Perceived stress in anxiety disorders and the general population: a study of the Sheehan stress vulnerability scale

The objectives of this study were to (1) validate and establish normative values for a single-item, self-rated measure of perceived stress, the Stress Vulnerability Scale (SVS); and (2) compare levels of perceived stress in patients with anxiety disorders with the general population. The sample was drawn from the general population (n=630) and from participants in pharmacotherapy trials of anxiety disorders (social phobia, n=127; posttraumatic stress disorder, n=116). The SVS was administered at baseline in all groups and following treatment in the placebo-controlled clinical trial samples. The SVS demonstrated good reliability and validity. Pretreatment scores in the anxiety disorders were significantly greater than in the general population. Perceptions of vulnerability to the effects of daily stress are considerably greater in anxiety disorders compared to the general population and also differ within the anxiety disorders.

An open-label study of tiagabine in panic disorder

γ-aminobutyric acid (GABA) has been implicated in the pathophysiology of anxiety disorders, including panic. Tiagabine, a selective GABA reuptake inhibitor (SGRI), has been shown to reduce symptoms of anxiety. This pilot study evaluated the efficacy and safety of tiagabine in patients with panic disorder. Male and female outpatients aged 18-64 years with a DSM-IV diagnosis of severe to moderately severe panic disorder (with or without agoraphobia) received open-label tiagabine 2-20 mg/day for 10 weeks. Outcome assessments included the Sheehan Panic Disorder Scale (SPS), Panic Disorder Severity Scale (PDSS), Bandelow Panic and Agoraphobia Scale (PAS), Hamilton Rating Scale for Anxiety (HAM-A), 21-point Clinician Global Improvement Scale (CGI-21), 21-point Patient Global Improvement (PGI-21) and the Sheehan Disability Scale (SDS). Scores were recorded at baseline and weekly intervals thereafter. Adverse events were monitored throughout the study. Of the 28 patients who enrolled in the study, 23 had one post-baseline visit and were available for LOCF outcome analysis. Although statistically significant reductions from baseline were observed for all of the outcome measures, the percentage improvements on individual scales were only in the 25-32% range which is not clinically significant. Tiagabine was generally well tolerated; the most common adverse events were nausea, dizziness and headaches. Only one patient discontinued tiagabine due to adverse events. These findings suggest that administration of tiagabine may be of little benefit in patients with panic disorder.

Current approaches to the pharmacologic treatment of anxiety disorders

Despite their high prevalence, the anxiety disorders are underdiagnosed and undertreated. Benzodiazepines, once the first line of treatment, have been superceded by SSRIs as the treatment of choice. Preclinical studies, however, suggest that CRF antagonists and antagonists of nicotinic,glutamate,5-HT1A,and NK-1 receptors may have potential anxiolytic action. Preliminary data suggest that tiagabine, the only available SGRI, may also be beneficial in the anxiety disorders. Further research on these novel agents in anxiety disorders is needed.

The speed of onset of action of alprazolam-XR compared to alprazolam-CT in panic disorder

This study compares the speed of onset of action of the extended release (XR) formulation of alprazolam with that of the compressed tablet (CT) formulation in a sample of outpatients with DSM-IV panic disorder. Diary records of hourly antianxiety benefit from a 9-week open label switch study of 30-patients stabilized on alprazolam- CT for 3 weeks and then switched to an equivalent dose of alprazolam-XR, were used to examine the timing and magnitude of clinical benefit on both formulations. The magnitude of benefit at the first hour after the first morning dose was similar for both formulations. The peak benefit, over the hours after the first morning dose, was also similar and 90% of peak benefit that was achieved in the first hour on both formulations. Mean time to peak benefit was similar (1.5 h for alprazolam-CT vs. 1.6 h for alprazolam-XR) and the percent of patients achieving peak benefit in the first hour was also similar. Compared to the CT formulation, alprazolam-XR had a much longer duration of therapeutic action (11.3 +/- 4.2 h vs. 5.1 +/- 1.7 h). The results, which may be related to the biotechnology (and resultant pharmacokinetic profile) of the XR preparation, suggest that alprazolam-XR has value as a "rescue" as well as a prophylactic or maintenance treatment in panic disorder. These results must be viewed in the context of the study limitations including its small size, the lack of independence of groups in a switch study, and the limitations of the diary records used.

