Effect of peripheral administration of cinnarizine and verapamil on the abstinence syndrome in diazepam-dependent rats

Depression and anxiety in people with epilepsy

Many recent epidemiological studies have found the prevalence of depression and anxiety to be higher in people with epilepsy (PWE) than in people without epilepsy. Furthermore, people with depression or anxiety have been more likely to suffer from epilepsy than those without depression or anxiety. Almost one-third of PWE suffer from depression and anxiety, which is similar to the prevalence of drug-refractory epilepsy. Various brain areas, including the frontal, temporal, and limbic regions, are associated with the biological pathogenesis of depression in PWE. It has been suggested that structural abnormalities, monoamine pathways, cerebral glucose metabolism, the hypothalamic-pituitary-adrenal axis, and interleukin-1b are associated with the pathogenesis of depression in PWE. The amygdala and the hippocampus are important anatomical structures related to anxiety, and γ-aminobutyric acid and serotonin are associated with its pathogenesis. Depression and anxiety may lead to suicidal ideation or attempts and feelings of stigmatization. These experiences are also likely to increase the adverse effects associated with antiepileptic drugs and have been related to poor responses to pharmacological and surgical treatments. Ultimately, the quality of life is likely to be worse in PWE with depression and anxiety than in PWE without these disorders, which makes the early detection and appropriate management of depression and anxiety in PWE indispensable. Simple screening instruments may be helpful for in this regard, particularly in busy epilepsy clinics. Although both medical and psychobehavioral therapies may ameliorate these conditions, randomized controlled trials are needed to confirm that.

Anxiety symptoms in epilepsy: salient issues for future research

This paper reviews the distinct symptom profile, epidemiology, pathogenesis, assessment, and treatment of anxiety disorders. It highlights emerging neuroimaging research in mood and anxiety disorders in people with epilepsy. While structural neuroimaging has implicated frontal temporal grey matter structures in mood and anxiety disorders, diffusion tensor imaging and magnetic resonance spectroscopy (MRS) show promise in elucidating white matter changes. In addition, future MRS studies may demonstrate changes in glutamate and gamma-aminobutyric acid (GABA) levels in these regions and hopefully help inform response to treatment.

Analysis of the chronic intake of and withdrawal from diazepam on emotional reactivity and sensory information processing in rats

It has been demonstrated that, on abrupt withdrawal, patients with chronic exposure can experience a number of symptoms indicative of a dependent state. In clinical patients, the earliest to arise and most persistent signal of withdrawal from chronic benzodiazepine (Bzp) treatment is anxiety. In laboratory animals, anxiety-like effects following abrupt interruption of chronic Bzp treatment can also be reproduced. In fact, signs that oscillate from irritability to extreme fear behaviours and seizures have been described already. As anxiety remains one of the most important symptoms of Bzp withdrawal, in this study we evaluated the anxiety levels of rats withdrawn from diazepam. Also studied were the effects on the motor performance and preattentive sensory gating process of rats under diazepam chronic treatment and upon 48-h withdrawal on three animal models of anxiety, the elevated plus-maze (EPM), ultrasonic vocalizations (USV) and startle+prepulse inhibition tests. Data obtained showed an anxiolytic- and anxiogenic-like profile of the chronic intake of and withdrawal from diazepam regimen in the EPM test, 22-KHz USV and startle reflex. Diazepam chronic effects or its withdrawal were ineffective in promoting any alteration in the prepulse inhibition (PPI). However, an increase of PPI was achieved in both sucrose and diazepam pretreated rats on 48-h withdrawal, suggesting a procedural rather than a specific effect of withdrawal on sensory gating processes. It is also possible that the prepulse can function as a conditioned stimulus to informing the delivery of an aversive event, as the auditory startling-eliciting stimulus. All these findings are indicative of a sensitization of the neural substrates of aversion in diazepam-withdrawn animals without concomitant changes on the processing of sensory information.

