Introduction to behavioral addictions

BACKGROUND

Several behaviors, besides psychoactive substance ingestion, produce short-term reward that may engender persistent behavior, despite knowledge of adverse consequences, i.e., diminished control over the behavior. These disorders have historically been conceptualized in several ways. One view posits these disorders as lying along an impulsive-compulsive spectrum, with some classified as impulse control disorders. An alternate, but not mutually exclusive, conceptualization considers the disorders as non-substance or "behavioral" addictions.

OBJECTIVES

Inform the discussion on the relationship between psychoactive substance and behavioral addictions.

METHODS

We review data illustrating similarities and differences between impulse control disorders or behavioral addictions and substance addictions. This topic is particularly relevant to the optimal classification of these disorders in the forthcoming fifth edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-V).

RESULTS

Growing evidence suggests that behavioral addictions resemble substance addictions in many domains, including natural history, phenomenology, tolerance, comorbidity, overlapping genetic contribution, neurobiological mechanisms, and response to treatment, supporting the DSM-V Task Force proposed new category of Addiction and Related Disorders encompassing both substance use disorders and non-substance addictions. Current data suggest that this combined category may be appropriate for pathological gambling and a few other better studied behavioral addictions, e.g., Internet addiction. There is currently insufficient data to justify any classification of other proposed behavioral addictions.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Proper categorization of behavioral addictions or impulse control disorders has substantial implications for the development of improved prevention and treatment strategies.

An open pilot study of tiagabine in alcohol dependence: tolerability and clinical effects

There is evidence that GABAergic anticonvulsants can be efficacious in the treatment of alcohol dependence and in the prevention of alcohol relapse because these agents act on the substrate that is involved in alcoholism. Tiagabine, a selective GABA transporter1 reuptake inhibitor, may be a promising candidate for the treatment of alcohol-dependent individuals. In this randomized, open pilot study, we aimed to investigate the efficacy and tolerability of tiagabine as adjunctive treatment of alcohol-dependent individuals (N = 60) during the immediate post-detoxification period and during a 6-month follow-up period following alcohol withdrawal. A control non-medicated group of alcohol-dependent individuals (N = 60) was used for comparisons in terms of anxiety and depressive symptoms, craving and drinking outcome. Although a steady improvement in terms of psychopathology, craving and global functioning was observed in both groups throughout the study, subjects on tiagabine improved significantly more compared to the control subjects (P < 0.001). Furthermore, the relapse rate in the tiagabine group was lower than in the control group (7 vs 14.3%). Tiagabine was well tolerated and only a minority of the participants reported some adverse effects in the beginning of tiagabine treatment. Results from this study suggest that tiagabine is a safe and effective medication for the management of alcohol dependence when given adjunctively to a standard psychotherapy treatment. Further studies are warranted before definite conclusions can be reached.

Pregabalin versus naltrexone in alcohol dependence: a randomised, double-blind, comparison trial

Pregabalin (PRE) acts as a presynaptic inhibitor of the release of excessive levels of excitatory neurotransmitters by selectively binding to the alpha(2)-delta subunit of voltage-gated calcium channels. In this randomised, double-blind comparison trial with naltrexone (NAL), we aimed to investigate the efficacy of PRE on alcohol drinking indices. Craving reduction and improvement of psychiatric symptoms were the secondary endpoints. Seventy-one alcohol-dependent subjects were detoxified and subsequently randomised into two groups, receiving 50 mg of NAL or 150-450 mg of PRE. Craving (VAS; OCDS), withdrawal (CIWA-Ar) and psychiatric symptoms (SCL-90-R) rating scales were applied. Alcohol drinking indices and craving scores were not significantly different between groups. Compared with NAL, PRE resulted in greater improvement of specific symptoms in the areas of anxiety, hostility and psychoticism, and survival function (duration of abstinence from alcohol). PRE also resulted in better outcome in patients reporting a comorbid psychiatric disorder. Results from this study globally place PRE within the same range of efficacy as that of NAL. The mechanism involved in the efficacy of PRE in relapse prevention could be less related to alcohol craving and more associated with the treatment of the comorbid psychiatric symptomatology.

Eating ourselves to death (and despair): the contribution of adiposity and inflammation to depression

Obesity and related metabolic conditions are of epidemic proportions in most of the world, affecting both adults and children. The accumulation of lipids in the body in the form of white adipose tissue in the abdomen is now known to activate innate immune mechanisms. Lipid accumulation causes adipocytes to directly secrete the cytokines interleukin (IL) 6 and tumor necrosis factor alpha (TNFalpha), but also monocyte chemoattractant protein 1 (MCP-1), which results in the accumulation of leukocytes in fat tissue. This sets up a chronic inflammatory state which is known to mediate the association between obesity and conditions such as cardiovascular disease, type 2 diabetes, and cancer. There is also a substantial literature linking inflammation with risk for depression. This includes the observations that: (1) people with inflammatory diseases such as multiple sclerosis, cardiovascular disease, and psoriasis have elevated rates of depression; (2) many people administered inflammatory cytokines such as interferon alpha develop depression that is indistinguishable from depression in non-medically ill populations; (3) a significant proportion of depressed persons show upregulation of inflammatory factors such as IL-6, C-reactive protein, and TNFalpha; (4) inflammatory cytokines can interact with virtually every pathophysiologic domain relevant to depression, including neurotransmitter metabolism, neuroendocrine function, and synaptic plasticity. While many factors may contribute to the association between inflammatory mediators and depression, we hypothesize that increased adiposity may be one causal pathway. Mediational analysis suggests a bi-directional association between adiposity and depression, with inflammation possibly playing an intermediary role.

