A double-blind study comparing paroxetine and maprotiline in depressed outpatients

A double-blind multicenter randomized parallel group study comparing paroxetine and maprotiline was carried out in a total of 544 outpatients. Included were patients with varying degrees of severity of depressive symptoms who fulfilled modified RDC criteria for either Minor or Major Depression and showed a HAMD-17 score of > or = 13. No concomitant benzodiazepine treatment was allowed. Duration of treatment was 6 weeks, after an initial wash-out period. Doses were fixed during the first 3 weeks of treatment, patients receiving either 20 mg paroxetine or 100 mg maprotiline daily. An option for dose escalation was provided for insufficient responders after 3 weeks. The weekly assessments comprised rating of the HAMD-17, MADRS, BRMS, RDS, HAMA, CAS, and CGI scales and registration of adverse events by non-leading questions. An intention-to-treat and a completer analysis were performed. Response was defined as a HAMD-17 reduction of > or = 50% or a HAMD-17 score of < or = 9 at the end of the study or at dropout. The treatment groups were comparable according to demographic data. Overall evaluation indicated equieffective and good antidepressant and anxiety-reducing properties for paroxetine and maprotiline. No persistent significant differences between treatment groups were observed on any assessment instrument. There was no difference in the frequency of observed side-effects, but side-effect profiles were markedly different, as maprotiline patients had more anticholinergic and paroxetine patients more SSRI-typical side-effects.

Dose escalation vs. continued doses of paroxetine and maprotiline: a prospective study in depressed out-patients with inadequate treatment response

In view of the fact that controlled prospective studies on the benefits of dose escalation of the selective serotonin re-uptake inhibitor (SSRI) paroxetine are lacking, we conducted a double-blind, randomized, parallel-group multicentre study designed to compare the possible benefits of dose escalation of paroxetine and maprotiline in patients suffering from major or minor depression according to modified Research Diagnostic Criteria (RDC) with inadequate treatment response. The study sample consisted of 544 out-patients with different degrees of severity of depression. Patients received either 20 mg paroxetine (n = 271) or 100 mg maprotiline (n = 273) for the first 3 weeks in a double-blind manner. Response after 3 weeks was defined using explicit operationalized criteria. Patients with inadequate treatment response (paroxetine group, n = 86; maprotiline group, n = 88) were again randomized to either continuation of the previous dosage (paroxetine, n = 36; maprotiline, n = 48) or increased doses, i.e. 40 mg paroxetine (n = 50) or 150 mg maprotiline (n = 40), respectively. Intention-to-treat and completer analyses were performed. Defining response as a reduction in Hamilton Depression Rating Scale (17-item version) (HAMD-17) score of at least 50% from baseline, no significant benefits of dose escalation were found for either paroxetine or maprotiline. Stratification according to baseline severity of depression also revealed no significant benefits of dose escalation. After dose escalation, new adverse events that had not been present during treatment with lower doses rarely occurred. Our results support the view that a dose of 20 mg paroxetine is optimal for the acute treatment of depression in the majority of patients.

Guidelines for the implementation of drug utilization observation (DUO) studies in psychopharmacological therapy. The "Phase IV Research" Task-Force of the Association for Neuropsychopharmacology and Pharmacopsychiatry (AGNP)

The task-force on Phase-IV-Research of the Association for Neuropharmacology and Pharmacopsychiatry (AGNP) has developed guidelines for the implementation of scientifically sound drug utilisation observation studies (DUO studies). These guidelines have been adopted by the executive committee as the position of the association. DUO studies are prospective pharmacoepidemiological studies, by which prescription, illness, and patient data of individual patients are collected without interference with the routine course of treatment. They can answer questions on the interaction of treatment modalities with positive and negative treatment outcome. Scientific standards require that there is a study protocol which describes the epidemiological, statistical, procedural, and quality assurance methodology and states who is responsible for what. As such studies can violate data protection regulations or can be used for sales instead of scientific purposes, consultation of an ethics committee is recommended.

