Treatment of somatoform disorders with St. John's wort: a randomized, double-blind and placebo-controlled trial

A Review on Natural Antioxidants for Their Role in the Treatment of Parkinson's Disease

The neurodegenerative condition known as Parkinson's disease (PD) is brought on by the depletion of dopaminergic neurons in the basal ganglia, which is the brain region that controls body movement. PD occurs due to many factors, from which one of the acknowledged effects of oxidative stress is pathogenic pathways that play a role in the development of Parkinson's disease. Antioxidants, including flavonoids, vitamins E and C, and polyphenolic substances, help to reduce the oxidative stress brought on by free radicals. Consequently, this lowers the risk of neurodegenerative disorders in the long term. Although there is currently no cure for neurodegenerative illnesses, these conditions can be controlled. The treatment of this disease lessens its symptoms, which helps to preserve the patient's quality of life. Therefore, the use of naturally occurring antioxidants, such as polyphenols, which may be obtained through food or nutritional supplements and have a variety of positive effects, has emerged as an appealing alternative management strategy. This article will examine the extent of knowledge about antioxidants in the treatment of neurodegenerative illnesses, as well as future directions for research. Additionally, an evaluation of the value of antioxidants as neuroprotective agents will be provided.

Herb-drug Interactions in Neuropsychiatric Pharmacotherapy - A Review of Clinically Relevant Findings

The management of neuropsychiatric disorders relies heavily on pharmacotherapy. The use of herbal products as complimentary medicine, often concomitantly, is common among patients taking prescription neuropsychiatric drugs. Herb-drug interaction, a clinical consequence of this practice, may jeopardize the success of pharmacotherapy in neuropsychiatry. Besides the wellknown ability of phytochemicals to inhibit and/or induce drug-metabolizing enzymes and transport proteins, several phytoconstituents are capable of exerting pharmacological effects on the central nervous system. This study reviewed the relevant literature and identified 13 commonly used herbal products - celery, echinacea, ginkgo, ginseng, hydroxycut, kava, kratom, moringa, piperine, rhodiola, St. John's wort, terminalia/commiphora ayurvedic mixture and valerian - which have shown clinically relevant interactions with prescription drugs used in the management of neuropsychiatric disorders. The consequent pharmacokinetic and pharmacodynamic interactions with orthodox medications often result in deleterious clinical consequences. This underscores the importance of caution in herb-drug co-medication.

Herbal Interaction With Chemotherapeutic Drugs-A Focus on Clinically Significant Findings

One of the most consequential risks associated with the concomitant use of herbal products and chemotherapeutic agents is herb-drug interactions. The risk is higher in patients with chronic conditions taking multiple medications. Herb-drug interaction is particularly undesirable in cancer management because of the precipitous dose-effect relationship and toxicity of chemotherapeutic agents. The most common mechanism of herb-drug interaction is the herbal-mediated inhibition and/or induction of drug-metabolizing enzymes (DME) and/or transport proteins leading to the alteration in the pharmacokinetic disposition of the victim drug. Most mechanistic research has focused on laboratory-based studies, determining the effects of herbal products on DMEs and extrapolating findings to predict clinical relevance; however, not all DME/transporter protein inhibition/induction results in clinical herb-drug interaction. This study reviews relevant literature and identified six herbal products namely echinacea, garlic, ginseng, grapefruit juice, milk thistle, and St John's wort, which have shown interactions with chemotherapeutic agents in humans. This focus on clinically significant herb-drug interaction, should be of interest to the public including practitioners, researchers, and consumers of cancer chemotherapy.

Dysfunction in Serotonergic and Noradrenergic Systems and Somatic Symptoms in Psychiatric Disorders

Somatic symptoms include a range of physical experiences, such as pain, muscle tension, body shaking, difficulty in breathing, heart palpitation, blushing, fatigue, and sweating. Somatic symptoms are common in major depressive disorder (MDD), anxiety disorders, and some other psychiatric disorders. However, the etiology of somatic symptoms remains unclear. Somatic symptoms could be a response to emotional distress in patients with those psychiatric conditions. Increasing evidence supports the role of aberrant serotoninergic and noradrenergic neurotransmission in somatic symptoms. The physiological alterations underlying diminished serotonin (5-HT) and norepinephrine (NE) signaling may contribute to impaired signal transduction, reduced 5-HT, or NE release from terminals of presynaptic neurons, and result in alternations in function and/or number of receptors and changes in intracellular signal processing. Multiple resources of data support each of these mechanisms. Animal models have shown physiological responses, similar to somatic symptoms seen in psychiatric patients, after manipulations of 5-HT and NE neurotransmission. Human genetic studies have identified many single-nucleotide polymorphisms risk loci associated with somatic symptoms. Several neuroimaging findings support that somatic symptoms are possibly associated with a state of reduced receptor binding. This narrative literature review aimed to discuss the involvement of serotonergic and noradrenergic systems in the pathophysiology of somatic symptoms. Future research combining neuroimaging techniques and genetic analysis to further elucidate the biological mechanisms of somatic symptoms and to develop novel treatment strategies is needed.

