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Yoshinaga N, Matsuki S, Niitsu T, Sato Y, Tanaka M, Ibuki H, Takanashi R, Ohshiro K, Ohshima F, Asano K, Kobori O, Yoshimura K, Hirano Y, Sawaguchi K, Koshizaka M, Hanaoka H, Nakagawa A, Nakazato M, Iyo M, Shimizu E. Cognitive Behavioral Therapy for Patients with Social Anxiety Disorder Who Remain Symptomatic following Antidepressant Treatment: A Randomized, Assessor-Blinded, Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:208-17. [PMID: 27230862 DOI: 10.1159/000444221] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 01/17/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although antidepressants are still a commonly used treatment for social anxiety disorder (SAD), a significant proportion of patients fail to remit following antidepressants. However, no standard approach has been established for managing such patients. This study aimed to examine the effectiveness of cognitive behavioral therapy (CBT) as an adjunct to usual care (UC) compared with UC alone in SAD patients who remain symptomatic following antidepressant treatment. METHODS This was a prospective randomized open-blinded end-point study with two parallel groups (CBT + UC, and UC alone, both for 16 weeks) conducted from June 2012 to March 2014. SAD patients who remain symptomatic following antidepressant treatment were recruited, and a total sample size of 42 was set based on pilot results. RESULTS Patients were randomly allocated to CBT + UC (n = 21) or UC alone (n = 21). After 16 weeks, adjusted mean reduction in the Liebowitz Social Anxiety Scale from baseline for CBT + UC and UC alone was -40.87 and 0.68, respectively; the between-group difference was -41.55 (-53.68 to -29.42, p < 0.0001). Response rates were 85.7 and 10.0% for CBT + UC and UC alone, respectively (p < 0.0001). The corresponding remission rates were 47.6 and 0.0%, respectively (p = 0.0005). Significant differences were also found in favor of CBT + UC for social anxiety symptoms, depressive symptoms, and functional impairment. CONCLUSIONS Our results suggest that in SAD patients who have been ineffectively treated with antidepressants, CBT is an effective treatment adjunct to UC over 16 weeks in reducing social anxiety and related symptoms.
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Affiliation(s)
- Naoki Yoshinaga
- Organization for Promotion of Tenure Track, University of Miyazaki, Miyazaki, Japan
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Pairas GN, Perperopoulou F, Tsoungas PG, Varvounis G. The Isoxazole Ring and ItsN-Oxide: A Privileged Core Structure in Neuropsychiatric Therapeutics. ChemMedChem 2017; 12:408-419. [DOI: 10.1002/cmdc.201700023] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/13/2017] [Indexed: 01/23/2023]
Affiliation(s)
- George N. Pairas
- Laboratory of Medicinal Chemistry, Department of Pharmacy; University of Patras; 265 04 Patras Greece
| | - Fereniki Perperopoulou
- Laboratory of Enzyme Technology, Department of Biotechnology; Agricultural University of Athens; 75 Iera Odos St. 118 55 Athens Greece
| | - Petros G. Tsoungas
- Laboratory of Biochemistry; Hellenic Pasteur Institute; 127 Vas. Sofias Ave. 115 21 Athens Greece
| | - George Varvounis
- Section of Organic Chemistry and Biochemistry, Department of Chemistry; University of Ioannina; 451 10 Ioannina Greece
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203
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Klein NS, van Rijsbergen GD, Ten Doesschate MC, Hollon SD, Burger H, Bockting CLH. Beliefs about the causes of depression and recovery and their impact on adherence, dosage, and successful tapering of antidepressants. Depress Anxiety 2017; 34:227-235. [PMID: 28102582 DOI: 10.1002/da.22598] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 12/07/2016] [Accepted: 12/12/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Continuation of antidepressant medication (ADM) after remission is widely used to prevent depressive relapse/recurrence. Little is known about predictors of ADM use in terms of adherence, dosage, and successful tapering. The current study aimed to explore beliefs about the causes of depression and recovery (i.e., causal beliefs) and to examine whether they predict ADM use. METHODS The data were drawn from a controlled trial and an extension of this trial with additional experience sampling. In total, 289 remitted patients with recurrent depression (ADM ≥ 6 months) were randomly assigned to Preventive Cognitive Therapy (PCT) with ADM tapering, PCT with maintenance ADM, or maintenance ADM alone. Adherence, ADM dosage, and causal beliefs regarding the first and last depressive episodes were explored via questionnaires. RESULTS Most patients mentioned stressful life events as cause of depression, although more patients tended to endorse external causes for the first episode and internal causes for the last episode. ADM was most often mentioned as helpful during recovery from both episodes. Over half of all patients were adherent and under half of the patients in the tapering condition were able to complete the taper. Causal beliefs did not predict ADM use. CONCLUSIONS The results suggest that causal beliefs play little role in the use of maintenance ADM. More information is needed on factors contributing to successful tapering. The results must be interpreted with caution as this is not a naturalistic study and the results might be biased toward a more favorable view regarding ADM.
