Minaprine: an anticholinergic-free antidepressant? Results of a controlled trial of mianserin

Minaprine is an amino-phenylpyridazine antidepressant reported to be relatively free of anticholinergic effects, cardiotoxicity, drowsiness, and weight gain. Minaprine (100 mg t.d.s. and 100 mg b.d.) was compared with mianserin (20 mg t.d.s.) in 117 depressed patients, and all three regimes produced significant reductions in scores on the HRSD at the end of six weeks' treatment. There were no anticholinergic effects, but there was a significantly greater incidence of drowsiness with mianserin than with minaprine.

Arnold-Chiari malformation: a diagnostic challenge

Arnold-Chiari malformation is a disorder of embryologic development. In Type I, there is cerebellar displacement into the spinal canal, but hydrocephalus and syringomyelia are variable. Type II usually is manifested by severe hydrocephalus and myelomeningocele in infancy. Type I malformations may pose diagnostic challenges because they often produce bizarre and vague symptoms. A careful history and physical examination, coupled with neurologic testing, especially magnetic resonance imaging, will lead to the correct diagnosis.

New hypnotic agents: clinical studies in general practice

The type of sleep problem should be determined so that the most appropriate hypnotic can be used, and in this respect duration of action is an important property. The benzodiazepine hypnotics are adequate for this purpose, but problems may arise due to daytime after-effects and the possibility of dependence developing. Non-benzodiazepine hypnotics may be useful alternatives and our group has undertaken double-blind comparative trials with two such compounds, namely zopiclone and zolpidem. Zopiclone was compared to temazepam in a cross-over trial on 36 patients and similar hypnotic effects were recorded. In a parallel group study, zolpidem 10 mg was compared to zolpidem 20 mg and placebo in 88 patients. Both doses of zolpidem were significantly better than placebo on a number of the parameters recorded, side-effects were negligible and there was no evidence of any rebound insomnia during the final control week.

Use of anti-anxiety drugs in the medically ill

The Stress Clinic at the Maudsley Hospital investigates anxiety due to stress and its pharmacological treatment. Nine stress areas are investigated and their relative severities estimated: social habits, social relationships, life events, psychiatric morbidity, sexual stresses, sleep, stress in old age, menstrual stresses and stress and the heart. From the results a Stress Profile can be constructed for each patient to compare the importance of these different stresses and this can also be used as a measure of change in response to treatment. The benzodiazepine (BZD) anxiolytics can be divided into two groups according to duration of action, medium (8-12 h) and long (30-100 h). Short-acting BZD drugs are particularly useful for situational anxiety, when treatment can be interrupted over night and at weekends. To overcome problems of dependence, withdrawal effects, and daytime side-effects, new non-BZD anxiolytics have been developed: buspirone, alpidem and suriclone. These may be particularly useful for long-term treatment of anxiety. Another alternative is the use of adrenergic beta-blocking drugs of which propranolol and betaxolol have been used in the Clinic, because of their relatively high concentration in the brain when taken orally. Anxiety accompanying coronary heart disease and hypertension can be controlled with anxiolytic drugs and other illnesses with an anxiety component are: sexual disorders, menstrual disorders, asthma, gastro-intestinal conditions, dermatological conditions and chronic illnesses such as malignancy and AIDS. Lack of sleep is a subtle form of stress exerting an adverse effect in almost every illness known to man. BZD hypnotics can be divided into four groups: ultra-short-acting (3-4 h), short-acting (5-6 h), medium-acting (7-8 h) and long-acting (9-12 h). Depending on the nature of the insomnia, ultra-short-acting and short-acting BZD are particularly convenient with minimal disadvantages. Nevertheless, new non-BZD hypnotics are also being developed, i.e. zolpidem and zopiclone. These drugs are relatively short-acting and of equivalent potency to the BZD without problems of dependence etc. Anxiety, as either cause or effect, accompanies many medical illnesses and the use of anti-anxiety drugs as concomitant therapy can both reduce morbidity and improve prognosis.