Emerging drugs to treat alcoholism

IMPORTANCE OF THE FIELD

Alcoholism is a widespread disorder with substantial mortality and negative treatment outcomes. To date, few medications have been found to reduce relapse rates or drinking in alcohol-dependent patients.

AREAS COVERED IN THIS REVIEW

This review focuses on drugs that have been clinically tested for the treatment of alcohol dependence in clinical trials, pilot trials or which are considered to have a clinical perspective. For this purpose, a detailed Medline search was conducted on this issue. Although the neurochemical basis of alcoholism and the neuronal circuitry mediating its psychotropic effects have been explored in great detail in recent years, few drugs have emerged for the treatment of alcohol dependence, also because pharmaceutical companies have only a limited interest in this area of research. Acamprosate and the opioid antagonist naltrexone have been found to be effective, although data are mixed. A depot formula of naltrexone and the alternate opioid antagonist nalmefene have been studied in clinical trials and will presumably be introduced in the markets soon. Other emerging drugs are topiramate, novel acetaldehyde dehydrogenase (ALDH) inhibitors, baclofen, a combination therapy of gababentin and flumazenil and drugs targeting the cortitropin-releasing factor/neuropeptide Y mediated stress axis.

WHAT THE READER WILL GAIN

Insights on the neurochemical basis of alcohol dependence and possible targets of medications.

TAKE HOME MESSAGE

Acamprosate, naltrexone and the ALDH inhibitor disulfiram are proven medications for the treatment of alcohol dependence with modest efficacy. Novel alternate medications, a depot formulation of the opioid antagonist naltrexone and another oral opioid antagonist, nalmefene, are available now with good evidence for clinical efficacy. Novel ALDH inhibitors, antiepileptic drugs such as topiramate and drugs targeting the stress axis are currently among the most promising emerging drugs.

Retrospect and prospect of active principles from Chinese herbs in the treatment of dementia

With an ageing population, dementia has become one of the world's primary health challenges. However, existing remedies offer limited benefits with certain side effects, which has prompted researchers to seek complementary and alternative therapies. China has long been known for abundant usage of various herbs. Some of these herbal decoctions are effective in stimulating blood circulation, supplementing vital energy and resisting aging, the lack of which are believed to underlie dementia. These herbs are regarded as new and promising sources of potential anti-dementia drugs. With the rapid evolution of life science and technology, numerous active components have been identified that are highly potent and multi-targeted with low toxicity, and therefore meet the requirements for dementia therapy. This review updates the research progress of Chinese herbs in the treatment of dementia, focusing on their effective principles.

Choosing among antiepileptic drugs

Selecting an antiepileptic drug (AED) for treatment of seizures is daunting because there are now 20 from which to choose. Following simple principles allows a systematic approach to drug selection. Efficacy studies provide limited information. For initial monotherapy of partial seizures, high-level evidence exists for the efficacy of lamotrigine, carbamazepine, oxcarbazepine, and topiramate. For initial monotherapy of generalized seizures, high-level evidence is available for valproate, lamotrigine, topiramate, and oxcarbazepine. For initial monotherapy of absence seizures, high-level evidence exists for valproate, lamotrigine, and ethosaximide. All second-generation AEDs have efficacy as adjunctive therapy for partial seizures. AEDs are often useful for comorbid conditions or have properties that should be avoided in some groups. Thus, AEDs should usually be selected on the basis of comorbid conditions, including depression, migraine, chronic pain, obesity, and nephrolithiasis, or patient characteristics, especially for women of childbearing potential and older adults.

Pathophysiological basis of cardiovascular disease and depression: a chicken-and-egg dilemma

OBJECTIVE

To describe the pathophysiological basis linking cardiovascular disease (CVD) and depression; to discuss the causal relationship between them, and to review the effects of antidepressant treatment on cardiovascular disease.

METHOD

A review of the literature based on the PubMed database.

DISCUSSION

Depression and cardiovascular disease are both highly prevalent. Several studies have shown that the two are closely related. They share common pathophysiological etiologies or co-morbidities, such as alterations in the hypothalamic-pituitary axis, cardiac rhythm disturbances, and hemorheologic, inflammatory and serotoninergic changes. Furthermore, antidepressant treatment is associated with worse cardiac outcomes (in case of tricyclics), which are not observed with selective serotonin reuptake inhibitors.

CONCLUSION

Although there is a strong association between depression and cardiovascular disease, it is still unclear whether depression is actually a causal factor for CVD, or is a mere consequence, or whether both conditions share a common pathophysiological etiology. Nevertheless, both conditions must be treated concomitantly. Drugs other than tricyclics must be used, when needed, to treat the underlying depression and not as mere prophylactic of cardiac outcomes.

Neuroprotective herbs and foods from different traditional medicines and diets

Plant secondary metabolites include an array of bioactive constituents form both medicinal and food plants able to improve human health. The exposure to these phytochemicals, including phenylpropanoids, isoprenoids and alkaloids, through correct dietary habits, may promote health benefits, protecting against the chronic degenerative disorders mainly seen in Western industrialized countries, such as cancer, cardiovascular and neurodegenerative diseases. In this review, we briefly deal with some plant foods and herbs of traditional medicines and diets, focusing on their neuroprotective active components. Because oxidative stress and neuroinflammation resulting from neuroglial activation, at the level of neurons, microglial cells and astrocytes, are key factors in the etiopathogenesis of both neurodegenerative and neurological diseases, emphasis will be placed on the antioxidant and anti-inflammatory activity exerted by specific molecules present in food plants or in remedies prescribed by herbal medicines.

Prevalences and correlates of sleep problems among adolescents in specialty mental health services and in the community: what differs?

