Nefazodone in the treatment of elderly patients with depressive disorders: a prospective, observational study

OBJECTIVES

The aim of this study was to evaluate the clinical effectiveness and tolerability of nefazodone for the treatment of depression in elderly patients in clinical routine practice.

PATIENTS AND STUDY DESIGN

Seventy-nine patients with a mean age of 72.81 years, who had major depression or dysthymia according to DSM-IV criteria, were enrolled into this open label study. Patients were prescribed nefazodone starting at 50 mg/day, increasing every 4 days until a dosage of 200 mg/day was attained, and subsequently upward to 600 mg/day if no dose-limiting adverse effects appeared. Effectiveness was evaluated at the end of weeks 2, 4, 8 and 12 by completion of the Hamilton Depression Rating Scale (HAM-D), the Geriatric Depression Scale (GDS) and the Clinical Global Impressions scale. The Hamilton Anxiety Rating Scale (HAM-A), the sleep satisfaction item of the Oviedo Sleep Questionnaire (OSQ) and the Short Portable Mental Status Questionnaire (SPMSQ) were used to assess the patients at the end of week 12. Primary efficacy analysis was based on an intention-to-treat, last-observation-carried-forward data set.

RESULTS

HAM-D scores decreased progressively from a baseline mean of 22.3 to 14.2 at the study endpoint; although this was a significant reduction, the endpoint score indicates that a significant residual symptomatology remained in the patients. Similarly, the GDS and HAM-A scores had decreased significantly by week 12. Response and remission rates were 47 and 37.5%, respectively. The percentage of patients who were satisfied, much satisfied or very much satisfied with their sleep according to the OSQ increased from 4.2% at baseline up to 62.2% at the study endpoint. A significant reduction in the SPMSQ total score was observed at the study endpoint, although the clinical relevance of this finding is doubtful. Forty-two (53.2%) patients completed the study. The most common reasons for withdrawal from the study were a lack of efficacy and adverse effects. Most adverse reactions were mild to moderate in severity and included dizziness, dry mouth, gastrointestinal distress, sedation, anxiety and malaise.

CONCLUSION

Our results suggest that nefazodone may be a well tolerated and effective alternative for treating elderly patients with depression. Although the HAM-D score at study endpoint indicated significant residual symptomatology, a similar finding has been described in several meta-analyses of antidepressant treatment in the elderly. Further research is needed to evaluate a different nefazodone dose regimen, especially a slower dose titration rate, which could result in a reduced discontinuation rate and thus a better treatment outcome.

Depression and anxiety symptoms in relation to anthropometry and metabolism in men

Depression is associated with an increased risk of developing cardiovascular disease and type 2 diabetes mellitus. Abdominal obesity is also a high risk factor for these diseases. Therefore, symptoms of depression and anxiety were examined in relation to abdominal obesity. A total of 59 middle-aged men volunteered for measurements with the Hamilton Depression Scale (HDS), the Montgomery-Asberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI) and the Hamilton Anxiety Scale (HAS). These results were examined in relation to body mass index (BMI), waist/hip ratio (WHR) and sagittal abdominal diameter, a measurement of intra-abdominal fat mass, and metabolic variables. Men with WHR>1.0 (n=26) in comparison with men with normal WHR (<1.0, n=33) showed significantly higher sum scores in all the scales used. There were positive correlations between the sum scores of all the depression scales and the WHR or the sagittal abdominal diameter. BMI correlated comparatively weakly only with the HDS. The correlations with the WHR remained when the influence of BMI was eliminated, suggesting that obesity is less involved than centralization of body fat. Insulin and glucose were significantly related to the HDS. Morning cortisol levels were negatively related to the BDI and (borderline) to the MADRS, suggesting perturbations of the regulation of the hypothalamic-pituitary-adrenal axis. We conclude that men with abdominal obesity have symptoms of depression and anxiety.

Does adverse family environment or sex matter in the salivary cortisol responses to anticipatory stress?

We previously reported that in anticipation of a modest stressor, preadolescent sons of drug-dependent fathers (HR) demonstrated a diminished salivary cortisol response relative to comparison boys. No data were available concerning anticipatory salivary cortisol responses in preadolescent daughters of HR fathers. Additionally, we hypothesized that diminished stress responses in HR youth might be an adaptation to a stressful family environment. Consequently, in this report we have examined the role of family environment in the anticipatory salivary cortisol responses in both HR boys and girls as well as their association with a measure of distress in the family environment. Independent of sex, HR children had diminished anticipatory cortisol responses. Girls had significantly higher salivary cortisol concentrations, pre- and post-stressor. However, contrary to our expectation, we could not demonstrate an association between salivary cortisol responses and the measures of the family environment. These results suggest that there may be a sex difference in salivary cortisol dynamics in preadolescent children; however, the functional status of the current family environment does not appear to be related to cortisol reactivity.

Biophysical methods to study ligand-receptor interactions of neuropeptide Y

Neuropeptide Y (NPY) is a 36 amino acids peptide amide that was isolated for the first time almost 20 years ago from porcine brain. NPY displays a multiplicity of physiological effects that are transmitted by at least six G-protein coupled receptors (GPCRs) named Y(1), Y(2), Y(3), Y(4), Y(5), and y(6). Because of the difficulty in obtaining high-resolution crystallographic structures from GPCRs that all belong to seven transmembrane helices proteins, a variety of biophysical methods have been applied in order to characterize the interaction of ligand and receptor. In this review article we present the most relevant outcomes of the studies performed in this field by our group and others. The use of photoaffinity labeling allowed the molecular characterization of the Y(2) receptor. The concerted application of molecular modeling and mutagenesis studies led to a model for the interaction of the natural agonist and nonpeptide antagonists with the Y(1) receptor. The three-dimensional (3D) structure and dynamics of micelle-bound NPY and their implications for receptor selection have been studied by NMR. The characterization of the tertiary and quaternary structure of the NPY dimer in solution at millimolar concentrations has been performed by NMR and extended to physiologically relevant concentrations by fluorescence resonance energy transfer (FRET) experiments performed with fluorescence-labeled analogues.

To screen or not to screen--that is the question in perinatal depression

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, economical screening tool (the Edinburgh Postnatal Depression Scale, EPDS) is available. Arguments against screening pertain largely to lack of evidence about the acceptability of routine use of the EPDS during pregnancy and the postnatal period, and inadequate evidence regarding outcomes and cost-effectiveness. To address these concerns, the National Postnatal Depression Prevention and Early Intervention Program will evaluate outcomes of screening in terms of acceptability, cost-effectiveness, access and satisfaction with management in up to 100 000 women.

Binge eating disorder, anxiety, depression and body image in grade III obesity patients

INTRODUCTION: The objective of this study was to assess the frequency of Binge Eating Disorder (BED) or Binge Eating episodes (BINGE), anxiety, depression and body image disturbances in severely obese patients seeking treatment for obesity. METHOD: We assessed 50 patients (10M and 40F) with Body Mass Index (BMI) between 40 and 81.7 Kg/m² (mean 52.2±9.2 Kg/m²) and aging from 18 to 56 years (mean 38.5±9.7). Used instruments: Questionnaire on Eating and Weight Patterns <FONT FACE=Symbol>¾</FONT> Revised (QEWP-R) for BED or BINGE assessment, Beck Depression Inventory (BDI) for depressive symptoms, State - Trait Anxiety Inventory (STAI-TRAIT and STAI-STATE) for anxiety and Body Shape Questionnaire (BSQ) for body image assessments. RESULTS: In this population BED and BINGE frequencies were 36% and 54%, respectively. Symptoms of depression were detected in 100% while severe symptomatology was found in 84% of the cases. The frequency of anxiety as a trait was 70%, as a state, 54% and 76% of all patients reported discomfort regarding body image. The frequency of BED was higher in patients with higher anxiety scores as a personality trait (>40) but not as a state (46% vs. 13%; p<0,05). A high frequency of BINGE was found in those with higher scores (>140) in the BSQ assessment. CONCLUSION: Our results indicate a high frequency of binge eating episodes, severe depressive symptoms, anxiety and concern with body image in grade III obesity patients.