Primary enduring negative symptoms in schizophrenia and major depression

Primary enduring negative symptoms (PENS) were studied in 26 patients with DSM-III-R schizophrenia and in 94 patients with unipolar major depressive episodes 5 years after the index episode. PENS were assessed with the Schedule for Deficit Syndrome (SDS). Negative symptoms were also assessed with the Scale for Assessment of Negative Symptoms (SANS) and subclassified into primary and secondary according to the SDS. The frequency of PENS did not differ significantly between schizophrenics and non-schizophrenic patients. Enduring negative symptoms (regardless of whether primary or not) were more frequently observed in schizophrenia (65% according to the SDS, and 88% according to the SANS) than in patients who had major depressive episodes (29% according to the SDS and 32% according to the SANS). By applying the SDS criteria for PENS, their frequency decreased in a manner which would probably affect the availability of patients samples for testing antinegative drugs. The results suggest that neither the negative symptomatology nor the primary enduring subtype ("deficit") is specific for schizophrenia. This finding might imply potential advantages of non-nosological, functional approaches for research into PENS.

[Pharmacotherapy of anxiety disorders]

Many out-patients suffer from anxiety disorders which can be diagnosed and treated pharmacologically by the family doctor. In a study of our own, including 500 outpatients with actual complaints being not sufficiently explainable by physical findings, we could diagnose anxiety disorders according to DMS-III-R in 21% of the cases (9). Knowing the basic diagnostic rules, which differentiate between the different types of anxiety disorders, a differential and rational treatment with benzodiazepines, antidepressants and neuroleptics is possible. Knowing the typical risks, applying the correct rules of indication, and accepting the counselling of a psychiatrist when necessary, the family doctor will be able to undertake a qualified primary pharmacological treatment of anxiety disorders.

The deficit syndrome in schizophrenic and nonschizophrenic patients: preliminary studies

One hundred and eighty-seven patients suffering from DSM-III-R schizophrenia, schizoaffective, schizophreniform (psychotic group), unipolar, bipolar and other disorders were interviewed 5 years after discharge. Deficiencies were assessed by means of the Schedule for Deficit Syndrome (SDS) and the Scale for Assessment of Negative Symptoms (SANS). Binocular thresholds for discomfort to high luminances (TDHL) were assessed in 17 patients with a deficit syndrome. Results suggest that patients with psychotic disorders are in a high-risk group for deficit syndrome. Nevertheless, 9-28% and 9-30% of the 'nonpsychotic' group according to the SANS and the SDS, respectively, showed primary enduring negative symptoms. A positive correlation between the SANS total score and TDHL (r = 0.81) was found. These results suggest the nonspecificity of primary enduring negative syndromes. Furthermore preliminary data indicate a possible link between light sensitivity and the deficit syndrome, independently of diagnoses.

[Minor depression--how useful and valid a diagnostic concept]

Recent classification research has shown, that there is a great number of mildly depressed patients, who do not fit into the more severe diagnostic criteria of major depression. We therefore asked whether it is necessary to introduce a diagnostic category of minor depression below that of major depression. Using a large outpatient sample, we studied whether such a diagnosis of minor depression would reach sufficient validity according to a variety of independent validation criteria. The results were not very convincing. We therefore discuss alternative definitions of mild depression.

Subtypes of negative symptoms: the primary subtype in schizophrenic and non-schizophrenic patients

1. The specificity of negative symptoms remains an open question and requires further research. 2. Subtyping negative symptoms has been showed to be a very relevant point for the identification of primary negative symptoms and for their pharmacotherapy. Negative symptoms as a whole have been demonstrated in schizophrenic and non-schizophrenic patients, but these studies did not report about the primary and secondary subtypes. 3. The present study is the first one investigating primary negative symptoms in schizophrenic and non-schizophrenic patients. 84 consecutively admitted psychiatric patients have been studied 5 years after their discharge. 4. All negative symptoms (including the primary subtype) according to Carpenter (Kirkpatrick et al. 1989) and Andreasen (Andreasen 1981) could be identified in all diagnostic groups.