AIMS

Knowledge of sleep problems and their relationships among adolescent psychiatric patients is limited. This study investigated whether adolescents in specialty mental health care differ in rate and correlates of sleep problems from adolescents in a community sample; 2465 adolescents from a community sample were compared with a representative clinical sample of 129 adolescent patients.

METHODS

Comparisons were made on frequent sleep problems according to scores on the Youth Self-Report, the Mood and Feelings Questionnaire, and instruments assessing coping styles, stresses and family functioning.

RESULTS

Sleep problems were more frequent in the clinical sample than the community sample (31.3% vs. 5%). Sleeping little and being overtired were the most common sleep problems. Sleep problems were multivariately associated with internalizing problems in both samples. Poor family functioning and distractive coping were multivariately associated with sleep problems among adolescent patients, whereas depressive symptoms were multivariately associated in community adolescents.

CONCLUSIONS

Prevalences of sleep problems were high among adolescent patients. However, sleep problems may be in danger of being unnoticed in clinical practice. Clinicians should ask about such problems and be aware of possible connections with family functioning, depression and suicidality. Therapeutic interventions directed towards sleep problems should be considered.

Predicting the course and outcome of bipolar disorder: a review

Despite of advances in pharmacological and non-pharmacological treatments, bipolar disorder often entails multiple relapses and impaired psychological functioning. The extent to which modern treatments have influenced the natural course of a mental disorder is uncertain. Prediction of the course and outcome of bipolar disorders continues to be challenging, despite the multiple research efforts worldwide. Due to a lack of laboratory diagnostic tests and biomarkers, psychiatric interview and examination provide the basis for outcome prediction. While considered to have more favorable prognosis than schizophrenia, it is not uncommon for bipolar disorder to include persisting alterations of psychosocial functioning. Although long-term symptomatic remission does not guarantee functional recovery, it may have a favorable impact on long-term overall prognosis. The high degree of treatment resistance in patients with bipolar disorder highlights the need to develop better identification of outcome predictors, prognosis and treatment intervention, designed to reverse or prevent this illness burden. This review summarizes the main factors involved in predicting the course and outcome of bipolar disorder.

Complementary and alternative medicine for the treatment of multiple sclerosis

Multiple sclerosis (MS) is a chronic disabling disease of the CNS that affects people during early adulthood. Despite several US FDA-approved medications, the treatment options in MS are limited. Many people with MS explore complementary and alternative medicine (CAM) treatments to help control their MS and treat their symptoms. Surveys suggest that up to 70% of people with MS have tried one or more CAM treatment for their MS. People with MS using CAM generally report deriving some benefit from the therapies. The CAM therapies most frequently used include diet, omega-3 fatty acids and antioxidants. There is very limited research evaluating the safety and effectiveness of CAM in MS. The most promising among CAM therapies that warrant further investigation are a low-fat diet, omega-3 fatty acids, lipoic acid and vitamin D supplementation as potential anti-inflammatory and neuroprotective agents in both relapsing and progressive forms of MS. There is very limited research evaluating the safety and effectiveness of CAM in MS. However, in recent years, the NIH and the National MS Society have been actively supporting the research in this very important area.

Omega-3 fatty acids: potential role in the management of early Alzheimer's disease

Omega-3 fatty acids are essential for brain growth and development. They play an important role throughout life, as critical modulators of neuronal function and regulation of oxidative stress mechanisms, in brain health and disease. Docosahexanoic acid (DHA), the major omega-3 fatty acid found in neurons, has taken on a central role as a target for therapeutic intervention in Alzheimer’s disease (AD). A plethora of in vitro, animal model, and human data, gathered over the past decade, highlight the important role DHA may play in the development of a variety of neurological and psychiatric disorders, including AD. Cross sectional and prospective cohort data have demonstrated that reduced dietary intake or low brain levels of DHA are associated with accelerated cognitive decline or the development of incipient dementia, including AD. Several clinical trials investigating the effects of omega-3 fatty acid supplementation in AD have been completed and all failed to demonstrate its efficacy in the treatment of AD. However, these trials produced intriguing data suggesting that the beneficial effects of omega-3 fatty acid supplementation may depend on the stage of disease, other dietary mediators, and apolipoprotein E status.

Suicidal thoughts in epilepsy: a community-based study in Brazil

Epilepsy has been associated with increased risk of suicide; however, few studies have examined the relationship between epilepsy and suicidal behavior. The aims of this study were to evaluate the frequency of suicidal behavior in people with epilepsy and to identify characteristics that are associated with suicidal ideation in epilepsy. Of 171 people with epilepsy identified in a previous survey, 139 were included. A structured interview was conducted, and a second psychiatric evaluation was scheduled for those who agreed. The frequencies of suicidal thoughts, plans, and attempts during lifetime were 36.7, 18.2, and 12.1%, respectively. The following conditions were strongly associated with suicidal thoughts: anxiety (OR=3.3, 95% CI=1.4-7.5, P=0.001), depression (OR=4.8, 95% CI=1.9-12.5, P=0.001), and two or more standardized psychiatric diagnoses (OR=21.6, 95% CI=4.4-105.9, P<0.0001). Although specific characteristics of epilepsy were found to be related to suicidal thoughts, psychiatric diseases also play an essential role.