Hypericum perforatum in the treatment of psychiatric and neurodegenerative disorders: Current evidence and potential mechanisms of action

BACKGROUND

Psychiatric disorders are substantially associated with reduced quality of life and increased mortality. Depression and anxiety are two of the most common psychiatric disorders that often co-occur with each other as well as with other mental health conditions. Because of the limitations of currently available antidepressant therapies, there is a need for agents with improved efficacy and less adverse effects. Hypericum perforatum, widely known as St. John's wort, is a perennial herbaceous plant most well known for its antidepressant properties.

METHODS

We reviewed the available in vitro, in vivo, and clinical evidence on the efficacy, safety, and mechanisms of action of St. John's wort and its active constituents in the treatment of psychiatric and neurodegenerative disorders.

RESULTS

Several interesting data have been reported about the antidepressant properties of H. perforatum in clinical trials with different designs. In particular, a number of antidepressant-controlled trials demonstrated that H. perforatum and its active ingredients, hypericin and hyperforin, possess antidepressant properties similar to those of tricyclic antidepressants and selective serotonin reuptake inhibitors but with fewer and milder side effects.

CONCLUSION

St. John's wort may exert potent antidepressant effects and represents an efficacious and safe treatment. However, the current clinical evidence regarding the efficacy of H. perforatum in other psychiatric and neurodegenerative disorders is not sufficient to draw a robust conclusion.

Use of monoamine oxidase inhibitors in chronic neurodegeneration

INTRODUCTION

Neurotransmission by biogenic monoamines is important for brain function. Biogenic amine turnover employs the enzymes catechol-O-methyltransferase and monoamine oxidase in neuronal and glial cells. Inhibition of these enzymes elevates biogenic amine levels in the synaptic cleft. Subtype selectivity of inhibition is lost during long-term use of 'selective' monoamine oxidase inhibitors. Areas covered: This narrative review discusses use of monoamine oxidase inhibitors in the context with chronic neurodegeneration. Expert opinion: Antidepressant drugs increase synaptic concentrations of biogenic amines. In the aging brain, then one of the two enzymes involved in degrading synaptic amines, catechol-O-methyl transferase, increasingly catalyzes methylation processes. Therefore, metabolism by monoamine oxidase plays an incremental, predominant role in biogenic amine turnover, leading to greater oxidative stress. In patients with chronic neurodegenerative disorders, symptoms, such as depression and apathy, are often treated with drugs that elevate biogenic amine levels. This therapeutic strategy increases biogenic amine turnover, thereby generating neurotoxic aldehydes and enhanced oxidative stress, each of which influence and accelerate the course of neurodegeneration. We propose that antidepressant therapy should be initiated first with monoamine oxidase inhibitors only. If adequate clinical response is not achieved, only then they should be supplemented with a further antidepressant.

Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge

Somatic symptom disorder (SSD) is characterised by a dysfunctional preoccupation with one or more physical symptoms. Patients with SSD often pursue excessive and unnecessary investigations, hospitalisations and treatments that significantly affect quality of life and drain healthcare resources. Thus, appropriate diagnosis and careful management are required to mitigate the patient's distress and to reduce the burden to the healthcare system. SSD is a new disorder defined in the Diagnostic and Statistical Manual Fifth Edition (DSM-5), replacing somatoform and related disorders in the DSM-4-Text Revision with diagnostic criteria that are inclusive of a broad array of presentations. This report presents a detailed clinical case of an elderly man with a history of frequent hospital visits presenting with SSD. We discuss diagnostic challenges and evidence-based management in acute inpatient as well as in outpatient settings. We also review data on healthcare utilisation associated with SSD.

