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de Nooij L, Wirz L, Heling E, Pais M, Hendriks GJ, Verkes RJ, Roozendaal B, Hermans EJ. Exogenous glucocorticoids to improve extinction learning for post-traumatic stress disorder patients with hypothalamic-pituitary-adrenal-axis dysregulation: a study protocol description. Eur J Psychotraumatol 2024; 15:2364441. [PMID: 38973398 PMCID: PMC11232644 DOI: 10.1080/20008066.2024.2364441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/15/2024] [Indexed: 07/09/2024] Open
Abstract
Background: Trauma-focused treatments for post-traumatic stress disorder (PTSD) are effective for many patients. However, relapse may occur when acquired extinction memories fail to generalize beyond treatment contexts. A subgroup of PTSD patients - potentially with substantial exposure to early-life adversity (ELA) - show dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which results in lower cortisol levels. Glucocorticoids, including cortisol, appear to facilitate strength and generalization of emotional memories.Objective: We describe the protocol of an integrated PTSD study. We investigate (A) associations between HPA-axis dysregulation, ELA, epigenetic markers, and PTSD treatment outcome (observational study); and (B) effects of exogenous glucocorticoids on strength and generalization of extinction memories and associated neural mechanisms [pharmacological intervention study with functional magnetic resonance imaging (fMRI)]. The objective is to provide proof of concept that PTSD patients with HPA-axis dysregulation often experienced ELA and may show improved strength and generalization of extinction learning after glucocorticoid administration.Method: The observational study (n = 160 PTSD group, n = 30 control group) assesses ELA, follow-up PTSD symptoms, epigenetic markers, and HPA-axis characteristics (salivary cortisol levels during low-dose dexamethasone suppression test and socially evaluated cold-pressor test). The pharmacological intervention study (n = 80 PTSD group, with and without HPA-axis dysregulation) is a placebo-controlled fMRI study with a crossover design. To investigate strength and generalization of extinction memories, we use a differential fear acquisition, extinction, and extinction recall task with spatial contexts within a virtual environment. Prior to extinction learning, 20 mg hydrocortisone or placebo is administered. During next-day recall, strength of the extinction memory is determined by recovery of skin conductance and pupil dilation differential responding, whereas generalization is assessed by comparing responses between different spatial contexts.Conclusion: The integrated study described in the current protocol paper could inform a personalized treatment approach in which these PTSD patients may receive glucocorticoids as a treatment enhancer in trauma-focused therapies.Trial registration: The research project is registered in the European Union Drug Regulating Authorities Clinical Trials (EudraCT) database, https://eudract.ema.europa.eu/, EudraCT number 2020-000712-30.
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Affiliation(s)
- Laura de Nooij
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Lisa Wirz
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Cognitive Psychology, Ruhr-University Bochum, Bochum, Germany
| | - Emma Heling
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Mariana Pais
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Gert-Jan Hendriks
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- ‘Overwaal’ Center of Expertise for Anxiety, Obsessive Compulsive and Posttraumatic Stress Disorders, Institution for Integrated Mental Health Care “Pro Persona”, Nijmegen, The Netherlands
| | - Robbert-Jan Verkes
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
- Kairos Forensic Care, Pompestichting, Nijmegen, The Netherlands
| | - Benno Roozendaal
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Erno J. Hermans
- Department of Cognitive Neuroscience, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Montag C, Ali R, Al-Thani D, Hall BJ. On artificial intelligence and global mental health. Asian J Psychiatr 2024; 91:103855. [PMID: 38113698 DOI: 10.1016/j.ajp.2023.103855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/06/2023] [Accepted: 12/03/2023] [Indexed: 12/21/2023]
Abstract
Artificial intelligence (AI) is affecting global societies and reshaping the status quo. AI technologies possess great potential to tackle some of mankind's most pressing problems, although much of what can be achieved is still a matter of imagination and critical discussion (e.g., AI might also be a source of harm). In the present short communication, we outline AI's potential for addressing several core issues in global mental health including its application in psychotherapeutic settings.
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Affiliation(s)
- Christian Montag
- Department of Molecular Psychology, Institute of Psychology and Education, Ulm University, Ulm, Germany.
| | - Raian Ali
- College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar
| | - Dena Al-Thani
- College of Science and Engineering, Hamad Bin Khalifa University, Doha, Qatar
| | - Brian J Hall
- Center for Global Health Equity, New York University, Shanghai, China
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Stephenson C, Moghimi E, Shao Y, Kumar A, Yee CS, Miller S, Stefatos A, Gholamzadehmir M, Abbaspour Z, Jagayat J, Shirazi A, Gizzarelli T, Gutierrez G, Khan F, Patel C, Patel A, Yang M, Omrani M, Alavi N. Comparing the efficacy of electronic cognitive behavioral therapy to medication and combination therapy for generalized anxiety disorder: a quasi-experimental clinical trial. Front Psychiatry 2023; 14:1194955. [PMID: 38125282 PMCID: PMC10732166 DOI: 10.3389/fpsyt.2023.1194955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Background Generalized anxiety disorder (GAD) is a debilitating mental health disorder with first-line treatments include cognitive behavioral therapy (CBT) and pharmacotherapy. CBT is costly, time-consuming, and inaccessible. Electronic delivery (e-CBT) is a promising solution to address these barriers. However, due to the novelty of this intervention, more research testing the e-CBT efficacy independently and in conjunction with other treatments is needed. Objective This study investigated the efficacy of e-CBT compared to and in conjunction with pharmacotherapy for GAD. Methods This study employed a quasi-experimental design where patients selected their preferred treatment modality. Patients with GAD were enrolled in either e-CBT, medication, or combination arms. The 12-week e-CBT program was delivered through a digital platform. The medications followed clinical guidelines. The efficacy of each arm was evaluated using questionnaires measuring depression, anxiety, and stress severity, as well as quality of life. Results There were no significant differences between arms (N e-CBT = 41; N Medication = 41; N Combination = 33) in the number of weeks completed or baseline scores. All arms showed improvements in anxiety scores after treatment. The medication and combination arms improved depression scores. The e-CBT and Combination arms improved quality of life, and the combination arm improved stress scores. There were no differences between the groups in depression, anxiety, or stress scores post-treatment. However, the combination arm had a significantly larger improvement in quality of life. Gender and treatment arm were not predictors of dropout, whereas younger age was. Conclusion Incorporating e-CBT on its own or in combination with pharmaceutical interventions is a viable option for treating GAD. Treating GAD with e-CBT or medication appears to offer significant improvements in symptoms, with no meaningful difference between the two. Combining the treatments also offer significant improvements, while not necessarily superior to either independently. The findings suggest that all options are viable. Taking the patient's preferred treatment route based on their lifestyle, personality, and beliefs into account when deciding on treatment should be a priority for care providers.
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Affiliation(s)
- Callum Stephenson
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Elnaz Moghimi
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Yijia Shao
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- Department of Psychology, Faculty of Arts and Science, University of Toronto, Toronto, ON, Canada
| | - Anchan Kumar
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Caitlin S. Yee
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Shadé Miller
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Anthi Stefatos
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Maedeh Gholamzadehmir
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Zara Abbaspour
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Jasleen Jagayat
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Amirhossein Shirazi
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- OPTT Inc., Digital Media Zone, Ryerson University, Toronto, ON, Canada
| | - Tessa Gizzarelli
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Gilmar Gutierrez
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Ferwa Khan
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Charmy Patel
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Archana Patel
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Megan Yang
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Mohsen Omrani
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- OPTT Inc., Digital Media Zone, Ryerson University, Toronto, ON, Canada
| | - Nazanin Alavi
- Department of Psychiatry, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
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Newman MG, Basterfield C, Erickson TM, Caulley E, Przeworski A, Llera SJ. Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts. Expert Rev Neurother 2022; 22:751-770. [PMID: 36107159 PMCID: PMC9754763 DOI: 10.1080/14737175.2022.2125800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT. AREAS COVERED The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups. EXPERT OPINION We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.
