The drug treatment of anxiety

Exploring the Pathogenesis and Mechanism-Targeted Treatments of Rosacea: Previous Understanding and Updates

Rosacea is a chronic inflammatory skin disease characterized by recurrent erythema, flushing, telangiectasia, papules, pustules, and phymatous changes in the central area of the face. Patients with this condition often experience a significant negative impact on their quality of life, self-esteem, and overall well-being. Despite its prevalence, the pathogenesis of rosacea is not yet fully understood. Recent research advances are reshaping our understanding of the underlying mechanisms of rosacea, and treatment options based on the pathophysiological perspective hold promise to improve patient outcomes and reduce incidence. In this comprehensive review, we investigate the pathogenesis of rosacea in depth, with a focus on emerging and novel mechanisms, and provide an up-to-date overview of therapeutic strategies that target the diverse pathogenic mechanisms of rosacea. Lastly, we discuss potential future research directions aimed at enhancing our understanding of the condition and developing effective treatments.

Benzodiazepine-Receptor Agonist Utilization in Outpatients with Anxiety Disorder: A Retrospective Study Based on Electronic Healthcare Data from a Large General Tertiary Hospital

Benzodiazepine-receptor agonists (BZRAs), including benzodiazepines (BZDs) and drugs related to BZDs (Z-drugs), are commonly used for anxiety, but often have side effects. We retrospectively investigated the utilization and prescription characteristics of BZRAs for patients with anxiety disorders in a large tertiary care general hospital between 2018 and 2021, based on electronic healthcare records. We also examined the pattern of simultaneous consumption of multiple BZRA drugs, and the diseases coexisting with anxiety that are associated with this. The numbers of patients and BZRA prescriptions increased over the 4 years. Moreover, 7195 prescriptions from 694 patients contained two or more BZRAs, of which 78.08% contained both BZDs and Z-drugs, 19.78% contained multiple BZDs, and 2.14% contained multiple Z-drugs. For anxiety patients with concomitant Alzheimer's disease or Parkinson's disease, and dyslipidemia, they were more likely to consume multiple BZRAs simultaneously, whereas patients with concomitant insomnia, depression, hypertension, diabetes, or tumors were less likely to consume multiple BZRAs (all p < 0.05). Furthermore, older patients who consume multiple BZRAs simultaneously may have higher probabilities of long-term drug use. Better interventions supporting standardized BZD utilization may be needed to minimize the side effects of inappropriate BZRA administration.

Socio-demographic and clinical characteristics of benzodiazepine long-term users: Results from a tertiary care center

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.

Anxiety

PURPOSE OF REVIEW

This article provides an overview of anxiety disorders including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria with practical key features. The article discusses neurologic and other medical comorbidities as well as treatment strategies, keeping in mind the co-occurrence of anxiety disorders with depression.

RECENT FINDINGS

Several studies have emphasized the high prevalence of comorbid mental and medical conditions including, but not limited to, cardiovascular and neurologic illnesses, making the overall management of these patients more costly and complex, ultimately leading to decreased length and quality of life. However, several research studies have suggested that appropriate and effective comanagement of anxiety and depression improves overall outcomes of those individuals with chronic medical conditions.

SUMMARY

Anxiety and depression are common psychiatric conditions that not only co-occur, but also co-occur with other neurologic illnesses. Early recognition and treatment of these comorbidities are imperative in order to achieve better health outcomes for patients.

Symptomatic treatment of idiopathic and rosacea-associated cutaneous flushing with propranolol

Flushing has been associated with medications, rosacea, menopause, carcinoid syndrome, pheochromocytoma, polycythemia, and mastocytosis, although it can occur without known cause. There are no known specific treatments available, but beta-blockers have suppressed flushing reactions in some patients, particularly when associated with anxiety. The medical histories and clinical characteristics of 9 patients with either idiopathic flushing or flushing associated with rosacea were reviewed. Eight patients experienced subjective improvement with propranolol therapy.

Mechanisms involved in the water intake-related pressor response in the rat

OBJECTIVE

In this study we aimed to characterize and clarify the mechanisms involved in the acute blood pressure increase observed concomitantly with water intake in moderately dehydrated rats.

DESIGN

Short-term water deprivation was employed as a model to induce controlled water intake to study concomitant cardiovascular responses in the rat.

