Depressive disorders among somatizing patients in primary health care

Efficacy and safety of vortioxetine in treatment of patients with major depressive disorder and common co-morbid physical illness

BACKGROUND

The multimodal antidepressant vortioxetine is effective in reducing somatic symptoms in patients with major depressive disorder (MDD), but little is known about its effects in reducing depressive symptoms in patients with common comorbid physical illnesses.

METHODS

This was a pooled analysis of 13 randomized, placebo-controlled trials which evaluated the efficacy (using the Montgomery-Åsberg Depression Rating Scale [MADRS]) and safety of vortioxetine (5-20 mg/day) in adult patients with MDD. We evaluated stable somatic comorbid conditions that were verified by a diagnosis and had sufficient database representation.

RESULTS

Of the 5982 patients included in the database, 963 (16.1%) patients had a diagnosis of cardiovascular disease, 152 (2.5%) had diabetes mellitus and 26 (0.4%) had chronic obstructive pulmonary disorder (COPD). At Week 8, adjusted mean[95%CI] treatment differences (vortioxetine vs. placebo) on MADRS total scores were -2.7[-4.2, -1.3] (p = 0.0002) points for the cardiovascular disease, -4.0[-7.7, -0.4] (p = 0.03) for the diabetes, and -6.2[-21.3, 8.9] (p = 0.36) for the COPD groups. The rate and pattern of adverse events were similar across the sub-groups with comorbidities and was consistent with that expected for vortioxetine treatment.

LIMITATIONS

The primary studies were not designed to investigate the relationship between vortioxetine and comorbidities, nor were the post hoc analyses powered to detect group differences.

CONCLUSIONS

Patients with MDD and comorbid cardiovascular disease or diabetes respond to vortioxetine in a similar way to the broader MDD population. Vortioxetine was generally safe and well tolerated and without unexpected adverse events in these subpopulations, most of whom are taking multiple concomitant medications.

Alexithymia in ankylosing spondylitis

Objectives

This study aims to determine the effect of ankylosing spondylitis (AS) on alexithymia.

Patients and methods

In this study, a total of 55 AS patients (30 males, 25 females; mean age: 40±8 years; range, 21 to 57 years) who were under follow-up and 55 age- and sex-matched healthy volunteers (31 males, 24 females; mean age: 38.9±8.5 years; range, 21 to 53 years) were included between March 2016 and August 2016. Toronto Alexithymia Scale (TAS), and Beck Depression Inventory (BDI) were performed to assess both patient and control groups. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and Ankylosing Spondylitis Quality of Life (ASQoL) were performed to assess AS patients.

Results

The mean diagnosis time in the patient group was 5.18±4.32 (range, 1 to 18) years. Compared to the control group, depression scores were higher in the patient group and the alexithymic characteristics were significantly higher in the patient group (p<0.05). There was a positive correlation between complaint duration and BASMI, BASFI, and ASQoL scores (p<0.01). In our study, alexithymia rate was significantly higher in women (p<0.05).

Conclusion

As in all inflammatory chronic diseases, depression and anxiety are commonly seen in AS patients. Alexithymia of these patients should be considered carefully.

Education of the primary health care staff based on acceptance and commitment therapy is associated with reduced sick leave in a prospective controlled trial

Background

The use of cognitive behavioral therapy (CBT) to cope with mental distress and pain issues has helped many patients in primary health care in Sweden. However, the effects of CBT to reduce sick leave has not been equally convincing. Acceptance and Commitment Therapy (ACT) is an evolution of traditional CBT and we aimed to study if education based on ACT of the staff rather than the patients could reduce sick leave in primary health care.

Methods

This was a prospective trial in 6 primary health care centers in Kalmar (total amount of registered subjects of 28,930) in which the staff (physicians, nurses and therapists) received group-based education according to ACT during 2018 and 2019. The effects were compared with 5 similarly sized control health care centers in the neighboring Region of Jönköping in which no such education took place. The main aim was to study changes in sick leave in the 6 primary care centers of Kalmar and to keep track of more general trends by studying sick leave also in Jönköping, letting sick leave in the year 2017 to be the reference period for both areas.