Differences in total medical costs across the SSRIs for the treatment of depression and anxiety

There is growing evidence that adherence to the recommended duration of antidepressant therapy results in reduced medical costs compared with nonadherence, and that the likelihood of adhering to therapy is not equivalent across the selective serotonin reuptake inhibitors (SSRIs). As such, the purpose of this study was to assess differences in 6-month medical costs between paroxetine controlled-release (CR) and immediate-release (IR) SSRI agents in a retrospective analysis of patients initiating SSRI therapy identified from the Integrated Healthcare Information Services National Managed Care Benchmark Database during a 2.5-year time frame. Inferential analyses were performed to evaluate differences in 6-month medical costs, controlling for differences in age, sex, utilization of psychiatric specialty care services, titration, pre-period costs, and comorbidity measures. Of the 146 075 patients included in this study, approximately 7% received paroxetine CR. Approximately 29.5% of patients had an anxiety disorder diagnosis; 26.0% had a depression-only diagnosis; and 13.2% had comorbid anxiety and depression. The 6-month medical costs were 244 US dollars lower for patients initiating with paroxetine CR compared with the average medical costs for patients receiving IR SSRIs. Paroxetine CR also had the lowest medical costs compared with each individual SSRI evaluated. After log transformation of costs and adjustment for baseline covariates, the aggregated IR SSRIs were associated with 8.7% higher 6-month medical costs than paroxetine CR (P <.001) and even greater costs after stratifying by diagnosis: 12.5% higher costs in patients with anxiety, 14.3% higher costs in patients with depression, and 15.9% higher costs in patients with comorbid anxiety and depression (P <.001 for all). Each individual IR SSRI was also associated with significantly higher medical costs than paroxetine CR, irrespective of diagnosis. As demonstrated, medical costs over a 6-month time frame were significantly greater for IR SSRIs versus paroxetine CR, even after adjusting for background characteristics and stratifying by diagnosis. Future studies should measure rates of adherence in relation to medical outcomes over an expanded time frame.

Comparing the effects of antidepressants: consensus guidelines for evaluating quantitative reviews of antidepressant efficacy

With increasing numbers of treatment options available for patients with major depression over the last decade and the growing body of evidence describing their efficacy and safety, clinicians often find it difficult to determine the best and most appropriate evidence-based treatment for each patient. Systematic reviews utilizing statistical methods that synthesize and evaluate data from a number of studies have become increasingly more available over the past decade. We review major findings and lessons learned from salient examples of quantitative analyses of antidepressant research and provide recommendations for meta-analysts, journal and grant reviewers, and research 'consumers' (ie, clinicians) for conducting, reporting, and evaluating such analyses.

Efficacy and tolerability of controlled-release paroxetine in the treatment of panic disorder

OBJECTIVE

To assess the efficacy and tolerability of controlled-release paroxetine (paroxetine CR) in the treatment of adults with panic disorder.

METHOD

Paroxetine CR (25-75 mg/day; N = 444) was compared with placebo (N = 445) in patients with DSM-IV panic disorder with or without agoraphobia in 3 identical, double-blind, placebo-controlled, 10-week clinical trials that were pooled for analysis.

RESULTS

Paroxetine CR was statistically superior to placebo in the primary outcome measure, percentage of patients who were free of panic attacks in the 2 weeks prior to endpoint. Of the total population that completed or prematurely terminated treatment, 63% and 53% of paroxetine CR-and placebo-treated patients, respectively, were panic-free during the final 2 weeks (p < .005; odds ratio [OR] = 1.63; 95% CI = 1.21 to 2.19). For week 10 completers (72% of total), 73% and 60% of paroxetine CR- and placebo-treated patients, respectively, were panic-free at week 10 (p < .005; OR = 2.11; 95% CI = 1.45 to 3.07). Paroxetine CR was also statistically superior to placebo on the global improvement and severity items of the Clinical Global Impressions scale and in reducing anxiety symptoms as measured by the Hamilton Rating Scale for Anxiety total score and total fear and avoidance on the Marks-Sheehan Phobia Scale. Adverse events leading to study withdrawal were minimal and occurred in 11% of the paroxetine CR group and 6% of the placebo group. Most of the treatment-emergent adverse events were rated as mild to moderate in severity and occurred early in the study. There were no unexpected adverse events, and serious adverse events were uncommon (10 [2.3%] of the 444 patients treated with paroxetine CR vs. 8 [1.8%] of the 445 patients treated with placebo).

CONCLUSION

Paroxetine CR is an effective and well-tolerated treatment for panic disorder. Paroxetine CR is associated with low rates of treatment-emergent anxiety as well as low dropout rates from adverse events.