Benzodiazepine-induced hippocampal CA1 neuron α-amino-3-hydroxy-5-methylisoxasole-4-propionic acid (AMPA) receptor plasticity linked to severity of withdrawal anxiety: differential role of voltage-gated calcium channels and N-methyl-D-aspartic acid receptors

Withdrawal from 1-week oral administration of the benzodiazepine, flurazepam (FZP) is associated with increased alpha-amino-3-hydroxy-5-methylisoxasole-4-propionic acid (AMPA) receptor (AMPAR) miniature excitatory postsynaptic currents (mEPSCs) but reduction of N-methyl-D-aspartic acid (NMDA) receptor (NMDAR)-evoked (e)EPSCs in hippocampal CA1 neurons. A positive correlation was observed between increased AMPAR-mediated mEPSC amplitude and anxiety-like behavior in 1-day FZP-withdrawn rats. These effects were disrupted by systemic AMPAR antagonist administration (GYKI-52466, 0.5 mg/kg, intraperitoneal) at withdrawal onset, strengthening the hypothesis that CA1 neuron AMPAR-mediated hyperexcitability is a central component of a functional anatomic circuit associated with the expression of withdrawal anxiety. Abolition of AMPAR current upregulation in 2-day FZP withdrawn rats by GYKI-52466 injection also reversed the reduction in NMDAR-mediated eEPSC amplitude in CA1 neurons from the same rats, suggesting that downregulation of NMDAR function may serve a protective, negative-feedback role to prevent AMPAR-mediated neuronal overexcitation. NMDAR antagonist administration (MK-801, 0.25 mg/kg intraperitoneally) had no effect on modifying increased glutamatergic strength or on withdrawal anxiety, whereas injection of an L-type voltage-gated calcium channel antagonist, nimodipine (10 mg/kg, intraperitoneally) averted AMPAR current enhancement and anxiety-like behavior, suggesting that these manifestations may be initiated by a voltage-gated calcium channel-dependent signal transduction pathway. An evidence-based model of likely cellular mechanisms in the hippocampus contributing to benzodiazepine withdrawal anxiety was proposed implicating regulation of multiple CA1 neuron ion channels.

The role of anticonvulsant drugs in anxiety disorders: a critical review of the evidence

Antiepileptic drugs (AEDs) have been successfully used in the treatment of mood disturbances, leading clinicians and researchers to investigate their use in other psychiatric disorders. This article reviews the literature about the potential efficacy of AEDs in anxiety disorders. An updated MEDLINE search (January 1970 to September 2006) using the terms "panic disorder," "agoraphobia," "posttraumatic stress disorder," "obsessive-compulsive disorder," "generalized anxiety disorder," "social phobia," "phobia," "carbamazepine," "phenobarbital," "phenytoin," "valproate," "lamotrigine," "topiramate," "vigabatrin," "tiagabine," "gabapentin," "levetiracetam," and "pregabalin" showed more than 70 articles and 38 published studies. Only articles published in English were reviewed. We have assigned level 1 of evidence to meta-analysis and replicated randomized controlled trials, level 2 to at least 1 randomized controlled trial, level 3 to uncontrolled trials with 10 or more subjects, and level 4 to anecdotal case reports. The strongest evidence has been demonstrated for pregabalin in social phobia and generalized anxiety disorder, lamotrigine in posttraumatic stress disorder, and gabapentin in social anxiety. The available data about gabapentin in panic disorder are somewhat mixed, and more definitive conclusion would require additional studies. This review suggests that AEDs can be an alternative treatment in some anxiety disorders. Further investigation is needed to determine in what circumstances they should be used in individuals who are partially responsive or nonresponsive to conventional therapy.

Effect of diazepam treatment and its withdrawal on pro/antioxidative processes in rat brain

Exploratory studies were undertaken to ascertain the role of pro/antioxidative processes during a 3 weeks administration of low sub-toxic dose of diazepam and its withdrawal. Rats were administered 3 mg/kg diazepam for 21 consecutive days and the changes observed in different regions of rat brain at the sub-cellular level. Mitochondria from cerebrum showed a 27% lowering of TBARS whereas those from cerebellum and brain stem showed 48 and 24% enhanced MDA levels respectively. No significant alteration in the SOD isozymes was observed after the dose schedule. The mitochondrial glutathione reductase (GR) activity showed a decrease in all the regions with maximum decrease (36%) recorded in brain stem while post mitochondrial fraction showed significant lowering in cerebrum (37%). Total -SH content increased in all the three regions with maximum enhancement recorded in cerebellum while the free thiol content also showed significant changes (p < 0.001) in cerebellum and brain stem. One week after the withdrawal of the drug MDA levels decreased by 38% in cerebrum and 53% each in mitochondrial fractions of cerebellum and brain stem. Regional heterogeneity in response was also observed in the post mitochondrial fractions. Mn-SOD showed lowered activity in cerebellum (22%) and in brain stem (15%). The mitochondrial GR activity decreased in all the regions being highest in cerebrum with no significant change in post mitochondrial fractions. The total and free -SH content in the withdrawn animals increased by 46% in cerebellum with no change in the other two regions. The results indicate towards lower oxidative phenomenon during 3 weeks treatment with diazepam while abrupt withdrawal causes lowering of antioxidant defenses which showed regional heterogeneity. A decrease in peroxidative decomposition of polyunsaturated fatty acids of membranes was observed on withdrawal, which could be due to stabilisation of membranes after long-term binding of diazepam.