Late-life depression: psychopathology, medical interventions, and dental implications

BACKGROUND

Late-life depression (LLD) initially occurs after age 65 years and is a major public health concern because the elderly who are at high risk constitute an ever-expanding segment of the population. LLD is a mental illness in which mood, thought content, and behavioral patterns are impaired, causing the individual distress, compromising social function, and impairing self-maintenance skills (eg, bathing, dressing, hygiene). LLD characterized by marked sadness or a loss of interest or pleasure in daily activities and may be accompanied by weight change, sleep disturbance, fatigue, difficulty in concentration, and a high suicide rate. Diagnosis of LLD is sometimes complicated by a denial of mood change and an inability to distinguish symptoms of a concurrent physical illness from those of a depressive etiology. The disorder is most frequently treated with antidepressant medications, and although older individuals have a recovery rate that is comparable with younger adults, they often take longer to recover, have more frequent relapses, and are more sensitive to the side effects of the drugs.

CLINICAL IMPLICATIONS

Individuals undergoing treatment for LLD and those whose illness has not been diagnosed or treated often are seen with significant oral disease by the dentist. Dentists need to be cognizant of how to safely and compassionately provide care to those already receiving mental health services. They must also be familiar with the psychiatric symptoms of the disorder to effectuate a timely referral to a physician of those with occult or relapsing disease. LLD is frequently associated with a disinterest in oral hygiene, a cariogenic diet, diminished salivary flow, rampant dental decay, advanced periodontal disease, and oral dysesthesias. Many medications used to treat the disease magnify the xerostomia and increase the incidence of dental disease. Appropriate dental management necessitates a vigorous preventive dental education program, the use of artificial salivary products, antiseptic mouthwash, daily fluoride mouth rinse, and special precautions in administration of local anesthetics with vasoconstrictors and prescription of analgesics.

CONCLUSION

Dentists who invoke appropriate precautions can usually provide a full range of services to individuals with LLD, thereby enhancing patient self-esteem and contributing to the psychotherapeutic aspect of management.

Effects of mirtazapine in patients with post-traumatic stress disorder in Korea: a pilot study

This study was aimed at testing the efficacy and tolerability of mirtazapine in the treatment of Korean patients with chronic post-traumatic stress disorder (PTSD). Mirtazapine was administered for 8 weeks using a flexible-dose regime in 15 Korean patients with PTSD based on the DSM-IV criteria. We evaluated the patients at baseline and at weeks 4 and 8 after treatment with the interviewer-administered structured interview for PTSD (SIP), short PTSD rating interview (SPRINT), impact of event scale-revised (IES-R) and the Montgomery Asberg depression rating scale (MADRS). Scores on the SIP, SPRINT, IES-R and MADRS had significantly reduced after 8 weeks treatment. In this pilot study, mirtazapine was found to be effective and well tolerated in the treatment of patients with PTSD. This calls for further evaluation of the effect of this drug on subjects with PTSD with randomized placebo-controlled studies.

Depression, anxiety, post-traumatic stress, and alcohol-related problems among veterans with chronic hepatitis C

OBJECTIVE

The aim of this study was to determine the incidence of psychiatric comorbidities among veterans with chronic hepatitis C.

METHODS

Depression, anxiety sensitivity, post-traumatic stress symptoms, and alcohol use were assessed using standardized questionnaires in 120 consecutive veterans with chronic hepatitis C referred to the Liver Clinic.

RESULTS

Using well-established scoring criteria of the questionnaires, clinically significant levels of depression (44.2%), anxiety (38.1%), post-traumatic stress disorder (20.8%), and alcohol-related problems (26.7%) were observed. The majority of patients had a clinically significant score for at least one questionnaire, whereas 37.2% had significant scores in two or more questionnaires. Positive correlations were found between post-traumatic symptoms and depressive symptoms, anxiety sensitivity, and alcohol use problems. Depressive symptoms were also correlated with anxiety. Responses to the questionnaires, in general, correlated poorly with psychiatric histories documented in the medical record. Overall, 79 (65.8%) patients had one or more possible contraindications to antiviral therapy: coexisting unstable psychiatric disorders and/or recent substance use was found in 73.4% of these patients.

CONCLUSIONS

Psychiatric comorbidities were very common among veterans with chronic hepatitis C and correlated poorly with diagnoses documented in the medical record. We recommend a multidisciplinary approach that includes psychological assessment using standardized questionnaires in the evaluation of these patients for antiviral therapy.

Platelet serotonergic markers in posttraumatic stress disorder

The neurobiological basis of posttraumatic stress disorder (PTSD) is believed to involve alterations in different neurotransmitter systems, and recent studies elucidated the role of serotonin (5-hydroxytryptamine, 5-HT) in PTSD. The data on the role of 5-HT have been obtained using blood platelets as a peripheral model for central serotonergic neurons. The reports suggested that platelet 5-HT concentration and monoamine oxidase (MAO) activity might serve as biological, even trait, markers for particular mental disturbances. Since the data on the peripheral serotonergic markers in PTSD subjects are controversial, the aim of the study was to determine platelet 5-HT concentration and platelet MAO activity in war veterans with PTSD, war veterans who did not develop PTSD, and in war veterans who were prisoners of war and developed PTSD. Platelet 5-HT concentration and MAO activity did not differ significantly between war veterans with or without PTSD, and prisoners of war with PTSD. Clinician-Administered PTSD Scale (CAPS) scores did not differ between war veterans with PTSD and prisoners of war, but Montgomery-Asberg Depression Rating Scale (MADRS) scores were significantly higher in prisoners of war who developed PTSD than in war veterans with PTSD. There was no significant correlation between platelet 5-HT concentration or platelet MAO activity and CAPS or MADRS scores within these groups. Platelet 5-HT concentration was slightly higher and platelet MAO activity slightly lower in prisoners of war with PTSD, than in all other groups. These findings suggest that platelet 5-HT concentration and platelet MAO activity are not altered in three drug-free groups--war veterans who did or did not develop PTSD, or in prisoners of war with PTSD--and that these platelet serotonergic markers are not associated with symptoms of PTSD or comorbid depression.