Correlation between cognition and symptomatic severity in patients with late-life somatoform disorders

OBJECTIVES

Various aging associated factors, such as functional decline, psychosocial problems, and cognitive dysfunction, are risk factors for somatoform disorders (SDs) in the elderly. The aim of the present study was to evaluate how cognition is correlated with the severity of late-life SDs from a neuropsychological viewpoint.

METHODS

Fifty-three patients over 60 years of age who had been diagnosed as having SDs were examined in this study. The severity of the somatic symptoms was assessed using the Hamilton Anxiety Rating Scales (HAMA). Cognitive functions were assessed using the Mini-Mental State Examination (MMSE), the Frontal Assessment Battery (FAB), and the Japanese version of the Neurobehavioral Cognitive Examination (J-COGNISTAT).

RESULTS

The J-COGNISTAT subtest score for attention was below the cutoff point (8 points) but was not correlated with the severity of the somatic symptoms in the patients with late-life SDs. The severity of anxiety as assessed using the HAMA was significantly correlated with the calculation scores (P < 0.005) among the J-COGNISTAT subtests, the FAB total (P < 0.05), and the FAB subtest scores (similarities and motor series) (P < 0.01). Other factors, including the benzodiazepine dosage, antidepressant dosage, the duration of illness, and the onset age, were not significantly correlated with the symptomatic severities.

CONCLUSION

Patients with late-life SDs showed attention deficits, but no correlation was seen between the attention deficits and symptomatic severities. Attention deficits might be associated with the appearance of symptoms. Executive dysfunction and working memory might be associated with the severity of symptoms.

Pharmacological interventions for somatoform disorders in adults

BACKGROUND

Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.

OBJECTIVES

To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation & Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.

SELECTION CRITERIA

We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.

DATA COLLECTION AND ANALYSIS

One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.

MAIN RESULTS

We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95% CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2%; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95% CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63%). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95% CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0%).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95% CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42%; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95% CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0%).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95% CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23%).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95% CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0%; low-quality evidence) or NPs and placebo (RR 0.85, 95% CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0%; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95% CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14%; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95% CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0%; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0% to 32%), but low for NPs (0% to 1.7%).The risk of bias was high in many domains across studies. Seventeen trials (65.4%) gave no information about random sequence generation and only two (7.7%) provided information about allocation concealment. Eighteen studies (69.2%) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.

AUTHORS' CONCLUSIONS

The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

St. John's wort for the treatment of psychiatric disorders

St. John's wort (Hypericum perforatum) has been extensively studied and reviewed for its use in depression; however, there is less salient discussion on its clinical application for a range of other psychiatric disorders. This article outlines the current evidence of the efficacy of St John's wort in common psychiatric disorders, including major depression, bipolar depression, attention-deficit hyperactivity disorder, obsessive-compulsive disorder, social phobia, and somatization disorder. Mechanisms of action, including emerging pharmacogenetic data, safety, and clinical considerations are also detailed.

[Psychopharmacological treatment in patients with somatoform disorders and functional body syndromes]

Somatoform disorders and functional body syndromes define a major, diagnostically heterogeneous group of patients with medically unexplained physical symptoms. Psychopharmacological approaches can be derived from the conceptualization of somatoform symptoms and syndromes within a biopsychosocial model. The survey presented focuses on randomized, double-blind and placebo-controlled studies. Antidepressants show a statistically and clinically relevant impact on many somatoform symptoms. In special reference to pain symptoms serotonergic and noradrenergic antidepressants seem to mediate a more favorable effect than selective serotonin reuptake inhibitors. For some functional body syndromes, e.g. irritable bowel syndrome and fibromyalgia, a major analgesic effect of antidepressants can be underlined as well. The empirical data for fibromyalgia, however, seem to be more convincing than for irritable bowel syndrome. Pregabalin holds an empirically well established position in the treatment of fibromyalgia. As yet there is no convincing psychopharmacological strategy for chronic fatigue syndrome. Probably due to the inherent relationships to anxiety, obsessive-compulsive and depressive disorders, both hypochondria and body dysmorphic disorder can be positively treated by serotonergic antidepressants as well.

