Feasibility of pharmacotherapy in HIV-related affective spectrum disorders: an open trial with fluvoxamine

Among HIV patients treated for AIDS-related adjustment, major depressive disorders and other affective disorders, we assessed in an open study the feasibility of using a serotonergic antidepressant (fluvoxamine). Thirty-five seropositive patients with the above conditions (22 men and 13 women) were followed over a minimum period of four weeks. At the end of the treatment, a large number of patients (77%) showed marked improvement. “Nuclear” depressive and anxiety symptoms remitted, while the “somatic” ones seemed less sensitive to treatment. Treatment had to be terminated prematurely due to side effects in only two patients (6%).

Presence of serotonin1A (5-HT1A) receptor mRNA without binding of [3H]-8-OH-DPAT in peripheral blood mononuclear cells

The authors investigated the presence of serotonin receptor type 1A (5-HT1A) as labeled by the specific ligand 3H-8 hydroxy-2-(di-N-propylamino)tetralin (3H-8-OH-DPAT) in saturation experiments, and the expression of the mRNA encoding them, in human peripheral blood mononuclear cells (PBMC). In situ hybridization experiments were performed as well. The results, showing that the binding of [3H]-8-OH-DPAT to lymphocyte membranes increased linearly up to 100 nM without reaching saturation, may indicate that the 3H-8-OH-DPAT was not specifically labeling the 5-HT1A receptor. By contrast, the expression studies revealed 5-HT1A mRNA in PBMC. These findings suggest that, despite the presence of mRNA, 5-HT1A receptors are not expressed in PBMC, at least in healthy controls.

Long-term follow-up after a drug trial for panic disorder

BACKGROUND

This study investigates the naturalistic course of panic disorder over four years and attempts to identify predictors for outcome.

METHOD

423 DSM-III-R panic disorder patients who had taken part in an international multicentre drug trial were selected for follow-up; we were able to re-interview 367 (87%). For panic attacks, phobic avoidance and disabilities the same rating scales were administered as had been used for the clinical trials.

RESULTS

While 61% of all patients experienced at least occasional panic attacks at follow-up, few suffered from serious phobic avoidance (16.7%) or serious disabilities (work 7.9%); family 8.7%; social 13.9%). Panic attack frequency at baseline, original trial medication and continuous use of psychotropic medication during follow-up are not related to outcome, whereas longer duration of illness and more severe phobic avoidance at baseline are unfavourable.

CONCLUSION

The course of panic disorder is not uniform. Since long duration of illness and severe phobic avoidance at baseline are predictors for an unfavourable outcome, more rigorous efforts should be undertaken to detect and treat panic disorder at an early stage.

Phenomenology and neurobiology of cocaine withdrawal: are they related?

1. The presence of mood disturbances and platelet 3H-imipramine binding, a putative peripheral serotonergic marker, were evaluated in a group of 27 cocaine users three days after drug withdrawal. 2. Parameters of cocaine use and the linkage between cocaine withdrawal and "post-cocaine depression" were also investigated. In a subgroup of 10 patients, both psychopathological and biological measurements were repeated after 5 or 6 weeks. 3. Interpretation of the data by Pearson's analysis showed a statistically significant and positive correlation between Hamilton Rating Scale for Depression (HAM-D) scores and period of use. A trend towards a negative correlation, which however did not reach the statistical significance, was found between 3H-Imipramine binding and period of cocaine use, number of days of abstinence and HAM-D scores 4. When compared with normal volunteers at baseline, patients had significantly lower Bmax and Kd values which returned towards normal values after 5 or 6 weeks of cocaine withdrawal. 5. These results indicate the presence of a decreased platelet imipramine binding during cocaine withdrawal which may be due to the effect of the drug or alternatively, a result of concomitant depression which may be primary or secondary in origin. The decreased imipramine binding is a reversible phenomenon, since it increases with the time, in parallel with the improvement of depressive symptoms.