Concomitant prescribing of benzodiazepines during antidepressant therapy in the elderly

A follow-up study was performed in two ambulatory cohorts aged > or =65 to investigate whether the prevalence and incidence of anxiolytic/hypnotic benzodiazepine drug prescribing is comparable between users of serotonin reuptake inhibitors (SSRIs) and users of tricyclic antidepressants (TCAs). The prevalence and incidence of benzodiazepines during antidepressant therapy was estimated among users of TCAs and SSRIs. Coprescribing of benzodiazepines occurred in 53% of the TCA users and 57% of the SSRI users (prevalence RR 1.1; CI(95) 0.9-1.2). The average duration of benzodiazepine drug use was >65 days per 100 days of antidepressant use. During SSRI therapy, significantly more people started benzodiazepine drug therapy than during TCA therapy (incidence rate ratio (RR) 1.7; CI(95) 1.2-2.4). Analyses repeated 5 years later yielded similar results (overall incidence RR(MH) 1.6; CI(95) 1.3-2.0). These data indicate that SSRI use is associated with a significantly higher chance of starting benzodiazepines compared with TCA use.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders

In this report, recommendations for the pharmacological treatment of anxiety and obsessive-compulsive disorders are presented, based on available randomized, placebo- or comparator-controlled clinical studies. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for panic disorder. Tri2-cyclic antidepressants (TCAs) are equally effective, but they are less well tolerated than the SSRIs. In treatment-resistant cases, benzodiazepines like alprazolam may be used when the patient does not have a history of dependency and tolerance. Due to possible serious side effects and interactions with other drugs and food components, the irreversible monamine oxidase inhibitor (MAOI) phenelzine should be used only when first-line drugs have failed. In generalised anxiety disorder, venlafaxine and SSRIs can be recommended, while buspirone and imipramine may be alternatives. For social phobia, SSRIs are recommended for the first line, and MAOIs, moclobemide and benzodiazepines as second line. Obsessive-compulsive disorder is best treated with SSRIs or clomipramine.

Co-occurrence of disturbed sleep and appetite loss differentiates between unipolar and bipolar depressive episodes

The aim of this study was to examine whether the co-occurrence of disturbed sleep and appetite loss, two commonly encountered somatic symptoms of depression, can differentiate the clinical expression of depressive episodes between bipolar (BP) and unipolar patients (UP). Forty BP and 40 UP outpatients were interviewed through the Schedules for the Clinical Assessment in Neuropsychiatry (SCAN) and the presence of sleep disturbance and appetite loss during their most severe depressive episode was determined. Other variables studied were patients' gender and age, clinical characteristics related to the course of the disease (age at onset, duration of illness, and number and frequency of depressive and manic episodes), severity of the worst major depressive episode, and presence or absence of certain associated symptoms during that episode (loss of energy, low interest, feelings of guilt and/or self-reproach, impaired concentration, suicidal ideation, and agitation or retardation). Appetite loss was found to be more frequently present in UP (78%) than BP patients (55%, P<.05). No significant difference in the occurrence of sleep disturbance was found between the two groups. Among BP patients, appetite loss was present in 73% of those with sleep disturbance vs. 33% of those without (P<.02), while no such difference in co-occurrence of sleep disturbance and appetite loss was noticed among UP patients (74% vs. 85%, respectively, n.s.); this finding did not seem to be related to differences in severity of depression among UP and BP patients. Furthermore, those BP patients with co-occurrence of the two somatic symptoms complained also of loss of energy and low interest more often than those without (P<.01 and P<.05, respectively). No similar differences were observed among UP patients. The results of the present study suggest that the pathophysiological mechanisms underlying depressive episodes may differ between BP and UP affective disorder, and that those BP patients with simultaneous occurrence of sleep disturbance and appetite loss can be considered to belong to a particular nosologic subgroup with potential therapeutic and prognostic implications.

Efficacy of venlafaxine in major depression resistant to selective serotonin reuptake inhibitors

INTRODUCTION

Some studies suggest that venlafaxine, due to its pharmacodynamic characteristics, could be an effective drug in depression, resistant to other antidepressive agents. This investigation explores the efficacy and tolerability of venlafaxine in major depression, resistant to a selective serotonin reuptake inhibitor (SSRI).

METHODS

A multicenter naturalistic study was performed during 6 months and included those patients diagnosed of major depression according to the criteria of DSM-IV who had a minimum score of 18 on the Hamilton Depression Rating Scale (HAM-D) and who had not responded to previous treatment with a SSRI at therapeutic doses for a minimum of 4 weeks. The assessment of efficacy was performed with the HAM-D scale, the Montgomery-Asberg Depression Rating Scale (MADRS), the Hamilton Anxiety Rating Scale (HAM-A) and the Global Clinical Impression (GCI). Tolerability was evaluated by recording the adverse reactions and with the GCI score on overall drug tolerability.

RESULTS

A total of 69 patients, of which 59 were evaluable for efficacy (they had fulfilled at least 4 weeks of treatment), were included. About 81% of all of them obtained a reduction of at least 50% in the HAM-D, 74% were considered as "quite improved" or "very improved" in the GCI and 69% met both criteria. The mean dose of venlafaxine used was 170.4 (S.D.=43.8) mg. Of the 21 patients who did not complete the 6 months of treatment, 3 were due to lack of efficacy, 6 due to adverse effects and 12 for other reasons. About 89.2% of side effects were considered as mild or moderate.

CONCLUSION

The results of our study support the efficacy and tolerability of venlafaxine in patients suffering from depression who have not responded to SSRI treatment.

Pramipexole in treatment-resistant depression: a 16-week naturalistic study

OBJECTIVE

To assess the antidepressant efficacy and tolerability of adjunctive pramipexole, a D2-D3 dopamine agonist, in patients with drug-resistant depression.

METHODS

The study sample consisted of in-patients with major depressive episode, according to the DSM-IV, and drug resistance. Pramipexole was added to antidepressant treatment with TCA or SSRI, at increasing doses from 0.375 to 1.0 mg/day. Two independent response criteria were adopted: a > 50% reduction of the Montgomery-Asberg Depressive Rating Scale (MADRS) total score and a score of I or 2 on the Clinical Global Impression scale (CGI-1) at endpoint. Side-effects were assessed by the Dosage Record Treatment Emergent Symptom Scale (DOTES).

RESULTS

Thirty-seven patients were enrolled. Of these. 16 had unipolar depression and 21 had bipolar depression. Six patients dropped out in the first week. Of the 31 patients included in the analyses. 19 completed the 16-week follow-up. Mean maximal dose of pramipexole was 0.95 mg/day. Mean scores on MADRS decreased from 33.3 +/- 8.4 at baseline to 13.9 +/- 11.5 at endpoint (p < 0.001) and the CGI-S decreased from 4.6 +/- 0.8 at baseline to 2.8 +/- 1.3 at endpoint (p < 0.001). At endpoint, 67.7% (21/31) of patients were responders on MADRS and 74.2% on CGI-I. Of the 37 patients enrolled, 10 discontinued pramipexole because of adverse events.

CONCLUSIONS

These preliminary data suggest that pramipexole adjunction to antidepressant treatment may be effective and well tolerated in patients with resistant major depression.

The importance of psychosocial factors, gender, and severity of depression in distinguishing between adjustment and depressive disorders

BACKGROUND

This study evaluated the severity of depressive symptomatology as it relates to: (a) sociodemographic factors and (b) the occurrence and type of acute and chronic psychosocial triggers or life events before admission.

METHODS

In total, 718 psychiatric inpatients were assessed with the AMDP-system by the treating psychiatrist within the first 2 days after admission.

RESULTS

In the females, sociodemographic factors (being married, children in the household, higher education and the quality of interactions) but not psychosocial stressors or life events were found to be related to severity of depression on admission. Females showed more severe depressive syndromes than males, however, depression severity in males was independent of sociodemographic factors, life events or psychosocial triggers.

LIMITATIONS

Clinical assessment was based on retrospective history taking. The sample consisted of inpatients only, the results require replication using larger and more diverse samples.

CONCLUSION

Gender differences and life conditions such as familial distress are related to severity of depression. The present criteria for the differentiation between depressive disorders and adjustment disorders are not independent and should be substituted by a multiaxial assessment.

Effect of intraperitoneal mRNA antisense-oligodeoxynucleotides to cholecystokinin on anxiety-like and learning behaviors in rats: association with pre-experimental stress

RATIONALE

Cholecystokinin and its analogs generate anxiety in humans and measurable anxiety-like behaviors in rats. Cholecystokinin receptor blockers have been reported to have variable effects in the treatment of anxiety disorders. We demonstrated that intracerebroventricular administration of Cholecystokinin-antisense oligodeoxynucleotides (ASODN) for 3 days significantly diminished anxiety-like behavior in rats.