[Modification of sexual functions by antidepressants]

Sexual dysfunctions appear to be frequently occurring adverse events in treatment with antidepressants. Due to methodological reasons, a reliable estimation of the frequency of such events is currently not yet possible. There is evidence, that antidepressants could be differentiated with respect to their potency and specificity for disturbances of certain sexual subfunctions according to their pharmacological profile. With SSRIs in particular impaired functions of orgasm and ejaculation can be observed. No deteriorations are reported for buproprion and an improvement of sexual dysfunctions within the course of treatment for moclobemide. Viloxazine and trazodone appear to possess marked stimulating effects on libido and erectile functions. Generally the incidence of sexual adverse events is underestimated, although there is a pronounced impact on patient compliance. Taking into account this well documented side effect, sexual impairments should be monitored carefully within antidepressive treatment.

Psychotropic drugs in the management of chronic pain syndromes

Psychotropic drugs have been integrated into the management of chronic pain syndromes for more than 30 years. Numerous open and controlled studies have taken place evaluating especially the antinociceptive efficacy of antidepressive drugs. This survey comprises the results of clinical reports, open clinical studies, placebo-controlled studies, and comparative studies of different substances. It will be shown that antidepressants are by far the best evaluated psychopharmacological substances, showing superiority against placebo in 70% of a total of 67 placebo-controlled studies. The synopsis of controlled comparison studies of different antidepressants tends to demonstrate a superiority of clomipramine; however, the number of comparative studies is too small to draw final conclusions, especially because a number of methodological shortcomings reduce the comparability of different studies. The literature is concerning the pharmacological mechanisms and the interaction of antidepressive and antinociceptive effects of antidepressants is reviewed. Finally, treatment guidelines are formulated, which summarize the recommendations of the international literature.

Benzyloxycarbonyl-D-Phe-Pro-methoxypropylboroglycine: a novel inhibitor of thrombin with high selectivity containing a neutral side chain at the P1 position

Thrombin, the blood-clotting enzyme, is a serine proteinase with trypsin-like specificity and is able to cleave Arg-Xaa peptide bonds but only in a very limited number of substrates (and sites therein). For the prevention and treatment of thrombosis the control of thrombin activity is a key target, and a variety of synthetic inhibitors have been introduced recently, all of which have a positive charge at the P1 site. We report the synthesis of the first example of a new class of inhibitor containing a neutral side chain at the P1 site, the peptide benzyloxycarbonyl-D-Phe-Pro- methoxypropylboroglycine. The peptide is a potent inhibitor of thrombin [Ki (limiting) = 7 nM] and is highly selective for its target enzyme in respect of other serine proteinases. This may be expected to confer considerable advantage in terms of specificity of action and reduced toxicity over conventional, positively charged, inhibitors.

A comparison study of moclobemide and doxepin in major depression with special reference to effects on sexual dysfunction

A double-blind parallel-group comparison study of moclobemide versus doxepin in 237 patients with major depression confirmed that moclobemide was equal in efficacy and better tolerated than doxepin. It was less sedating and caused fewer anticholinergic adverse events as measured by the UKU side-effect rating scale. Unexpectedly, moclobemide therapy more often than doxepin resulted in increased sexual desire. An exploratory analysis of UKU-measured symptoms of impaired sexual function prior to commencement of the study revealed that moclobemide more often than doxepin led to an improvement of reduced libido and impaired erection, ejaculation and orgasm. This finding is compatible with the assumption that there is a greater likelihood that the anticholinergic reuptake inhibitor doxepin has a higher risk of impairing sexual function than the non-anticholinergic RIMA moclobemide. A single case report of moclobemide-induced sexual hyperarousal supports the alternative assumption that moclobemide has a specific sexually stimulative effect in depression.