Na+ and Cl- net absorption by the isolated skin of Rana esculenta

In the last five years, several measurements of 22Na+ influx (Ji) and outflux (Jo) across symmetrical parts of the isolated skin of Rana esculenta, under permanent short circuitation, were performed in our Institute. The mean value of the 22Na+ net fluxes (Ji-Jo) exceeded the mean value of the short circuit current measurements (1.14 +/- 0.04 versus 0.98 +/- 0.02 microE.cm-2.h-1, 253 experiments). Since this discrepancy could be due to a concomitant Cl- net absorption, 36Cl- unidirectional fluxes were detected under similar experimental conditions. The Cl- net flux mean value was 0.11 +/- 0.02 microE.cm-2.h-1 (316 experiments) which accounts for 70% of the discrepancy between the Na+ net flux and short circuit current. This Cl- net absorption occurred in the absence of electrochemical gradients and was very likely maintained by a Na+/K+/2Cl- cotransport located at the outermost membrane of the epithelium. In fact bumetanide challenge (10(-5) M in the external fluid) strongly inhibited 36Cl- influx and 22Na+ influx across this tissue and cleared off the discrepancy between short circuit current and sodium net flux.

Effectiveness of the combination verapamil and chlorpromazine in the treatment of severe manic or mixed patients

1. The authors investigated the possible antimanic properties of a Calcium channel blocker, Verapamil, in 15 in-patients admitted consecutively to the female psychiatric ward at Pisa University for a manic episode. 2. The results showed that most of the patients presented a global improvement of the manic symptoms and, in some cases, even a complete clinical remission. 3. Although it was necessary to add chlorpromazine for the severe conditions of several patients, verapamil appeared to speed the positive outcome and to lead to a faster resolution of the symptoms. In addition, the association of verapamil and chlorpromazine did not produce any relevant side-effect. These preliminary findings thus indicate that verapamil by itself does not seem to be sufficient in the treatment of a severe affective episode, but it may constitute an alternative to lithium salts in association with neuroleptics.

Human platelet sulfotransferase shows seasonal rhythms

Our study aimed to investigate the possible presence of seasonal changes in platelet phenolsulfotransferase (ST) in a group of 20 healthy, drug-free subjects of both sexes between 24 and 37 years of age. Blood samples were taken four times a year in the period immediately following the equinoxes and the solstices. The results showed that both Sts underwent seasonal changes: the lowest values were found in autumn and in winter, and the highest in the summer. A positive correlation between the two STs and the length of the photoperiod was observed in winter whereas in the spring we detected a negative correlation between the TL ST and the photoperiod length. Future studies should clarify whether platelet ST of patients with mood disorders shows a similar seasonality.

Headache, panic disorder and depression: comorbidity or a spectrum?

Past epidemiological and clinical research has identified depression as the most common psychiatric disorder associated with headache. The present study carried out in a neurology headache clinic showed that the major associations were with current anxiety disorders, especially panic and related conditions. These findings were particularly true of the subgroup of migraine with aura; in the relatively few patients with mood disorders, depression was nearly always comorbid with panic or other anxiety disorders. Past history of depression was mainly a characteristic of the tension headache group. These data are compatible with the hypothesis that migraine, especially that with aura, panic disorder and some forms of depressive illness are part of the same spectrum.

Solubilization and characterization of [3H]imipramine and [3H]paroxetine binding sites from calf striatum

The serotonin (5-HT) transporter from calf striatum cerebral membranes was solubilized with digitonin and characterized by gel exclusion chromatography. [3H]Imipramine and [3H]paroxetine were utilized as markers for labeling it. 3H-imipramine labels a high- and a low-affinity site on striatum membranes, whereas it binds to a single high-affinity site on the solubilized fraction. [3H]Paroxetine binds with the same affinity to a single site on both membranes and solubilized preparations. After gel exclusion chromatography of the solubilizate both [3H]imipramine and [3H]paroxetine bind on an identical fraction of 205 kDa molecular weight, with a similar maximum number of binding sites (Bmax). Our results suggest that both 3H-imipramine and [3H]paroxetine bind to a common site on the 5-HT transporter.

Localization and gene expression of serotonin 1A (5HT1A) receptors in human brain postmortem

We investigated the binding parameters, i.e. the maximum binding capacity (Bmax) and the dissociation constant (Kd), of [3H]8-hydroxy-2-(di-N-propylamino)tetralin ([3H]8-OH-DPAT) labeling the serotonin receptor of the 1A type (5HT1A), and the distribution of the mRNA encoding it in some human brain areas obtained from autoptic samples. The results showed that the Bmax was significantly higher in the hippocampus than in the prefrontal cortex and the striatum, while the Kd had the inverse, although not significant, pattern. The expression study revealed that 5HT1A mRNA distribution in the hippocampus and prefrontal cortex was consistent with the data of the [3H]8-OH-DPAT binding. A different result was obtained in the striatum where no 5HT1A mRNA expression was detected, despite the measurement of specific [3H]8-OH-DPAT binding. These findings underline the different nature of [3H]8-OH-DPAT binding sites in different brain areas and the need for further studies on 5HT receptor gene expression in human brain.