Evaluating the economic consequences of early antidepressant treatment discontinuation: a comparison between controlled-release and immediate-release paroxetine

INTRODUCTION

Early antidepressant discontinuation has been linked to significant clinical and economic consequences. Clinical practice guidelines suggest that treatment should last for at least 3 to 9 months into the continuation phase; however, 30% of patients discontinue therapy within 30 days, and over 40% discontinue therapy within 90 days of initiation, primarily due to adverse events. Clinical trials have shown that controlled-release (CR) paroxetine has a favorable tolerability profile when compared to immediate-release (IR) paroxetine, which may result in lower discontinuation rates and improved economic outcomes. This is the first study to directly compare treatment discontinuation rates and health care expenditures of a CR selective serotonin reuptake inhibitors with its IR counterpart.

METHODS

This matched retrospective study used claims from a national managed care database to assess differences in discontinuation rates and health care expenditures between paroxetine CR and IR for treating depression and/or anxiety. Discontinuation was assessed by survival analysis, and health care expenditure was assessed using average monthly medical and pharmacy charges.

RESULTS

There were 1275 paroxetine CR patients and 2550 paroxetine IR patients matched in the analysis. At 90 days, 62% of paroxetine CR patients continued therapy versus 56% of paroxetine IR patients. At 180 days, 51% of paroxetine CR patients continued therapy versus 42% of paroxetine IR patients. When evaluating all medical charges, paroxetine CR patients incurred US 119 dollars less per month than paroxetine IR patients (P = 0.054).

CONCLUSIONS

Patients receiving paroxetine CR remained on therapy longer than patients on paroxetine IR, which resulted in lower total monthly medical costs for patients receiving paroxetine CR. Differences in costs were primarily driven by reduction in hospitalization expenditures.

Depression: underdiagnosed, undertreated, underappreciated

Major depressive disorder is significantly underdiagnosed and undertreated, particularly in the primary care environment. Although more patients are seeking help for depression and the utilization of antidepressants is on the rise, the level of treatment is inadequate. Rectifying this will involve patients, providers, payers, employers, accrediting agencies, and even governmental entities.

Nicotinic acetylcholine receptors as targets for antidepressants

While the monoamine deficiency hypothesis of depression is still most commonly used to explain the actions of antidepressant drugs, a growing body of evidence has accumulated that is not adequately explained by the hypothesis. This article draws attention to contributions from another apparently common pharmacological property of antidepressant medications--the inhibition of nicotinic acetylcholine receptors (nAChR). Evidence is presented suggesting the hypercholinergic neurotransmission, which is associated with depressed mood states, may be mediated through excessive neuronal nicotinic receptor activation and that the therapeutic actions of many antidepressants may be, in part, mediated through inhibition of these receptors. In support of this hypothesis, preliminary evidence is presented suggesting that the potent, centrally acting nAChR antagonist, mecamylamine, which is devoid of monoamine reuptake inhibition, may reduce symptoms of depression and mood instability in patients with comorbid depression and bipolar disorder. If this hypothesis is supported by further preclinical and clinical research, nicotinic acetylcholine receptor antagonists may represent a novel class of therapeutic agents for treating mood disorders.

The management of panic disorder

The evidence for benzodiazepines in panic disorder is compelling; along with the selective serotonin reuptake inhibitors (SSRIs), they are a standard treatment for panic and other anxiety disorders. However, extended-release formulations of these agents may prove to be as effective as the immediate-release formulations, and extended-release agents have clinical benefits that may make them more attractive treatments than the currently available, shorter-acting benzodiazepines. Because of their longer duration of action, extended-release benzodiazepines can protect against breakthrough anxiety and need to be taken only once or twice a day, which may improve compliance in some patients. Because the other standard treatments of panic disorder, the SSRIs, have a slow onset of action, adding an extended-release benzodiazepine to the treatment regimen for the initial 6 to 8 weeks could serve as an effective bridge until the desired SSRI effect is realized.

Paroxetine treatment of generalized anxiety disorder

Generalized anxiety disorder (GAD) is a prevalent and disabling anxiety disorder, conservatively believed to affect at least 5% of the general population. Cardinal symptoms of GAD include chronic and uncontrollable worry, anxiety, and tension, which result in difficulty fulfilling social, professional, and family roles. Treatment options include benzodiazepines, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine XR. Because of the high comorbidity of GAD with other psychiatric disorders, pharmacologic therapy should possess both anxiolytic and antidepressive properties for best outcomes. The SSRIs are a good treatment option, and paroxetine is the best studied SSRI for GAD and the only SSRI to date approved by the US Food and Drug Administration for this indication. Results of randomized, controlled studies of paroxetine have demonstrated its efficacy in the short-term treatment of GAD, in achieving and sustaining full remission, and in preventing relapse. This article provides an overview of GAD and a discussion of studies of paroxetine treatment in this anxiety disorder.