Results

The staff at the health care centers in Kalmar reported to having attended a mean of 5.2 ± 2 educational ACT-sessions with psychiatrist Kadowaki in Kalmar. Sick leave for ICD-10 F43 (reaction to severe stress and related adjustment-disorders) was reduced from a mean value of 28.7 ± 9.1ongoing sick leaves/month in 2017 to 22.6 ± 7.0 sick leaves/month in 2018 (-21%, p = 0.033) and to 18.1 ± 10 sick leaves/month in 2019 (-37%, p = 0.038). The corresponding sick leave for any diagnosis (total sick leave) was reduced from 132 ± 39 sick leaves/month in 2017 to 118 ± 38 sick leaves/month in 2018 (-11%, p = 0.056) and to 102 ± 37 sick leaves/month in 2019 (-21%, p = 0.021). The corresponding sick leave comparisons in the control health centers did not show any significant changes (all p-values ≥ 0.24).

Conclusions

Total monthly mean sick leave was reduced 21% in the health care centers in Kalmar during the second year of the educational ACT intervention of the staff while it was unchanged in Jönköping. This suggests a significant effect to induce a reduction in long-term sick leave for patients in primary health care in which the staff received education according to ACT. The results of this trial could serve as a basis for a randomized trial in order to ascertain causality.

Trial registration

Pre-registration November 9, 2018 on ClinicalTrials.gov with number NCT03737019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01526-5.

The association of depression and painful physical symptoms–a review of the European literature

Objective:

The presence of painful physical symptoms may confound the diagnosis of major depressive disorder and may worsen patient prognosis. Epidemiological literature was reviewed to investigate the association between depression and painful physical symptoms.

Method:

MEDLINE and EMBASE database searches were conducted. Studies where a definable organic basis for pain was given were excluded. The search was unrestricted by language but limited to European studies and countries. After filters were applied, 70 eligible studies were reviewed.

Results:

The majority of studies reviewed showed an association between depression and painful physical symptoms. Over 40% of all studies examining the association between pain and depression were carried out in pain clinics in secondary care. Very few studies were conducted in psychiatric settings.

Conclusion:

The findings of this review suggest that painful physical symptoms may be an important part of the depressive syndrome. Although the relationship between depression and painful physical symptoms is not yet fully understood, findings suggest that diagnosis and treatment of depression should involve investigating and treating the full spectrum of symptoms (emotional and physical). Further research in psychiatric and generalist settings is needed to elucidate the relationship between depression and painful physical symptoms as experienced by patients and at the clinical level.

Alexithymia and Self-Esteem in Patients with Ankylosing Spondylitis

INTRODUCTION

Ankylosing spondylitis (AS), which has an unknown etiology, inflammatory disorder, characterized by inflammation of the spinal joints and adjacent structures. It has a negatif effect on all aspects of a patients's life: Physcally, psychologically and socially. The purpose of this study was to determine the effect of AS on self-esteem and alexithymia.

METHOD

In this study, 50 patients from the department of physical therapy and rehabilitation with the diaognosis of AS who were under traetment and follow-up and 50 healty volunteers who matched for age and gender were taken. Toronto Alexithymia Scale (TAS), Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale (RSES), Beck Anxiety Inventory (BAI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were performed to both patients and control group.

RESULTS

Compared to the control group, the anxiety and depression scores were higher in the patient group and the alexithymic characteristics were significantly higher, self-esteem scores were significantly lower in the patient group (p<.05).

CONCLUSION

Like all the other inflammatory chronic diseases, depression and anxiety are commonly seen in AS patients. Alexithymai and self-esteem of these patients should be considered carefully. More studies are needed on this regard.