Psychopharmacotherapy of somatic symptoms disorders

Somatic symptoms are often common causes for medical consultation. The treatment of somatic symptoms disorders is complicated by lack of boundary, conceptual clarity, and overemphasis on psychosocial causation and effectiveness of psychological treatments. In clinical practice all classes of psychotropics are used to treat somatic symptoms disorder. Five principal groups of drugs such as tricyclic antidepressants (TCA), serotonin reuptake inhibitors (SSRI), serotonin and noradrenalin reuptake inhibitors (SNRI), atypical antipsychotics and herbal medication are systematically studied. The evidence indicates that all five groups are effective in a wide range of disorders. All classes of antidepressants seem to be effective against somatoform and related disorders. SSRIs are more effective against hypochondriasis and body dysmorphic disorder (BDD), and SNRIs appear to be more effective than other antidepressants when pain is the predominant symptom. Research leaves many unanswered questions regarding dosing, duration of treatment, sustainability of improvement in the long term and differential response to different class drugs. Further studies need to focus on treatments based on clinical features/psychopathology and collaborative research with other specialists in understanding the relation of somatic symptom disorders and functional somatic syndromes (FSS), and comparing psychotropics and non-psychotropics and combinations treatments.

St. John's wort extract LI160 for the treatment of depression with atypical features - a double-blind, randomized, and placebo-controlled trial

Preliminary data suggest that hypericum extract LI160 is effective in atypical depression. Reported is the outcome of an 8-week double-blind, placebo-controlled, randomized trial of 600 mg LI160 vs. placebo in patients with vegetative features of atypical depression, i.e. hyperphagia or hypersomnia. One-hundred (100) patients with mild and 100 patients with moderate severity of a major depression according to ICD-10 were randomized. Patients needed to meet a score of 2 in at least one of the items 22-26 of the Hamilton-Depression-Rating-Scale (HAM-D) 28-item version and episode duration of at least 3 months. The primary outcome variable was the relative change of the HAM-D(17) from Baseline. Secondary outcome variables were the depression sub-score of the Patient Health Questionnaire (PHQ-9), the Clinical Global Impression (CGI), a patient's satisfaction scale, the Hamilton-Anxiety-Scale (HAM-A) and the sum score of atypical vegetative symptoms of the HAM-D(28). The percentage reduction of the HAM-D(17) for LI160 compared to placebo approached statistical significance (p=0.051) in the Full Analysis Set (FAS)-population. Using the conventional criterion of the absolute reduction of the HAM-D(17) significance was achieved (p<0.05). No significant benefit could be observed for the sum score of the atypical vegetative items of the HAM-D(28;) however, the sum score of the hypersomnia items (items 22-24) showed a significant superiority for LI160. The HAM-A, PHQ-9, and CGI-I scales demonstrated superiority of LI160 (p<0.01). Confining the analysis to moderately depressed patients, a highly significant benefit for the primary outcome variable was revealed. The study supports the beneficial effect of LI160 in depression with atypical features and the validity of the definition of atypical depression on the basis of reversed vegetative signs. Further, it identifies the PHQ-9 as a useful outcome variable in this population.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

Potential medicinal plants for CNS disorders: an overview

Although very few drugs are currently approved by regulatory authorities for treating multi-factorial ailments and disorders of cognition such as Alzheimer's disease, certain plant-derived agents, including, for example, galantamine and rivastigmine (a semi-synthetic derivative of physostigmine) are finding an application in modern medicine. However, in Ayurveda, the Indian traditional system of medicine which is more than 5000 years old, selected plants have long been classified as 'medhya rasayanas', from the Sanskrit words 'medhya', meaning intellect or cognition, and 'rasayana', meaning 'rejuvenation'. These plants are used both in herbal and conventional medicine and offer benefits that pharmaceutical drugs lack. In the present article, an attempt has been made to review the most important medicinal plants, including Ginkgo biloba, St John's wort, Kava-kava, Valerian, Bacopa monniera and Convolvulus pluricaulis, which are widely used for their reputed effectiveness in CNS disorders.

Hypericum and Nurses

Purpose: Many patients look to complementary and alternative medicine for a herbal solution to depression. This literature review summarizes recently published research on the treatment of depression using St. John's wort ( Hypericum perforatum). Conclusions: The compounds in St. John's wort herbal preparations are more effective than placebo and, in several studies, more effective than common antidepressant medications in treating minor depression. However, the efficacy of St. John's wort for treating major depression, cyclothymia, or bipolar disorder is less evident. Although some studies are promising in the treatment of these major disorders, research support is lacking, and it is a controversial aspect of Hypericum therapy. Practice implications: As with any herbal treatment, risks from adverse reactions and drug interactions exist. Providers have an ethical and legal obligation to stay current in knowledge and to provide useful, accurate information to patients.