OBJECTIVE

This study was designed to examine the effects of peripheral (intraperitoneal) administration of Cholecystokinin-ASODN on anxiety-like and learning behaviors in rats, in general and in a pre-experiment stress paradigm.

METHODS

In the first study Cholecystokinin-ASODN was injected intraperitoneally to rats five times at 24-h intervals. Control groups received injections of either a scrambled oligodeoxynucleotide (ScrODN) or vehicle. On the sixth day, the rats were assessed in the elevated plus-maze paradigm and in the Morris water maze. In the second study, rats were pre-exposed to a cat for 10 min as a model for psychological stress, and then treated with intraperitoneal Cholecystokinin-ASODN and tested in both paradigms.

RESULTS

The results show that for intact rats, intraperitoneal Cholecystokinin-ASODN significantly increased anxiety-like behavior and impaired retention performance in the Morris water maze, compared to both control groups. In stressed rats, Cholecystokinin-ASODN reduced anxiety-like behaviors in the plus-maze and improved performance in the water maze compared with controls.

CONCLUSIONS

These results indicate that the anxiolytic effect of intraperitoneal Cholecystokinin-ASODN may be dependent on the baseline endogenous level of stress (i.e., on the Cholecystokinin levels). Basal endogenous levels of Cholecystokinin, as well as exogenous dosage of Cholecystokinin agonists and/or anxiolytic agents, appear to play an important role in the expression and/or control of anxiety-related behaviors in rats.

Escitalopram

Escitalopram oxalate (S-citalopram, Lexapro), a selective serotonin re-uptake inhibitor antidepressant which is the S-enantiomer of citalopram, is in clinical development worldwide for the treatment of depression and anxiety disorders. Preclinical studies demonstrate that the therapeutic activity of citalopram resides in the S-isomer and that escitalopram binds with high affinity to the human serotonin transporter. Conversely, R-citalopram is approximately 30-fold less potent than escitalopram at this transporter. Escitalopram has linear pharmacokinetics, so that plasma levels increase proportionately and predictably with increased doses and its half-life of 27 - 32 h is consistent with once-daily dosing. In addition, escitalopram has negligible effects on cytochrome P450 drug-metabolising enzymes in vitro, suggesting a low potential for drug-drug interactions. The efficacy of escitalopram in patients with major depressive disorder has been demonstrated in multiple short-term, placebo-controlled clinical trials, three of which included citalopram as an active control, as well as in a 36-week study evaluating efficacy in the prevention of depression relapse. In these studies, escitalopram was shown to have robust efficacy in the treatment of depression and associated symptoms of anxiety relative to placebo. Efficacy has also been shown in treating generalised anxiety disorder, panic disorder and social anxiety disorder. Results also suggest that, at comparable doses, escitalopram demonstrates clinically relevant and statistically significant superiority to placebo treatment earlier than citalopram. Analysis of the safety database shows a low rate of discontinuation due to adverse events, and there was no statistically significant difference between escitalopram 10 mg/day and placebo in the proportion of patients who discontinued treatment early because of adverse events. The most common adverse events associated with escitalopram which occurred at a rate greater than placebo include nausea, insomnia, ejaculation disorder, diarrhoea, dry mouth and somnolence. Only nausea occurred in > 10% of escitalopram-treated patients.

The Bech-Rafaelsen Melancholia Scale (MES) in clinical trials of therapies in depressive disorders: a 20-year review of its use as outcome measure

OBJECTIVE

To evaluate the psychometric properties of the Bech-Rafaelsen Melancholia Scale (MES) by reviewing clinical trials in which it has been used as outcome measure.

METHOD

The psychometric analysis included internal validity (total scores being a sufficient statistic), interobserver reliability, and external validity (responsiveness in short-term trials and relapse prevention in long-term trials).

RESULTS

The results showed that the MES is a unidimensional scale, indicating that the total score is a sufficient statistic. The interobserver reliability of the MES has been found adequate both in unipolar and bipolar depression. External validity including both relapse, response and recurrence indicated that the MES has a high responsiveness and sensitivity.

CONCLUSION

The MES has been found a valid and reliable scale for the measurement of changes in depressive states during short-term as well as long-term treatment.

A pilot study of loading versus titration of valproate in the treatment of acute mania

OBJECTIVE

This double-blind pilot study compares the effectiveness and incidence of adverse effects of oral loading versus titration schedules of valproate in acute mania.

METHOD

Consecutive new admissions for an acute manic episode were prescribed either an oral loading dose (20 mg/kg/day; n = 5; mean age = 33.4) or slower titration dose (10 mg/kg/day, n = 6. mean age = 30.6) of valproate for 7 days without other psychotropic agents. with the exception of benzodiazepines. Daily outcome measures included: serum valproic acid levels, the Young Mania Rating Scale (YMRS), the Brief Psychiatry Rating Scale (BPRS), the Clinical Global Impression Scale (CGI) and the Adverse Effect Rating Scale.

RESULTS

The mean serum valproic acid levels were significantly higher in the loading group when compared with the titration group after 1 and 2 days following the initiation of treatment (p < 0.05). After 3 days of treatment there was a trend for the group that received the loading regimen to have slightly more improvement in YMRS scores compared with the titration group. Side-effects were minor for both treatments, however, a higher incidence of side-effects was reported in the titration group, with 50% of patients reporting sedation most likely because of increased use of benzodiazepines.

CONCLUSION

This suggests that a loading dose of valproate is likely safe and may provide an earlier onset of antimanic effects in patients with bipolar disorder. Future studies with larger sample sizes are indicated.

Left prefrontal-repetitive transcranial magnetic stimulation (rTMS) and regional cerebral glucose metabolism in normal volunteers

Repetitive transcranial magnetic stimulation (rTMS) holds promise as a probe into the pathophysiology and possible treatment of neuropsychiatric disorders. To explore its regional effects, we combined rTMS with positron emission tomography (PET). Fourteen healthy volunteers participated in a baseline 18-fluorodeoxyglucose (FDG) PET scan. During a second FDG infusion on the same day, seven subjects received 30 min of 1 Hz rTMS at 80% of motor threshold to left prefrontal cortex, and seven other subjects received sham rTMS under identical conditions. Global and normalized regional cerebral glucose metabolic rates (rCMRglu) from the active and sham conditions were compared to baseline and then to each other. Sham, but not active 1 Hz rTMS, was associated with significantly increased global CMRglu. Compared to baseline, active rTMS induced normalized decreases in rCMRglu in right prefrontal cortex, bilateral anterior cingulate, basal ganglia (L>R), hypothalamus, midbrain, and cerebellum. Increases in rCMRglu were seen in bilateral posterior temporal and occipital cortices. Sham rTMS compared to baseline resulted in isolated normalized decreases in rCMRglu in left dorsal anterior cingulate and left basal ganglia, and increases in posterior association and occiptal regions. Differences between the 1 Hz active versus sham changes from baseline revealed that active rTMS induced relative decrements in rCMRglu in the left superior frontal gyrus and increases in the cuneus (L>R). One Hertz rTMS at 80% motor threshold over the left prefrontal cortex in healthy subjects compared to sham rTMS in another group (each compared to baseline) induced an area of decreased normalized left prefrontal rCMRglu not directly under the stimulation site, as well as increases in occipital cortex. While these results are in the predicted direction, further studies using other designs and higher intensities and frequencies of rTMS are indicated to better describe the local and distant changes induced by rTMS.