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Affiliation(s)
- Michelle G Newman
- Department of Psychology, The Pennsylvania State University, Park, PA, USA
| | | | - Thane M Erickson
- Department of Psychology, Seattle Pacific University, Seattle, Washington, USA
| | - Evan Caulley
- Department of Psychology, Seattle Pacific University, Seattle, Washington, USA
| | - Amy Przeworski
- Department of Psychology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sandra J Llera
- Department of Psychology, Towson University, Baltimore, Maryland, USA
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Shepardson RL, Buckheit KA, Funderburk JS. Anxiety treatment preferences among veteran primary care patients: Demographic, mental health, and treatment-related correlates. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2021; 39:563-575. [PMID: 34472956 PMCID: PMC9358443 DOI: 10.1037/fsh0000628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Anxiety symptoms are common, yet undertreated, among primary care patients. Accommodating patient treatment preferences improves engagement and retention. In contrast to depression, little is known about primary care patients' preferences for anxiety treatment. METHOD Participants were 144 veterans experiencing anxiety symptoms but not receiving psychotherapy who were recruited from primary care. Preferences for 11 anxiety treatment attributes (method; location; type; format; provider; frequency, length, and number of appointments; psychotherapy orientation; symptom focus; and topic/skill) and demographic, mental health (e.g., anxiety symptom severity), and treatment-related (e.g., psychotherapy history) variables were assessed via mailed survey. We used chi-square goodness of fit tests to identify patient preferences for each attribute and multivariate multinomial logistic regression models to explore demographic, mental health, and treatment-related correlates of treatment preferences. RESULTS Patient preferences were largely consistent with integrated primary care models, particularly Primary Care Behavioral Health, with a few exceptions. Patients preferred longer appointments (e.g., 45-60 minutes) and a longer duration of treatment (e.g., ≥13 appointments) than is typically offered in primary care. Several variables, particularly education level, perceived need for help, anxiety symptom severity, and attitudes toward psychotherapy, were repeatedly associated with preferences for various anxiety treatment attributes. DISCUSSION Results from this study suggest that patients tend to have distinct preferences for anxiety treatment in primary care that are largely consistent with common integrated primary care models. Results also identify several variables that may be associated with specific preferences, which may help match patients to their preferred type of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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O'Connor C, Vaughan S. Does selectively endorsing different approaches to treating mental illness affect lay beliefs about the cause and course of mental illness? Psychiatry Res 2021; 297:113726. [PMID: 33486271 DOI: 10.1016/j.psychres.2021.113726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/11/2021] [Indexed: 02/01/2023]
Abstract
The current paper reports three experimental studies that investigate how selectively emphasising different treatment approaches (biological, psychological or social) for mental health difficulties affects lay beliefs about those illnesses. Online experimental vignettes exposed participants to different treatment narratives for a clinical case of Major Depressive Disorder (Study 1; n=164), Generalized Anxiety Disorder (Study 2; n=173) and Schizophrenia (Study 3, n=170). Measures of causal attributions and illness perceptions assessed effects on beliefs about the causes and course of the illness. Emphasising psychological treatment of Major Depressive Disorder promoted more causal attributions to personal weakness, while endorsing biological treatment weakened confidence in individual control over the course of the illness. For Generalized Anxiety Disorder, stressing social treatment encouraged more causal attributions to personal weakness and lifestyle factors. Causal attributions for Schizophrenia did not shift according to treatment modality, but highlighting biological treatment made the symptoms appear more treatable, while emphasising psychological treatment made the illness seem more personally controllable. As lay understandings of the causes and course of mental illness have implications for help-seeking, treatment engagement and stigma, effects on illness beliefs may be an important consideration when endorsing a particular treatment approach in public discourse or clinical communication.
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Affiliation(s)
| | - Sarah Vaughan
- School of Psychology, University College Dublin, Dublin, Ireland
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Fordham B, Sugavanam T, Edwards K, Hemming K, Howick J, Copsey B, Lee H, Kaidesoja M, Kirtley S, Hopewell S, das Nair R, Howard R, Stallard P, Hamer-Hunt J, Cooper Z, Lamb SE. Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis. Health Technol Assess 2021; 25:1-378. [PMID: 33629950 PMCID: PMC7957459 DOI: 10.3310/hta25090] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. OBJECTIVES This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. DATA SOURCES The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. REVIEW METHODS Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. RESULTS A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. LIMITATIONS Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. CONCLUSION Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. FUTURE WORK Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. STUDY REGISTRATION This study is registered as PROSPERO CRD42017078690. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Beth Fordham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katherine Edwards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jeremy Howick
- Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Bethan Copsey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hopin Lee
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Milla Kaidesoja
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Shona Kirtley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roshan das Nair
- Department of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | | | | | - Zafra Cooper
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Abstract
MicroRNAs as critical regulators of gene expression important for functions including neuronal development, synapse formation, and synaptic plasticity have been linked with the regulation of neurobiological systems that underlie anxiety processing in the brain. In this chapter, we give an update on associative evidence linking regulation of microRNAs with anxiety- and trauma-related disorders. Moving beyond correlative research, functional studies have emerged recently that explore causal relationships between microRNA expression and anxiety-like behavior. It has been demonstrated that experimental up- or downregulation of the candidate microRNAs in important nodes of the anxiety neurocircuitry can indeed modulate anxiety-related behavior in animal models. Improved methodologies for assessing microRNA-mediated modulation have aided such functional studies, revealing a number of anxiety-regulating microRNAs including miR-15a, miR-17-92, miR-34, miR-101, miR-124, miR-135, and miR-155. Important functional target genes of these identified microRNAs are associated with specific neurotransmitter/neuromodulator signaling, neurotrophin (e.g., BDNF) expression and other aspects of synaptic plasticity, as well as with stress-regulatory/hypothalamic-pituitary-axis function. Furthermore, microRNAs have been revealed that are regulated in distinct brain regions following various anxiety-attenuating strategies. These include pharmacological treatments such as antidepressants and other drugs, as well as non-pharmacological interventions such as fear extinction/exposure therapy or positive stimuli such as exposure to environmental enrichment. These are first indications for a role for microRNAs in the mechanism of action of anxiolytic treatments. As research continues, there is much hope that a deeper understanding of the microRNA-mediated mechanisms underlying anxiety-related disorders could open up possibilities for future novel biomarker and treatment strategies.
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Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis. J Psychiatr Res 2019; 118:73-83. [PMID: 31494377 DOI: 10.1016/j.jpsychires.2019.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 02/06/2023]
Abstract
Generalized anxiety disorder (GAD) is a significant and common mental illness with a lifetime prevalence of 3.7%. Regardless of the complexity of treatment decisions for GAD, few studies have conducted systematic comparisons of the efficacies of varying interventions. Thus, this study performed a valid network meta-analysis (NMA) of randomized controlled trials (RCTs) to synthesize direct and indirect evidence for alternative interventions for GAD. We searched four major bibliographic databases, the Cochrane Central Register of Controlled Trials, Embase, PsycINFO, and PubMed, for published RCTs of adult patients with a diagnosis of GAD and allowed for all comorbidities. A total of 91 articles (14,812 participants) were identified in the final NMA. The results showed that all pharmacological treatments except for serotonin modulators and second-generation antipsychotics had greater effects than placebo: norepinephrine-dopamine reuptake inhibitors (standardized mean difference (SMD) -1.84, 95% credible interval -3.05 to -0.62), noradrenergic and specific serotonergic antidepressants (-0.91, -1.62 to -0.20), melatonergic receptor agonists (-0.68, -1.15 to -0.21), selective serotonin reuptake inhibitors (SSRIs; -0.67, -0.90 to -0.43), azapirones (-0.58, -1.00 to -0.17), anticonvulsants (-0.56, -0.85 to -0.28), serotonin-norepinephrine reuptake inhibitors (SNRIs; -0.54, -0.79 to -0.30), and benzodiazepines (BZDs; -0.40, -0.65 to -0.15). Most psychological and self-help interventions exerted greater effects than the waitlist group. However, no psychological interventions had greater effects compared with the psychological placebo. Overall, most pharmacological interventions had larger effect sizes than psychological interventions, and most psychological interventions showed larger effect sizes than self-help interventions.