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Affiliation(s)
- Nicola S Klein
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands
| | - Gerard D van Rijsbergen
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands.,Department of early detection and intervention in psychosis, GGZ Drenthe, the Netherlands
| | | | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Huibert Burger
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Claudi L H Bockting
- Department of Clinical Psychology, University of Groningen, Groningen, the Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
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Abstract
Treatment resistance to the antidepressive pharmacotherapy represents one of the most important clinical challenges in the pharmacological management of unipolar depression. In this review, we aimed to summarise the evidence for various pharmacological treatment options in therapy-resistant unipolar depression derived from clinical trials, systematic reviews, meta-analyses and treatment guidelines. The first measure in case of insufficient response to the initial antidepressant monotherapy contains the debarment of 'pseudo-resistance', potentially caused by inadequate dose and treatment duration of the antidepressant, insufficient plasma levels, non-compliance of the patient regarding medication intake or relevant psychiatric and/or somatic comorbidities. Applying a dose escalation of the current antidepressant cannot be generally recommended as evidence-based treatment option and the efficacy depends on the class of antidepressants. There is no compelling evidence for a switch to another, new antidepressant compound after insufficient response to a previous antidepressant. The combination of two antidepressants should be preferentially established with antidepressants characterised by different mechanisms of action (e.g. reuptake inhibitors together with presynaptic autoreceptor inhibitors). At present, the most convincing body of evidence exists for the augmentation of antidepressants with second-generation antipsychotic drugs and lithium. Hence, both strategies are consistently advised by treatment guidelines as pharmacological first-line strategy in treatment-resistant depression.
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Affiliation(s)
- Markus Dold
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | - Siegfried Kasper
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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Cosci F. Withdrawal symptoms after discontinuation of a noradrenergic and specific serotonergic antidepressant: A case report and review of the literature. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.pmip.2016.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hengartner MP. Methodological Flaws, Conflicts of Interest, and Scientific Fallacies: Implications for the Evaluation of Antidepressants' Efficacy and Harm. Front Psychiatry 2017; 8:275. [PMID: 29270136 PMCID: PMC5725408 DOI: 10.3389/fpsyt.2017.00275] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/24/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In current psychiatric practice, antidepressants are widely and with ever-increasing frequency prescribed to patients. However, several scientific biases obfuscate estimates of antidepressants' efficacy and harm, and these are barely recognized in treatment guidelines. The aim of this mini-review is to critically evaluate the efficacy and harm of antidepressants for acute and maintenance treatment with respect to systematic biases related to industry funding and trial methodology. METHODS Narrative review based on a comprehensive search of the literature. RESULTS It is shown that the pooled efficacy of antidepressants is weak and below the threshold of a minimally clinically important change once publication and reporting biases are considered. Moreover, the small mean difference in symptom reductions relative to placebo is possibly attributable to observer effects in unblinded assessors and patient expectancies. With respect to trial dropout rates, a hard outcome not subjected to observer bias, no difference was observed between antidepressants and placebo. The discontinuation trials on the efficacy of antidepressants in maintenance therapy are systematically flawed, because in these studies, spontaneous remitters are excluded, whereas half of all patients who remitted on antidepressants are abruptly switched to placebo. This can cause a severe withdrawal syndrome that is easily misdiagnosed as a relapse when assessed on subjective symptom rating scales. In accordance, the findings of naturalistic long-term studies suggest that maintenance therapy has no clear benefit, and non-drug users do not show increased recurrence rates. Moreover, a growing body of evidence from hundreds of randomized controlled trials suggests that antidepressants cause suicidality, but this risk is underestimated because data from industry-funded trials are systematically flawed. Unselected, population-wide observational studies indicate that depressive patients who use antidepressants are at an increased risk of suicide and that they have a higher rate of all-cause mortality than matched controls. CONCLUSION The strong reliance on industry-funded research results in an uncritical approval of antidepressants. Due to several flaws such as publication and reporting bias, unblinding of outcome assessors, concealment and recoding of serious adverse events, the efficacy of antidepressants is systematically overestimated, and harm is systematically underestimated. Therefore, I conclude that antidepressants are largely ineffective and potentially harmful.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), Zurich, Switzerland
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Abstract
In 1968, DiMascio and Shader provided a conceptual framework for behavioral toxicity of psychotropic drugs (ie, the pharmacological actions of a drug that, within the dose range in which it has been found to possess clinical utility, may produce alterations in mood, perceptual, cognitive, and psychomotor functions that limit the capacity of the individual or constitute a hazard to one's well-being). A drug effect such as sedation or motor stimulation may be considered adverse for one patient and yet therapeutic and desired for another patient; within the same patient, it may be of value at one stage of one's illness and adverse at a later stage. The concept of behavioral toxicity encompasses adverse events that may be limited to the period of drug administration and/or persist long after their discontinuation. These latter phenomena can be subsumed under the rubric of iatrogenic comorbidity. Behavioral toxicity may ensue with any type of medical drug. Examples related to antidepressant drug use (onset of suicidality and aggression, switching from unipolar to bipolar course, withdrawal phenomena upon discontinuation, postwithdrawal persistent disorders) are discussed. Consideration of potential vulnerability to adverse events including behavioral toxicity should be placed in the context of the benefits that treatment may entail.