Fluoxetine versus sertraline in the treatment of patients with undifferentiated somatoform disorder: a randomized, open-label, 12-week, parallel-group trial

The present study was conducted to compare the effectiveness and tolerability of fluoxetine and sertraline in the treatment of undifferentiated somatoform disorder (USD), using the Patient Health Questionnaire (PHQ-15), which was specifically designed for assessing the severity of somatic symptoms. A randomized, 12-week, open-label trial of fluoxetine (10-60 mg/d) and sertraline (25-350 mg/d) in patients with USD was conducted. Six visits, at baseline and weeks 1, 2, 4, 8, and 12, were scheduled. Assessments for effectiveness and tolerability were conducted at each visit. The primary effectiveness measure was the mean change in PHQ-15 total score, from baseline to the end of treatment. Secondary effectiveness measures were the mean changes in total scores on the Beck Depression Inventory (BDI) and the 12-item General Health Questionnaire (GHQ-12), from baseline to the end of treatment. A total of 45 subjects were enrolled; of them, 28 were randomly assigned to receive fluoxetine and 17 to receive sertraline. The total score on the PHQ-15 from baseline to the end of treatment significantly decreased in the fluoxetine (-10.7, p<0.0001) and sertraline (-10.3, p<0.0001) treatment groups, with no between-group difference (F=0.0701, p=0.7924). Overall, both treatments were well tolerated and no serious adverse event was reported. This study suggests that both agents may have a potential role in the treatment of USD. A double-blind, placebo-controlled trial and/or head-to-head comparison study with larger samples are required to draw more definite conclusions.

Validity of current somatoform disorder diagnoses: perspectives for classification in DSM-V and ICD-11

BACKGROUND

The impending revisions of DSM-IV and ICD-10 provide an excellent opportunity to improve the diagnostic accuracy of the current somatoform disorder classification. To prepare for these revisions, this study systematically investigates the validity of the current classification of somatoform disorders.

METHODS

We searched Medline, Psycinfo and reference lists to investigate convergent, divergent, criterion and predictive validity of the current somatoform disorder classification.

RESULTS

Substantial associations of somatoform disorders with functional impairment and elevated health care costs give evidence for the clinical and societal importance of somatoform disorders and for the convergent validity of the current operationalization. The specificity of the current somatoform disorder classification, i.e. their divergent validity, is demonstrated by the fact that functional somatic syndromes and their consequences are only partially explained by association with anxiety and depression. However, the imprecision of the diagnostic criteria, which are not based on positive criteria but on the exclusion of organic disease, largely limits the criterion validity of the current classification systems. Finally, studies investigating the predictive potential of somatoform disorders are lacking, and to date predictive validity has to be considered as low.

CONCLUSIONS

The insufficient criterion and predictive validity of the present somatoform classification underlines the need to revise the diagnostic criteria. However, an abolishment of the whole category of somatoform disorders would ignore the substantial convergent and divergent validity of the current classification and would exclude patients with somatoform symptoms from the current health care system. A careful revision of the current somatoform disorder diagnoses, based on positive criteria of psychological, biological and social features, has the potential to substantially improve the reproducibility and clinical utility of the existing classification system.

Escitalopram in the treatment of multisomatoform disorder: a double-blind, placebo-controlled trial

Despite the prevalence of multisomatoform disorder (MSD), there are few controlled trials of its pharmacotherapy. The aim of this study was to compare the efficacy and safety of escitalopram (10-20 mg/day) with that of placebo in treating patients with MSD over a 12-week period. Fifty-one outpatients aged from 18 to 65 years, with multiple medically unexplained symptoms, were recruited. The primary efficacy measure was a change on the Patient Health Questionnaire-15 scores from baseline to endpoint. Secondary efficacy endpoints included the Clinical Global Impression-Improvement score, the psychic and somatic subscales of the Hamilton Anxiety Scale, Montgomery-Asberg Depression Rating Scale, the Visual Analogue Pain Rating Scale, the Scale for the Assessment of Illness Behaviour and the Sheehan Disability Scale. On the primary analysis of covariance, escitalopram-treated patients had significantly greater reductions in Patient Health Questionnaire scores (P<0.0001) compared with placebo at week 12. Significant separation from placebo occurred from week 6 onwards. Escitalopram was superior to placebo on all secondary outcome endpoints, with the exception of the Scale for the Assessment of Illness Behaviour. The medication was well tolerated. In conclusion, in this 12-week, randomized, placebo-controlled study, escitalopram (10-20 mg/day) was both effective and well tolerated in the treatment of patients with MSD. Compared with placebo, escitalopram was associated with lower symptom scores, increased response and remission rates, and improved functioning.