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Khaiyom JHA, Mukhtar F, Po OT. Treatments for Anxiety Disorders in Malaysia. Malays J Med Sci 2019; 26:24-36. [PMID: 31303848 PMCID: PMC6613468 DOI: 10.21315/mjms2019.26.3.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 09/15/2018] [Indexed: 12/18/2022] Open
Abstract
This current study aims to systematically review the treatments for anxiety disorders in Malaysia. PsycINFO, MEDLINE databases, and 28 local journals were used to search published papers in this area. Eight articles were subjected to review after excluding 273 papers that did not meet the inclusion criteria. A total of 598 participants with various types of anxiety disorders were included in the review. Based on the findings, the combination of pharmacotherapy and psychotherapy provided better treatment outcomes if compared to psychotherapy or pharmacotherapy alone. The combination of selective serotonin reuptake inhibitors and cognitive behaviour therapy was considered as one of the most effective treatment to treat patients with anxiety disorders in Malaysia. This is in line with the clinical practice guidelines from the Ministry of Health Singapore and Canada. Even though there were some limitations in the methodology and reporting of the results, it can be concluded that efforts have been taken to conduct studies related to treatments for patients with anxiety disorders in Malaysia. Future studies are suggested to make conscious efforts to overcome these limitations.
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Affiliation(s)
| | - Firdaus Mukhtar
- Department of Psychiatry, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Oei Tian Po
- School of Psychology and CBT Unit, Toowong Hospital, University of Queensland, Brisbane, St Lucia QLD, Australia.,Department of Psychology, James Cook University, 149 Sims Drive, Singapore
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Federman D, Shimoni S, Turjeman N. ‘Attentive movement’ as a method for treating depression. BODY MOVEMENT AND DANCE IN PSYCHOTHERAPY 2019. [DOI: 10.1080/17432979.2019.1586773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Dita Federman
- The School of Creative Art Therapies, the Faculty of social welfare & health sciences, The Emili Sagol CAT Research Center University of Haifa, Haifa, Israel
| | - Shalev Shimoni
- The School of Creative Art Therapies, the Faculty of social welfare & health sciences, University of Haifa, Haifa, Israel
| | - Nataly Turjeman
- The School of Creative Art Therapies, the Faculty of social welfare & health sciences, The Emili Sagol CAT Research Center University of Haifa, Haifa, Israel
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Glucocorticoid-induced enhancement of extinction-from animal models to clinical trials. Psychopharmacology (Berl) 2019; 236:183-199. [PMID: 30610352 PMCID: PMC6373196 DOI: 10.1007/s00213-018-5116-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/06/2018] [Indexed: 12/13/2022]
Abstract
Extensive evidence from both animal model and human research indicates that glucocorticoid hormones are crucially involved in modulating memory performance. Glucocorticoids, which are released during stressful or emotionally arousing experiences, enhance the consolidation of new memories, including extinction memory, but reduce the retrieval of previously stored memories. These memory-modulating properties of glucocorticoids have recently received considerable interest for translational purposes because strong aversive memories lie at the core of several fear-related disorders, including post-traumatic stress disorder and phobias. Moreover, exposure-based psychological treatment of these disorders relies on successful fear extinction. In this review, we argue that glucocorticoid-based interventions facilitate fear extinction by reducing the retrieval of aversive memories and enhancing the consolidation of extinction memories. Several clinical trials have already indicated that glucocorticoids might be indeed helpful in the treatment of fear-related disorders.
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Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder. Aust N Z J Psychiatry 2018. [DOI: 10.1177/0004867418799453] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand. Method: Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders. Results: The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy. Conclusion: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.
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Barić H, Đorđević V, Cerovečki I, Trkulja V. Complementary and Alternative Medicine Treatments for Generalized Anxiety Disorder: Systematic Review and Meta-analysis of Randomized Controlled Trials. Adv Ther 2018; 35:261-288. [PMID: 29508154 DOI: 10.1007/s12325-018-0680-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The objective was to evaluate efficacy/safety of complementary and alternative medicine (CAM) methods for generalized anxiety disorder (GAD) based on randomized controlled trials in adults. METHODS Data sources. Six electronic databases ("generalized anxiety (disorder)" and "randomized trial") and reference lists of identified publications were searched to March 2017. STUDY SELECTION Eligibility: full-text publications (English, German language); CAM versus conventional treatment, placebo/sham or no treatment; GAD diagnosed according to standard criteria; and a validated scale for disease severity. Of the 6693 screened records, 32 were included (18 on biologically-based therapies, exclusively herbal preparations; eight on manipulative and body-based therapies; and three on alternative medical systems and three on mind-body therapies). DATA EXTRACTION Cochrane Collaboration methodology was used for quality assessment and data extraction. RESULTS Direct comparisons of Kava Kava (Piper methysticum) extracts to placebo (4 quality trials, n = 233) were highly heterogeneous. Network meta-regression reduced heterogeneity and suggested a modest Kava effect [end-of-treatment Hamilton Anxiety scale score difference adjusted for baseline scores and trial duration: - 3.24 (95% CI - 6.65, 0.17; P = 0.059), Kava Kava 4 arms, n = 139; placebo 5 arms, n = 359]. Lavender (Lavandula angustifolia) extract (1 quality trial, 10 weeks, n = 523) and a combination of extracts of C. oxycantha, E. californica and magnesium (1 quality trial, 12 weeks, n = 264) were superior to placebo and balneotherapy was superior to paroxetine (1 quality trial, 8 weeks, n = 237) indicating efficacy. All other trials were small and/or of modest/low quality and/or lacked assay sensitivity. Safety reporting was poor. CONCLUSION Evidence about efficacy/safety of most CAM methods in GAD is limited. Apparent efficacy of certain herbal preparations and body-based therapies requires further confirmation.
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Affiliation(s)
- Hrvoje Barić
- Department of Neurosurgery, University Hospital Center Zagreb, Zagreb University School of Medicine, Zagreb, Croatia
| | - Veljko Đorđević
- Center for Palliative Medicine, Medical Ethics and Communication Skills (CEPAMET), Zagreb University School of Medicine, Zagreb, Croatia
| | | | - Vladimir Trkulja
- Department of Pharmacology, Zagreb University School of Medicine, Zagreb, Croatia.
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Tolin DF. Can Cognitive Behavioral Therapy for Anxiety and Depression Be Improved with Pharmacotherapy? A Meta-analysis. Psychiatr Clin North Am 2017; 40:715-738. [PMID: 29080596 DOI: 10.1016/j.psc.2017.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The present meta-analysis examined controlled trials of pharmacologic augmentation of cognitive-behavioral therapy (CBT) for patients with anxiety or depressive disorders. The additive effect of medications was small for both anxiety and depressive disorders at posttreatment, and there was no additive benefit after medications were discontinued. A small body of evidence suggested that antidepressant medications are an efficacious second-line treatment for patients failing to respond to CBT alone. In anxiety disorders, novel agents thought to potentiate the biological mechanisms of CBT showed small effects at posttreatment; after discontinuation, some of these agents were associated with an increasing effect.
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Affiliation(s)
- David F Tolin
- The Institute of Living, Anxiety Disorders Center, 200 Retreat Avenue, Hartford, CT 06106, USA.