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Fava GA. The Hidden Costs of Financial Conflicts of Interest in Medicine. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 85:65-70. [PMID: 26807570 DOI: 10.1159/000442694] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/18/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Department of Psychology, University of Bologna, Bologna, Italy; Department of Psychiatry, State University of New York at Buffalo, Buffalo, N.Y., USA
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AlQuorain S, Alfaraj S, Alshahrani M. Bilateral acute closed angle glaucoma associated with the discontinuation of escitalopram: a case report. Open Access Emerg Med 2016; 8:61-5. [PMID: 27660499 PMCID: PMC5019444 DOI: 10.2147/oaem.s107551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 45-year-old woman presented to the Emergency Department complaining of severe headache for 3 hours duration associated with bilateral blurred vision, photophobia, and one attack of vomiting. Her clinical examination revealed normal vital signs and decrease in visual acuity with hazy cornea bilaterally. There were no signs of increased intracranial pressure and no neck rigidity or meningeal signs. The patient was diagnosed with bilateral acute closed angle glaucoma (AACG) with intraocular pressure of 60 mmHg in both eyes. She was using escitalopram for the treatment of depression, which was the only known risk factor for her condition. Standard treatment for AACG was provided. It included topical β-blocker, α agonists, and acetazolamide. This was followed by bilateral peripheral iridotomy. Follow-up intraocular pressure measurement revealed a value of 5 mmHg after 24 hours, indicating complete recovery. To the best of our knowledge, this is the first case to describe AACG after stopping the medication. It is highly important that clinicians be aware of this risk factor for AACG and have high index of suspicion in such patients with vision-threatening condition even after discontinuing the medication, because the risk persists for some time.
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Affiliation(s)
| | - Sukayna Alfaraj
- Department of Emergency Medicine, King Fahad Hospital of the University, University of Dammam, Dammam, Saudi Arabia
| | - Mohammed Alshahrani
- Department of Emergency Medicine, King Fahad Hospital of the University, University of Dammam, Dammam, Saudi Arabia
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Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, Hasnain M, Jollant F, Levitt AJ, MacQueen GM, McInerney SJ, McIntosh D, Milev RV, Müller DJ, Parikh SV, Pearson NL, Ravindran AV, Uher R. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:540-60. [PMID: 27486148 PMCID: PMC4994790 DOI: 10.1177/0706743716659417] [Citation(s) in RCA: 688] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The Canadian Network for Mood and Anxiety Treatments (CANMAT) conducted a revision of the 2009 guidelines by updating the evidence and recommendations. The scope of the 2016 guidelines remains the management of major depressive disorder (MDD) in adults, with a target audience of psychiatrists and other mental health professionals. METHODS Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Pharmacological Treatments" is the third of six sections of the 2016 guidelines. With little new information on older medications, treatment recommendations focus on second-generation antidepressants. RESULTS Evidence-informed responses are given for 21 questions under 4 broad categories: 1) principles of pharmacological management, including individualized assessment of patient and medication factors for antidepressant selection, regular and frequent monitoring, and assessing clinical and functional outcomes with measurement-based care; 2) comparative aspects of antidepressant medications based on efficacy, tolerability, and safety, including summaries of newly approved drugs since 2009; 3) practical approaches to pharmacological management, including drug-drug interactions and maintenance recommendations; and 4) managing inadequate response and treatment resistance, with a focus on switching antidepressants, applying adjunctive treatments, and new and emerging agents. CONCLUSIONS Evidence-based pharmacological treatments are available for first-line treatment of MDD and for management of inadequate response. However, given the limitations of the evidence base, pharmacological management of MDD still depends on tailoring treatments to the patient.