Ginkgo biloba e memória - revisão sistemática

INTRODUÇÃO: Com o envelhecimento da população, os distúrbios de memória têm-se tornado patologias cada vez mais frequentes. Com exceção de uma minoria dos casos cujas causas são reversíveis, estas doenças possuem prognóstico desanimador, curso inexorável e opções terapêuticas muito limitadas. O medicamento fitoterápico mais frequentemente utilizado para distúrbios de memória é o extrato seco de ginkgo biloba (GB). Suas ações antioxidantes, antiagregantes e vasodilatadoras têm encorajado diversos profissionais a utilizarem-no neste tratamento, porém não há registros convincentes que comprovem a eficácia do uso desta substância para tal fim. OBJETIVOS: Avaliar a eficácia do GB na prevenção e no tratamento de distúrbios de memória. MÉTODOS: Revisão sistemática da literatura dos últimos dez anos dos estudos clínicos duplo-cegos, randomizados, placebo-controlados, publicados na língua inglesa. RESULTADOS E CONCLUSÕES: Embora tenhamos obtido poucos ensaios controlados sobre o tema, não há evidências suficientes para se indicar o uso da droga com a finalidade de tratar e/ou prevenir distúrbios de memória.

Impact of the novel antidepressant agomelatine on disturbed sleep-wake cycles in depressed patients

BACKGROUND

Disturbance of sleep-wake cycles is common in major depressive disorder (MDD), usually as insomnia, but also as hypersomnia or reduced daytime alertness. Agomelatine, an MT(1) and MT(2) receptor agonist and 5-HT(2C) receptor antagonist, represents a novel approach in MDD, with proven antidepressant efficacy and a positive impact on the sleep-wake cycle. We review the effects of agomelatine 25/50 mg/day on objective and subjective measures of the sleep-wake cycle in MDD.

SUBJECTIVE MEASURES

Agomelatine improved all aspects of the sleep-wake cycle from as early as 1 week in randomized trials versus selective serotonin reuptake inhibitors and venlafaxine, particularly getting off to sleep and quality of sleep, with an improvement in daytime alertness.

OBJECTIVE MEASURES

Agomelatine's effect on sleep architecture in MDD has been measured by polysomnography (PSG). There were significant improvements in sleep efficiency, slow-wave sleep (SWS), and the distribution of delta activity throughout the night, but no change in amount or latency of rapid eye movement (REM) sleep. Furthermore, the slow-wave sleep was resynchronized to the first sleep cycle of the night.

CONCLUSION

Agomelatine, a novel antidepressant, improves disturbed sleep-wake cycles in MDD. The improvement of both nighttime sleep and daytime functioning with agomelatine are promising features of this antidepressant regarding the management of MDD.

Pregabalin in outpatient detoxification of subjects with mild-to-moderate alcohol withdrawal syndrome

OBJECTIVE

In this open, prospective study we aimed to investigate the efficacy, medical safety and practicability of pregabalin in outpatient detoxification of alcohol-dependent patients with mild-to-moderate alcohol withdrawal syndrome (AWS). Craving reduction, improvement of psychiatric symptoms and quality of life were the secondary endpoints.

METHODS

Forty alcohol dependent patients (DSM-IV) were detoxified receiving 200-450 mg of pregabalin. Withdrawal (Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)) and craving (Visual Analogue Scale (VAS); Obsessive and Compulsive Drinking Scale (OCDS)) rating scales were applied; psychiatric symptoms and quality of life were evaluated using the Symptom Check List-90 Revised (SCL-90-R) and the QL-Index, respectively. Relapsed and abstinent patients in the post-detoxification evaluation have been compared.

RESULTS

Alcohol withdrawal symptoms and craving for alcohol resulted significantly reduced (p < 0.001) over time after pregabalin treatment. Pregabalin also resulted in a favourable improvement in psychiatric symptoms and quality of life (p < 0.001).

CONCLUSIONS

To our knowledge, this is the first open, prospective study, about the possible use of pregabalin as an outpatient detoxification agent. These preliminary data show its efficacy and safety in the management of patients with mild-to-moderate AWS.

Pregabalin in the treatment of alcohol and benzodiazepines dependence

We review all available studies on the use of the newer anticonvulsant drug pregabalin (PGB) in the treatment of both alcohol dependence (AD) and benzodiazepine dependence (BD). In AD, the available evidence includes one open-label and one double-blind randomized studies, whereas in BD, only a few case reports and one open-label study are as yet available. In both conditions, PGB was found efficacious with significant improvement in withdrawal symptoms at the dosage ranges of 150-450 mg/day (AD) and 225-900 mg/day (BD). Moreover, its side effects were mild and transient. Despite the limited quality of the studies design, their findings suggest that PGB might constitute a novel efficacious and safe option in the treatment of both AD and BD.

Anticonvulsants for alcohol withdrawal

BACKGROUND

Alcohol abuse and dependence represents a most serious health problem worldwide with major social, interpersonal and legal interpolations. Besides benzodiazepines, anticonvulsants are often used for the treatment of alcohol withdrawal symptoms. Anticonvulsants drugs are indicated for the treatment of alcohol withdrawal syndrome, alone or in combination with benzodiazepine treatments. In spite of the wide use, the exact role of the anticonvulsants for the treatment of alcohol withdrawal has not yet bee adequately assessed.

OBJECTIVES

To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal.

SEARCH STRATEGY

We searched Cochrane Drugs and Alcohol Group' Register of Trials (December 2009), PubMed, EMBASE, CINAHL (1966 to December 2009), EconLIT (1969 to December 2009). Parallel searches on web sites of health technology assessment and related agencies, and their databases.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining the effectiveness, safety and overall risk-benefit of anticonvulsants in comparison with a placebo or other pharmacological treatment. All patients were included regardless of age, gender, nationality, and outpatient or inpatient therapy.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and extracted data from studies.