METHODS

Male Wistar rats were deprived of water for 18-24 h before the experiments and were allowed to drink for 20 s periods during the experimental session. During these periods water intake was accompanied by steady arterial pressure increases. This pressor response was unaffected by topical anesthesia of the oral cavity. Direct administration of water into the stomach did not cause pressor responses. The pressor response was not affected by bilateral adrenal demedullation or by pretreatment with diazepam, homatropine methyl bromide, d(CH2)5 Tyr(Me)AVP, losartan or RX821002. The pressor response was significantly reduced by ganglionic blockade with mecamylamine or pretreatment with the alpha1-adrenoceptor antagonist, prazosin.

CONCLUSIONS

Our results show that: (1) short-term dehydration can be used as a model to study cardiovascular responses associated with water intake in rats; and (2) the sympathetic nervous system and vascular smooth muscle alpha1-adrenoceptors are involved in the pressor response to water intake by dehydrated rats.

Chronic cocaine differentially affects diazepam's anxiolytic and anticonvulsant actions. Relationship to GABA(A) receptor subunit expression

Benzodiazepines are used to treat the anxiety associated with cocaine withdrawal, as well as cocaine-induced seizures. Since cocaine exposure was shown to affect BZ binding density, abuse liability, subjective hypnotic actions and seizure susceptibility, we assessed whether chronic cocaine alters diazepam's anxiolytic and anticonvulsant actions. Changes in GABA(A) receptor subunit protein expression were also assessed as they may relate to BZ activity at the receptor. Male Sprague-Dawley rats were injected with cocaine-HCl (15 mg/kg, i.p.) or saline once daily for 14 days. One day after the last injection, DZP (1 mg/kg i.p.) significantly increased time spent on and entries into open arms of an elevated plus maze in both saline- and cocaine-treated groups, yet the effect was greater in cocaine-treated rats. Eight days after cessation of treatment DZP did not have a significant anxiolytic effect in either group. To assess the effect of cocaine on DZP's anticonvulsant actions, PTZ was infused at a constant rate via the lateral tail vein and clonus onset was recorded in the presence and absence of DZP (5 mg/kg, i.p). DZP significantly elevated seizure threshold in both groups of rats. Chronic cocaine also had no effect on the beta-CCM seizure threshold. Quantitative immunohistochemistry of GABA(A) receptor subunit protein demonstrated significant regulation of alpha2 (-10%) and beta3 (+9%) subunits in the hippocampal dentate gyrus and CA1 regions, respectively. Small changes in GABAR subunit expression in specific brain areas may relate to DZP's enhanced anxiolytic effectiveness whereas it's anticonvulsant actions likely remain intact following cocaine administration.

Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified?

The benzodiazepines are still extensively used in psychiatry, neurology and medicine in general. Anxiety disorder and severe insomnia are important syndromal indications, but these drugs are widely prescribed at the symptomatic level, resulting in potential overuse. The official data sheets recommend short durations of usage and conservative dosage. Although short-term efficacy is established, long-term efficacy remains controversial, as relevant data are scanty and relapse, rebound and dependence on withdrawal not clearly distinguished. The risks of the benzodiazepines are well-documented and comprise psychological and physical effects. Among the former are subjective sedation, paradoxical release of anxiety and/or hostility, psychomotor impairment, memory disruption, and risks of accidents. Physical effects include vertigo, dysarthria, ataxia with falls, especially in the elderly. Dependence can supervene on long-term use, occasionally with dose escalation. The benzodiazepines are now recognised as major drugs of abuse and addiction. Other drug and non-drug therapies are available and have a superior risk benefit ratio in long-term use. It is concluded that benzodiazepines should be reserved for short-term use--up to 4 weeks--and in conservative dosage.

Serotonin (5-HT1A-receptor) agonist-induced collecting duct vacuolation and renal papillary necrosis in the rat

General anxiety in humans is treated with azaspirodecanedions, which act through a reduction of serotonin transmission. Ipsapirone also represents a serotonin (5-HT1A) receptor agonist and was under development as an anxiolytic drug. Histopathologic evaluation of animal experiments revealed cellular swelling and/or vacuolation of renal papillary and medullary collecting duct (MCD) epithelium in rats but not in dogs or mice. The changes ensued already after 1 wk of dosing and were first localized in the inner MCDs. Longer treatment periods showed that these changes proceeded from proximal to distal, approaching the papillary collecting ducts. The changes were most likely the result of altered hemodynamics in the papillary tip. Swelling resulted in partial or total papillary necrosis in some cases. Furthermore, rats treated with ipsapirone showed a sharp and transient rise in urinary endothelin excretion. Concomitantly, urinary PGE2 levels were elevated. In contrast, no elevated levels of endothelin were detected in urine samples of patients from a volunteer study, leading to the conclusion that the human kidney is not susceptible to the ipsapirone-induced alterations seen in the collecting ducts of rats.