Platelet 3H-imipramine binding and sulphotransferase activity in primary headache

We investigated platelet 3H-imipramine (3H-IMI) binding, a putative peripheral serotonergic marker, and the activity of sulphotransferase (ST), an enzyme involved in the catabolism of catecholamines and phenolic compounds, in 14 patients suffering from migraine without aura (MWoA) and in 10 with tension-type headache (TH), as compared with a group of controls. The possible relationships between the biological parameters and clinical features were also examined. The results showed that the two groups of patients had a lower number of 3H-IMI binding sites and a lower activity of the thermolabile form of ST, which acts preferentially on monoamine substrates, than the healthy controls, with no intergroup differences. Significant correlations between psychopathological rating scales and characteristics of the illness were observed in the patients with TH. The decreased number of platelet 3H-IMI binding sites is suggestive of a presynaptic serotonergic dysfunction and confirms the involvement of 5HT in primary headaches. The reduced ST activity might produce changes in the level of sulphated biogenic amines, including dopamine and tyramine, which might have an additional role in the pathophysiology of some aspects of primary headache.

Adverse effects associated with the short-term treatment of panic disorder with imipramine, alprazolam or placebo

Side effects play a significant role in the selection of drugs to be used in panic disorder/agoraphobia whose polyphobic symptomatology often includes a suspiciousness about taking drugs and a fear of undesired side effects which may lead to the refusal of treatment. The safety, side effects and patients' acceptance of alprazolam and imipramine versus placebo were evaluated in 1168 subjects with panic disorder/agoraphobia who had been enrolled in the second phase of the Upjohn World Wide Panic Study. Side effects that worsened over baseline to a greater extent with alprazolam than with imipramine and placebo were sedation, fatigue/weakness, memory problems, ataxia and slurred speech. In the imipramine group blurred vision, tachycardia/palpitations, insomnia, sleep disturbance, excitement/nervousness, malaise, dizziness/faintness, headache, nausea/vomiting and decrease in appetite were worse than in the other groups. In the placebo group the anxious symptoms were most prominent. The highest level of compliance was shown in the alprazolam-treated group and the lowest in the placebo-treated group. Strong predictors of side effects were not observed. If a side effect profile is known, it will be easier for a clinician to choose the right drug and the appropriate management by taking into account compliance, safety and efficacy in each patient under treatment. Further information about side effects in long-term maintenance treatment would be of great clinical pertinence in ensuring safety and enhancing patients' quality of life.

Age-related changes in peripheral benzodiazepine receptors of human platelets

Using 3H-PK 11195 as radioligand, the number and affinity of peripheral benzodiazepine receptors in platelets of 15 elderly healthy subjects were compared to those of 15 young subjects. The results showed that the dissociation constant (Kd) was significantly higher in the elderly than in the young subjects, while the density of binding sites did not differ. These findings suggest that the age-related changes in peripheral benzodiazepine receptors may be coupled with secondary changes in their hypothesized functions.

Action of capsaicin and related peptides on the ionic transport across the skin of Rana esculenta

Capsaicin at low concentrations increases the short circuit current (SCC) across frog skin. Simultaneous measurements of both transepithelial fluxes of 22Na or 36Cl demonstrate that the SCC increase is due to stimulation of sodium active absorption. Capsaicin acts through the liberation of several peptides; thus these peptides were tested on the SCC across frog skin. Those more active are, in order of potency: Cyclic Calcitonin Gene Related Peptide (CGRP), Kassinin and Eledoisin, Substance P (SP) and Neurokinin A. Neurokinin B and Vasoactive Intestinal Peptide (VIP) have no effect. Also the actions of SP and CGRP are due mainly to stimulation of Na+ active absorption. A strict parallelism regarding the sensitivity to inhibitors (Naproxen, SQ22536 and CP96345) between SP, CGRP and Capsaicin strengthens the hypothesis that SP and CGRP are liberated by Capsaicin in this tissue.

Changes in peripheral benzodiazepine receptors in patients with panic disorder and obsessive-compulsive disorder

Peripheral benzodiazepine (BDZ) receptors were investigated through the binding of the specific ligand 3H-PK-11195 to platelet membranes, in 17 patients suffering from panic disorder (PD) and in 16 patients affected by obsessive-compulsive disorder (OCD). The results, showing that the density (Bmax) of peripheral BDZ receptors was significantly lower in patients with PD than in controls or OC patients, suggest that the number of platelet BDZ receptors varies with different anxiety disorders and that perhaps this marker may be beneficial in differentiating some subtypes of these disorders.