Effect of five-consecutive-day exposure to an anxiogenic stressor on sleep-wake activity in rats

Repeated exposure to an anxiogenic stressor (AS) is a known environmental factor for the development of depression, yet the progression of sleep-wake (S-W) changes associated with the onset of AS-induced depression (ASID) is not completely understood. Thus, the aim of this study was to identify these progressive S-W changes by developing ASID in rats, via repeated exposure to an AS, and compare this ASID-associated sleep phenotype with the sleep phenotype of human depression. To achieve this aim, rats were first recorded for a 6 h period of baseline S-W activity without AS. Then, rats were subjected to 5 days of AS [Day 1: inescapable foot-shock; 5 trials of 3 s foot-shocks (1.0 mA) at 3 min intervals; Days 3–5: 15 trials of 5 s foot-shocks at 45 s intervals]. S-W activity was recorded for 6 h immediately after each AS treatment session. Two days later rats were again recorded for 6 h of S-W activity, but with no exposure to the AS (NASD). Compared to the baseline day: Day 1 of AS (ASD-1) increased wakefulness, slow-wave sleep (SWS) latency, and rapid-eye movement (REM) sleep latency, but decreased the total amount of REM sleep; ASD-2 animals remained awake throughout the 6 h S-W recording period; ASD-3, ASD-4, and ASD-5 (ASDs-3–5) decreased wakefulness, SWS latency, and REM sleep latency, but increased the total amount of REM sleep. Interestingly, these results reveal that initial exposure to the AS versus later, repeated exposure to the AS produced opposing S-W changes. On NASD, animals exhibited baseline-like S-W activity, except slightly less REM sleep. These results suggest that repeated AS produces a sleep phenotype that resembles the sleep phenotype of depression in humans, but consistent re-exposure to the AS is required. These results are promising because the methodological simplicity and reversibility of the ASID-associated S-W phenotype could be more advantageous than other animal models for studying the pathophysiological mechanisms that underlie the expression of ASID.

IPS multicentric study: Functional somatic symptoms in depression

BACKGROUND

As a pilot project, Indian Psychiatric Society conducted the first multicentric study involving diverse settings from teaching institutions in public and private sectors and even privately run psychiatric clinics.

AIM OF THE STUDY

To study the typology of functional somatic complaints (FSC) in patients with first episode depression.

MATERIALS AND METHODS

A total of 741 patients from 16 centers across the country participated in the study. They were assessed on Bradford Somatic Symptom inventory for FSC, Beck Depression Inventory for severity of depression, and Comprehensive Psychopathological Rating Scale- anxiety index (CPRS-AI) for anxiety symptoms.

RESULTS

The mean age of the study sample was 38.23 years (SD-11.52). There was equal gender distribution (male - 49.8% vs. females 50.2%). Majority of the patients were married (74.5%), Hindus (57%), and from nuclear family (68.2%). A little over half of the patients were from urban background (52.9%). The mean duration of illness at the time of assessment was 25.55 months. Most of the patients (77%) had more than 10 FSCs, with 39.7% having more than 20 FSCs as assessed on Bradford Somatic Inventory. The more common FSC as assessed on Bradford Somatic Inventory were lack of energy (weakness) much of the time (76.2%), severe headache (74%) and feeling tired when not working (71%), pain in legs (64%), aware of palpitations (59.5%), head feeling heavy (59.4%), aches and pains all over the body (55.5%), mouth or throat getting dry (55.2%), pain or tension in neck and shoulder (54%), head feeling hot or burning (54%), and darkness or mist in front of the eyes (49.1%). The prevalence and typology of FSCs is to a certain extent influenced by the sociodemographic variables and severity of depression.

CONCLUSION

Functional somatic symptoms are highly prevalent in Indian depressed patients and hence deserve more attention while diagnosing depression in Indian setting.