Effects found in a one-year oral toxicity study in Sprague-Dawley rats of a novel 5-HT1A receptor partial agonist for the treatment of anxiety in humans

A potent and selective serotonin (5-HT1A) partial agonist with potential as a human anxiolytic drug was given in oral doses of 0, 5, 15, or 50 mg/kg/day by gavage to Sprague-Dawley rats for 6 or 12 mo. Some animals were allowed 1 mo to recover after each treatment period. The 10-fold increase in dose resulted in a 20-fold increase in drug plasma concentration due to saturable first-pass metabolism. This resulted in disproportionately higher concentrations and greater bioavailability of the 15- and 50-mg/kg/day regimens. Drug exposure was associated with decreased spontaneous activity in the 15- and 50-mg/kg rats. The activity of these rats returned to normal during the recovery period. There were significant (p < 0.05) decreases in mean body weights during the study for 50-mg/kg males, with improvement during the recovery periods. No biologically significant effects were noted in clinical laboratory parameters. Based on organ weight increases and histopathological evaluation, drug-related effects after 6 and 12 mo of treatment were in the pituitary (both sexes) and all treated female reproductive organs. In general, these effects persisted into periods of recovery, except for pituitary hyperplasia, which was not apparent following recovery after treatment for 6 mo. After treatment for 12 mo and the following recovery, there were significant increases in adrenal weights in the 15- and 50-mg/kg/day males with no morphological correlate. There was increased pituitary hyperplasia that persisted through the recovery period in all treated groups in both sexes, but there was no increase in pituitary neoplasms. In treated females, there was also morphologic evidence of persistent diestrus (estrogenic effect) evidenced by endometrial squamous metaplasia, increased corpora lutea, vaginal mucification, and decreased uterine size. The clinical and pathological changes seen with these 2 regimens were considered exaggerated pharmacological effects of the drug on serotonin receptor-rich organs.

Analysis of tandospirone (SM-3997) interactions with neurotransmitter receptor binding sites

The interactions of tandospirone (formerly called SM-3997) with 5-HT and other neurotransmitter receptor binding sites were determined in brain homogenates. Tandospirone is most potent at the 5-HT1A receptor, displaying a Ki value of 27 +/- 5 nM. The agent is approximately two to three orders of magnitude less potent at 5-HT2, 5-HT1C, alpha 1-adrenergic, alpha 2-adrenergic, and dopamine D1 and D2 receptors (Ki values ranging from 1300 to 41000 nM). Tandospirone is essentially inactive at 5-HT1B receptors; 5-HT uptake sites; beta-adrenergic, muscarinic cholinergic, and benzodiazepine receptors. This pharmacological profile differs slightly from that of other novel anxiolytics such as buspirone, ipsapirone, and gepirone. Saturation and competition studies using 3H-tandospirone also suggest that the drug interacts with 5-HT1A receptor binding sites in rat cortical membranes (KD = 4.5 +/- 0.8 nM; Bmax = 2.2 +/- 0.6 pmol/g tissue). Based on adenylate cyclase studies which measure 5-HT1A receptor-mediated effects, tandospirone displays approximately 60% of the agonist effect of 8-OH-DPAT, a selective 5-HT1A agonist. Thus, the primary pharmacological effect of tandospirone appears to be partial agonism at the 5-HT1A receptor, an activity similar to other pyrimidinyl-piperazines which are being developed as novel anxiolytic agents.

Anxiolytics and stress-induced behavioural and cardiac responses: a study of diazepam and ipsapirone (TVX Q 7821)

The present study has been designed to investigate the effects of the 5-HT1A receptor agonist, ipsapirone (TVX Q 7821), a representative of a novel class of anxiolytics, and the classical benzodiazepine anxiolytic, diazepam, on cardiac and behavioural responses in an emotional stress situation. The emotional stress of fear of punishment, induced by training male Wistar rats in an inhibitory avoidance situation, was followed by a bradycardiac response relative to similarly trained, but non-punished, freely moving rats. The behavioural response of stressed rats was immobility in the dark compartment in which an electric footshock (0.6 mA a.c. for 3 s) had been administered as punishment a day earlier. Diazepam administered i.p. in doses of 2.5 mg/kg and 7.5 mg/kg caused a decrease in the interbeat interval (IBI) in shocked and non-shocked rats whereas ipsapirone administered i.p. in doses of 2.5 and 12.5 mg/kg decreased the IBI in shocked rats only. Ipsapirone diminished the duration of immobility in both shocked and non-shocked animals whereas diazepam decreased immobility in shocked rats only. These results suggest a differential effect of the two anxiolytics on the behavioural and cardiac responses to an emotional stress situation. It is suggested that ipsapirone has an anxiolytic-like effect and 'anti-stress' action that is clearly reflected in the cardiac physiology in an anxiety-inducing situation.