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16
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Murphy CP, Singewald N. Potential of microRNAs as novel targets in the alleviation of pathological fear. GENES BRAIN AND BEHAVIOR 2017; 17:e12427. [DOI: 10.1111/gbb.12427] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/20/2017] [Accepted: 10/05/2017] [Indexed: 12/16/2022]
Affiliation(s)
- C. P. Murphy
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Center for Molecular Biosciences Innsbruck; University of Innsbruck; Innsbruck Austria
| | - N. Singewald
- Department of Pharmacology and Toxicology, Institute of Pharmacy, Center for Molecular Biosciences Innsbruck; University of Innsbruck; Innsbruck Austria
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17
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Deppermann S, Vennewald N, Diemer J, Sickinger S, Haeussinger FB, Dresler T, Notzon S, Laeger I, Arolt V, Ehlis AC, Fallgatter AJ, Zwanzger P. Neurobiological and clinical effects of fNIRS-controlled rTMS in patients with panic disorder/agoraphobia during cognitive-behavioural therapy. Neuroimage Clin 2017; 16:668-677. [PMID: 29085773 PMCID: PMC5650598 DOI: 10.1016/j.nicl.2017.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 09/01/2017] [Accepted: 09/19/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND A relevant proportion of patients with panic disorder (PD) does not improve even though they receive state of the art treatment for anxiety disorders such as cognitive-behavioural therapy (CBT). At the same time, it is known, that from a neurobiological point of view, PD patients are often characterised by prefrontal hypoactivation. Intermittent Theta Burst Stimulation (iTBS) is a non-invasive type of neurostimulation which can modulate cortical activity and thus has the potential to normalise prefrontal hypoactivity found in PD. We therefore aimed at investigating the effects of iTBS as an innovative add-on to CBT in the treatment for PD. METHODS In this double-blind, bicentric study, 44 PD patients, randomised to sham or verum stimulation, received 15 sessions of iTBS over the left prefrontal cortex (PFC) in addition to 9 weeks of group CBT. Cortical activity during a cognitive as well as an emotional (Emotional Stroop) paradigm was assessed both at baseline and post-iTBS treatment using functional near-infrared spectroscopy (fNIRS) and compared to healthy controls. RESULTS In this manuscript we only report the results of the emotional paradigm; for the results of the cognitive paradigm please refer to Deppermann et al. (2014). During the Emotional Stroop test, PD patients showed significantly reduced activation to panic-related compared to neutral stimuli for the left PFC at baseline. Bilateral prefrontal activation for panic-related stimuli significantly increased after verum iTBS only. Clinical ratings significantly improved during CBT and remained stable at follow-up. However, no clinical differences between the verum- and sham-stimulated group were identified, except for a more stable reduction of agoraphobic avoidance during follow-up in the verum iTBS group. LIMITATIONS Limitations include insufficient blinding, the missing control for possible state-dependent iTBS effects, and the timing of iTBS application during CBT. CONCLUSION Prefrontal hypoactivity in PD patients was normalised by add-on iTBS. Clinical improvement of anxiety symptoms was not affected by iTBS.
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Key Words
- ANOVA, analysis of variance
- CAQ, Cardiac Anxiety Questionnaire
- CBSI, correlation-based signal improvement
- CBT, cognitive-behavioural therapy
- Cognitive-behavioural therapy
- ER, error rate
- Emotion regulation
- Functional near-infrared spectroscopy
- HAM-A, Hamilton Anxiety Rating Scale
- HHb, deoxyhemoglobin
- Intermittent Theta Burst Stimulation
- LOCF, last observation carried forward
- O2Hb, oxyhemoglobin
- PAS, Panic and Agoraphobia Scale
- PD, panic disorder
- PFC, prefrontal cortex
- Panic disorder
- RM-ANOVA, repeated-measures analysis of variance
- ROI, region of interest
- RT, reaction time
- fNIRS, functional near-infrared spectroscopy
- iTBS, intermittent Theta Burst Stimulation
- rTMS, repetitive Transcranial Magnetic Stimulation
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Affiliation(s)
- Saskia Deppermann
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
| | - Nadja Vennewald
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
| | - Julia Diemer
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
- kbo-Inn-Salzach-Hospital, Gabersee 7, 83512 Wasserburg am Inn, Germany
| | - Stephanie Sickinger
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
| | - Florian B. Haeussinger
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
| | - Thomas Dresler
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
- Graduate School LEAD, Europastr. 6, University of Tuebingen, 72072 Tuebingen, Germany
| | - Swantje Notzon
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
| | - Inga Laeger
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
- Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
| | - Volker Arolt
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
| | - Ann-Christine Ehlis
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
| | - Andreas J. Fallgatter
- Department of Psychiatry and Psychotherapy, Calwerstr. 14, University of Tuebingen, 72076 Tuebingen, Germany
- Graduate School LEAD, Europastr. 6, University of Tuebingen, 72072 Tuebingen, Germany
- Cluster of Excellence CIN, Otfried-Mueller-Str. 25, University of Tuebingen, 72076 Tuebingen, Germany
| | - Peter Zwanzger
- Mood and Anxiety Disorders Research Unit, Department of Psychiatry and Psychotherapy, Albert-Schweitzer-Campus 1, University of Muenster, Muenster, Germany
- kbo-Inn-Salzach-Hospital, Gabersee 7, 83512 Wasserburg am Inn, Germany
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Singh R, Turner RC, Nguyen L, Motwani K, Swatek M, Lucke-Wold BP. Pediatric Traumatic Brain Injury and Autism: Elucidating Shared Mechanisms. Behav Neurol 2016; 2016:8781725. [PMID: 28074078 PMCID: PMC5198096 DOI: 10.1155/2016/8781725] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 11/23/2016] [Indexed: 02/08/2023] Open
Abstract
Pediatric traumatic brain injury (TBI) and autism spectrum disorder (ASD) are two serious conditions that affect youth. Recent data, both preclinical and clinical, show that pediatric TBI and ASD share not only similar symptoms but also some of the same biologic mechanisms that cause these symptoms. Prominent symptoms for both disorders include gastrointestinal problems, learning difficulties, seizures, and sensory processing disruption. In this review, we highlight some of these shared mechanisms in order to discuss potential treatment options that might be applied for each condition. We discuss potential therapeutic and pharmacologic options as well as potential novel drug targets. Furthermore, we highlight advances in understanding of brain circuitry that is being propelled by improved imaging modalities. Going forward, advanced imaging will help in diagnosis and treatment planning strategies for pediatric patients. Lessons from each field can be applied to design better and more rigorous trials that can be used to improve guidelines for pediatric patients suffering from TBI or ASD.
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Affiliation(s)
- Rahul Singh
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, WV 26505, USA
| | - Ryan C. Turner
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, WV 26505, USA
| | - Linda Nguyen
- Department of Basic Pharmaceutical Sciences, West Virginia University School of Medicine, Morgantown, WV 26505, USA
| | - Kartik Motwani
- Department of Medical Sciences, University of Florida School of Medicine, Gainesville, FL 32611, USA
| | - Michelle Swatek
- Department of Psychology, North Carolina State University, Raleigh, NC 27695, USA
| | - Brandon P. Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, WV 26505, USA
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de Quervain D, Schwabe L, Roozendaal B. Stress, glucocorticoids and memory: implications for treating fear-related disorders. Nat Rev Neurosci 2016; 18:7-19. [PMID: 27881856 DOI: 10.1038/nrn.2016.155] [Citation(s) in RCA: 310] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Glucocorticoid stress hormones are crucially involved in modulating mnemonic processing of emotionally arousing experiences. They enhance the consolidation of new memories, including those that extinguish older memories, but impair the retrieval of information stored in long-term memory. As strong aversive memories lie at the core of several fear-related disorders, including post-traumatic stress disorder and phobias, the memory-modulating properties of glucocorticoids have recently become of considerable translational interest. Clinical trials have provided the first evidence that glucocorticoid-based pharmacotherapies aimed at attenuating aversive memories might be helpful in the treatment of fear-related disorders. Here, we review important advances in the understanding of how glucocorticoids mediate stress effects on memory processes, and discuss the translational potential of these new conceptual insights.
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Affiliation(s)
- Dominique de Quervain
- Transfaculty Research Platform, University of Basel, CH-4055, Basel, Switzerland.,Division of Cognitive Neuroscience, Department of Psychology, University of Basel, CH-4055, Basel, Switzerland.,University Psychiatric Clinics, University of Basel, CH-4012, Basel, Switzerland
| | - Lars Schwabe
- Department of Cognitive Psychology, Institute of Psychology, University of Hamburg, 20146 Hamburg, Germany
| | - Benno Roozendaal
- Department of Cognitive Neuroscience, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, 6525 EN Nijmegen, The Netherlands
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20
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The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Algorithm for Generalized Anxiety Disorder. Harv Rev Psychiatry 2016; 24:243-56. [PMID: 27384395 DOI: 10.1097/hrp.0000000000000098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This revision of previous algorithms for the pharmacotherapy of generalized anxiety disorder was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. Algorithms from 1999 and 2010 and associated references were reevaluated. Newer studies and reviews published from 2008-14 were obtained from PubMed and analyzed with a focus on their potential to justify changes in the recommendations. Exceptions to the main algorithm for special patient populations, such as women of childbearing potential, pregnant women, the elderly, and those with common medical and psychiatric comorbidities, were considered. Selective serotonin reuptake inhibitors (SSRIs) are still the basic first-line medication. Early alternatives include duloxetine, buspirone, hydroxyzine, pregabalin, or bupropion, in that order. If response is inadequate, then the second recommendation is to try a different SSRI. Additional alternatives now include benzodiazepines, venlafaxine, kava, and agomelatine. If the response to the second SSRI is unsatisfactory, then the recommendation is to try a serotonin-norepinephrine reuptake inhibitor (SNRI). Other alternatives to SSRIs and SNRIs for treatment-resistant or treatment-intolerant patients include tricyclic antidepressants, second-generation antipsychotics, and valproate. This revision of the GAD algorithm responds to issues raised by new treatments under development (such as pregabalin) and organizes the evidence systematically for practical clinical application.