Anxiety, depressive and somatic symptoms in adults with congenital heart disease

OBJECTIVE

Despite the improvement in life-expectancy of adults with congenital heart disease, they may experience unique medical and social challenges that could impact on their psychological functioning. The aims of this study were to address the experience of anxiety, depressive and somatic symptoms among adults with congenital heart disease in comparison with that of non-heart diseased persons considering the role of various factors (e.g. socio-economic).

METHODS

In cross-sectional case-control study, the participants consisted of 347 patients with congenital heart disease (18-64 years, 52.2% female) and 353 matched (by sex/age) non-heart diseased persons. The participants completed a questionnaire. The data were analyzed with bivariate and multivariate methods.

RESULTS

In bivariate analyses, scores in anxiety and somatic symptoms were higher among patients than the healthy controls (both at p≤0.001), whereas the groups did not differ in depressive symptoms. Following multiple-linear-regression-analyses, only the association between congenital heart disease and somatic symptoms was confirmed. Among the patients, perceived financial strain was significantly related to anxiety, depressive and somatic symptoms; lower perceived social support to anxiety and depression; and low annual income to somatic symptoms. Additionally, somatic symptoms were associated with anxiety and depressive symptoms, and vice versa. And no medical variables were related to anxiety, depressive and somatic symptoms.

CONCLUSIONS

Congenital heart disease was only independently associated with somatic symptoms. Financial strain, social support and co-existence of emotional distress with somatic symptoms should be considered in developing appropriate interventions to improve the well-being of patients with congenital heart disease. However, longitudinal research is warranted to clarify causality.

Functional somatic complaints in depression: An overview

Depression is a disorder of major public health importance which often manifests through functional somatic complaints. Concept of functional somatic complaints dates back to the time of Wernicke and is later substantiated by various authors. Although considered as an alternative 'idiom of distress' in certain culture, functional somatic complaints are universal. Various international, cross-cultural, inpatient and outpatient based studies have reported that about two-third of subjects of depression present to clinicians with functional somatic complaints which often leads to misrecognition of their illness and in turn leads to increased utilization of health services. These functional somatic complaints can be related to various organ systems but show remarkable homogeneity in their presentation across culture. Various instruments have attempted to tap the functional somatic complaints but are limited by their cross-cultural validity. Among important correlates of functional somatic complaints are female gender, severity of depression, subsyndromal anxiety, alexithymia, somatosensory amplification and hypochondriacal worry are to name a few. Neurobiological understanding implicates neurotransmitters serotonin and norepinephrine, resultantly Serotonin Norepinephrine Reuptake Inhibitors have been found to be effective in treating functional somatic complaints in depression. Future revisions in the nosological systems should consider giving proper importance to some of these symptoms for diagnosing depression.

Efficacy evaluation for depression with somatic symptoms treated by electroacupuncture combined with Fluoxetine

OBJECTIVE

This study is to investigate the clinical therapeutic effects and safety of treating mild or moderate depression with somatic symptoms with electroacupuncture combined with Fluoxetine.

METHODS

95 cases of mild or moderate depression with somatic symptoms were randomly divided into a Fluoxetine group, and an electroacupuncture plus Fluoxetine group. Hamilton Depression Scale (HAMD) was used for the assessment of clinical therapeutic effects and Treatment Emergent Symptom Scale (TESS) was used for assessment of adverse reactions.

RESULTS

The total effective rate was 77.27% in the Fluoxetine group and 78.26% in the electroacupuncture plus Fluoxetine group, showing no statistically significant difference between these two groups (P > 0.05). However, the treatment took effect after two weeks in the electroacupuncture plus Fluoxetine group but after four weeks in Fluoxetine group. During this time, a better therapeutic effect on depression with mild or moderate somatic symptoms was found in the electroacupuncture plus Fluoxetine group, which also had fewer adverse reactions than the Fluoxetine group.

CONCLUSION

Electroacupuncture combined with Fluoxetine takes effect faster for relieving the somatic symptoms with fewer adverse reactions. It is worth popularizing clinically.