Treatment guidelines for psychotropic drug use in pregnancy

Despite the apparent risks of psychotropic drug exposure in pregnancy, many pregnant women receive psychotropics. The major concerns associated with the use of antipsychotics, antidepressants, benzodiazepines, and lithium carbonate in pregnancy are reviewed, with clinical approaches for assessing the relative risks and benefits of treatment of psychiatrically ill pregnant patients and for choosing and instituting therapy with these agents.

Effect of nadolol on flushing reactions in rosacea

The effect of nadolol versus placebo on both flushing provoked in a laboratory setting and spontaneous flushing was studied in 15 patients with erythematous telangiectatic rosacea. The intensity of the flushing reactions was assessed in the laboratory by the cutaneous perfusion index method with laser-Doppler velocimetry. No effect of nadolol on the flushing reactions provoked in the laboratory was detected.

Recognizing the drug-resistant patient in anxiety and depression

The number and variety of anxiolytic and antidepressant medications available to the modern clinician lend an unparalleled efficacy to the outpatient treatment of anxiety disorders and depression. Where diagnosis is precise and complicating organic factors have been excluded, true treatment resistance in either anxiety disorders or depression is rare. Proper patient education to assist compliance, adequate dosage of individual agents, patience to give the medication time to work, overcoming the reluctance to attribute the patient's problem to a medically treatable disorder rather than to moral or characterologic defect, and the flexibility to shift to other or to additional medications on encountering initial treatment resistance are the keystones to the successful management of more than 90 per cent of all cases.

Somatization in primary care: patients with unexplained and vexing medical complaints

Somatizing patients experience or express emotional discomfort and psychosocial distress as physical symptoms. Somatization occurs in a broad spectrum of illnesses, in association with a wide variety of mental disorders, including depression, anxiety, and the somatoform disorders. Primary care providers must detect and treat these patients. Diagnosis is based on positive criteria. Care rests upon conservative medical management and evaluation; a physician-patient relationship based on acceptance, caring, and trust; reinforcement of positive behaviors and elimination of destructive ones; and the gradual use of the relationship to promote healthy relating in the patient.

Contributions of benzodiazepines to cancer therapy

We have reviewed the therapeutic effects of benzodiazepines employed as adjuncts to cancer treatment. These agents have been used primarily for alleviating or attenuating situational anxiety, insomnia, chemotherapy-induced nausea and vomiting, and anticipatory nausea and vomiting. Situational anxiety not corrected by psychosocial support, symptom control, or time may be successfully treated with benzodiazepines. Procedure-related anxiety, for example, that related to bone marrow biopsy, venipuncture, intrathecal therapy, and the insertion of subclavian and femoral catheters, is a serious problem that may be alleviated by the use of benzodiazepines. Insomnia not caused by a depression serious enough to warrant treatment with a tricyclic antidepressant also may be successfully treated with benzodiazepines. Many clinicians have found benzodiazepines to be useful adjuncts to a cancer chemotherapy regimen because of their anxiolytic, sedative, and amnesic properties and also because of their suspected antiemetic properties when these drugs are used in conjunction with known antiemetic agents. The ability of lorazepam to induce antegrade amnesia has proved particularly useful in alleviating anticipatory nausea and vomiting connected with repeated courses of cytotoxic chemotherapy. Furthermore, since benzodiazepines are relatively safe drugs, their continued and probably expanded uses as cancer therapy adjuncts can be anticipated.