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Affiliation(s)
- Sidney H Kennedy
- Department of Psychiatry, University of Toronto, Toronto, Ontario *Co-first authors.
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia *Co-first authors
| | - Roger S McIntyre
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | - Venkat Bhat
- Department of Psychiatry, McGill University, Montréal, Quebec
| | - Pierre Blier
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario
| | - Mehrul Hasnain
- Department of Psychiatry, Memorial University, St. John's, Newfoundland
| | - Fabrice Jollant
- Department of Psychiatry, McGill University, Montréal, Quebec
| | - Anthony J Levitt
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | | | | | - Diane McIntosh
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia
| | - Roumen V Milev
- Department of Psychiatry, Queen's University, Kingston, Ontario
| | - Daniel J Müller
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Sagar V Parikh
- Department of Psychiatry, University of Toronto, Toronto, Ontario Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | | | - Arun V Ravindran
- Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia
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Cosci F, Mansueto G, Faccini M, Casari R, Lugoboni F. Socio-demographic and clinical characteristics of benzodiazepine long-term users: Results from a tertiary care center. Compr Psychiatry 2016; 69:211-5. [PMID: 27423363 DOI: 10.1016/j.comppsych.2016.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/03/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE The use of benzodiazepines (BDZs) represents a critical issue since a long-term treatment may lead to dependence. This study aimed at evaluating socio-demographic and clinical characteristics of BZD long-term users who followed a detoxification program at a tertiary care center. METHOD Two hundred-five inpatients were evaluated. Socio-demographic (e.g., gender, age, education) and clinical information (e.g., BZD used, dose, reason of prescription) was collected. BZDs dose was standardized as diazepam dose equivalents and was compared via the Defined Daily Dose (DDD). Chi-square, Fisher test, ANOVA and Bonferroni analyses were performed. RESULTS Females were more frequently BDZ long-term users than males. Hypnotic BZDs were frequently prescribed for problems different from sleep disturbances. Lorazepam, alprazolam, and lormetazepam were the most prescribed drugs. Lorazepam was more frequently used by males, consumed for a long period, in pills, and prescribed for anxiety. Lormetazepam was more frequently consumed by females with a high school education, having a psychiatric disorder, taken in drops and prescribed for insomnia. Lormetazepam had the highest DDD. CONCLUSION A specific profile of BZD long-term user seems to exist and presents different socio-demographic and clinical characteristics according to the benzodiazepine taken into account.
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Affiliation(s)
- F Cosci
- Department of Health Sciences, University of Florence, via di San Salvi 12, 50135, Florence, Italy.
| | - G Mansueto
- Department of Health Sciences, University of Florence, via di San Salvi 12, 50135, Florence, Italy
| | - M Faccini
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - R Casari
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - F Lugoboni
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
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Etiological theories of addiction: A comprehensive update on neurobiological, genetic and behavioural vulnerability. Pharmacol Biochem Behav 2016; 148:59-68. [PMID: 27306332 DOI: 10.1016/j.pbb.2016.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 06/01/2016] [Accepted: 06/10/2016] [Indexed: 12/21/2022]
Abstract
Currently, about 246 million people around the world have used an illicit drug. The reasons for this use are multiple: e.g. to augment the sensation of pleasure or to reduce the withdrawal and other aversive effects of a given substance. This raises the problem of addiction, which remains a disease of modern society. This review offers a comprehensive update of the different theories about the etiology of addictive behaviors with emphasis on the neurobiological, environmental, psychopathological, behavioural and genetic aspects of addictions, discussed from an evolutionary perspective. The main conclusion of this review is that vulnerability to drug addiction suggests an interaction between many brain systems (including the reward, decision-making, serotonergic, oxytocin, interoceptive insula, CRF, norepinephrine, dynorphin/KOR, orexin and vasopressin systems), genetic predisposition, sociocultural context, impulsivity and drugs types. Further advances in biological and psychological science are needed to address the problems of addiction at its roots.