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Daghaghzadeh H, Naji F, Afshar H, Sharbafchi MR, Feizi A, Maroufi M, Tabatabaeeyan M, Adibi P, Tavakoli H. Efficacy of duloxetine add on in treatment of inflammatory bowel disease patients: A double-blind controlled study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2015; 20:595-601. [PMID: 26600836 PMCID: PMC4621655 DOI: 10.4103/1735-1995.165969] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background: Treating inflammatory bowel disease (IBD) with antidepressants might be of utility to improve patient's condition. The aim of this study was to assess the efficacy of Duloxetine on depression, anxiety, severity of symptoms, and quality of life (QOL) in IBD patients. Materials and Methods: In a randomized, double-blind, controlled clinical trial on 2013-2014, in Alzahra Hospital (Isfahan, Iran), 44 IBD patients were chosen to receive either duloxetine (60 mg/day) or placebo. They were treated in a 12 weeks program, and all of the participants also received mesalazine, 2-4 g daily. We assessed anxiety and depression with Hospital Anxiety and Depression Scale, the severity of symptoms with Lichtiger Colitis Activity Index and QOL with World Health Organization Quality of Life Instruments, before and just after the treatment. The data were analyzed using Paired sample t-test and ANCOVA. Results: In 35 subjects who completed the study, the mean (standard error [SE]) scores of depression and anxiety were reduced in duloxetine more than placebo group, significantly (P = 0.041 and P = 0.049, respectively). The mean (SE) scores of severity of symptom were also reduced in duloxetine more than the placebo group, significantly (P = 0.02). The mean (SE) scores of physical, psychological, and social dimensions of QOL were increased after treatment with duloxetine more than placebo group, significantly (P = 0.001, P = 0.038, and P = 0.015, respectively). The environmental QOL was not increased significantly (P = 0.260). Conclusion: Duloxetine is probably effective and safe for reducing depression, anxiety and severity of physical symptoms. It also could increase physical, psychological, and social QOL in patients.
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Affiliation(s)
- Hamed Daghaghzadeh
- Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fateme Naji
- Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran ; Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Afshar
- Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran ; Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Reza Sharbafchi
- Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran ; Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Maroufi
- Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran ; Behavioral Science Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahshid Tabatabaeeyan
- Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran ; Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Adibi
- Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Tavakoli
- Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Mavranezouli I, Mayo-Wilson E, Dias S, Kew K, Clark DM, Ades AE, Pilling S. The Cost Effectiveness of Psychological and Pharmacological Interventions for Social Anxiety Disorder: A Model-Based Economic Analysis. PLoS One 2015; 10:e0140704. [PMID: 26506554 PMCID: PMC4624770 DOI: 10.1371/journal.pone.0140704] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/28/2015] [Indexed: 11/26/2022] Open
Abstract
Background Social anxiety disorder is one of the most persistent and common anxiety disorders. Individually delivered psychological therapies are the most effective treatment options for adults with social anxiety disorder, but they are associated with high intervention costs. Therefore, the objective of this study was to assess the relative cost effectiveness of a variety of psychological and pharmacological interventions for adults with social anxiety disorder. Methods A decision-analytic model was constructed to compare costs and quality adjusted life years (QALYs) of 28 interventions for social anxiety disorder from the perspective of the British National Health Service and personal social services. Efficacy data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published literature and national sources, supplemented by expert opinion. Results Individual cognitive therapy was the most cost-effective intervention for adults with social anxiety disorder, followed by generic individual cognitive behavioural therapy (CBT), phenelzine and book-based self-help without support. Other drugs, group-based psychological interventions and other individually delivered psychological interventions were less cost-effective. Results were influenced by limited evidence suggesting superiority of psychological interventions over drugs in retaining long-term effects. The analysis did not take into account side effects of drugs. Conclusion Various forms of individually delivered CBT appear to be the most cost-effective options for the treatment of adults with social anxiety disorder. Consideration of side effects of drugs would only strengthen this conclusion, as it would improve even further the cost effectiveness of individually delivered CBT relative to phenelzine, which was the next most cost-effective option, due to the serious side effects associated with phenelzine. Further research needs to determine more accurately the long-term comparative benefits and harms of psychological and pharmacological interventions for social anxiety disorder and establish their relative cost effectiveness with greater certainty.
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Affiliation(s)
- Ifigeneia Mavranezouli
- National Collaborating Centre for Mental Health, Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
- * E-mail:
| | - Evan Mayo-Wilson
- National Collaborating Centre for Mental Health, Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Sofia Dias
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Kayleigh Kew
- National Collaborating Centre for Mental Health, Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - David M. Clark
- Department of Experimental Psychology, University of Oxford & Oxford Cognitive Health NIHR Clinical Research Facility, Oxford, United Kingdom
| | - A. E. Ades
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Stephen Pilling
- National Collaborating Centre for Mental Health, Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
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Abstract
To our knowledge, no previous meta-analysis has attempted to compare the efficacy of pharmacological, psychological and combined treatments for the three main anxiety disorders (panic disorder, generalized anxiety disorder and social phobia). Pre-post and treated versus control effect sizes (ES) were calculated for all evaluable randomized-controlled studies (n = 234), involving 37,333 patients. Medications were associated with a significantly higher average pre-post ES [Cohen's d = 2.02 (1.90-2.15); 28,051 patients] than psychotherapies [1.22 (1.14-1.30); 6992 patients; P < 0.0001]. ES were 2.25 for serotonin-noradrenaline reuptake inhibitors (n = 23 study arms), 2.15 for benzodiazepines (n = 42), 2.09 for selective serotonin reuptake inhibitors (n = 62) and 1.83 for tricyclic antidepressants (n = 15). ES for psychotherapies were mindfulness therapies, 1.56 (n = 4); relaxation, 1.36 (n = 17); individual cognitive behavioural/exposure therapy (CBT), 1.30 (n = 93); group CBT, 1.22 (n = 18); psychodynamic therapy 1.17 (n = 5); therapies without face-to-face contact (e.g. Internet therapies), 1.11 (n = 34); eye movement desensitization reprocessing, 1.03 (n = 3); and interpersonal therapy 0.78 (n = 4). The ES was 2.12 (n = 16) for CBT/drug combinations. Exercise had an ES of 1.23 (n = 3). For control groups, ES were 1.29 for placebo pills (n = 111), 0.83 for psychological placebos (n = 16) and 0.20 for waitlists (n = 50). In direct comparisons with control groups, all investigated drugs, except for citalopram, opipramol and moclobemide, were significantly more effective than placebo. Individual CBT was more effective than waiting list, psychological placebo and pill placebo. When looking at the average pre-post ES, medications were more effective than psychotherapies. Pre-post ES for psychotherapies did not differ from pill placebos; this finding cannot be explained by heterogeneity, publication bias or allegiance effects. However, the decision on whether to choose psychotherapy, medications or a combination of the two should be left to the patient as drugs may have side effects, interactions and contraindications.
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Abstract
Inflammatory bowel disease (IBD) causes severe physical symptoms and is also associated with psychological comorbidities. Abnormal anxiety levels are found in up to 40% of patients with IBD. Anxiety symptoms are often related to flares of IBD but may persist in times of remission. Detection of anxiety disorder (AD) in patients with IBD can be challenging. Patients with anxiety may also exhibit symptoms in keeping with functional gastrointestinal disorders (FGID). Evidence for the effectiveness of pharmacological and psychological therapies for anxiety stems from patients without IBD. Studies in patients with IBD have either been small or shown negative results. In light of this, a combined approach involving IBD physicians to improve disease control and psychologists or psychiatrists to treat anxiety is advised. This review examines the evidence of anxiety issues in IBD with a focus on extent of the problem, risk factors for anxiety, and the effectiveness of interventions.