MAIN RESULTS

Fifty-six studies, with a total of 4076 participants, met the inclusion criteria. Comparing anticonvulsants with placebo, no statistically significant differences for the six outcomes considered.Comparing anticonvulsant versus other drug, 19 outcomes considered, results favour anticonvulsants only in the comparison carbamazepine versus benzodiazepine (oxazepam and lorazepam) for alcohol withdrawal symptoms (CIWA-Ar score): 3 studies, 262 participants, MD -1.04 (-1.89 to -0.20), none of the other comparisons reached statistical significance.Comparing different anticonvulsants no statistically significant differences in the two outcomes considered.Comparing anticonvulsants plus other drugs versus other drugs (3 outcomes considered), results from one study, 72 participants, favour paraldehyde plus chloral hydrate versus chlordiazepoxide, for the severe-life threatening side effects, RR 0.12 (0.03 to 0.44).

AUTHORS' CONCLUSIONS

Results of this review do not provide sufficient evidence in favour of anticonvulsants for the treatment of AWS. There are some suggestions that carbamazepine may actually be more effective in treating some aspects of alcohol withdrawal when compared to benzodiazepines, the current first-line regimen for alcohol withdrawal syndrome. Anticonvulsants seem to have limited side effects, although adverse effects are not rigorously reported in the analysed trials.

Oxidative stress and neurobehavioral problems in pediatric acute lymphoblastic leukemia patients undergoing chemotherapy

Neurobehavioral problems after chemotherapy treatment for pediatric acute lymphoblastic leukemia (ALL) have been a recent focus of investigation. This study extended previous research that suggested oxidative stress as a potential mechanism for chemotherapy-induced central nervous system injury by examining early markers of oxidative stress in relation to subsequent neurobehavioral problems. Oxidized and unoxidized components of phosphatidylcholine (PC) were measured in the cerebrospinal fluid of 87 children with ALL at diagnosis, induction, and consolidation. Behavioral assessments were conducted postconsolidation and at the end of chemotherapy. Results revealed a significant association between physiologic reactivity (high vs. low PC changes from diagnosis) and behavioral outcomes (high vs. low pathology). Elevated oxidized PC fraction change was predictive of increased problems with aggression at the end of therapy as well as postconsolidation adaptability. Furthermore, symptoms of hyperactivity systematically changed over time in relation to both unoxidized PC and oxidized PC fraction reactivity. These findings suggest that symptoms of behavioral problems occur early in the course of chemotherapy and that increases in the cerebrospinal fluid PC markers of oxidative stress during induction and consolidation may help to predict certain future behavioral problems.

Who benefits the most from psychiatric day hospitals? A comparison of three clinical groups

Comparison of the effects of psychiatric day hospital programs between homogenous clinical groups is an important issue that requires more attention. One group of day hospital patients who have not been included in most studies are people with cluster B personality disorders. The purpose of this study was to compare clinical and social participation outcomes in three groups of individuals treated in a psychiatric day hospital: patients with psychotic disorders, patients with mood and anxiety disorders, and patients with cluster B personality disorders. A pre-experimental, pre-test post-test design was used. During the first and last week of treatment, as well as 6 months after discharge, 20 participants in each group completed questionnaires on severity of symptoms, distress, accomplishment, satisfaction with social participation, and self-esteem. During the intervention, there was significant improvement in all groups on all variables, except for self-esteem in people with psychotic disorders, which remained stable. The patients with psychotic disorders showed significantly less improvement than the two other groups in severity of symptoms, distress, and self-esteem. Following discharge, the degree of change was comparable in the three groups on all variables based on between-groups analyses. However, based on within-group analyses, patients in the mood and anxiety disorders group continued to show significant improvement over time after discharge on self-esteem, accomplishment, and satisfaction with social participation, while no significant changes were seen in the other two groups. Although all three clinical groups made significant gains during their participation at the day hospital and maintained these gains after discharge, those with mood and anxiety disorders benefited the most from their day hospital experience.

Pregabalin, tiapride and lorazepam in alcohol withdrawal syndrome: a multi-centre, randomized, single-blind comparison trial

INTRODUCTION

The aim of this trial was to compare lorazepam with non-benzodiazepine medications such as pregabalin and tiapride in the treatment of alcohol withdrawal syndrome (AWS). These drugs were chosen for their inhibitorial effects on the hypersecretion of neurotransmitters usually observed in AWS. Craving reduction and improvement of psychiatric symptoms were the secondary end-points.

METHODS

One hundred and ninety subjects affected by current alcohol dependence were considered consecutively: 111 were enrolled and divided into three groups of 37 subjects each. Within a treatment duration of 14 days, medication was given up to the following maximum doses (pregabalin 450 mg/day; tiapride 800 mg/day; lorazepam 10 mg/day). Withdrawal (CIWA-Ar), craving [visual analogue scale (VAS); Obsessive and Compulsive Drinking Scale (OCDS)], psychiatric symptoms [Symptom Check List 90 Revised (SCL-90-R)] and quality of life (QL-index) rating scales were applied.

RESULTS

On the CIWA-Ar score, all the groups showed a significant reduction between times (P < 0.001) with a higher reduction for the pregabalin group (P < 0.01) on items regarding headache and orientation. Retention in treatment was lower in the tiapride group (P < 0.05), while the number of subjects remaining alcohol free was higher in the pregabalin group (P < 0.05). Significant reduction between baseline and the end of the treatment was found in all the groups at the OCDS and the VAS for craving, at the SCL-90-R and QL-index (P < 0.001).

DISCUSSION

All the medications in the trial showed evidence of safety and efficacy in the treatment of uncomplicated forms of AWS, with some particular differences. The efficacy of pregabalin was superior to that of tiapride, used largely in research trials and, for some measures, to that of the 'gold standard', lorazepam. Accordingly, pregabalin may be considered as a potentially useful new drug for treatment of AWS, deserving further investigation.