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Regunath H, Chinnakotla B, Rojas-Moreno C, Salzer W, Hughes NJ, Sangha H. A Case of Fatal Serotonin Syndrome-Like Human Rabies Caused by Tricolored Bat-Associated Rabies Virus. Am J Trop Med Hyg 2016; 94:1376-9. [PMID: 27001756 PMCID: PMC4889760 DOI: 10.4269/ajtmh.15-0852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/17/2016] [Indexed: 12/25/2022] Open
Abstract
Human rabies is a fatal disease, transmitted by saliva of infected animals, and the diagnosis requires a high index of suspicion. Very few cases are reported annually in the United States. We present a case of human rabies without a clear exposure history that masqueraded as serotonin syndrome.
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Affiliation(s)
- Hariharan Regunath
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
| | - Bhavana Chinnakotla
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
| | - Christian Rojas-Moreno
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
| | - William Salzer
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
| | - Natalie J Hughes
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
| | - Harbaksh Sangha
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Medicine, University of Missouri, Columbia, Missouri; Division of Infectious Diseases, Department of Medicine, University of Missouri, Columbia, Missouri; Department of Medicine, University of Florida, Gainesville, Florida
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Abstract
Switching from one antidepressant to another is frequently indicated due to an inadequate treatment response or unacceptable adverse effects. All antidepressant switches must be carried out cautiously and under close observation. Conservative switching strategies involve gradually tapering the first antidepressant followed by an adequate washout period before the new antidepressant is started. This can take a long time and include periods of no treatment with the risk of potentially life-threatening exacerbations of illness. Clinical expertise is needed for more rapid or cross-taper switching as drug toxicity, including serotonin syndrome, may result from inappropriate co-administration of antidepressants. Some antidepressants must not be combined. Antidepressants can cause withdrawal syndromes if discontinued abruptly after prolonged use. Relapse and exacerbation of depression can also occur. Gradual dose reduction over days to weeks reduces the risk and severity of complications.
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Affiliation(s)
| | | | - Simone Keogh
- Centre for Mental Health Education and Research, Delmont Private Hospital, Melbourne
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Gibson K, Cartwright C, Read J. 'In my life antidepressants have been…': a qualitative analysis of users' diverse experiences with antidepressants. BMC Psychiatry 2016; 16:135. [PMID: 27165309 PMCID: PMC4863327 DOI: 10.1186/s12888-016-0844-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/04/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND While mental health professionals have focused on concerns about whether antidepressants work on a neurochemical level it is important to understand the meaning this medication holds in the lives of people who use it. This study explores diversity in the experience of antidepressant users. METHODS One thousand seven hundred forty-seven New Zealand antidepressant users responded to an open-ended question about their experience of antidepressants. This was analysed using content and thematic analysis. RESULTS There was considerable diversity in participants' responses including positive (54 %), negative (16 %) and mixed (28 %) experiences with antidepressants. Those with positive experiences saw antidepressants as a necessary treatment for a 'disease', a life saver, a way of meeting social obligations, dealing with difficult circumstances or a stepping stone to further help. Negative themes described antidepressants as being ineffective, having unbearable side effects, undermining emotional authenticity, masking real problems and reducing the experience of control. Mixed experience themes showed how participants weighed up the unpleasant side effects against the benefits, felt calmer but less like themselves, struggled to find the one or dosage and felt stuck with continuing on antidepressants when they wished to stop. CONCLUSIONS Mental health professions need to recognize that antidepressants are not a 'one size fits all' solution.