What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies

OBJECTIVE

To review published literature for the highest level of evidence on the efficacy of treatment for patients with medically unexplained symptoms.

METHODS

A comprehensive literature search was carried out in Cochrane library, Medline (1971-2007), PsychINFO (1974-2006), and EMBASE (1980-2007) to identify pharmacological, nonpharmacological, psychological, and other interventions, using the search terms "medically unexplained symptoms," "somatisation," "somatization," "somatoform disorders," "psychological therapies," "cognitive behavior therapy," "pharmacological therapies," "management," "therapy," "drug therapy," and "anti-depressants" with Boolean operators AND and OR on the entire text. Searches were confined to literature in English.

RESULTS

Studies were carried out in primary, secondary, and tertiary care settings. The therapists ranged from medical specialists, psychiatrists, and psychologists to primary care physicians. Three types of interventions (antidepressant medication, cognitive behavioral therapy (CBT), and other nonspecific interventions) were supported by evidence on the efficacy of treatment for patients with medically unexplained symptoms. There is more level I evidence for CBT compared with the amount for other approaches. There was only one study reported from the developing world.

CONCLUSIONS

CBT is efficacious for either symptom syndromes or for the broader category of medically unexplained symptoms, reducing physical symptoms, psychological distress, and disability. A relatively small number of studies were carried out in primary care, but the trend has been changing over the last decade. No studies have compared pharmacological and psychological treatments. Most trials assessed only short-term outcomes. Use of divergent selection procedures, interventions, outcome measures, and instruments, and other methodological differences observed in these studies hamper the ability to compare treatment effects across studies.

Efficacy of treatment for somatoform disorders: a review of randomized controlled trials

OBJECTIVE

To review the evidence from randomized clinical trials (RCTs) that have focused on the treatment of patients with Diagnostic and Statistical Manual of Mental Disorders, 4(th) Edition (DSM-IV) somatoform disorders. Although somatoform disorders are among the most common mental disorders presenting in the general medical setting, the strength of evidence for specific treatments has not been well synthesized.

METHODS

MEDLINE search of articles published in English from 1966 to 2006, using the following search terms: randomized clinical trial, somatoform disorders, somatization disorder, undifferentiated somatoform disorder, hypochrondriasis, conversion disorder, pain disorder, and body dysmorphic disorder.

RESULTS

A total of 34 RCTs involving 3922 patients were included. Two thirds of the studies involved somatization disorder (n = 4 studies) and lower threshold variants, such as abridged somatization disorder (n = 9) and medically unexplained symptoms (n = 10). Cognitive behavioral therapy (CBT) was effective in most studies (11 of 13), as were antidepressants in a small number (4 of 5) of studies. RCTs examining a variety of other treatments showed benefit in half (8 of 16) of the studies, the most consistent evidence existing for a consultation letter to the primary care physician. Effective treatments have been established for all somatoform disorders except conversion disorder (1 of 3 studies showing benefit) and pain disorder (no studies reported).

CONCLUSION

CBT is the best established treatment for a variety of somatoform disorders, with some benefit also demonstrated for a consultation letter to the primary care physician. Preliminary but not yet conclusive evidence exists for antidepressants.

Nondrug treatments for psychogenic nonepileptic seizures: what's the evidence?

OBJECTIVE

The purpose of this Cochrane Review was to establish the evidence base for treatment of psychogenic nonepileptic seizures.

METHODS

Six hundred eight references were identified using a search strategy designed with the support of the Cochrane Review Epilepsy Group library. The search employed Medline and PsychInfo, and included hand searches of relevant journals (Seizure, Epilepsia, Epilepsy &Behavior, Epilepsy Research).

RESULTS

Three studies were found that met the inclusion criteria; two used hypnosis and one used paradoxical therapy. None included detailed reports of improved seizure frequency or quality of life, although reduction in seizure frequency was mentioned. All three studies concluded that the intervention used was beneficial in the treatment of psychogenic nonepileptic seizures.

CONCLUSIONS

The limited number of studies and poor methodology preclude these results from being generalizable. There is a need for well-designed clinical trials to identify the most suitable treatments for this population.