Nimodipine in acute alcohol withdrawal state

The effect of the calcium channel blocker, nimodipine, in acute alcohol withdrawal was investigated in a randomized, placebo controlled, double blind study. Thirty-two male patients with a history of alcohol dependence according to DSM-III criteria, but no other substance abuse, were included. A new rating instrument which fulfilled theoretical test criteria was applied to determine the severity of the alcohol withdrawal state. The patients received nimodipine or a placebo on four separate occasions (4 x 60 mg) and, in addition, clomethiazole, according to a standardized procedure. Our investigation has shown that, in the first 48-72 h of alcohol withdrawal, both groups consumed similar amounts of additional clomethiazole medication. Thus, no significant effect of nimodipine on the acute alcohol withdrawal state could be demonstrated. There was some tendency for nimodipine to ameliorate psychosensory dysfunction.

Brugia malayi: patterns of expression of surface-associated antigens

Patterns of expression of surface-associated antigens were analyzed in the filarial nematode Brugia malayi immediately prior, and during development in the vertebrate host. Two surface-associated protein molecules, i.e., accessible to surface radioiodination and soluble in aqueous buffers, were investigated: Mrs 29-30,000 and 16,000, both of which are antigenic in infected animals. The Mr 29-30,000 glycoprotein is expressed in a surface-associated manner by adult worms and by fourth-stage larvae, but is not detectable in preparasitic third-stage larvae. The 16,000 component, which appears not to be glycosylated, is surface-associated in adult worms and fourth-stage larvae. In contrast to the 29-30,000 glycoprotein, the 16,000 protein is also expressed both by pre- and postparastic third-stage larvae. However, it becomes surface-associated only after infection. Thus, immediately prior, and during development within the vertebrate host, B. malayi displays at least two different patterns of expression of surface-associated antigens: (i) de novo, intiated either immediately after infection (phase specific) or during genesis of the fourth-stage larva (stage specific); (ii) continuous, but with phase-dependent surface exposure of previously cryptic antigens, during the transition from intermediate to definitive host.

Development of a rating scale for quantitative measurement of the alcohol withdrawal syndrome

The alcohol withdrawal syndrome consists of autonomic, neurological and mental symptoms. For its assessment, these symptoms have to be rated in a quantitative and valid manner. We developed a new rating scale for mild and moderate alcohol withdrawal states. Difficulty, discrimination coefficient, internal consistency, and the principal component analysis were assessed. External validation was tested on a separate sample of inpatients. Eight of 12 original items fulfilled test-theoretical criteria. From these a psychosensory and an autonomic factor have been extracted. This instrument can be used repeatedly for clinical assessment as well as for evaluation of the alcohol withdrawal syndrome in clinical drug studies.

Differentiation between major and minor depression

Though the concept of Major Depression was generated by clinicians using depressed inpatients as models, a polydiagnostic study in 600 psychiatric inpatients with heterogenous psychological disturbances revealed that all six competing operational definitions of Major Depression (including DSM-III-R and ICD-10) were too restrictive to serve as a general concept of depression. Another polydiagnostic study in 500 primary care outpatients showed that more than two-thirds of all non-chronic depressed cases were below the severity threshold of Major Depression: these patients are classified as Depression Not Otherwise Specified (NOS) by DSM-III-R. Loosening of the over-restrictive time criteria would broaden the concept of Major Depression so as to meet the requirements of a general concept of depression, while the definition of Minor Depression below the threshold of Major Depression would add to a reduction of cases of NOS Depression by more than 80%. For the evaluation of antidepressant drugs in outpatient samples, we propose that patients with these modified definitions of Major and Minor Depression be included, provided they meet a minimum severity criterion of 13 or more points on the Hamilton Depression Scale; four-fifths of the modified Major Depression group and one-third of the Minor Depression group do in fact meet this criterion.