Interpreting significance in an antidepressant drug trial

In a clinical trial to compare two antidepressants, mianserin and dothiepin, the Last Visit Carried Forward (LVCF) analysis was used for the statistical tests. By this method, no significant differences were demonstrated between the antidepressant response of each drug, as measured by the Hamilton Depression Scale. Statistical significance (or lack of it) does not necessarily correlate with clinical significance and, since antidepressant drugs usually take 10-14 days to exert any effect, a further analysis was undertaken excluding patients who completed less than 2 weeks of the trial. This further analysis then demonstrated a statistically significant difference in favour of mianserin (p less than 0.05). In designing statistical analysis for clinical drug trials, it is important to take into account the therapeutic characteristics of the drugs under trial.

Insomnia in general practice: the role of temazepam and a comparison with zopiclone

The aetiology of insomnia can be conveniently divided into six groups: physical (pain, cough, etc.), physiological (shift-workers etc.), psychological (life events), psychiatric (depression, anxiety, etc.), iatrogenic (stimulant drugs, etc.) and idiopathic (no obvious cause). The four main types of insomnia are: prolonged latency, frequent short awakenings, one or two long awakenings and early morning awakening. Patients' habits that may interfere with sleep are related to: alcohol, smoking, tea and coffee drinking, and bedtime drinks. In a double-blind comparison between temazepam and nitrazepam, both drugs were shown to be effective hypnotics, nitrazepam being better for early morning wakening, although at the expense of more hangover effects. Zopiclone, a new cyclopyrrolone hypnotic, was also compared to temazepam in a double-blind cross-over trial and similar hypnotic effects were recorded with both drugs.

Brotizolam: a new short-acting hypnotic

A new short-acting thieno-diazepine compound, brotizolam, has been compared to nitrazepam in a double-blind trial. Following an initial 3-day control period with no treatment, insomniac patients were allocated to 2 weeks treatment with one or the other drug according to random selection. This was then followed by a further 3-day no-drug control period. Morning and evening questionnaires were used to assess various sleep parameters and possible daytime "hang-over" effects. The patients also made actual records of the periods awake during the night (somnography). Highly significant effects were shown for both drugs in comparison to both control periods, in relation to all of the sleep parameters. However, no significant differences from either control period were demonstrated for either drug on the daytime measures, with the exception of how the patients felt at work with brotizolam and how they felt with others on nitrazepam, on both of which measures the patients felt better whilst on the drug. Comparing the figures between the initial and final no-drug control periods, did not reveal any evidence to suggest a rebound effect with either drug.

A comparison of diltiazem and atenolol in angina

Diltiazem was compared to atenolol in a double-blind trial involving 78 patients suffering from coronary heart disease. Following a 2 week control period, patients were randomly allocated to 6 weeks treatment with one or the other drug. The patients themselves made daily records of anginal attacks, trinitrate requirements, well-being and exercise tolerance. With both drugs there were highly significant reductions in the anginal attack rate and trinitrate requirements, and significant improvement on the other measures. However, there were no significant between drug differences. The incidence of side effects with diltiazem was very low and no patient had to omit treatment for this reason, although three patients did so on atenolol.

Pressure sores and paraplegia: an experimental model

An investigation into the effect of spinal cord transection on pressure sore development is presented and the critical importance of soft tissue atrophy is examined. A technique of spinal laminectomy and spinal cord transection was developed in pigs and shown to have a minimal morbidity rate. Following tissue atrophy, pressure was applied to the paraplegic animals for varying durations. Pressure application was achieved by a computer-controlled application system. The experimental model produced pressure sores extending down to the bone. The resulting tissue damage was assessed, graded, and a pressure-duration curve for paraplegic animals established.

Zopiclone: a non-benzodiazepine hypnotic. Controlled comparison to temazepam in insomnia

Zopiclone, a non-benzodiazepine hypnotic, was compared with temazepam in the treatment of 36 patients suffering from insomnia; the trial period was two weeks, with cross-over of medications at one week and a randomised order of administration. There were highly significant improvements with both drugs, as compared to the control period in respect of: sleep latency, number of times waking during the night, and quality and duration of sleep. The incidence of side-effects was very low. No significant between-drug differences were found in respect to any of the assessment measures or of the incidence of side-effects.