Psychiatric management of acute myocardial infarction in the coronary care unit

Failure to recognize and treat the psychiatric complications of myocardial infarction (MI) may aggravate the underlying cardiac condition and interfere with its treatment. The timing and manifestations of several distinct psychiatric conditions that commonly accompany the acute phase of MI (anxiety, depression, delirium, and behavioral abnormalities secondary to a person's premorbid character style) will be reviewed. In addition, the importance of psychological risk factors for the development of coronary artery disease (e.g., life stress and the Type A behavior pattern) and the impact of denial on the cardiac patient's condition will be discussed. Management strategies that include nonpharmacologic (i.e., support, reassurance, brief psychotherapy and cardiac rehabilitation) and psychopharmacologic interventions (e.g., the rational use of benzodiazepines, antidepressants and neuroleptic agents) for psychiatric conditions in the MI patient will be provided. Postdischarge issues that occur in both the patient and his or her family are outlined, and the enrollment in cardiac rehabilitation programs is encouraged.

Benzodiazepines: selective administration

Benzodiazepines are unique chemicals with anxiolytic, anticonvulsant, muscle relaxant and hypnotic properties. Twelve preparations of this group are available in the U.S.A.: two of them belong to the triazolo and one to the 3-nitro groups, the remaining ones are 3-OH or 2-keto benzodiazepines. A number of commonly employed drugs interact with benzodiazepines. Benzodiazepine receptor antagonists which block only one of its actions have been isolated. These promise to lead to preparations with only anxiolytic action without sedation or anticonvulsant action in the future. Guidelines for the selection of the proper drug and for the prevention of dependence are described.

Excellent results with clorazepate in recalcitrant childhood epilepsies

Eleven children with severe incapacitating generalized seizures were treated with sodium valproate and clorazepate and responded with a marked decrease in seizure frequency. Three children received clorazepate alone, either because of valproate toxicity or because of parental concern over side effects. These children, 5 males and 6 females, ranged in age from 3 to 17 years. They manifested normal to severely retarded intelligence. Although valproate levels were in the therapeutic range, seizure control was inadequate. When clorazepate was added to valproate therapy a marked reduction in seizure frequency occurred within 24 hours and became optimal within 48 to 72 hours. Side effects were minimal with the exception of a nocturnal generalized tonic-clonic seizure in a single patient. Three children were withdrawn from therapy after a year because of recurrent seizures. One patient was restarted on therapy after 6 months and seizure control improved. Clorazepate may be a useful adjunct in the treatment of primary generalized seizures in children.

Selective interaction of novel anxiolytics with 5-hydroxytryptamine1A receptors

Radioligand binding studies were used to analyze the interactions of two novel anxiolytics, buspirone and TVX Q 7821, with a series of 10 neuronal membrane receptor sites. Buspirone (IC50 = 24 nM) and TVX Q 7821 (IC50 = 9.5 nM) display the highest affinity for 5-hydroxytryptamine1A (5-HT1A) binding sites labeled by 3H-8-hydroxy-2-(di-n-pro-pylamino) tetralin (DPAT). By contrast, buspirone is 16-fold weaker at dopamine (D2) receptors (IC50 = 380 nM), whereas TVX Q 7821 is 6-fold less potent at alpha-adrenergic1 sites (IC50 = 58 nM). At the other receptors studied, buspirone and TVX Q 7821 had similar pharmacological profiles. Both agents display moderate affinity for histamine (H1), alpha-adrenergic2, and 5-HT2 binding sites. The drugs are essentially inactive at 5-HT1B, calcium channel antagonist, muscarinic cholinergic, and benzodiazepine receptors. These results suggest that the anxiolytic effects of buspirone and TVX Q 7821 may be mediated by central 5-HT1A receptors.

Minocycline in chronic abacterial prostatitis: a double-blind prospective trial

In patients with chronic abacterial prostatitis, a double-blind trial of 3 months of treatment with minocycline 100 mg twice daily compared with diazepam 5 mg twice daily was undertaken. The percentage fall in polymorphonuclear leucocyte counts in the expressed prostatic secretions was much more marked after treatment with minocycline than with diazepam. Over a follow-up period of at least 12 months, further treatment was necessary in more patients originally treated with diazepam than with minocycline.

Coping with the negative therapeutic response in psychosocial problems in family medicine

Four brief case reports are presented from a series of Balint-type seminars on psychosocial problems at a university Family Medicine Centre. These cases illustrate the difficulties encountered by family practitioners when faced with a negative therapeutic response. When confronted by this outcome, it is important for the physician to define the dependency relationship which exists between himself/herself and the patient. It is often necessary to negotiate an explicit therapeutic contract. In doing so the physician should consider his own limitations of time, expertise and inclination and gather enough information to allow him to identify the focus of therapy and to consider his options for dealing with that specific focus.