Adaptation of interpersonal psychotherapy to borderline personality disorder: a comparison of combined therapy and single pharmacotherapy

OBJECTIVE

Combined treatment with interpersonal psychotherapy (IPT) and antidepressants (ADs) has been found more effective than single pharmacotherapy in patients with major depression and concomitant borderline personality disorder (BPD). The aim of our study is to investigate whether combined treatment with a modified version of IPT is still superior to ADs when treating patients with a single diagnosis of BPD.

METHOD

Fifty-five consecutive outpatients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis of BPD were enrolled. They were randomly assigned to 2 treatment arms for 32 weeks: fluoxetine 20 to 40 mg per day plus clinical management; and fluoxetine 20 to 40 mg per day plus IPT adapted to BPD (IPT-BPD). Eleven patients (20%) discontinued treatment owing to noncompliance. Forty-four patients completed the treatment period. They were assessed at baseline, and at week 16 and 32 with: a semi-structured interview for demographic and clinical variables; Clinical Global Impression Scale (CGI-S); Hamilton Depression Rating Scale (HDRS); Hamilton Anxiety Rating Scale (HARS); Social and Occupational Functioning Assessment Scale (SOFAS); BPD Severity Index (BPD-SI); and a questionnaire for quality of life (Satisfaction Profile [SAT-P]). A univariate general linear model was performed with 2 factors: duration and type of treatment. P values of less than 0.05 were considered significant.

RESULTS

Remission rates did not differ significantly between subgroups. Duration, but not type of treatment, had a significant effect on CGI-S, HDRS, SOFAS, and total BPD-SI score changes. Combined therapy was more effective on the HARS; the items: interpersonal relationships, affective instability, and impulsivity of BPD-SI; and the factors: psychological functioning and social functioning of SAT-P.

CONCLUSIONS

Combined therapy with adapted IPT was superior to fluoxetine alone in BPD patients, concerning a few core symptoms of the disorder, anxiety, and quality of life.

White matter abnormalities in bipolar disorder: insights from diffusion tensor imaging studies

Diffusion tensor imaging (DTI) is a neuroimaging technique with the potential to elucidate white matter abnormalities. Recently, it has been applied to help in better understanding of the pathophysiology of bipolar disorder (BD). This review sought to synthesise existing literature on DTI studies in BD, summarise current findings and highlight brain regions that have consistently been implicated in BD, as well as posit possible future directions for DTI research in BD. The extant findings from this review suggest loss of white matter network connectivity as a possible phenomenon associated with bipolar disorder, involving prefrontal and frontal regions, projection, associative and commissural fibres, with sparse and less consistent evidence implicating the subcortical and non-frontal lobes of the brain. There are some differences in the direction of changes observed in white matter indices, and these may be attributed to factors including sample heterogeneity and limitations of DTI techniques. The possible roles of the parietal, temporal and occipital lobes and subcortical regions in BD await further investigation. Studies of bipolar disorder using DTI lag behind other neuropsychiatric diseases such as schizophrenia, but DTI research in BD is fast gaining pace. The emerging trends from these DTI findings underscore the importance of further research to unravel the underlying neural mechanisms and clinico-anatomical correlations involving white matter in BD.

Excessive substance use in bipolar disorder is associated with impaired functioning rather than clinical characteristics, a descriptive study

BACKGROUND

There is a strong association between bipolar disorder (BD) and substance use disorder (SUD). The clinical and functional correlates of SUD in BD are still unclear and little is known about the role of excessive substance use that does not meet SUD criteria. Thus, the aims of the current study were to investigate lifetime rates of illicit substance use in BD relative to the normal population and if there are differences in clinical and functional features between BD patients with and without excessive substance use.

METHODS

125 consecutively recruited BD in- and outpatients from the Oslo University Hospitals and 327 persons randomly drawn from the population in Oslo, Norway participated. Clinical and functional variables were assessed. Excessive substance use was defined as DSM-IV SUD and/or excessive use according to predefined criteria.

RESULTS

The rate of lifetime illicit substance use was significantly higher among patients compared to the reference population (OR = 3.03, CI = 1.9-4.8, p < .001). Patients with excessive substance use (45% of total) had poorer educational level, occupational status, GAF-scores and medication compliance, with a trend towards higher suicidality rates, compared to patients without. There were no significant group differences in current symptom levels or disease course between groups.

CONCLUSION

The percentage of patients with BD that had tried illicit substances was significantly higher than in the normal population. BD patients with excessive substance use clearly had impaired functioning, but not a worse course of illness compared to patients without excessive substance use. An assessment of substance use beyond SUD criteria in BD is clinically relevant.

The Ginkgo biloba extract EGb 761(R) and its main constituent flavonoids and ginkgolides increase extracellular dopamine levels in the rat prefrontal cortex

BACKGROUND AND PURPOSE

Experimental and clinical data suggest that extracts of Ginkgo biloba improve cognitive function. However, the neurochemical correlates of these effects are not yet fully clarified. The purpose of this study was to examine the effects of acute and repeated oral administration of the standardized extract EGb 761((R)) on extracellular levels of dopamine, noradrenaline and serotonin (5-HT), and the dopamine metabolites 3,4-dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) in the prefrontal cortex (PFC) and striatum of conscious rats.

EXPERIMENTAL APPROACH

Monoamines and their metabolites were monitored by the use of microdialysis sampling and HPLC with electrochemical or fluorescence detection.

KEY RESULTS

A single oral dose of EGb 761 (100 mg.kg(-1)) had no effect on monoamine levels. However, following chronic (100 mg.kg(-1)/14 days/once daily) treatment, the same dose significantly increased extracellular dopamine and noradrenaline levels, while 5-HT levels were unaffected. Chronic treatment with EGb 761 showed dose-dependent increases in frontocortical dopamine levels and, to a lesser extent, in the striatum. The extracellular levels of HVA and DOPAC were not affected by either acute or repeated doses. Treatment with the main constituents of EGb 761 revealed that the increase in dopamine levels was mostly caused by the flavonol glycosides and ginkgolide fractions, whereas bilobalide treatment was without effect.