Psychological stress and cardiovascular diseases

Mental stress may directly influence coronary heart disease (CHD) and also a number of its etiologic risk factors. Research work carried out by the Psychopharmacology Research Group in the United Kingdom indicates that antianxiety drugs may have an application in the management of the stress factors influencing CHD. In one study there was a significant reduction in the glyceryl trinitrate requirements of patients treated with a tranquilizer, but this result was not confirmed in two other studies. However, out of a total of 77 patients treated with a placebo, there were five cases of myocardial infarction during the trial periods as compared to no such cases among 81 patients treated with the antianxiety drugs.

Azapropazone in arthritis: a long-term treatment

A long-term open assessment of azapropazone (900 mg to 1200 mg daily) was carried out in 51 patients suffering from osteoarthritis for periods of up to 1 year. Of these patients, 70% completed 9 to 12 months of treatment. Clinical assessments were made before and during the study of pain on motion or weight bearing, night pain, functional activity, morning stiffness, doctor's overall assessment, patients' overall assessment, and details of side-effects recorded. There were statistically significant improvements in the mean rating scores for each of the clinical assessments and these became apparent at 1 month, maximal at 3 to 6 months and persisted at the same level to the end of the trial. There were no side-effects recorded at any period of the trial in 30 (59%) patients. When side-effects did occur they were mild in 12 (24%), moderate in 3 (6%) and severe in 6 (12%) patients. The most frequent side-effects were related to the gastro-intestinal tract and gastric pain occurred in 7 (14%) patients, whilst rash or eczema occurred in 4 (8%) patients. It was concluded that, for the patients in the trial, long-term treatment with azapropazone was a useful and effective procedure.

Studies in general practice with brotizolam

Brotizolam (0.25 mg) was compared with placebo, and in a separate study, with nitrazepam (5.0 mg) in patients being treated for insomnia in general practice. Brotizolam (0.25 mg) and nitrazepam (5.0 mg) were equally effective and there was no evidence of residual effects the next day with either drug.

Buspirone: multicenter efficacy study

The efficacy and safety of buspirone (Buspar), diazepam (Valium), and placebo were compared in a 3-week double-blind study of 131 patients with scores of at least 15 on the Hamilton Rating Scale for Anxiety. Active drugs were administered orally in 5-mg tablets to a maximum dose of 10 mg t.i.d. Buspirone was given to 43 patients, diazepam to 46 and placebo to 42. There was significant improvement in all three treatment groups at 1 and 2 weeks, with further significant improvement with both active drugs, but not with placebo, at 3 weeks. The incidence of side effects reported voluntarily by patients was similar with the two active drugs, but drowsiness was significantly more frequent with diazepam.

A new weight-reducing drug with novel properties

Ciclazindol, a tetracyclic compound originally developed as an antidepressant, was compared to placebo in a double-blind trial involving 114 individuals who were at least 15% overweight. Following a one week control period patients were allocated to active or placebo groups by random distribution for a period of 4 weeks and this was followed by a final one-week observation period.

The mean weight loss of 47 patients who completed the trial on ciclazindol was 6·95 lbs (3·13 kg) and of 48 patients who completed the trial on placebo it was 5·0 lbs (2·25 kg) a difference which is statistically significant in favour of ciclazindol (P < 0·05).

The trial demonstrated a marked placebo effect resulting in loss of weight in these patients, but the drug effect was significantly greater.

Analgesic properties of fluproquazone

Fluproquazone, a new analgesic, was compared to a dextropropoxyphene hydrochloride and paracetamol combination (Cosalgesic) in a single blind trial lasting for five days. The trial included cases of various soft-tissue lesions and osteoarthrosis. Treatment was given to 170 patients, 84 of whom received fluproquazone and 86 the combination analgesic. The patients themselves made daily records of the severity of pain on a 100 mm visual analogue scale and in both treatment groups there was highly significant relief of pain, but with no significant differences between them. However, the incidence of side-effects was significantly higher with dextropropoxyphene hydrochloride-paracetamol (30%) than with fluproquazone (9%).