The new antiepileptic drug levetiracetam normalises chlordiazepoxide withdrawal-induced anxiety in mice

Some antiepileptic drugs have been used with success to counteract withdrawal symptoms following chronic use of sedatives, hypnotics or alcohol. We evaluated the potential of levetiracetam (Keppra), a new antiepileptic drug, to prevent benzodiazepine withdrawal in an animal model sensitive to the anxiogenic effect resulting from drug cessation. The effects of levetiracetam (17 and 54 mg/kg) given intraperitoneally (i.p.) were determined on anxiety induced in female NMRI mice by withdrawal from 21 days of chronic administration of chlordiazepoxide. Administration of chlordiazepoxide was i.p. twice daily, in increments of 2 mg/kg, from 10 up to 40 mg/kg. Anxiety was evaluated using an elevated plus-maze test 24-h after chlordiazepoxide withdrawal. Discontinuation of chronic chlordiazepoxide induced a significant anxiogenic profile in the plus-maze test mainly characterised by a decrease in open arm exploration. This effect was dose-dependently prevented by administration of levetiracetam during the withdrawal period. The highest dose tested (54 mg/kg) induced statistically significant effects on all variables recorded but had no effect upon plus-maze exploration in normal mice. This suggests that the observed effects are dependent upon the level of stress or anxiety of the animals. These results support potential efficacy of levetiracetam in the benzodiazepine withdrawal syndrome.

Effects of flunarizine and diltiazem on physical dependence on barbital in rats

The effects of flunarizine and diltiazem both on development of physical dependence on barbital and on barbital withdrawal signs in rats were examined using the drug-admixed food (DAF) method. Rats were chronically treated with barbital or barbital in combination with flunarizine (fixed at 1.5 mg/g of food) or diltiazem (fixed at 0.75 mg/g of food)-admixed food on the schedule of gradually increasing doses of barbital. Motor incoordination during the treatment was potentiated by coadministration of flunarizine, but not by coadministration of diltiazem. After the termination of drug treatment, the body weight loss and withdrawal scores were significantly suppressed in the group coadministered flunarizine, but not in that coadministered diltiazem. There were no significant differences in plasma barbital levels after the withdrawal between groups. In the substitution test, flunarizine (20 and 40 mg/kg, IP) significantly suppressed the body weight loss and withdrawal scores after the withdrawal, but diltiazem (20 mg/kg, IP) did not. These results indicated that flunarizine suppressed both the development of physical dependence on barbital and barbital withdrawal signs, mainly according to the suppression of convulsions, but not diltiazem, which is known to poorly penetrate into the brain. Therefore, the present findings suggest that central calcium channels may be involved in both the development of physical dependence on barbital and the appearance of barbital withdrawal signs.

Effects of Ca2+ channel blockers on physical dependence on diazepam in mice

The effects of Ca2+ channel blockers on the development of physical dependence on diazepam were examined in mice. Co-administration of flunarizine (T-type Ca2+ channel sensitive blocker), but not of either nifedipine or diltiazem (L-type Ca2+ channel sensitive blockers), with diazepam significantly suppressed the hypersensitivity to FG 7142 following chronic treatment with diazepam. The hypersensitivity to FG 7142 may reflect benzodiazepine withdrawal convulsions. These results suggest that flunarizine, but not nifedipine or diltiazem, may suppress the development of physical dependence on diazepam, and that T-type Ca2+ channels in the brain, rather than L-type Ca2+ channels, may be involved in the development of physical dependence on diazepam.