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Affiliation(s)
- Ayman S Bannaga
- Department of Gastroenterology, Doncaster Royal Infirmary, Doncaster, UK
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Coles ME, Coleman SL, Schubert J. College students' recommendations for dealing with anxiety disorders. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2015. [DOI: 10.1080/14623730.2015.1005969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gaudlitz K, Plag J, Dimeo F, Ströhle A. Aerobic exercise training facilitates the effectiveness of cognitive behavioral therapy in panic disorder. Depress Anxiety 2015; 32:221-8. [PMID: 25515221 DOI: 10.1002/da.22337] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 10/22/2014] [Accepted: 11/02/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Physical activity has been discussed as a therapeutic alternative or add-on for the treatment of anxiety disorders. We studied whether aerobic exercise compared to physical activity with low impact can improve the effect of cognitive behavioral therapy (CBT) in patients with panic disorder (PD) with/without agoraphobia. METHODS Forty-seven patients received group CBT treatment over 1 month, which was augmented with an 8-week protocol of either aerobic exercise (three times/week, 30 min, 70% VO(2) max; n = 24) or a training program including exercises with very low intensity (n = 23) in a randomized controlled double-blind design. The primary outcome measure was the total score on the Hamilton Anxiety Scale (Ham-A). A 2 × 3 analysis of covariance (ANCOVA) with baseline value as a covariate was conducted for data analysis. RESULTS Time × group interaction for the Ham-A revealed a significant effect (P = .047, η(2) p = .072), which represented the significant group difference at a 7-month follow-up. For the other clinical outcome measures no statistical significance emerged, although improvement was more sustained in the exercise group. CONCLUSIONS For patients with PD, regular aerobic exercise adds an additional benefit to CBT. This supports previous results and provides evidence about the intensity of exercise that needs to be performed.
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Affiliation(s)
- Katharina Gaudlitz
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
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Singewald N, Schmuckermair C, Whittle N, Holmes A, Ressler KJ. Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders. Pharmacol Ther 2014; 149:150-90. [PMID: 25550231 PMCID: PMC4380664 DOI: 10.1016/j.pharmthera.2014.12.004] [Citation(s) in RCA: 275] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/24/2014] [Indexed: 12/20/2022]
Abstract
Pathological fear and anxiety are highly debilitating and, despite considerable advances in psychotherapy and pharmacotherapy they remain insufficiently treated in many patients with PTSD, phobias, panic and other anxiety disorders. Increasing preclinical and clinical evidence indicates that pharmacological treatments including cognitive enhancers, when given as adjuncts to psychotherapeutic approaches [cognitive behavioral therapy including extinction-based exposure therapy] enhance treatment efficacy, while using anxiolytics such as benzodiazepines as adjuncts can undermine long-term treatment success. The purpose of this review is to outline the literature showing how pharmacological interventions targeting neurotransmitter systems including serotonin, dopamine, noradrenaline, histamine, glutamate, GABA, cannabinoids, neuropeptides (oxytocin, neuropeptides Y and S, opioids) and other targets (neurotrophins BDNF and FGF2, glucocorticoids, L-type-calcium channels, epigenetic modifications) as well as their downstream signaling pathways, can augment fear extinction and strengthen extinction memory persistently in preclinical models. Particularly promising approaches are discussed in regard to their effects on specific aspects of fear extinction namely, acquisition, consolidation and retrieval, including long-term protection from return of fear (relapse) phenomena like spontaneous recovery, reinstatement and renewal of fear. We also highlight the promising translational value of the preclinial research and the clinical potential of targeting certain neurochemical systems with, for example d-cycloserine, yohimbine, cortisol, and L-DOPA. The current body of research reveals important new insights into the neurobiology and neurochemistry of fear extinction and holds significant promise for pharmacologically-augmented psychotherapy as an improved approach to treat trauma and anxiety-related disorders in a more efficient and persistent way promoting enhanced symptom remission and recovery.
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Affiliation(s)
- N Singewald
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria.
| | - C Schmuckermair
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria
| | - N Whittle
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens University of Innsbruck, Innrain 80-82, A-6020 Innsbruck, Austria
| | - A Holmes
- Laboratory of Behavioral and Genomic Neuroscience, National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, USA
| | - K J Ressler
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Stewart BJR, Turnbull D, Mikocka-Walus AA, Harley HAJ, Andrews JM. Acceptability of psychotherapy, pharmacotherapy, and self-directed therapies in Australians living with chronic hepatitis C. J Clin Psychol Med Settings 2014; 20:427-39. [PMID: 23756631 DOI: 10.1007/s10880-012-9339-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite the prevalence of psychiatric co-morbidity in chronic hepatitis C (CHC), treatment is under-researched. Patient preferences are likely to affect treatment uptake, adherence, and success. Thus, the acceptability of psychological supports was explored. A postal survey of Australian CHC outpatients of the Royal Adelaide Hospital and online survey of Australians living with CHC was conducted, assessing demographic and disease-related variables, psychosocial characteristics, past experience with psychological support, and psychological support acceptability. The final sample of 156 patients (58 % male) had significantly worse depression, anxiety, stress, and social support than norms. The most acceptable support type was individual psychotherapy (83 %), followed by bibliotherapy (61 %), pharmacotherapy (56 %), online therapy (45 %), and group psychotherapy (37 %). The most prominent predictor of support acceptability was satisfaction with past use. While individual psychotherapy acceptability was encouragingly high, potentially less costly modalities including group psychotherapy or online therapy may be hampered by low acceptability, the reasons for which need to be further explored.
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Affiliation(s)
- Benjamin J R Stewart
- School of Psychology, University of Adelaide, North Terrace, Adelaide, SA, 5005, Australia,
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Howard P, Twycross R, Shuster J, Mihalyo M, Wilcock A. Benzodiazepines. J Pain Symptom Manage 2014; 47:955-64. [PMID: 24681184 DOI: 10.1016/j.jpainsymman.2014.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/06/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Paul Howard
- Earl Mountbatten Hospice, Isle of Wight, United Kingdom
| | | | | | - Mary Mihalyo
- Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
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Baldwin DS, Anderson IM, Nutt DJ, Allgulander C, Bandelow B, den Boer JA, Christmas DM, Davies S, Fineberg N, Lidbetter N, Malizia A, McCrone P, Nabarro D, O'Neill C, Scott J, van der Wee N, Wittchen HU. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol 2014; 28:403-39. [PMID: 24713617 DOI: 10.1177/0269881114525674] [Citation(s) in RCA: 375] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.
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Affiliation(s)
- David S Baldwin
- 1Faculty of Medicine, University of Southampton, Southampton, UK
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Lonsdorf TB, Haaker J, Fadai T, Kalisch R. No evidence for enhanced extinction memory consolidation through noradrenergic reuptake inhibition-delayed memory test and reinstatement in human fMRI. Psychopharmacology (Berl) 2014; 231:1949-62. [PMID: 24193372 DOI: 10.1007/s00213-013-3338-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/14/2013] [Indexed: 01/12/2023]
Abstract
RATIONALE One promising approach in the current ambition to maximise treatment benefit for anxiety disorders is the pharmacological enhancement of cognitive-behavioural treatment efficacy, which can be experimentally modelled by pharmacological enhancement of extinction learning/consolidation. Noradrenaline (NA) is involved in memory consolidation, and NAergic innervations are found in brain areas implicated in fear conditioning and extinction. OBJECTIVES Thus, to enhance extinction memory consolidation through boosted NAergic signalling, we administered 4 mg reboxetine (RBX) immediately after extinction learning (day 2, 24 h after conditioning on day 1) in a randomised, placebo (PLC)-controlled design. At a delayed memory test (day 8), we probed cued and contextual fear and extinction memories before and after a reinstatement manipulation. RESULTS After reinstatement, we find significantly enhanced amygdala and posterior hippocampus activation in the RBX group, areas implicated in fear memory expression, while the PLC group exhibited enhanced activation in areas associated with extinction memory expression (vmPFC, anterior hippocampus). No group differences were found in skin conductance responses. CONCLUSIONS Thus, our data do not support our hypothesis that enhancement of NA signalling may facilitate extinction memory consolidation and provide preliminary evidence that this might rather enhance fear memories on a neural but not physiological (skin conductance responses) level.