Duloxetine in the treatment of major depressive disorder

Since depression impacts all body systems, antidepressant treatments should relieve both the emotional and physical symptoms of depression. Duloxetine demonstrated antidepressant efficacy at a dose of 60 mg qd in two placebo-controlled, randomized, double-blind studies and significantly improved remission rates compared with placebo. Duloxetine-treated patients had significant reduction in severity of the symptoms of depression as assessed by the HAM-D(17), anxious symptoms as measured by the HAM-A and quality of life measures compared to placebo. Duloxetine also improved somatic symptoms, particularly painful symptoms which may have contributed to significantly improved remission rates compared to placebo. Approximately 10% of the 1139 patients with major depressive disorder in placebo-controlled trials discontinued treatment due to an adverse event, compared to 4% of the 777 patients receiving placebo. In addition to nausea (1.4% incidence), which was the most common reason for discontinuation, dizziness, somnolence, and fatigue were the most common AEs reported as reasons for discontinuation and all were considered drug-related. Duloxetine treatment lacks effects on ECG, increases heart rate, and has little effect on blood pressure or weight.

The level of recognition of physical symptoms in patients with a major depression episode in the outpatient psychiatric practice in Puerto Rico: an observational study

BACKGROUND

This study was designed to evaluate the psychiatrists' level of recognition of somatic symptoms associated to a major depressive episode (MDE) (DSM-IV-TR criteria) and the impact of those somatic symptoms on the treatment effectiveness.

METHODS

This non-interventional study was conducted in 25 medical offices in Puerto Rico from February to December 2003. It had 2 visits separated by 8 weeks. The level of recognition was determined by: the correlation between the physician clinical evaluation and their patients' self-evaluations through different validated instruments using kappa statistics. Chi-square test was used to evaluate the impact of somatic symptoms on treatment antidepressants' effectiveness.

RESULTS

All the 145 recruited patients reported the presence of at least one somatic symptom associated with their current MDE. In the two visits covered by the study, a fair agreement between the psychiatrists' and the patients' reports was noted for headache, abdominal pain and upper limb pains (0.4003 <or= kappa >or= 0.6594). For other painful symptoms and painless somatic symptoms, the Kappa values obtained were non-significant. Slight but significant reductions in depression and painful symptoms severity were observed after 8 weeks of treatment. A proportional relationship between the pain and depression severity was observed (p < 0.0001).

CONCLUSION

The study results show that somatic symptoms: are very common in depressed Puerto Rican patients; are significant under-reported by psychiatrists; and have a significant impact on the antidepressant effectiveness.

Duloxetine 60 mg once-daily in the treatment of painful physical symptoms in patients with major depressive disorder

BACKGROUND

While emotional symptoms such as depressed mood and loss of interest have traditionally been considered to constitute the core symptoms of major depressive disorder (MDD), the prevalence and importance of painful physical symptoms such as back pain, abdominal pain, and musculoskeletal pain is becoming increasingly appreciated. Antidepressants possessing dual serotonin/norepinephrine (5-HT/NE) reuptake inhibition may demonstrate greater efficacy in the alleviation of pain. The efficacy of duloxetine, a balanced and potent dual reuptake inhibitor of 5-HT and NE, was evaluated within a cohort of depressed patients with associated painful physical symptoms.

METHODS

In this multicenter, double-blind, placebo-controlled study, patients meeting DSM-IV criteria for MDD were randomized to receive placebo (N=141) or duloxetine 60 mg QD (N=141). Patients were required to have a 17-item Hamilton Rating Scale for Depression (HAMD17) total score 15, a Clinical Global Impression of Severity (CGI-S) score 4, and a Brief Pain Inventory (BPI) Average Pain score 2 at baseline. The primary efficacy measure was the BPI Average Pain score, while secondary measures included other BPI items, the HAMD17 total score, CGI-S, the Patient Global Impression of Improvement (PGI-I) scale, Visual Analog Scales (VAS) for pain, and the Symptom Questionnaire, Somatic Subscale (SQSS). Safety was evaluated by recording treatment-emergent adverse events (spontaneously reported), vital signs, and laboratory analytes.