Drug Treatment in Juvenile Depression - Is St. John's Wort a Safe and Effective Alternative?

Analyses of juvenile depression studies with long established anti-depressants (tricyclic anti-depressants) have revealed discouragingly little benefit, while side effects have been profound. Modern anti-depressants like selective serotonin reuptake inhibitors seemed to solve part of this problem until they were found to be associated with an increased risk of suicidal attempts and ideation, hostile behaviour and self-harm, while meta-analyses have revealed only marginal therapeutic effects for the majority. Actually, no drug is unequivocally accepted as the gold-standard for young depressive patients. St. John's Wort (SJW) has been traditionally used in Europe to treat symptoms associated with juvenile depression. Close to 50 clinical studies performed over the last two decades have been presented as evidence that standardized SJW preparations are equally effective as synthetic anti-depressants in the treatment of mild to moderate depression in adults. Tolerability is excellent, but some relevant drug interactions have to be considered. Today, SJW is by far the most frequently prescribed medication for child and adolescent depression in Germany. Some pilot and observational studies from Germany, Canada and the US have delivered promising results. However, randomised controlled trials amongst this age group have yet to be carried out and are long overdue.

[New developments in hypericum extracts: data on efficacy and interactions]

The recent clinical studies on hypericum extract support the present indications for its use in mild to moderate depression and depressive episodes. The effectiveness is superior to placebo and comparable with synthetic antidepressive drugs. The rate of unwanted events is explicitly lower and their severity in general only mild. A further indication for hypericum could be somatoform disorders, but further clinical studies are recommended. The main compound responsible for interactions is presumably hyperforin, but further ingredients could contribute according to the specific composition of the particular extract.

Herbal medicines in the treatment of psychiatric disorders: a systematic review

This paper reports a critical review of 27 herbal medicines and formulas in treating a broad range of psychiatric disorders (in addition to anxiety and depression), including obsessive-compulsive, seasonal affective, bipolar depressive, psychotic, phobic and somatoform disorders. Ovid Medline, Pubmed and the Cochrane Library were searched for pharmacological and clinical evidence of herbal medicines with psychotropic activity. A forward search of later citations was also conducted. Whilst substantial high-quality evidence exists for the use of kava and St John's wort in the treatment of anxiety and depression respectively, currently there is insufficient robust clinical evidence for the use of many other herbal medicines in psychiatric disorders. Phytotherapies which potentially have significant use in psychiatry, and urgently require more research are Rhodiola rosea (roseroot) and Crocus sativus (saffron) for depression; Passiflora incarnata (passionflower), Scutellaria lateriflora (scullcap) and Zizyphus jujuba (sour date) for anxiety disorders; and Piper methysticum (kava) for phobic, panic and obsessive-compulsive disorders. While depression and anxiety are commonly researched, the efficacy of herbal medicines in other mental disorders requires attention. The review addresses current issues in herbal psychotherapy: herbal safety, future areas of application, the relationship of herbal medicine with pharmaceuticals and the potential prescriptive integration of phytomedicines with synthetic psychotropic medicines. Particular attention is given to clinical and safety issues with St John's wort and kava.

Treatments for non-epileptic attack disorder

BACKGROUND

Psychogenic non-epileptic seizures (NES) have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of NES which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of NES.

OBJECTIVES

To assess whether treatments for NES result in a reduction in frequency of seizures and/or improvement in quality of life, and whether any treatment is significantly more effective than others.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group's Specialised Register (September 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to July 2005), and PsycINFO (1806 to July 2005). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies

SELECTION CRITERIA

Randomised or quasi-randomised studies were included that assessed one or more types of psychological or non-psychological interventions for the treatment of NES. Studies of childhood NES were excluded from our review.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life.

MAIN RESULTS

Three small studies met our inclusion criteria and were of poor methodological quality. Two assessed hypnosis and the other paradoxical therapy. There were no detailed reports of improved seizure frequency or quality of life outcomes, and these trials provide no reliable evidence of a beneficial effect of these interventions.

AUTHORS' CONCLUSIONS

In view of the methodological limitations and the small number of studies, we have no reliable evidence to support the use of any treatment including hypnosis or paradoxical injunction therapy in the treatment of NES. Randomised studies of these and other interventions are needed.

Depression, pain, and somatoform disorders

PURPOSE OF REVIEW

The frequent co-occurrence of depression and somatic symptoms poses a continuing challenge to clinicians, researchers and experts involved in drawing up classifications. In this review we present recently published literature on aspects of epidemiology, classification and treatment in this important overlap area.