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Affiliation(s)
- Tina B Lonsdorf
- Institute for Systems Neuroscience, University Medical Center Hamburg-Eppendorf (UKE), Martinistrasse 52, 20246, Hamburg, Germany,
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Arch JJ. Cognitive behavioral therapy and pharmacotherapy for anxiety: treatment preferences and credibility among pregnant and non-pregnant women. Behav Res Ther 2013; 52:53-60. [PMID: 24326075 DOI: 10.1016/j.brat.2013.11.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 10/16/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Relatively little is known about women's anxiety-related treatment preferences and no studies have examined potential differences between pregnant versus non-pregnant women. Treatment credibility and willingness are particularly important to understand regarding exposure-based cognitive behavioral therapy (CBT) and pharmacotherapy, the leading evidence-based treatments. METHODS A large U.S. sample of pregnant (n = 377) and matched non-pregnant (n = 399) women (total N = 776) rated overall treatment preferences and treatment credibility, concerns, and willingness to have CBT and pharmacotherapy if suffering from anxiety. RESULTS Women preferred anxiety-related treatment that included psychotherapy. Preference for psychotherapy alone was stronger among pregnant (74%) than non-pregnant (47%) women, p < .001. In response to treatment descriptions, both groups rated CBT more favorably than pharmacotherapy on treatment willingness, credibility, and concerns, ps < .001, with the magnitude of this preference significantly greater among pregnant than non-pregnant women, ps < .001. Pregnancy status was unrelated to CBT ratings. Treatment credibility and to a lesser extent total concerns mediated the relationship between pregnancy status and pharmacotherapy willingness. CONCLUSIONS Non-pregnant and especially pregnant women rated exposure-based CBT for anxiety more favorably than pharmacotherapy. Pregnancy status predicted general treatment preferences and pharmacotherapy, but not CBT, ratings.
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Affiliation(s)
- Joanna J Arch
- Department of Psychology and Neuroscience, University of Colorado, 345 UCB Muenzinger, Boulder, CO 80309-0345, USA.
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Abstract
This review summarizes the extant evidence of the effects of exercise training on anxiety among healthy adults, adults with a chronic illness, and individuals diagnosed with an anxiety disorder. A brief discussion of selected proposed mechanisms that may underlie relations of exercise and anxiety is also provided. The weight of the available empirical evidence indicates that exercise training reduces symptoms of anxiety among healthy adults, chronically ill patients, and patients with panic disorder. Preliminary data suggest that exercise training can serve as an alternative therapy for patients with social anxiety disorder, generalized anxiety disorder, and obsessive–compulsive disorder. Anxiety reductions appear to be comparable to empirically supported treatments for panic and generalized anxiety disorders. Large trials aimed at more precisely determining the magnitude and generalizability of exercise training effects appear to be warranted for panic and generalized anxiety disorders. Future well-designed randomized controlled trials should (a) examine the therapeutic effects of exercise training among understudied anxiety disorders, including specific phobias, social anxiety disorder and posttraumatic stress disorder; (b) focus on understudied exercise modalities, including resistance exercise training and programs that combine exercise with cognitive-behavioral therapies; and (c) elucidate putative mechanisms of the anxiolytic effects of exercise training.
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Affiliation(s)
- Matthew P. Herring
- Department of Epidemiology, University of Alabama at Birmingham, Alabama (MPH)
- Department of Kinesiology, The University of Georgia, Athens, Georgia (JBL, PJO)
| | - Jacob B. Lindheimer
- Department of Epidemiology, University of Alabama at Birmingham, Alabama (MPH)
- Department of Kinesiology, The University of Georgia, Athens, Georgia (JBL, PJO)
| | - Patrick J. O’Connor
- Department of Epidemiology, University of Alabama at Birmingham, Alabama (MPH)
- Department of Kinesiology, The University of Georgia, Athens, Georgia (JBL, PJO)
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Mula M. Treatment of anxiety disorders in epilepsy: An evidence-based approach. Epilepsia 2013; 54 Suppl 1:13-8. [DOI: 10.1111/epi.12101] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Marco Mula
- Division of Neurology, Trinity Hospital; Borgomanero; Italy
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Farach FJ, Pruitt LD, Jun JJ, Jerud AB, Zoellner LA, Roy-Byrne PP. Pharmacological treatment of anxiety disorders: current treatments and future directions. J Anxiety Disord 2012; 26:833-43. [PMID: 23023162 PMCID: PMC3539724 DOI: 10.1016/j.janxdis.2012.07.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 06/29/2012] [Accepted: 07/19/2012] [Indexed: 01/10/2023]
Abstract
Modern pharmacological treatments for anxiety disorders are safer and more tolerable than they were 30 years ago. Unfortunately, treatment efficacy and duration have not improved in most cases despite a greater understanding of the pathophysiology of anxiety. Moreover, innovative treatments have not reached the market despite billions of research dollars invested in drug development. In reviewing the literature on current treatments, we argue that evidence-based practice would benefit from better research on the causes of incomplete treatment response as well as the comparative efficacy of drug combinations and sequencing. We also survey two broad approaches to the development of innovative anxiety treatments:the continued development of drugs based on specific neuroreceptors and the pharmacological manipulation of fear-related memory. We highlight directions for future research, as neither of these approaches is ready for routine clinical use.
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Affiliation(s)
- Frank J Farach
- Department of Psychology, University of Washington, Seattle, WA 98195-1525, USA.
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Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).
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Affiliation(s)
- Paul Howard
- Duchess of Kent House, Reading, United Kingdom, Oxford
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Complementary medicine, exercise, meditation, diet, and lifestyle modification for anxiety disorders: a review of current evidence. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:809653. [PMID: 22969831 PMCID: PMC3434451 DOI: 10.1155/2012/809653] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 06/01/2012] [Indexed: 12/11/2022]
Abstract
Use of complementary medicines and therapies (CAM) and modification of lifestyle factors such as physical activity, exercise, and diet are being increasingly considered as potential therapeutic options for anxiety disorders. The objective of this metareview was to examine evidence across a broad range of CAM and lifestyle interventions in the treatment of anxiety disorders. In early 2012 we conducted a literature search of PubMed, Scopus, CINAHL, Web of Science, PsycInfo, and the Cochrane Library, for key studies, systematic reviews, and metaanalyses in the area. Our paper found that in respect to treatment of generalized anxiety or specific disorders, CAM evidence revealed current support for the herbal medicine Kava. One isolated study shows benefit for naturopathic medicine, whereas acupuncture, yoga, and Tai chi have tentative supportive evidence, which is hampered by overall poor methodology. The breadth of evidence does not support homeopathy for treating anxiety. Strong support exists for lifestyle modifications including adoption of moderate exercise and mindfulness meditation, whereas dietary improvement, avoidance of caffeine, alcohol, and nicotine offer encouraging preliminary data. In conclusion, certain lifestyle modifications and some CAMs may provide a beneficial role in the treatment of anxiety disorders.
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Haug T, Nordgreen T, Öst LG, Havik OE. Self-help treatment of anxiety disorders: A meta-analysis and meta-regression of effects and potential moderators. Clin Psychol Rev 2012; 32:425-45. [DOI: 10.1016/j.cpr.2012.04.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 04/11/2012] [Accepted: 04/11/2012] [Indexed: 11/24/2022]
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Abstract
This article proposes a number of recommendations for the treatment of generalized social phobia, based on a systematic literature review and meta-analysis. An optimal treatment regimen would include a combination of medication and psychotherapy, along with an assertive clinical management program. For medications, selective serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors are first-line choices based on their efficacy and tolerability profiles. The nonselective monoamine oxidase inhibitor, phenelzine, may be more potent than these two drug classes, but because of its food and drug interaction liabilities, its use should be restricted to patients not responding to selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors. There are other medication classes with demonstrated efficacy in social phobia (benzodiazepines, antipsychotics, alpha-2-delta ligands), but due to limited published clinical trial data and the potential for dependence and withdrawal issues with benzodiazepines, it is unclear how best to incorporate these drugs into treatment regimens. There are very few clinical trials on the use of combined medications. Cognitive behavior therapy appears to be more effective than other evidence-based psychological techniques, and its effects appear to be more enduring than those of pharmacotherapy. There is some evidence, albeit limited to certain drug classes, that the combination of medication and cognitive behavior therapy may be more effective than either strategy used alone. Generalized social phobia is a chronic disorder, and many patients will require long-term support and treatment.