Social adjustment in panic-agoraphobic patients reconsidered

Forty-eight depressed panic-agoraphobic patients--clinically matched for severity of depression with 35 primary chronic depressives--had significantly better adjustment in most areas of social functioning, especially those related to interpersonal contact, work, leisure activities, and sexual life. Even when depressed, panic-agoraphobic patients appear to possess sufficient interpersonal skills--that is, by learning on significant others--to engage in a range of social activities, both at home and beyond. These data, which are open to different interpretations, nonetheless suggest that anxiety and mood disorders differently affect certain key areas of social adjustment.

Affective comorbidity in panic disorder: is there a bipolar connection?

Although theoretical explanations for comorbidity in panic disorder (PD) abound in the literature, the complex clinical challenges of these patients have been neglected, especially where panic, obsessive-compulsive and 'soft' bipolar (e.g., hypomanic, cyclothymic and hyperthymic) conditions might co-exist. The aim of the present study has been to systematically explore the spectrum of intra-episodic and longitudinal comorbidity of 140 DSM-III-R PD patients--67.1% of whom concomitantly met the criteria for Agoraphobia--and who were consecutively admitted to the ambulatory service of the Psychiatric Clinic of the University of Pisa over a 2-year period. Comorbidity with strictly defined anxiety disorders--i.e., not explained as mere symptomatic extensions of PD--was relatively uncommon, and included Simple Phobia (10.7%), Social Phobia (6.4%), Generalized Anxiety Disorder (3.6%), and Obsessive-Compulsive Disorder (4.2%). Comorbidity with Major Depression--strictly limited to the melancholic subtype--occurred in 22.9%. Comorbidity with Bipolar Disorders included 2.1% with mania, 5% with hypomania, as well as 6.4% with cyclothymia, for a total of 13.5%; an additional 34.3% of PD patients met the criteria for hyperthymic temperament. We submit that such comorbid patterns are at the root of unwieldy clinical constructs like 'atypical depression' and 'borderline personality'. The relationship of panic disorder to other anxious-phobic and depressive states has been known for some time. Our data extend this relationship to soft bipolar disorders. Studies from other centers are needed to verify that the proposed new link is not merely due to referral bias to a tertiary university setting.

The pharmacologic treatment of depression: drug selection criteria

Currently, the pharmacologic treatment of depression is undergoing significant changes that are aimed not only at resolving the acute episode but also at preventing relapse and enhancing the quality of life once full remission is achieved. In addition, the clinical observation of soft residual symptomatology after "full-blown" episodes and of the features of post-depressive personality with severe long-lasting maladjustment has expanded the concept of chronicity and duration in mood disorders. Developing a treatment strategy entails diagnosing the specific subtype of depression, establishing a threshold for initiating pharmacotherapy, and selecting an effective and safe antidepressant. Both the clinical features of the presenting episode and the longitudinal aspects of the mood disorder are relevant when one is defining subtypes of major depression. In 1989, the Pisa-Memphis Collaborative Study, which focused on patients presenting with a major depressive episode, clarified the role of soft indicators of bipolarity in defining subtypes of major depression. Combining a cross-sectional with a longitudinal evaluation can provide guidelines for choosing the most appropriate drug for a depressive episode that is often part of a comorbid condition. When selecting a pharmacologic treatment for the depressed patient, the physician must consider a number of factors, including, but not limited to, efficacy and safety. Although research has demonstrated that tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), atypical antidepressants, and selective serotonin reuptake inhibitors (SSRIs) are of comparable efficacy in patients with severe depression, SSRIs should be considered the agents of first choice for patients with comorbidity and chronicity, adolescents and young adults, and the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

Social class and mood disorders: clinical features

We examined clinical features in 877 in- and outpatients affected by depression who were enrolled in psychopharmacological trials, subdivided according to Hollingshead's method into five social classes. The results showed that social class correlated significantly with the subtypes of mood disorders, with bipolar disorder being more frequent amongst the upper than the lower social classes. Furthermore, as already reported in other countries, social class appeared to influence the psychopathological pattern of depressive symptoms: somatization and anxiety were more frequent amongst the lower social classes, while psychic and cognitive symptoms were more common amongst the upper classes.