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Affiliation(s)
- Kerry Gibson
- School of Psychology, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Claire Cartwright
- School of Psychology, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - John Read
- School of Psychology, University of East London, London, United Kingdom
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Variation and ethnic inequalities in treatment of common mental disorders before, during and after pregnancy: combined analysis of routine and research data in the Born in Bradford cohort. BMC Psychiatry 2016; 16:99. [PMID: 27071711 PMCID: PMC4830046 DOI: 10.1186/s12888-016-0805-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/05/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Common mental disorders (CMD) such as anxiety and depression during the maternal period can cause significant morbidity to the mother in addition to disrupting biological, attachment and parenting processes that affect child development. Pharmacological treatment is a first-line option for moderate to severe episodes. Many women prescribed pharmacological treatments cease them during pregnancy but it is unclear to what extent non-pharmacological options are offered as replacement. There are also concerns that treatments offered may not be proportionate to need in minority ethnic groups, but few data exist on treatment disparities in the maternal period. We examined these questions in a multi-ethnic cohort of women with CMD living in Bradford, England before, during and up to one year after pregnancy. METHODS We searched the primary care records of women enrolled in the Born in Bradford cohort for diagnoses, symptoms, signs ('identification'), referrals for treatment, non-pharmacological and pharmacological treatment and monitoring ('treatment') related to CMD. Records were linked with maternity data to classify women identified with a CMD as treated prior to, and one year after, delivery. We examined rates and types of treatment during pregnancy, and analysed potential ethnic group differences using adjusted Poisson and multinomial logistic regression models. RESULTS We analysed data on 2,234 women with indicators of CMD. Most women were discontinued from pharmacological treatment early in pregnancy, but this was accompanied by recorded access to non-drug treatments in only 15 % at the time of delivery. Fewer minority ethnic women accessed treatments compared to White British women despite minority ethnic women being 55-70 % more likely than White British women to have been identified with anxiety in their medical record. CONCLUSIONS Very few women who discontinued pharmacological treatment early in their pregnancy were offered other non-pharmacological treatments as replacement, and most appeared to complete their pregnancy untreated. Further investigation is warranted to replicate the finding that minority ethnic women are more likely to be identified as being anxious or having anxiety and understand what causes the variation in access to treatments.
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Starcevic V, Brakoulias V, Viswasam K, Berle D. Inconsistent portrayal of medication dependence, withdrawal and discontinuation symptoms in treatment guidelines for anxiety disorders. PSYCHOTHERAPY AND PSYCHOSOMATICS 2016; 84:379-80. [PMID: 26402919 DOI: 10.1159/000439137] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/03/2015] [Indexed: 01/06/2023]
Affiliation(s)
- Vladan Starcevic
- Discipline of Psychiatry, Sydney Medical School - Nepean, University of Sydney, Sydney, N.S.W., Australia
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221
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Affiliation(s)
- Dieter Riemann
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Disorders, University Hospital Freiburg, Freiburg, Germany.
| | - Elisabeth Hertenstein
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Disorders, University Hospital Freiburg, Freiburg, Germany
| | - Elisabeth Schramm
- Department of Clinical Psychology and Psychophysiology, Centre for Mental Disorders, University Hospital Freiburg, Freiburg, Germany
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222
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Dobson ET, Strawn JR. Pharmacotherapy for Pediatric Generalized Anxiety Disorder: A Systematic Evaluation of Efficacy, Safety and Tolerability. Paediatr Drugs 2016; 18:45-53. [PMID: 26660158 PMCID: PMC4925147 DOI: 10.1007/s40272-015-0153-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Randomized controlled trials consistently support the efficacy of antidepressants in treating youth with generalized anxiety disorder (GAD), although integrated examinations of efficacy, safety, and tolerability of psychotropic medications in GAD, specifically, are rare. With this in mind, we sought to describe the efficacy, safety, and tolerability of psychopharmacologic interventions in pediatric patients with GAD. METHODS Randomized, double-blind, placebo-controlled, prospective trials of psychopharmacologic interventions in youth with GAD were identified through a PubMed/Medline (1966-2015) search. Both authors manually reviewed trials and, to evaluate comparative efficacy and tolerability across medications, numbers needed to treat (NNT) [based on Pediatric Anxiety Rating Scale (PARS) remission criteria (PARS ≤8)] and number needed to harm (NNH) for selected treatment-emergent adverse events (TEAEs) were calculated. Finally, treatment-emergent suicidality and taper-emergent/post-study adverse events are reported descriptively. RESULTS Five trials that involved 1186 patients and evaluated four medications were reviewed and efficacy data were extracted with regard to dimensional measures of anxiety. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) demonstrated efficacy in the reduction of anxiety symptoms with NNTs ranging from 2.8 to 9.3. TEAEs varied considerably between studies but tended to be mild and generally did not lead to discontinuation. CONCLUSIONS Data from five trials of SSRI/SNRI in youth with GAD, many of whom had co-occurring separation and social anxiety disorders, suggest superiority to placebo and favorable tolerability profiles.
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Affiliation(s)
- Eric T Dobson
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Box 670559, Cincinnati, OH, 45267-0559, USA
| | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Box 670559, Cincinnati, OH, 45267-0559, USA.