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Affiliation(s)
- John Canton
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Kate M Scott
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Paul Glue
- Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Lampe L. Commentary on 'The role of alprazolam for the treatment of panic disorder in Australia'. Aust N Z J Psychiatry 2012; 46:273-4. [PMID: 22391286 DOI: 10.1177/0004867412437169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Lisa Lampe
- Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, Australia.
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Fullana MA, Fernández de la Cruz L, Bulbena A, Toro J. Eficacia de la terapia cognitivo-conductual para los trastornos mentales. Med Clin (Barc) 2012; 138:215-9. [DOI: 10.1016/j.medcli.2011.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 02/15/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Gould RL, Coulson MC, Howard RJ. Efficacy of Cognitive Behavioral Therapy for Anxiety Disorders in Older People: A Meta-Analysis and Meta-Regression of Randomized Controlled Trials. J Am Geriatr Soc 2012; 60:218-29. [DOI: 10.1111/j.1532-5415.2011.03824.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rebecca L. Gould
- Department of Old Age Psychiatry; Institute of Psychiatry; King's College London
| | - Mark C. Coulson
- Department of Psychology; School of Health and Social Sciences; Middlesex University; London; United Kingdom
| | - Robert J. Howard
- Department of Old Age Psychiatry; Institute of Psychiatry; King's College London
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Anxiety symptoms in epilepsy: salient issues for future research. Epilepsy Behav 2011; 22:63-8. [PMID: 21741882 DOI: 10.1016/j.yebeh.2011.04.064] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 04/24/2011] [Indexed: 11/22/2022]
Abstract
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.
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Roshanaei-Moghaddam B, Pauly MC, Atkins DC, Baldwin SA, Stein MB, Roy-Byrne P. Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress Anxiety 2011; 28:560-7. [PMID: 21608087 DOI: 10.1002/da.20829] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/09/2011] [Accepted: 04/18/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about whether cognitive behavioral therapy (CBT) or pharmacotherapy is relatively more advantageous for depressive versus anxiety disorders. METHODS We conducted a meta-analysis wherein we searched electronic databases and references to select randomized controlled studies comparing CBT and pharmacotherapy, with or without placebo, in adults with major depressive or anxiety disorders. The primary effect size was calculated from disorder-specific outcome measures as the difference between CBT and pharmacotherapy outcomes (i.e., positive effect size favors CBT; negative effect size favors pharmacotherapy). RESULTS Twenty-one anxiety (N = 1,266) and twenty-one depression (N = 2,027) studies comparing medication to CBT were included. Including all anxiety disorders, the overall effect size was.25 (95% CI: -0.02, 0.55, P =.07). Effects for panic disorder significantly favored CBT over medications (.50, 95% CI: 0.02, 0.98). Obsessive-compulsive disorder showed similar effects-sizes, though not statistically significant (.49, 95% CI: -0.11, 1.09). Medications showed a nonsignificant advantage for social anxiety disorder (-.22, 95% CI: -0.50, 0.06). The overall effect size for depression studies was.05 (95% CI: -0.09, 0.19), with no advantage for medications or CBT. Pooling anxiety disorder and depression studies, the omnibus comparison of the relative difference between anxiety and depression in effectiveness for CBT versus pharmacotherapy pointed to a nonsignificant advantage for CBT in anxiety versus depression (B =.14, 95% CI: -0.14, 0.43). CONCLUSIONS On balance, the evidence presented here indicates that there are at most very modest differences in effects of CBT versus pharmacotherapy in the treatment of anxiety versus depressive disorders. There seems to be larger differences between the anxiety disorders in terms of their relative responsiveness to pharmacotherapy versus CBT.
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Abstract
OBJECTIVE The aim of this paper was to examine the place of anxiety disorders in contemporary psychiatry, its origins, and possible implications for the future of psychiatry. CONCLUSIONS Several factors have led psychiatry away from neuroses and anxiety disorders and towards depression as a social paradigm of distress: a perception that anxiety disorders have relatively little relevance, the decline of psychoanalysis and rise of biological psychiatry, the downfall of the benzodiazepines and a failure to replace them with better anxiolytics, and the development of newer antidepressants. The subsequent imposition of the rigid conceptual dichotomy between depression and anxiety strengthened a notion that the focus of psychiatry should be on the 'depression side' of this divide. Having promoted cognitive-behavioural therapy as the best treatment for anxiety disorders, clinical psychologists have largely 'taken over' the anxiety disorders from psychiatrists. It is suggested that psychiatrists' surrender of the anxiety disorders may have negative consequences for the future of psychiatry.
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Affiliation(s)
- Vladan Starcevic
- Discipline of Psychiatry, University of Sydney, Sydney, NSW, Australia
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48
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Abstract
AbstractThis article provides an overview of the role of psychopharmacotherapy in common emotional disorders for cognitive behaviour therapists. We consider some of the philosophical difference between CBT and medication, when medication might interfere with CBT, when it may enhance outcome and when it might be safely discontinued. We highlight how to differentiate side-effects and symptoms of discontinuation of antidepressants from that of the underlying disorder. The scope of this article is confined to common emotional disorders and does not discuss the interaction of CBT with medication in, e.g. schizophrenia, bipolar disorder or dementia.
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Therapy-refractory panic: current research areas as possible perspectives in the treatment of anxiety. Eur Arch Psychiatry Clin Neurosci 2010; 260 Suppl 2:S127-31. [PMID: 20936296 DOI: 10.1007/s00406-010-0143-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
Panic disorder (PD) is characterized by recurrent panic attacks that are defined as distinct episodes of intense fear, accompanied by symptoms related to physical arousal. Because most patients interpret these symptoms as signs of serious somatic disease (e.g., a heart attack), utilization of healthcare services is high in PD sufferers. PD can become debilitating, interfering significantly with patients' lives. Fortunately, effective treatments are available, but a considerable proportion of patients do not respond sufficiently. The aim of this paper is to outline some promising research strategies aimed at improving established treatments.
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50
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Wedekind D, Broocks A, Weiss N, Engel K, Neubert K, Bandelow B. A randomized, controlled trial of aerobic exercise in combination with paroxetine in the treatment of panic disorder. World J Biol Psychiatry 2010; 11:904-13. [PMID: 20602575 DOI: 10.3109/15622975.2010.489620] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Regular aerobic exercise (running) has been shown to be superior to a pill placebo in the treatment of panic disorder. Combined drug and exercise treatment has not been investigated in randomized controlled studies to date. METHODS This is a randomized, 10-week, controlled, parallel group, pilot study. A total of 75 outpatients with panic disorder with or without agoraphobia (DSM-IV and ICD-10) received either (1) exercise plus paroxetine 40 mg/day (n=21), (2) relaxation plus paroxetine (n=17), (3) exercise plus pill placebo (n=20), or (4) relaxation plus pill placebo (n=17). Changes in the Panic and Agoraphobia Scale (P&A), and the Clinical Global Impression Scale (CGI) underwent repeated measure analysis. RESULTS Effects sizes were large for all groups (d=1.53-3.87), however not significantly different. Paroxetine-treated patients were significantly more improved than placebo-treated patients. On the CGI, patients in the exercise groups (plus paroxetine or placebo) had a trend toward better improvement compared to relaxation (P=0.06). Response and remission rates were higher in the paroxetine compared to pill placebo groups. CONCLUSIONS While paroxetine was superior to placebo, aerobic exercise did not differ from relaxation training in most efficacy measures.
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Affiliation(s)
- Dirk Wedekind
- Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany.
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