RECENT FINDINGS

From the multitude of papers published annually on the co-occurrence of different pain conditions and depression, temporomandibular dysfunction stands out this year by sheer quantity; it can be seen as a model case of the necessity for differentiated high-quality assessments on the biological as well as the psychosocial level. There is a general move to separate utility of diagnostic classifications from their validity, and this strengthens classificatory approaches that help to view the regular overlap of depression, pain and other somatic symptoms as the rule rather than the exception. The incorporation of cognitive variables like causal attributions should help to distinguish clinically relevant subtypes among overlap cases. The classificatory future of the category of 'somatoform disorders' is somewhat in doubt, but reforms seem to be more productive than abolishment. Psychopharmacology provides rather intense recent coverage of the overlap field, with newer dual serotonergic-noradrenergic reuptake inhibitors offering some promise.

SUMMARY

Treating the overlap of depression, pain and other somatic symptoms as the rule rather than the exception is necessary for adequate aetiological research as well as for diagnosis and treatment, with one-dimensional classificatory and treatment approaches almost certainly being insufficient.

Abnormal illness behaviour: physiological, psychological and social dimensions of coping with distress

PURPOSE OF REVIEW

Pilowsky introduced the term 'abnormal illness behaviour' to characterize syndromes of excessive or inadequate response to symptoms, including hypochondriasis, somatization, and denial of illness. This review summarizes recent work from sociology, health psychology and psychiatry that contributes to an understanding of the processes that may underlie abnormal illness behaviour.

RECENT FINDINGS

Disturbances in the regulation of physiological systems may account for many 'unexplained' symptoms and sickness behaviour. Increased attention to bodily sensations, sensitivity to pain and catastrophizing play important roles in illness behaviour in medical illness. Developmental adversities and parental modelling of illness behaviour in childhood may increase bodily preoccupation and health care utilization. Apparent cross-national differences in illness behaviour may reflect differences in health care systems, but cultural models of illness and social stigma remain important determinants of illness denial and avoidance of mental health services.

SUMMARY

Research into illness behaviour is relevant to efforts to rethink the psychiatric nosology of somatoform disorders. The discrete somatoform disorders might well be replaced by a dimensional framework that identifies specific pathological processes in cognition, perception and social behaviour that contribute to bodily distress, impaired coping, inappropriate use of health services, chronicity and disability.

Drug Interactions with St John???s Wort

The purpose of this paper is to review preclinical and clinical evidence relating to drug interactions with preparations of the medicinal herb St John's wort (Hypericum perforatum). A systematic literature search was carried out in three electronic databases up to June 2004. Information about case reports classified as St John's wort drug interactions was retrieved from the WHO Collaborating Centre for International Drug Monitoring and from the UK Medicines and Healthcare products Regulatory Agency in June 2003. Against the background of proven efficacy in mild to moderate depressive disorders and an excellent tolerability profile in monotherapy, there is sufficient evidence from interaction studies and case reports to suggest that St John's wort may induce the cytochrome P450 (CYP) 3A4 enzyme system and the P-glycoprotein drug transporter in a clinically relevant manner, thereby reducing efficacy of co-medications. Drugs most prominently affected and contraindicated for concomitant use with St John's wort are metabolised via both CYP3A4 and P-glycoprotein pathways, including HIV protease inhibitors, HIV non-nucleoside reverse transcriptase inhibitors (only CYP3A4), the immunosuppressants ciclosporin and tacrolimus, and the antineoplastic agents irinotecan and imatinib mesylate. Efficacy of hormonal contraceptives may be impaired as reflected by case reports of irregular bleedings and unwanted pregnancies. Drugs with a narrow therapeutic index should be monitored more closely when St John's wort is added, discontinued or the dosage is changed. The St John's wort constituent hyperforin is probably responsible for CYP3A4 induction via activation of a nuclear steroid/pregnane and xenobiotic receptor (SXR/PXR) and hypericin may be assumed to be the P-glycoprotein inducing compound, although the available evidence is less convincing. Combinations of St John's wort with serotonergic agents and other antidepressants should be restricted to prescription-only, by experienced clinicians, due to potential central pharmacodynamic interactions. In conclusion, providing certain precautions and contraindications are followed, and adequate information is given to healthcare professionals and patients, the safe and effective use of quality-tested St John's wort products can be ensured.