Impact of formulary restrictions on the cost-effectiveness of antidepressant treatment

Newer antidepressants are associated with higher costs of treatment of anxiety and depression. Managed care organizations are challenged to control treatment costs by implementing restricted formularies based on price and perceived medical value. Despite unfavorable side effects of efficacious tricyclic antidepressants, the low acquisition cost rationalizes the inclusion of this older class of agents on a formulary. On the other hand, cost-containment approaches have been taken toward more expensive drug classes (e.g., selective serotonin reuptake inhibitors) despite a superior safety profile of these drug classes over tricyclics. There is compelling evidence that dual reuptake inhibitors (e.g., venlafaxine extended-release), which have acquisition costs similar to serotonin reuptake inhibitors, have a broad spectrum of efficacy and thus added value, contributing to the cost-effectiveness of including this agent in the managed care formulary. Assessment of overall cost-effectiveness should not be limited by acquisition costs but should take total healthcare costs into consideration.

Characterization of the longitudinal course of improvement in generalized anxiety disorder during long-term treatment with venlafaxine XR

OBJECTIVE

To characterize the response to the serotonin and norepinephrine reuptake inhibitor, venlafaxine extended release (XR), during the long-term treatment of generalized anxiety disorder.

METHODS

Data from two double-blind, placebo-controlled, 6-month trials of venlafaxine XR for the treatment of generalised anxiety disorder were pooled. Criteria for response (> or = 50% improvement from baseline HAM-A score) and remission (HAM-A score < or = 7) and their temporal profile were used to characterize patient improvement over 6 months of treatment with venlafaxine XR and placebo.

RESULTS

Venlafaxine XR was associated with significantly (P<0.001) higher response and remission rates (66 and 43%, respectively) compared with placebo (39 and 19%), regardless of the level of baseline anxiety. In the venlafaxine XR group, 61% of the patients who had responded but not remitted by week 8 showed remission by the end of 6 months. In comparison, only 39% of placebo responders who did not qualify for remission at the end of the first 8 weeks of therapy remitted by the end of the 6 months (P=0.007). Relapse occurred in 6% of venlafaxine XR-treated patients and 15% of placebo-treated patients (P<0.01).

CONCLUSION

This analysis provides further insight into the outcome of long-term treatment of generalised anxiety disorder with venlafaxine XR and shows for the first time that long-term treatment might be necessary to achieve and maintain remission of symptoms.

Effect of Hypericum perforatum (St John's wort) in major depressive disorder: a randomized controlled trial

CONTEXT

Extracts of Hypericum perforatum (St John's wort) are widely used for the treatment of depression of varying severity. Their efficacy in major depressive disorder, however, has not been conclusively demonstrated.

OBJECTIVE

To test the efficacy and safety of a well-characterized H perforatum extract (LI-160) in major depressive disorder.

DESIGN AND SETTING

Double-blind, randomized, placebo-controlled trial conducted in 12 academic and community psychiatric research clinics in the United States.

PARTICIPANTS

Adult outpatients (n = 340) recruited between December 1998 and June 2000 with major depression and a baseline total score on the Hamilton Depression Scale (HAM-D) of at least 20.

INTERVENTIONS

Patients were randomly assigned to receive H perforatum, placebo, or sertraline (as an active comparator) for 8 weeks. Based on clinical response, the daily dose of H perforatum could range from 900 to 1500 mg and that of sertraline from 50 to 100 mg. Responders at week 8 could continue blinded treatment for another 18 weeks.

MAIN OUTCOME MEASURES

Change in the HAM-D total score from baseline to 8 weeks; rates of full response, determined by the HAM-D and Clinical Global Impressions (CGI) scores.

RESULTS

On the 2 primary outcome measures, neither sertraline nor H perforatum was significantly different from placebo. The random regression parameter estimate for mean (SE) change in HAM-D total score from baseline to week 8 (with a greater decline indicating more improvement) was -9.20 (0.67) (95% confidence interval [CI], -10.51 to -7.89) for placebo vs -8.68 (0.68) (95% CI, -10.01 to -7.35) for H perforatum (P =.59) and -10.53 (0.72) (95% CI, -11.94 to -9.12) for sertraline (P =.18). Full response occurred in 31.9% of the placebo-treated patients vs 23.9% of the H perforatum-treated patients (P =.21) and 24.8% of sertraline-treated patients (P =.26). Sertraline was better than placebo on the CGI improvement scale (P =.02), which was a secondary measure in this study. Adverse-effect profiles for H perforatum and sertraline differed relative to placebo.