RESULTS

Mean changes in BPI Average Pain for duloxetine- and placebo-treated patients differed significantly at most visits, but only approached significance at endpoint p=0.066. For the main effect of treatment (pooling all visits), significant advantages for duloxetine-treated patients were found in 10 of 11 assessed BPI pain severity and pain interference items, in addition to VAS overall pain and back pain. Mean changes in pain measures for duloxetine-treated patients corresponded to improvements of 25-50%, compared with 19-39% for placebo. Mean changes at endpoint in depression rating scales (HAMD17, CGI-S, PGI-I) did not differ significantly between duloxetine and placebo treatment groups due to unusually high placebo response. The magnitude of placebo treatment effects (as measured by HAMD17 total score and Maier subscale) was significantly smaller in patients with 1 previous depressive episode, compared to those patients with no previous episodes. In patients with 1 previous depressive episode the advantage of duloxetine over placebo was similar to previous studies. Rates of discontinuation due to adverse events were 14.2% vs. 2.1% for duloxetine and placebo, respectively p<0.001. Treatment-emergent adverse events reported at a significantly higher rate by duloxetine-treated patients included nausea, dry mouth, fatigue, and decreased appetite.

CONCLUSIONS

In this study, duloxetine (60 mg QD) was shown to be an effective treatment for the painful physical symptoms which are frequently associated with depression. Improvements in pain severity occurred independently of changes in depressive symptom severity.

Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care

This study examined the relations between disability, as measured by the Pain Disability Index (PDI) and self-efficacy, fear avoidance variables (kinesiophobia and catastrophizing), and pain intensity, using a prospective design. Two primary health care samples (n(1)=210; n(2)=161) of patients with subacute, chronic or recurring musculoskeletal pain completed sets of questionnaires at the beginning of a physiotherapy treatment period. Multiple hierarchial regression analyses showed that self-efficacy explained a considerably larger proportion of the variance in disability scores than the fear avoidance variables in the first sample. This finding was replicated in the second sample. Pain intensity explained a small, but significant proportion of the variance in disability scores in one sample only. Gender, age, and pain duration were not related to disability. These findings suggest that self-efficacy beliefs are more important determinants of disability than fear avoidance beliefs in primary health care patients with musculoskeletal pain. The findings also suggest that pain-related beliefs, such as self-efficacy and fear avoidance, in turn, are more important determinants of disability than pain intensity and pain duration in these patients.

Do general practitioners believe that their older patients physical symptoms are somatized?

OBJECTIVE

To establish general practitioner (GP) ratings of the origins of their older patients' physical symptoms, and to test the hypothesis that those older patients rated as somatizing would have similar clinical characteristics to those found in studies of younger attenders.

METHODS

A prospective study among older primary care attenders in two UK practices. All were rated for psychiatric disorder, physical illness, frequency of attendance and demographics. GPs rated degree of somatization on a 5-point scale.

RESULTS

Almost three quarters of attenders were considered to have some psychological component to physical presentations, with 13.3% rated as primarily or entirely psychological. Frequent attendance, female gender and antidepressant prescription were associated with high somatization ratings, but depressive disorder was not.

CONCLUSION

GPs consider somatization to be an important cause of physical presentations among older patients, especially among female frequent attenders.