A single electroconvulsive treatment affects platelet serotonin uptake in bipolar I patients

We evaluated serotonin (5HT) uptake parameters in platelets of a group of bipolar I patients in both a depressive phase and a mixed state, before (t0) and after (t1) the first electroconvulsive treatment (ECT). The results showed the presence of significant changes in the number of the carrier proteins for 5HT at t1, which in most cases preceded the clinical improvement. Although other mechanisms are certainly involved, these data suggest that ECT may influence the 5HT transport through platelet membranes.

Single episode of major depressive disorder. First episode of recurrent mood disorder or distinct subtype of late-onset depression?

Of 687 consecutive inpatients and outpatients with primary major depressive illness, 213 (31%) were categorized as single episode (SE) by DSM-III-R criteria. Systematic evaluation of familial, sociodemographic, temperamental and symptomatological characteristics permitted the nearly equal division of SE into two categories: a. early-onset (< 45 years) "first episode" superimposed on either depressive or hyperthymic temperaments (against a bipolar and unipolar familial background), more severe depression, higher rates of suicide attempts, greater anxiety-somatization and psychotic tendencies, and with the potential for recurrence; b. late-onset (> or = 45 years) isolated episode (against an unipolar familial background) with greater life stressors, pursuing a protracted course with less likelihood of recurrence. In most other respects, early-onset SE was intermediate between recurrent major depression and late-onset SE. The implications of these findings for the now largely abandoned category of "involutional melancholia" are discussed.

Double-blind study of the efficacy and safety of sertraline versus fluoxetine in major depression

An eight-week double-blind, multicentre study was performed to evaluate the efficacy and safety of sertraline vs. fluoxetine in the treatment of major depression (DSM-III-R). There were 108 out-patients, from nine Italian centres, entered into the study, of whom 88 were evaluable (48 sertraline, 40 fluoxetine). The final mean daily dose of sertraline was 72 mg and for fluoxetine it was 28 mg. Both treatment groups showed a statistically significant improvement from baseline at one week, and this was maintained until the end of treatment for all of the following measures: Hamilton Rating Scales for Depression and Anxiety, the Montgomery Asberg Depression Rating Scale, Clinical Global Impressions Scale, Zung Self-Rating Scale for Anxiety and the Leeds Sleep Evaluation Questionnaire. Although there was a numerical advantage for sertraline on several efficacy measures, there was no statistically significant difference found between the treatment groups. The incidence of adverse events was similar for both treatments; 40.4% for sertraline and 39.3% for fluoxetine. However, adverse events were generally rated by patients as of lower severity in the sertraline group. In addition, for the fluoxetine group, there was a higher incidence of agitation, anxiety and insomnia than for sertraline. Sertraline was considered to be better tolerated than fluoxetine overall, since only 9.6% of sertraline-treated patients discontinued treatment due to therapy failure whereas in the fluoxetine-treated group this figure was 19.6%. By contrast, 13.5% of sertraline-treated patients discontinued prematurely because of clinical improvement, compared with 10.7% of fluoxetine-treated patients.

Psychotic and nonpsychotic bipolar mixed states: comparisons with manic and schizoaffective disorders

We studied 259 female inpatients with bipolar spectrum disorders, of whom 26 (10%) were schizoaffective. Of the remaining 233, 61 (27%) met our conservatively set criteria for index mixed episodes (simultaneous presence of depressive and manic syndromes). These patients with rigorously defined mixed states were, in turn, about equally divided between psychotic and non-psychotic subgroups. The psychotic mixed patients (n = 32) were closer to the bipolar I pattern, and more often seem to come from a familial background of psychotic mood disorders; the nonpsychotic mixed patients (n = 29) conformed more closely to the bipolar II pattern, and more often had a hyperthymic and cyclothymic temperament and a family background of non-psychotic disorders and substance abuse. A three-way comparison between psychotic manic (n = 24), psychotic mixed (n = 32), and schizoaffective (n = 26) patients revealed few significant differences in temperamental, familial and course patterns. As expected, psychotic manic patients more often arose from a hyperthymic base and pursued a predominantly manic course; psychotic mixed patients were less likely to arise from such a base and more likely to pursue a mixed course. Finally, schizoaffective had earlier age at onset and longer duration of illness, suggesting that these patients had a more severe illness. Otherwise, interepisodic social adaptation was comparable in the three psychotic groups. The findings overall suggest that the presence of psychosis had relatively little impact on mixed states, which appear more based on temperamental characteristics.