- Department of Psychiatry, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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223
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Schramm E, Zobel I, Schoepf D, Fangmeier T, Schnell K, Walter H, Drost S, Schmidt P, Brakemeier EL, Berger M, Normann C. Cognitive Behavioral Analysis System of Psychotherapy versus Escitalopram in Chronic Major Depression. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:227-40. [PMID: 26022410 DOI: 10.1159/000381957] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/30/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND A specific psychotherapy for chronic depression, the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), was compared to escitalopram (ESC). METHODS Sixty patients with chronic major depression were randomized to 'CBASP' (22 sessions) or 'ESC plus clinical management' (ESC/CM) at two treatment sites. The primary outcome measure was the score on the Montgomery-Asberg Depression Rating Scale (MADRS) after 8 weeks of acute treatment assessed by blinded raters. In the case of nonimprovement (<20% reduction in the MADRS score), the other condition was augmented for the following 20 weeks of extended treatment. Secondary end points were, among others, depressive symptoms, remission (MADRS score of ≤9) and response rates (reduction of MADRS score of ≥50%) 28 weeks after randomization. RESULTS An intent-to-treat analysis revealed that clinician-rated depression scores decreased significantly after 8 and 28 weeks with no significant differences between the groups. The response rates after 28 weeks of treatment were high (CBASP: 68.4%, ESC/CM: 60.0%), and the remission rates were moderate (CBASP: 36.8%, ESC/CM: 50.0%) with neither group being superior. Nonimprovers to the initial treatment caught up with the initial improvers in terms of depression scores and response and remission rates by the end of the treatment after being augmented with the respective other condition. CONCLUSIONS CBASP and ESC/CM appear to be equally effective treatment options for chronically depressed outpatients. For nonimprovers to the initial treatment, it is efficacious to augment with medication in the case of nonresponse to CBASP and vice versa.
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Affiliation(s)
- Elisabeth Schramm
- Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
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Reinhold JA, Rickels K. Pharmacological treatment for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother 2015; 16:1669-81. [PMID: 26159446 DOI: 10.1517/14656566.2015.1059424] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Modest response and remission rates for the selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitors, coupled with mounting evidence that the tolerability of the antidepressants (ADs) may have been overstated in the literature, has contributed to changes in prescribing patterns for generalized anxiety disorder (GAD). New interest in the absence of evidence that supports these standard therapies as superior to benzodiazepines stimulated a review of the literature. AREAS COVERED A literature search was conducted in the MedLine database with search terms 'generalized anxiety disorder' and 'treatment' for purposes of including relevant literature related to pharmacologic treatment of GAD. Aside from a review of pivotal literature, the authors also included newer studies that evaluated novel drug treatments. Last, the database was searched for benzodiazepine comparisons to standard therapy secondary to concerns that such literature is sparse. The review of newer modalities and the decision to include related literature was also based on the strength of the evidence and the status of their approval for the treatment of GAD. EXPERT OPINION Although ADs remain the most frequently prescribed medications for GAD, alternative and off-label therapies such as pregabalin, the atypical antipsychotics and vortioxetine are garnering interest. Based on the evidence available to us, it is our recommendation that along with the ADs, benzodiazepines be considered a possible first-line therapy in eligible patients based on the discretion and clinical judgment of the treating physician.
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Affiliation(s)
- Jennifer A Reinhold
- University of the Sciences in Philadelphia, Department of Pharmacy Practice/Pharmacy Administration , 600 South 43rd Street, Philadelphia, PA 19104-4495 , USA
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225
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J. Koch H. REPEATED CONFUSIONAL STATES FOLLOWING DISCONTINUATION OF PROXETINE IN A 51-YEAR-OLD WOMEN SUFFERING FROM PSYCHOTIC DEPRESSION. ACTA MEDICA MEDIANAE 2015. [DOI: 10.5633/amm.2015.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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226
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Medical and Nonstroke Neurologic Causes of Acute, Continuous Vestibular Symptoms. Neurol Clin 2015; 33:699-716, xi. [DOI: 10.1016/j.ncl.2015.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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227