CONCLUSIONS AND IMPLICATIONS

The present results demonstrate that chronic but not acute treatment with EGb 761 increased dopaminergic transmission in the PFC. This finding may be one of the mechanisms underlying the reported effects of G. biloba in improving cognitive function.

Quantitative determination of Amaryllidaceae alkaloids from Galanthus reginae-olgae subsp. vernalis and in vitro activities relevant for neurodegenerative diseases

In the present work the qualitative and quantitative analysis of Amaryllidaceae-type alkaloids in the aerial parts and bulbs of Galanthus reginae-olgae Orph. subsp. vernalis Kamari is presented for the first time using GC-MS analysis. The alkaloids galanthamine, lycorine, and tazettine were identified in both extracts while crinine and neronine were found only in the bulbs. The yield of alkaloid fraction from bulbs (36.8%) is very high compared to the yield from aerial parts (9.34%). Lycorine was the major component in both fractions. The antioxidant potential was determined by three complementary methods. The preparations to reduce the stable free radical DPPH to the yellow-colored 1,1-diphenyl-2-picrylhydrazyl with IC(50) values of 39 and 29 mug/mL for MeOH extracts from aerial parts and bulbs, respectively. The higher activity was given by EtOAc fraction of aerial parts with IC(50) of 10 mug/mL. This activity is probably due to the presence in EtOAc fraction of polar compounds such as polyphenols. The fraction exhibited a significant antioxidant capacity also in the beta-carotene-linoleic acid test system. A higher level of antioxidant activity was observed for EtOAc fraction from bulbs with IC(50) of 10 mug/mL after 30 min and 9 mug/mL after 60 min of incubation. In contrast, the fraction from bulbs performed poorly in the lipid peroxidation liposomes assay. Significant activity was obtained for dichloromethane fraction from aerial parts (IC(50) of 74 mug/mL). The major abundance of alkaloid in dichloromethane fraction may be responsible of the bulbs anti-cholinesterase highest activity (38.5%) at 0.5 mg/mL.

Wisconsin Card Sorting Test performance and impulsivity in patients with temporal lobe epilepsy: suicidal risk and suicide attempts

OBJECTIVE

The goal of the study described here was to determine if executive dysfunction and impulsivity are related to risk for suicide and suicide attempts in patients with temporal lobe epilepsy.

METHOD

Forty-two patients with temporal lobe epilepsy were recruited. A detailed medical history, neurological examination, serial EEGs, Mini-International Neuropsychiatric Interview, executive function, and MRI were assessed. Multiple regression analysis was carried out to examine predictive associations between clinical variables and Wisconsin Card Sorting Test measures.

RESULTS

Patients' scores on the Risk for Suicide Scale (n=24) were greater than 7, which means they had the highest relative risk for suicide attempts. Family history of psychiatric disease, current major depressive episode, left temporal lobe epilepsy, and perseverative responses and total errors on the Wisconsin Card Sorting Test increased by 6.3 and 7.5 suicide risk and suicide attempts, respectively. Executive dysfunction (specifically perseverative responses and more total errors) contributed greatly to suicide risk.

CONCLUSION

Executive performance has a major impact on suicide risk and suicide attempts in patients with temporal lobe epilepsy.

From Galapagos to the labs: Darwinian medicine and epilepsy today

In 1991, a mummy frozen in ice was found by climbers in the Tyrolean Alps. Otzi the Iceman has since been studied in the light of evolutionary explanations for diseases. This year, which marks Charles Darwin's 200th birthday and the 150th anniversary of his publication On the Origin of Species, should re-ignite discussion of the importance of the correlation between nutritional diet and diseases. Epilepsy is one of the commonest diseases in the world. Individuals with epilepsy are at higher risk of death than the general population, and sudden unexpected death (SUDEP) is the most important direct epilepsy-related cause of death. A number of factors may influence the risk for SUDEP. Along these lines, several studies have demonstrated that polyunsaturated (omega-3) fatty acids may reduce the risk of cardiovascular mortality, and diminish neuronal excitability. Also, omega-3 fatty acids may decrease seizure frequency, contributing to the reduction of SUDEP risk. Reconstruction of the nutritional patterns of Stone Age humans and optimal human nutrition in the present may be relevant to the prevention and treatment of chronic diseases such as epilepsy and the catastrophic evolution into epilepsy refractoriness and SUDEP.

Novel piperazine derivative PMS1339 exhibits tri-functional properties and cognitive improvement in mice

Amyloid-beta-induced neuroinflammation plays a central role in the extensive loss of cholinergic neurons and cognitive decline in Alzheimer's disease. The acetylcholinesterase (AChE) inhibitors are the first class of drugs used to enhance surviving cholinergic activities. However, their limited effectiveness following long-term treatment raises a need for new multi-target therapies. We report herein a novel piperazine derivative compound PMS1339 possesses multifunctional properties including anti-platelet-activating factor, AChE inhibition, Abeta aggregation inhibition and cognitive improvement. PMS1339 could significantly inhibit both mice brain AChE (IC50=4.41+/-0.63 microM) and sera butyrylcholinesterase (BuChE, IC50=1.09+/-0.20 microM). PMS1339 was also found to inhibit neuronal AChE secreted by SH-SY5Y cell line (IC50=17.95+/-2.31 microM). Enzyme kinetics experiments performed on electric eel AChE indicated that PMS1339 acts as a mixed type competitive AChE inhibitor. Molecular docking studies using the X-ray crystal structure of AChE from Torpedo californica elucidated the interactions between PMS1339 and AChE: PMS1339 is well buried inside the active-site gorge of AChE interacting with Trp84 at the bottom, Tyr121 halfway down and Trp279 at the peripheral anionic site (PAS). Thioflavin T-based fluorimetric assay revealed the ability of PMS1339 to inhibit AChE-induced Abeta aggregation. In-vivo study indicated PMS1339 (1 mg/kg i.p.) reversed scopolamine-induced memory impairment in mice. Overall, these findings indicated that PMS1339 exhibits tri-functional properties in vitro and cognitive improvement in vivo, and revealed the emergence of a multi-target-directed ligand to tackle the determinants of Alzheimer's disease.