Somatic symptoms in treatment-resistant depression

The purpose of this work was to study the prevalence of somatic symptoms in patients with treatment-resistant depression (TRD) and their impact on the response to antidepressant treatment. Somatic symptoms were assessed during the screen visit with the Symptom Questionnaire (SQ) somatic symptom (SQ-SS) and somatic well-being sub-scales (SQ-SWB) in 40 patients with TRD enrolled in a 6-week open trial of nortriptyline. A logistic regression was used to test whether SQ-SS or SQ-SWB scores predicted clinical response to nortriptyline. Ninety-five percent of patients reported at least one somatic symptom. Higher SQ-SS scores during the screen visit predicted poorer response to nortriptyline. There was a trend for lower SQ-SWB scores to predict poor response to nortriptyline. None of the patients with SQ-SS scores above the mean for the sample responded to nortriptyline. The overwhelming majority of patients with TRD presented with somatic symptoms. In addition, a greater number of somatic symptoms during the screen visit placed patients at risk for further treatment resistance.

Duloxetine: A New Treatment for the Emotional and Physical Symptoms of Depression

BACKGROUND: Depression is underdiagnosed in the primary care setting. Physical symptoms such as aches, pains, and gastrointestinal disturbance are frequently associated with major depressive disorder (MDD) and are often the presenting symptoms. Duloxetine, a dual-reuptake inhibitor of serotonin and norepinephrine, may have a positive effect on physical symptoms in addition to efficacy in treating emotional symptoms of depression. METHOD: Efficacy was evaluated in 6 double-blind, placebo- and/or active comparator-controlled trials of duloxetine for patients with MDD (DSM-IV criteria). Efficacy in depression was determined primarily using the 17-item Hamilton Rating Scale for Depression (HAM-D-17). Secondary efficacy measures included subscales of the HAM-D-17 and assessment of physical symptoms. Safety evaluations included adverse events, vital signs, laboratory analyses, and electrocardiograms. Safety was evaluated by pooling the data from the MDD trials and a study of duloxetine in nondepressed patients. RESULTS: Duloxetine demonstrated significant differences from placebo on core mood symptoms, physical symptoms (e.g., back pain), and global functioning as early as week 1 of treatment. The estimated probabilities of remission in the studies that demonstrated efficacy ranged from 43% to 57%. The most frequently observed adverse events for duloxetine-treated patients included nausea, dizziness, insomnia, fatigue, and somnolence. Duloxetine did not prolong corrected QT intervals, and the rate of sustained elevations of blood pressure did not differ significantly from placebo. CONCLUSION: In these studies, duloxetine was safe and effective in the treatment of both emotional and physical symptoms of MDD. Based on dose assessments, 60 mg q.d. appears to be the optimum starting and therapeutic dose.

ALEXITHYMIA AND PSYCHIATRIC SYMPTOMS IN A POPULATION OF NURSERY WORKERS: A STUDY USING THE 20-ITEM TORONTO ALEXITHYMIA SCALE

This study investigated alexithymia in a sample of professional nursery workers in Huddinge community, Sweden. In a previous study in general practice it was found that alexithymia, in a mixed population seeking medical advice, was associated with higher age, male gender, low education and the personality traits suspicion and distance as well as undetected depression. The choice of a professional female population allowed alexithymia to be studied in a refined way without the impact of some of the confounding elements of previous studies. The six variables investigated apart from alexithymia were feelings of well-being, symptoms of somatic and psychic anxiety, depressive symptoms, gastro-intestinal symptoms, and level of social dysfunction. The prevalence of alexithymia was 7.9%. Fifty percent of the items assessing somatic anxiety and 28.5% of those assessing depressive symptoms were related to high TAS- 20 scores in this healthy all-female population. The feeling factors of TAS-20, difficulty in identifying and expressing feelings, accounted in this study for the majority of relations to the other variables whilst the third factor, externally oriented thinking, remained independent and mainly nonrelated to the other measured variables. It had been hypothesised that a deficit in the cognitive processing and modulation of emotions may leave alexithymic individuals prone to states of heightened sympathetic arousal. Confirmation of these theories was found in this study where subjects expressing high levels of vegetative and visceral symptoms of anxiety also scored high for alexithymia and depressive symptoms.