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Walitt B, Urrútia G, Nishishinya MB, Cantrell SE, Häuser W. Selective serotonin reuptake inhibitors for fibromyalgia syndrome. Cochrane Database Syst Rev 2015; 2015:CD011735. [PMID: 26046493 PMCID: PMC4755337 DOI: 10.1002/14651858.cd011735] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fibromyalgia is a clinically well-defined chronic condition with a biopsychosocial aetiology. Fibromyalgia is characterized by chronic widespread musculoskeletal pain, sleep problems, cognitive dysfunction, and fatigue. Patients often report high disability levels and poor quality of life. Since there is no specific treatment that alters the pathogenesis of fibromyalgia, drug therapy focuses on pain reduction and improvement of other aversive symptoms. OBJECTIVES The objective was to assess the benefits and harms of selective serotonin reuptake inhibitors (SSRIs) in the treatment of fibromyalgia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 5), MEDLINE (1966 to June 2014), EMBASE (1946 to June 2014), and the reference lists of reviewed articles. SELECTION CRITERIA We selected all randomized, double-blind trials of SSRIs used for the treatment of fibromyalgia symptoms in adult participants. We considered the following SSRIs in this review: citalopram, fluoxetine, escitalopram, fluvoxamine, paroxetine, and sertraline. DATA COLLECTION AND ANALYSIS Three authors extracted the data of all included studies and assessed the risks of bias of the studies. We resolved discrepancies by discussion. MAIN RESULTS The quality of evidence was very low for each outcome. We downgraded the quality of evidence to very low due to concerns about risk of bias and studies with few participants. We included seven placebo-controlled studies, two with citalopram, three with fluoxetine and two with paroxetine, with a median study duration of eight weeks (4 to 16 weeks) and 383 participants, who were pooled together.All studies had one or more sources of potential major bias. There was a small (10%) difference in patients who reported a 30% pain reduction between SSRIs (56/172 (32.6%)) and placebo (39/171 (22.8%)) risk difference (RD) 0.10, 95% confidence interval (CI) 0.01 to 0.20; number needed to treat for an additional beneficial outcome (NNTB) 10, 95% CI 5 to 100; and in global improvement (proportion of patients who reported to be much or very much improved: 50/168 (29.8%) of patients with SSRIs and 26/162 (16.0%) of patients with placebo) RD 0.14, 95% CI 0.06 to 0.23; NNTB 7, 95% CI 4 to 17.SSRIs did not statistically, or clinically, significantly reduce fatigue: standard mean difference (SMD) -0.26, 95% CI -0.55 to 0.03; 7.0% absolute improvement on a 0 to 10 scale, 95% CI 14.6% relative improvement to 0.8% relative deterioration; nor sleep problems: SMD 0.03, 95 % CI -0.26 to 0.31; 0.8 % absolute deterioration on a 0 to 100 scale, 95% CI 8.3% relative deterioration to 6.9% relative improvement.SSRIs were superior to placebo in the reduction of depression: SMD -0.39, 95% CI -0.65 to -0.14; 7.6% absolute improvement on a 0 to 10 scale, 95% CI 2.7% to 13.8% relative improvement; NNTB 13, 95% CI 7 to 37. The dropout rate due to adverse events was not higher with SSRI use than with placebo use (23/146 (15.8%) of patients with SSRIs and 14/138 (10.1%) of patients with placebo) RD 0.04, 95% CI -0.06 to 0.14. There was no statistically or clinically significant difference in serious adverse events with SSRI use and placebo use (3/84 (3.6%) in patients with SSRIs and 4/84 (4.8%) and patients with placebo) RD -0.01, 95% CI -0.07 to 0.05. AUTHORS' CONCLUSIONS There is no unbiased evidence that SSRIs are superior to placebo in treating the key symptoms of fibromyalgia, namely pain, fatigue and sleep problems. SSRIs might be considered for treating depression in people with fibromyalgia. The black box warning for increased suicidal tendency in young adults aged 18 to 24, with major depressive disorder, who have taken SSRIs, should be considered when appropriate.
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Affiliation(s)
- Brian Walitt
- National Institutes of HealthNational Center for Complementary and Integrative Health10 Center DriveBethesdaMDUSA20892
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
| | - María Betina Nishishinya
- Institute of Biomedical Research (IIB Sant Pau)Iberoamerican Cochrane CentreEd. Casa de ConvalescènciaSant Antoni M. Claret 171 4 plantaBarcelonaSpainE ‐ 08041
| | - Sarah E Cantrell
- Walter Reed National Military Medical CenterDarnall Medical Library8901 Wisconsin AvenueBuilding 1, Room 3458BethesdaMDUSA20889
| | - Winfried Häuser
- Technische Universität MünchenDepartment of Psychosomatic Medicine and PsychotherapyLangerstr. 3MünchenGermanyD‐81675
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Chouinard G, Chouinard VA. New Classification of Selective Serotonin Reuptake Inhibitor Withdrawal. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:63-71. [PMID: 25721565 DOI: 10.1159/000371865] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/06/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Guy Chouinard
- Clinical Pharmacology and Toxicology Program, Departments of Psychiatry and Medicine, McGill University, Montreal, Que., Canada
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