Emotional and physical precipitants of ventricular arrhythmia

BACKGROUND

Observational studies have suggested that psychological stress increases the incidence of sudden cardiac death. Whether emotional or physical stressors can trigger spontaneous ventricular arrhythmias in patients at risk has not been systematically evaluated.

METHODS AND RESULTS

Patients with implantable cardioverter-defibrillators (ICDs) were given diaries to record levels of defined mood states and physical activity, using a 5-point intensity scale, during 2 periods preceding spontaneously occurring ICD shocks (0 to 15 minutes and 15 minutes to 2 hours) and during control periods 1 week later. ICD-stored electrograms confirmed the rhythm at the time of shock. A total of 107 confirmed ventricular arrhythmias requiring shock were reported by 42 patients (33 men; mean age, 65 years; 78% had coronary artery disease) between August 1996 and September 1999. In the 15 minutes preceding shock, an anger level > or =3 preceded 15% of events compared with 3% of control periods (P<0.04; odds ratio, 1.83; 95% confidence intervals, 1.04 to 3.16) Other mood states (anxiety, worry, sadness, happiness, challenge, feeling in control, or interest) did not differ. Patients were more physically active preceding shock than in control periods. Anger and physical activity were independently associated with the preshock period.

CONCLUSIONS

Anger and physical activity can trigger ventricular arrhythmias in patients with ICDs. Future investigations of therapies aimed at blocking a response to these stressors may decrease ventricular arrhythmias and shocks in these patients.

Pharmacology for post-traumatic stress disorder related to childhood sexual abuse: a literature review

TOPIC

Post-traumatic stress disorder (PTSD) related to pharmacotherapy responses in general and specifically to noncombat symptomatology related to childhood sexual abuse.

PURPOSE

To explore findings related to pharmacological advances in the treatment of PTSD and relate the findings to the treatment of childhood sexual abuse.

SOURCES

Published literature.

CONCLUSIONS

The literature on pharmacotherapy for PTSD in general and childhood trauma and PTSD in particular is small and inconsistent, but we need to be aware of any and all advances.

Pharmacotherapy of postpartum depression

The postpartum period is an exceptionally high-risk time for the occurrence of episodes of depression in women with major depressive disorder or bipolar disorder. There is accumulating evidence that major depressive disorder with postpartum onset in some patients has a bipolar diathesis. This article reviews the pharmacological treatment of postpartum depression. Although the data are limited, studies have focused exclusively on the acute and prophylactic treatment of major depressive disorder. To date, there are no studies of bipolar depression with postpartum onset. A careful assessment of maternal and infant risks and benefits is required prior to initiation of pharmacological treatment. Strategies to reduce misdiagnosis of subtle forms of bipolar disorder are discussed and suggestions are made regarding possible treatment interventions. The urgent need to conduct further studies comparing the symptom patterns, response to treatment and illness course in women with major depressive disorders and bipolar depression with postpartum onset is highlighted.

Clinical indicators for the use of antidepressants in the treatment of bipolar I depression

OBJECTIVES

Current guidelines provide little practical information on the clinical characteristics of bipolar I patients who are likely to benefit from the combination of a mood stabilizer and an antidepressant. Rather, guidelines simply state that an adjunctive antidepressant is recommended in cases of 'severe' depression. Our objective was to evaluate the clinical and demographic differences between patients who remitted on a mood stabilizer alone and patients who subsequently required an adjunctive antidepressant to achieve stabilization.

METHODS

We retrospectively compared the pharmacological treatment strategies of 39 patients with bipolar I disorder who were in a current depressive episode. Patients who did not respond to mood stabilizer monotherapy were prescribed an adjunctive antidepressant. We evaluated the clinical differences at baseline and week 1, 2 and 3 of treatment between patients stabilizing on a mood stabilizer alone and patients that did not remit until they subsequently received an adjunctive antidepressant.

RESULTS

Patients who required an adjunctive antidepressant had significantly higher total Hamilton Depression Rating (HRS-D) scores at week 1, 2 and 3 of treatment, but not at baseline. Patients who remitted on mood stabilizer monotherapy were more likely to be married, achieved stabilization in less time, presented with higher Young Mania Rating Scale (YMRS) scores, and experienced the previous episode of depression more recently than patients who required an antidepressant.

CONCLUSIONS

Our findings suggest that rapid improvement after achieving a therapeutic dose of a mood stabilizer is clinically significant and represents a surrogate endpoint in the treatment of bipolar I depression. Larger, prospective, and controlled studies are needed to verify our results and to identify additional indicators for a mood stabilizer and antidepressant combination treatment strategy.

Extended, strategic therapy for recalcitrant mind/body healing: an integrative model

The development of the power therapies, behavioral medicine, and short term interventions have reported such success even with trauma cases that it is relevant to question the justification for lengthy psychotherapy. Yet some patients with complex mind/body conditions impervious to medical treatment/hypnosis may require extended, multi-modal, integrative therapy. This paper details a single complex case of paruresis as a prototype for illustrating a holographic treatment model for recalcitrant conditions: Component features of the proposed model presented include: 1) the sequential utilization of hypnobehavioral and analytic approaches; 2) uncovering work providing access to the somatic ego state associated with the illness condition; 3) the extended treatment time frame required for deep psycho-physiological change; and 4) the stages of counter-transference expectably evoked by such patients (e.g. urgency, exuberant optimism, frustration, discouragement), and the transformation of such reactions to achieve maximum therapeutic efficacy.

Safety of intraoperative transcranial electrical stimulation motor evoked potential monitoring

This article reviews intraoperative transcranial electrical stimulation (TES) motor evoked potential (MEP) monitoring safety based on comparison with other clinical and experimental brain stimulation methods and clinical experience in more than 15000 cases. Comparative analysis indicates that brain damage and kindling are highly unlikely. There have been remarkably few adverse events. Pulse train TES-induced or coincidental seizures (n = 5) are rare, probably because of very brief (<0.03 second) stimuli, anesthesia, and the general absence of predisposing cerebral conditions. Soft bite blocks may prevent tongue or lip laceration (n = 29) or mandibular fracture (n = 1). Rare cardiac arrhythmia (n = 5) and intraoperative awareness (n = 1) may be coincidental. Minor scalp burns (n = 2) are rare. Although possible, no spinal epidural recording electrode complications or injuries resulting from TES-induced movement were found. There have been no recognized adverse neuropsychological effects, headaches, or endocrine disturbances. Comprehensive relative contraindications include epilepsy, cortical lesions, convexity skull defects, raised intracranial pressure, cardiac disease, proconvulsant medications or anesthetics, intracranial electrodes, vascular clips or shunts, and cardiac pacemakers or other implanted biomedical devices. Otherwise unexplained intraoperative seizures and possibly arrhythmias are indications to abort TES. With appropriate precautions in expert hands, the well-established benefits of TES MEP monitoring decidedly outweigh the associated risks.