CONCLUSION

This study fails to support the efficacy of H perforatum in moderately severe major depression. The result may be due to low assay sensitivity of the trial, but the complete absence of trends suggestive of efficacy for H perforatum is noteworthy.

Generalized anxiety disorder: raising the expectations of treatment

Anxiety disorders are prevalent and associated with an increase in morbidity and mortality, particularly when present with additional psychiatric disorders. They represent a public health and economic burden, yet they are commonly underrecognized and undertreated. Benzodiazepines are effective anxiolytics, but they primarily treat the somatic symptoms of generalized anxiety disorder (GAD), and are not effective in treating the depressive symptoms that are often comorbid in chronic anxiety disorders like GAD. Some antidepressants may therefore offer the best choice of therapy. Their benefit in the treatment of GAD has been demonstrated using the tricyclic antidepressant, imipramine, and some selective serotonin reuptake inhibitors. The serotonin and norepinephrine reuptake inhibitor venlafaxine extended release (XR), has been indicated for GAD and has proven to be effective in both the short- and long-term treatment of patients with this disorder. Many patients treated with venlafaxine XR achieve and sustain remission from the symptoms of GAD, which is the goal of treatment.

Attaining remission in generalized anxiety disorder: venlafaxine extended release comparative data

Generalized anxiety disorder (GAD) is a chronic mental disorder that is characterized by excessive anxiety or worry. Traditionally, the treatment goal for GAD has been the attainment of a treatment response, clinically defined as a 40% to 50% symptomatic improvement relative to baseline. However, there is growing consensus among clinical psychiatrists that the treatment goal should be remission, a virtually asymptomatic state that corresponds to a score of < or = 7 on the Hamilton Rating Scale for Anxiety (HAM-A) or a > or = 70% symptomatic improvement from baseline. Venlafaxine extended release (XR), a serotonin-norepinephrine reuptake inhibitor, is the first pharmacotherapeutic agent to be indicated for both depression and GAD. This article reviews the efficacy data from several short- and long-term placebo-controlled studies of venlafaxine conducted to evaluate the potential of this agent to facilitate remission. Total scores on the HAM-A and the Clinical Global Impressions scale were used as the primary variables; scores for the HAM-A psychic and somatic anxiety factors and for the Hospital Anxiety and Depression scale were used as secondary variables. Venlafaxine XR showed a substantial effect size in the individual HAM-A items of worry, anxiety, and behavior at interview. The pooled analysis of 2 long-term studies indicated that the scores of venlafaxine remitters separated from those of responders by the second month, resulting in an overall increase in remitters. The results of these studies demonstrate the strong potential of venlafaxine XR in facilitating remission in GAD.

Multicenter, double-blind, placebo-controlled study of mecamylamine monotherapy for Tourette's disorder

OBJECTIVE

The safety and efficacy of mecamylamine as a monotherapy in children and adolescents with Tourette's disorder (TD) was investigated in an 8-week multicenter, double-blind, placebo-controlled study.

METHOD

Eligible subjects included subjects with TD (DSM-IV), with a naturalistic mix of comorbid diagnoses, nonsmokers, aged 8 to 17 years, whose behavioral and emotional symptoms (according to parents) were more disturbing than tics. After a washout period of all psychotropic medication, subjects were randomly assigned to either mecamylamine (n = 29) or placebo (n = 32). Mecamylamine doses ranged from 2.5 to 7.5 mg/day. Primary efficacy measures included the Tourette's Disorder Scale-Clinician Rated (TODS-CR) and 21-point Clinical Global Improvement scale; secondary efficacy measures included the Yale Global Tic Severity Scale and a rage-attack scale (RAScal).

RESULTS

Of the 61 subjects who were randomized, 50 (82%) completed at least 3 weeks on medication and 38 (62%) completed the full 8-week trial. Study withdrawals included 12/29 on mecamylamine and 11/32 on placebo. For the total sample, mecamylamine was no more effective than placebo on any of the outcome measures. However, an item analysis of the TODS-CR suggested that mecamylamine may have reduced sudden mood changes and depression in moderately to severely affected subjects. Except for a slight increase in heart rate during the 1st week in both the mecamylamine and the placebo groups, there where no significant mecamylamine-related changes in vital signs, electrocardiogram, complete blood cell count, or blood chemistry values.

CONCLUSIONS

Mecamylamine, in doses up to 7.5 mg/day, is well tolerated in children and adolescents, but as a monotherapy it does not appear to be an effective treatment for tics or for the total spectrum of symptoms associated with TD. However, further studies should be conducted to investigate its possible therapeutic effects in subjects with comorbid mood disorders and as an adjunct to neuroleptic medication.