long-term outcome of such programmes, and they have never been compared with usual care. After a 15-month follow-up of a randomised controlled trial comparing such a programme with and without psychotherapy with usual care, we found significantly higher longitudinal abstinence rates in long-term benzodiazepine users who received a benzodiazepine tapering-off programme without psychotherapy (25 out of 69, 36%) compared with those who received usual care (5 out of 33,15%; P=0.03).

Development and psychometric evaluation of the Benzodiazepine Craving Questionnaire

AIM

To assess the scalability, reliability and validity of a newly constructed self-report questionnaire on craving for benzodiazepines (BZs), the Benzodiazepine Craving Questionnaire (BCQ).

SETTING AND PARTICIPANTS

The BCQ was administered once to a sample of 113 long-term and 80 former long-term general practice BZ users participating in a large BZ reduction trial in general practice.

MEASUREMENTS

(1) Unidimensionality of the BCQ was tested by means of the Rasch model. (2) The Rasch-homogeneous BCQ items were assessed for subject and item discriminability. (3) Discriminative and construct validity were assessed.

FINDINGS

The BCQ met the requirements for Rasch homogeneity, i.e. BZ craving as assessed by the scale can be regarded as a unidimensional construct. Subject and item discriminability were good. Construct validity was modest. Highest significant associations were found with POMS depression (Kendall's tau-c = 0.15) and Dutch Shortened MMPI negativism (Kendall's tau-c = 0.14). Discriminative validity was satisfactory. Highest discriminative power was found for a subset of eight items (Mann-Whitney U Z = - 3.6, P = 0.000). The first signs of craving are represented by the acknowledgement of expectations of positive outcome, whereas high craving is characterized by direct intention to use.

CONCLUSIONS

The BCQ proved to be a reliable and psychometrically sound self-report instrument to assess BZ craving in a general practice sample of long-term BZ users.

Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial

BACKGROUND

Benzodiazepine withdrawal programmes have never been experimentally compared with a nonintervention control condition.

AIMS

To evaluate the efficacy and feasibility of tapering off long-term benzodiazepine use in general practice, and to evaluate the value of additional group cognitive-behavioural therapy (CBT).

METHOD

A 3-month randomised, 3-month controlled trial was conducted in which 180 people attempting to discontinue long-term benzodiazepine use were assigned to tapering off plus group CBT, tapering off alone or usual care.

RESULTS

Tapering off led to a significantly higher proportion of successful discontinuations than usual care (62% nu. 21%). Adding group CBT did not increase the success rate (58% v. 62%). Neither successful discontinuation nor intervention type affected psychological functioning. Both tapering strategies showed good feasibilityin general practice.

CONCLUSIONS

Tapering off is a feasible and effective way of discontinuing long-term benzodiazepine use in general practice. The addition of group CBT is of limited value.

[Treatment methods for discontinuation of long-term benzodiazepine use]

Treatment strategies for discontinuing long-term benzodiazepine usage can be divided into minimal interventions and gradual discontinuation programs. Minimal interventions invite patients to quit their long-term benzodiazepine usage on their own by making them aware of the adverse effects. This type of intervention is successful in about one fifth of patients. Gradual discontinuation programs are more extensive interventions in order to help those patients who are unable to discontinue benzodiazepine use on their own. These programs are successful in two-thirds of the patients and can be combined with additional pharmacological or psychological treatment. Once the withdrawal symptoms have diminished, most patients have an improved psychological functioning compared to when they were using benzodiazepines. Furthermore, no increase in medical consumption has been found.

[Long-term use of benzodiazepines]

Benzodiazepines are the most prescribed drugs in the Netherlands. There is scarcely an indication for long-term benzodiazepine use. Long-term use may lead to dependency and is associated with an increased risk of accidents/falls and cognitive function impairment. Therefore national and international guidelines advocate a conservative prescription policy, especially with respect to long-term prescription. It appears that these guidelines are not followed in practice. A standard sized general practice in the Netherlands contains, on average, 75 long-term benzodiazepine users. There appear to be both patient and GP related factors which influence the maintenance of this long-term use of benzodiazepines.