Lasting effects of adolescent nicotine exposure on the electroencephalogram, event related potentials, and locomotor activity in the rat

Tobacco smoking initiated during adolescence is often associated with rapid onset of dependence and difficulty in maintaining abstinence. Animal models have demonstrated that adolescent nicotine exposure causes cell death and altered neurochemistry in the cortex and hippocampus; however, little is known about the neurophysiological consequences of adolescent nicotine exposure in the adult. The primary objective of this study was to assess the consequences of adolescent nicotine exposure on the adult electroencephalogram (EEG) and event-related potentials. Male Sprague-Dawley rats were administered nicotine (5.0 mg/kg per day) for 5 days between postnatal days 35 and 40 using transdermal nicotine patches. Following 6-7 weeks of nicotine withdrawal, EEG activity and event related potentials were assessed. Motor activity and sucrose preference were also examined during the nicotine withdrawal period. Additionally, a set of rats was exposed to multiple doses of nicotine for a single day to assess nicotine and cotinine blood levels. Transdermal nicotine produced nicotine (88+/-21.5 ng/ml) and cotinine (647.6+/-123.2 ng/ml) levels comparable to those previously reported. Reduced motor activity, decreased 1-4 Hz power in the cortical electroencephalogram, and increased cortical N1 amplitude were observed in nicotine-exposed rats compared to controls. These data demonstrate that transdermal nicotine patches provide an effective and non-invasive nicotine delivery system for the adolescent rat. The combined neurophysiological and locomotor activity changes observed in nicotine-exposed rats demonstrate that adolescent nicotine exposure has lasting neurobehavioral consequences. These changes may be indicative of a lasting 'nicotine abstinence syndrome' characterized by increased arousal, anxiety, or emotionality.

Changes in neural circuitry of language before and after treatment of major depression

Language tasks requiring semantic analysis of word meaning activate distinct brain areas including the anterior cingulate gyrus at about 200 msec after the stimulus onset, the left lateral prefrontal cortex at about 250 msec, and the left temporo-parietal (Wernicke's) area at 500-600 msec. Reading the same words activate the insula around 800 msec and left occipital cortex around 200 msec stronger than the semantic analysis in normal subjects. Many of these brain areas also show abnormal activity in resting state in patients with major unipolar depression. We measured 128-channel event-related brain potentials (ERPs) and statistical probability mapping in the use generation task carried out with single visual nouns to explore the topography and time course of these cortical activations related to semantic processing in 11 patients with major unipolar depression before and 8 weeks after treatment with the selective serotonin reuptake inhibitor (SSRI) citalopram. Before treatment in depressed state, the time course for the left prefrontal cortex activation did not show slowing, but was accompanied by the right prefrontal activation with a similar time course. The left posterior temporo-parietal activation appeared later than in normals. Treatment was accompanied by the complete elimination of the right prefrontal activation in the same use generation task. Time course of the posterior left temporo-parietal area showed a trend toward normalization. Insula-related activation in reading task was not seen in depressed state, but was evident in the same patient group after the depression has lifted, presumably as a result of treatment with citalopram.

Development and natural history of mood disorders

To expand and accelerate research on mood disorders, the National Institute of Mental Health (NIMH) developed a project to formulate a strategic research plan for mood disorder research. One of the areas selected for review concerns the development and natural history of these disorders. The NIMH convened a multidisciplinary Workgroup of scientists to review the field and the NIMH portfolio and to generate specific recommendations. To encourage a balanced and creative set of proposals, experts were included within and outside this area of research, as well as public stakeholders. The Workgroup identified the need for expanded knowledge of mood disorders in children and adolescents, noting important gaps in understanding the onset, course, and recurrence of early-onset unipolar and bipolar disorder. Recommendations included the need for a multidisciplinary research initiative on the pathogenesis of unipolar depression encompassing genetic and environmental risk and protective factors. Specifically, we encourage the NIMH to convene a panel of experts and advocates to review the findings concerning children at high risk for unipolar depression. Joint analyses of existing data sets should examine specific risk factors to refine models of pathogenesis in preparation for the next era of multidisciplinary research. Other priority areas include the need to assess the long-term impact of successful treatment of juvenile depression and known precursors of depression, in particular, childhood anxiety disorders. Expanded knowledge of pediatric-onset bipolar disorder was identified as a particularly pressing issue because of the severity of the disorder, the controversies surrounding its diagnosis and treatment, and the possibility that widespread use of psychotropic medications in vulnerable children may precipitate the condition. The Workgroup recommends that the NIMH establish a collaborative multisite multidisciplinary Network of Research Programs on Pediatric-Onset Bipolar Disorder to achieve a better understanding of its causes, course, treatment, and prevention. The NIMH should develop a capacity-building plan to ensure the availability of trained investigators in the child and adolescent field. Mood disorders are among the most prevalent, recurrent, and disabling of all illnesses. They are often disorders of early onset. Although the NIMH has made important strides in mood disorders research, more data, beginning with at-risk infants, children, and adolescents, are needed concerning the etiology and developmental course of these disorders. A diverse program of multidisciplinary research is recommended to reduce the burden on children and families affected with these conditions.

Skating to where the puck is going to be: a plan for clinical trials and translation research in mood disorders

As part of the National Institute of Mental Health Strategic Plan for Mood Disorders Research effort, the Clinical Trials and Translation Workgroup was asked to define priorities for clinical trials in mood disorders and for research on how best to translate the results of such research to clinical practice settings. Through two face-to-face meetings and a series of conference calls, we established priorities based on the literature to date and what was known about research currently in progress in this area. We defined five areas of priority that cut across developmental stages, while noting that research on adult mood disorders was at a more advanced stage in each of these areas than research on child or geriatric disorders. The five areas of priority are: 1) maximizing the effectiveness and cost-effectiveness of initial (acute) treatments for mood disorders already known to be efficacious in selected populations and settings when they are applied across all populations and care settings; 2) learning what further treatments or services are most likely to reduce symptoms and improve functioning when the first treatment is delivered well, but the mood disorder does not remit or show adequate improvement; 3) learning what treatments or services are most cost-effective in preventing recurrence or relapse and maintaining optimal functioning after a patient's mood disorder has remitted or responded maximally to treatment; 4) developing and validating clinical, psychosocial, biological, or other markers that predict: a) which treatments are most effective, b) course of illness, c) risk of adverse events/tolerability and acceptability for individual patients or well-defined subgroups of patients; 5) developing clinical trial designs and methods that result in lower research costs and greater generalizability earlier in the treatment development and testing process. A rationale for the importance of each of these priorities is provided.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Developing novel treatments for mood disorders: accelerating discovery

This review was generated from discussions by the Pharmacologic and Somatic Treatments Section of the National Institute of Mental Health Strategic Plan for Mood Disorders Committee on advancing novel pharmacologic and somatic treatments for mood disorders. The opening section of the article summarizes in broad strokes, current pharmacologic treatments, and new directions in the field. Thereafter the topics focus on specific research initiatives that could advance the current therapeutics for mood disorders including new basic and clinical research in vivo human imaging procedures, somatic therapeutics, and the vast new area of pharmacogenetics. New scientific and technical opportunities exist today based on advances in basic neuroscience, opportunities in clinical testing, industry interest in advancing central nervous system therapeutics, and on active consumer advocacy groups. The question of how to bring all of these positive forces together to accelerate discovery in mood disorder thera-peutics is the topic of this article.