Anticonvulsants in the treatment of major depressive disorder: an overview

Major depressive disorder (MDD) is highly prevalent, potentially disabling, and sometimes fatal. Antidepressants (ADs) have improved its treatment, but incomplete response, sustained morbidity, recurrences, agitation, substance abuse, excess medical mortality, and suicide remain unsolved problems among mood disorder patients. AD treatment itself sometimes induces adverse behavioral responses. Several anticonvulsants (ACs) used to treat bipolar disorder (BPD) might also be of value for MDD. Accordingly, we reviewed published reports on ACs for MDD, identifying studies by computerized searches. We excluded reports dealing only with BPD patients or with sedatives, classified trials by design quality, and evaluated treatment of acute episodes and recurrences of adult MDD. We found 36 reports involving 41 relevant trials of carbamazepine (12 trials), valproate (11), lamotrigine (9), gabapentin (3), topiramate (3), phenytoin (2), and tiagabine (1). They include 9 blinded, controlled trials (of 28-70 days), involving carbamazepine (3 trials), lamotrigine (3), phenytoin (2), or topiramate (1) as primary treatments (5) or AD adjuncts (4). Some of these trials, as well as 7 of lesser quality, suggest benefits of carbamazepine, lamotrigine, and valproate, mainly as adjuncts to ADs. Another 20 anecdotes or small trials further suggest that these ACs might be useful as AD adjuncts-specifically to treat irritability or agitation in MDD. Overall, these reports provide suggestive evidence of beneficial effects of carbamazepine, lamotrigine, and valproate that require further study, especially for long-term adjunctive use, particularly in patients with recurring MDD with prominent irritability or agitation.

Omega-3 consumption and sudden cardiac death in schizophrenia

People with schizophrenia show a two- to three-fold increased risk to die prematurely. Mortality is accounted for by a combination of factors (patients' life style, suicide, premature cardiovascular disease, metabolic syndromes and, not so often mentioned, sudden death). The cause of sudden death in schizophrenia is unknown, but cardiac arrhythmia plays a potential role. Patients with schizophrenia are at high risk for cardiovascular disease, and some antipsychotics may be associated with cardiovascular adverse events (e.g., electrocardiograph QT interval prolongation), suggesting that this could lead to sudden cardiac death. Animal and clinical studies have shown that omega-3 fatty acids could be useful in the prevention and treatment of schizophrenia. As omega-3 fatty acids have been considered a cardioprotector agent, reducing cardiac arrhythmias and hence sudden cardiac deaths and given their relative safety and general health benefits, our update article summarizes the knowledge by the possible positive effects of omega-3 supplementation and fish consumption against sudden cardiac death in patients with schizophrenia. However, fish species should be selected with caution due to contamination with toxic methylmercury.

Conversion disorder and coexisting nonepileptic seizures in patients with refractory seizures

Nonepileptic seizures (NES) are commonly observed in patients with seizures resistant to antiepileptic drugs (AEDs). However, NES may be symptomatic of different diagnoses, in particular, conversion disorder (CD) and coexisting NES and epileptic seizures (CENES). We compared the clinical characteristics of these disorders in 219 patients with refractory seizures. The prevalence of NES was similar in children (11%) and adults (16%). In both groups, CENES represented the most frequent cause of NES (75%). In adults, CD was associated with a shorter duration of illness and normal neuroimaging and interictal EEG compared with the other groups. Patients with CD represented one-quarter of all patients with AED-resistant seizures with normal presentation during interictal investigations. In both children and adults with AED-resistant seizures, NES are frequently observed and are three times more likely to be CENES than CD.

Differential effects of levetiracetam, carbamazepine, and lamotrigine on reproductive endocrine function in adults

Animal studies have shown endocrine changes after levetiracetam treatment. The present study investigated reproductive and sexual function in patients with epilepsy (aged 18-45) treated with levetiracetam (LEV: 30 men/26 women), carbamazepine (CBZ: 63 men/30 women), or lamotrigine (LTG: 37 men/40 women) monotherapy and in healthy controls (36 men/44 women). In women, no endocrine changes were observed during LEV treatment, whereas steroid hormone-binding globulin levels were greater and progesterone levels lower in women using CBZ. Dehydroepiandrosterone sulfate levels were higher and androstenedione levels lower in LTG-treated women. Arizona Sexual Experience Scale scores, which were significantly lower in females using LTG or LEV, suggesting they have better sexual function than CBZ users and controls. In men, no drug-specific hormonal pattern was observed after LEV treatment. Male patients in all treatment groups had lower androstenedione and free testosterone. Those using CBZ had lower free androgen indices and dehydroepiandrosterone sulfate levels, and higher steroid hormone-binding globulin, follicle-stimulating hormone, and luteinizing hormone levels. Arizona Sexual Experience Scale scores for men were similar in all groups. In conclusion, LEV treatment apparently has no drug-specific sexual or endocrine side effects in men or women in this age group.