Generalised anxiety disorder: treatment options

In recent years generalised anxiety disorder (GAD) has become a much better defined disorder, with specific criteria distinguishing it from the other anxiety disorders; however, it still lacks the same public and scientific interests as some of the other anxiety disorders such as panic and social phobia. Nevertheless, refinement in the treatment of GAD is becoming more evident through the conduct of clinical trials. Up until the mid-1980's, treatment consisted primarily of benzodiazepines. However, as a result of growing characterisation of their abuse potential, other therapeutic options were explored. Benzodiazepines became seen as an effective short-term therapy, and buspirone and some of the newer antidepressants have become the treatment of choice for patients with GAD requiring long-term treatment. Buspirone was the first available alternative to the benzodiazepines in the US; however, the initial excitement over this agent was somewhat dampened because of its mild efficacy combined with a slow onset of action. The antidepressants were seen as beneficial for the treatment of GAD because of the high comorbidity with depression, thus allowing a better outcome for these patients. The antidepressants that offer both a good adverse effect profile and efficacy are the selective serotonin reuptake inhibitors including paroxetine, and the serotonin-norepinephrine reuptake inhibitors such as venlafaxine. Clinicians should also consider the potential benefits of psychotherapy as an adjunct to medication. There are a number of potentially new pharmacotherapies being investigated, including newer serotonin 5-HT1A receptor agonists, cholecystokinin receptor antagonists, neurokinin receptor antagonists, gabapentin and its analogues, and gamma-aminobutyric acid (GABA)A receptor modulators. However, these compounds are all in the early stages of investigation, and there are no new therapies expected to be released in the near future. Nonetheless, in the search for the ideal anxiolytic, a more positive outlook is allowed by imminent future research for new treatment options in patients with GAD.

Personality disorder comorbidity in panic disorder patients with or without current major depression

To investigate the relationship between current or past major depressive disorder (MDD) on comorbid personality disorders in patients with panic disorder, we compared the comorbidity of personality disorders using the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in 34 panic disorder patients with current MDD (current-MD group), 21 with a history of MDD but not current MDD (past-MD group), and 32 without lifetime MDD comorbidity (non-MD group). With regard to personality disorders, patients in the current-MD group met criteria for at least one personality disorder significantly more often than patients in the past-MD group or the non-MD group (82.4% vs. 52.4% and 56.3%, respectively). The current-MD group showed statistically significantly more borderline, dependent, and obsessive-compulsive personality disorders than the past-MD group or non-MD group. With stepwise regression analyses, number of MDD episodes emerged as an indicator of the comorbidity of cluster C personality disorder and any personality disorders. Future studies should determine whether aggressive treatment of comorbid personality disorders improves the outcome (e.g., lowers the likelihood of comorbid MDD) of patients with panic disorder.

Decreased chaos of heart rate time series in children of patients with panic disorder

This study examined the differences of heart rate variability measures between children of parents with panic disorder and children of healthy controls using linear as well as nonlinear techniques. Supine and standing heart rate variability indices were measured in all children using power spectral analysis and a measure of chaos, the largest Lyapunov exponent (LLE) of heart rate time series. No significant differences emerged between the children of panic disorder parents and children of normal controls on any of the spectral heart rate variability measures. However, children of patients with panic disorder had significantly lower LLE of heart rate time series in supine posture, suggesting a relative decrease of cardiac vagal function in this group of children. This suggests a possible heritable effect of certain measures of heart rate variability, as previous studies showed decreased heart rate variability in patients with panic disorder using spectral as well as nonlinear techniques. Recent evidence also suggests that some of these nonlinear measures are superior or of additional value to the traditional time and frequency domain measures of heart rate variability to predict serious ventricular arrhythmias and sudden death.

No melancholia in poststroke depression? A phenomenologic comparison of primary and poststroke depression

The present study aimed at the phenomenologic comparison of depressive symptoms in elderly patients with poststroke depression (PSD) or primary depression (depression without a known neuropathology). We investigated 20 patients with PSD and 41 patients with primary depression. A structured clinical interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, self- and observer-based depression rating scales, a clinical neurologic examination, and neuroradiologic analysis based on standardized computed tomographic scan analysis were applied. The Cornell Depression Scale was used to compare mood-related signs, behavioral disturbances, physical signs, disturbances of cyclic signs, and ideational disturbances in both groups of patients. Those with PSD exhibited no melancholia and fewer cyclic and ideational disturbances but more physical signs of depression. These findings are in line with those of endocrinologic studies. Differences between both groups of patients indicate that careful considerations and further research are needed before treatment strategies developed for and evaluated in patients with primary depression are applied to patients with PSD.

Delayed pharmacological effects of antidepressants

Although antidepressants may not be primary mood stabilizers, they are efficacious in the prophylaxis of recurrent depressive illnesses, as well as in the treatment of acute episodes. Pharmacological effects that may contribute to the prophylactic effects of these drugs are not understood. Studies have been carried out in which antidepressants have been given to laboratory animals, such as rats, for periods of up to 3-4 weeks. Data obtained in such studies are thought to be important for their beneficial effects in depressive episodes, but also may be relevant to their prophylactic effects. Results are presented showing that when selective inhibitors of serotonin or norepinephrine uptake are given for such time periods, they still produce selective effects on serotonergic or noradrenergic parameters. For example, long-term administration of selective norepinephrine reuptake inhibitors causes a down-regulation of beta(1) adrenoceptors. Selective serotonin reuptake inhibitors do not produce this effect. Long-term administration of selective serotonin reuptake inhibitors causes down-regulation of the serotonin transporter, but not the norepinephrine transporter. In contrast, selective norepinephrine reuptake inhibitors down-regulate the norepinephrine transporter but not the serotonin transporter. Substantial loss of serotonin transporter binding sites takes 15 days to occur and is accompanied by a marked reduction of serotonin transporter function in vivo.

Repetitive transcranial magnetic stimulation for the treatment of chronic pain - a pilot study

Invasive electrical stimulation of the motor cortex has been reported to be of therapeutic value in pain control. We were interested whether noninvasive repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortex might also act beneficially. Twelve patients with therapy-resistant chronic pain syndromes (mean age 51.3 +/- 12.6, 6 males) were included in a pilot study. They were treated with rTMS of the corresponding motor cortex area for 20 min (20 Hz, 20 x 2 s trains, intensity 80% of motor threshold) and sham stimulation (sequence-controlled cross-over design). Some of the patients (6/6) had an analgesic effect, but for the whole group, the difference between active and sham stimulation did not reach a level of significance (active rTMS: mean VAS reduction -4.0 +/- 15.6%; sham rTMS: -2.3 +/- 8.8%). Further studies using different rTMS stimulation parameters (duration and frequency of rTMS) or stimulation sites (e.g. anterior cingulate gyrus) are strongly encouraged.

Serotonin clearance in vivo is altered to a greater extent by antidepressant-induced downregulation of the serotonin transporter than by acute blockade of this transporter

Serotonin uptake, mediated by the serotonin transporter (SERT), is blocked acutely by antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), but such blockade does not correlate temporally with the onset of therapeutic improvement. Treatment with SSRIs for 21 d induced downregulation of the SERT (Benmansour et al., 1999). The time course of SERT downregulation as well as the time course for its recovery after cessation of treatment with the SSRI sertraline were investigated using tritiated cyanoimipramine to measure SERT binding sites. To determine if there was a temporal correlation between the time when sertraline induced downregulation of the SERT and when marked alteration in SERT function occurred, clearance of locally applied 5-HT into the CA3 region of hippocampus was achieved using in vivo electrochemistry. After 4 or 10 d treatment with sertraline, SERT binding sites decreased very little (15-30%), and the chronoamperometric signals for serotonin in sertraline-treated rats were comparable with ones obtained in control animals. By contrast, after 15 d of treatment, when SERT binding sites were markedly reduced by 80%, there was robust decrease in the clearance of 5-HT. Moreover, the functional consequences of SERT downregulation as measured by chronoamperometry were significantly greater than those seen after acute blockade of the SERT by SSRIs. SERT binding sites decreases are not a consequence of reduced SERT gene expression, as revealed by in situ hybridization measurements. SSRI-induced downregulation of the SERT may be a key component for the clinical response to SSRIs.

Sobre o transtorno de pânico e a hipocondria: uma revisão

Introdução/Objetivos: A hipocondria é associada a diversos transtornos de ansiedade, sobretudo ao transtorno de pânico (TP). Estima-se que 50% a 70% dos pacientes com TP tenham sintomas hipocondríacos, e que 13% a 17 % dos hipocondríacos tenham TP associado. O presente estudo teve como objetivo revisar a literatura sobre as relações clínicas, fenomenológicas, cognitivas e psicodinâmicas entre o TP e a hipocondria, além de discutir aspectos conceituais e critérios diagnósticos. Métodos: A busca de artigos foi feita pelo sistema Medline entre 1990 e 2001, utilizando-se, como palavras-chave, transtorno de pânico, agorafobia, hipocondria e preocupações hipocondríacas. Resultados: Considera-se que há comorbidade com hipocondria no TP quando as preocupações com saúde não se restringem a sintomas das crises de pânico. Apesar de geralmente consideradas secundárias, vários pacientes com TP apresentam, antes da primeira crise, manifestações hipocondríacas que podem ser consideradas prodrômicas. A ansiedade pode gerar, num círculo vicioso, preocupações excessivas com saúde, auto-observação seletiva e antecipação do pior. Apesar do viés catastrófico comum, no TP sintomas autonômicos aumentam rapidamente até culminar num ataque, a catástrofe temida é iminente, com comportamentos de esquiva e busca imediata de socorro. Na hipocondria, temem-se doenças mais insidiosas, predominam comportamentos de hipervigilância e busca de reafirmação, as crenças são mais disfuncionais, é pior a relação médico-paciente e maior o foco de sensações erroneamente interpretadas catastroficamente. O medo patológico da morte e a alexitimia estariam presentes nos dois quadros. Conclusão: A sobreposição clínica entre TP/agorafobia e hipocondria é relevante, mas não completa. A relação entre os dois quadros é complexa e possivelmente bidirecional, um aumentando a vulnerabilidade ao outro. Há diferenças fenomenológicas identificáveis e relevantes, com implicações diagnósticas e terapêuticas.

Venlafaxine: a new class of antidepressant

Venlafaxine represents a new class of antidepressant, the serotonin and noradrenaline re-uptake inhibitor (or SNRI). This article discusses its evolution, pharmacological properties and role in the treatment of depression and related disorders, beginning with an outline of the biology of depression.

Self-esteem, social adjustment and suicidality in affective disorders

Self-esteem (SE) and social adjustment (SA) are often impaired during the course of affective disorders; this impairment is associated with suicidal behaviour. The aim of the present study was to investigate SE and SA in unipolar or bipolar patients in relation to demographic and clinical characteristics, especially the presence of suicidality (ideation and/or attempt). Forty-four patients, 28 bipolar and 16 unipolar, in remission for at least 3 months, and 50 healthy individuals were examined through a structured clinical interview. SE and SA were assessed by the Rosenberg self-esteem scale and the social adjustment scale, respectively. The results have shown that bipolar patients did not differ from controls in terms of SE, while unipolar patients had lower SE than bipolars and controls. No significant differences in the mean SA scores were found between the three groups. Suicidality during depression was associated only in bipolar patients with lower SE at remission; similar but not as pronounced was the association of suicidality with SA. It is concluded that low SE lasting into remission seems to be related to the expression of suicidality during depressive episodes of bipolar patients, while no similar pattern is evident in unipolar patients.

Treatment-seeking rates and associated mediating factors among individuals with depression

OBJECTIVE

To systematically review the literature with respect to treatment-seeking rates for depression and associated mediating factors. This review focuses on adolescents and adults of all ages.

METHODS

A structured literature review using Medline and PsychInfo databases revealed 38 relevant papers. Two trained reviewers independently and blindly assessed each study according to 4 inclusion criteria. A total of 17 papers met all 4 criteria.

RESULTS

Between 17.0% and 77.8% of individuals with depressive episodes or disorders sought treatment in these studies. We could explain the range in rates by diverse measures of depression, mediating factors that influence treatment-seeking, varied years in which the studies were done, and different time periods over which treatment-seeking was assessed.

CONCLUSIONS

Treatment-seeking rates for major depression appear to have increased over the years. Age, race, social supports, and clinical and psychiatric factors seem to influence treatment-seeking rates most. Public health initiatives can use this information to facilitate service access and delivery.

An examination of thought control strategies employed by acute and chronic insomniacs

STUDY OBJECTIVES

Theoretical accounts of the progression of insomnia from acute to chronic are lacking. A framework is proposed and tested to examine differences in cognitive coping styles between acute and chronic insomniacs and the relation of cognitive processing and sleep hygiene to causal attributions of insomnia.

METHOD

In a cross-sectional design, the relationship among sleep disturbance, causal attributions and various psychological and behavioural variables was examined in a convenience sample of acute and chronic insomniacs from the general population (N=308).

RESULTS

Negative appraisals and the cognitive coping styles 'Worry' and 'Punishment' were found to be associated with both acute and chronic insomnia, whereas 'Distraction' as a cognitive coping strategy significantly reduced reports of chronic insomnia. The results are discussed in relation to multi-level interventions and future directions in theory, research and application.

Depression, antidepressant therapies, and erectile dysfunction: clinical trials of sildenafil citrate (Viagra) in treated and untreated patients with depression

Erectile dysfunction (ED) and depression are highly prevalent conditions and frequently occur concomitantly in predisposed individuals. Men with ED and depression are also likely to have other comorbid conditions, including diabetes, hypertension, and heart disease. Because ED is also a common adverse effect of some medications for these conditions, patients are frequently noncompliant with treatment. Sildenafil citrate (Viagra) is effective in treating ED of a broad range of etiologies, suggesting that it may be equally beneficial in patients with ED that is associated with depressive symptoms and in those with ED resulting from serotonergic reuptake inhibitor (SRI) antidepressant treatment. We review the results of 3 randomized, placebo-controlled trials and a retrospective analysis of data pooled from 10 clinical trials that examine the efficacy of sildenafil in treating ED associated with depression and as an adverse effect of SRI treatment. The results suggest that sildenafil is efficacious as a first-line treatment for ED in men with untreated minor depression, in men with ED that is refractory to successful SRI treatment of depression, and in those whose depression was successfully treated but who developed ED as a consequence of SRI treatment. Given the complex interrelations among ED, depression, and other comorbid conditions, the key to proper management is a comprehensive evaluation, including sexual function, and an accurate differential diagnosis.

Breaking the myths: new treatment approaches for chronic depression

BACKGROUND

Chronic depressive disorders are common, accounting for approximately one-third of all cases of depression and posing a major public health problem. In the past, chronic depression has been thought to be treatment-resistant, and evidence suggests that it is currently underdiagnosed, misdiagnosed, and suboptimally treated.

OBJECTIVES

To review the subtypes of chronic depression and the evidence-base concerning their optimal treatment and to discuss some key clinical issues and areas of future research.

METHODS

We identified key studies and randomized controlled trials (RCTs) by systematically searching electronic databases and hand searching specialist journals and bibliographies.

RESULTS

Chronic depressive disorders respond well to standard pharmacologic interventions in the acute and maintenance phases of treatment. Standard psychotherapies alone may not be efficacious for chronic depression (especially dysthymia). Recent evidence suggests that treatment combining psychotherapy and medications may be superior to either treatment alone.

CONCLUSIONS

Chronic depressive disorders are amenable to treatment, provided that intervention is both thorough and intensive. Although our knowledge about the optimal treatment of chronic depression has developed rapidly, changes in clinical practice have been slower to evolve. Further research is required to assess the effectiveness of multimodal interventions for chronic depression in more naturalistic settings.