Predictors of clinical worsening during a discontinuation trial of serotonin reuptake inhibitors for obsessive compulsive disorder

OBJECTIVE

To explore predictors and moderators of clinical worsening during a double-blind trial in which patients with obsessive-compulsive disorder (OCD) were randomized to either continue or discontinue their Serotonin Reuptake Inhibitor (SRI) medication after achieving wellness from the addition of exposure and response prevention (EX/RP) therapy.

METHOD

The data came from a double-blind discontinuation trial that included N = 101 participants, 35 of whom were removed from the study due to clinical worsening. We first used LASSO logistic regression to identify which of the 34 potential baseline variables of interest (including demographics, diagnoses, other relevant clinical constructs, and specific genotypes), might moderate or predict this clinical worsening. Then logistic regression was used to examine which of these identified variables were significantly related to later clinical worsening. We verified the validity of our final prediction model using k-fold cross-validation.

RESULTS

There was one significant predictor of clinical worsening: In both groups, those with more past diagnoses had a greater likelihood of clinical worsening (p = .015). There were several moderators. Rates of clinical worsening were higher in the Discontinuation group compared to the Continuation group for participants who were taking a shorter half-life SRI (p = .044), were female (p = .022), had higher baseline levels of maladaptive metacognitions (p < .001), had fewer sleep problems at baseline (p = .001), and/or had more years of education (p < .001).

CONCLUSIONS

Our results identified several factors that may predict the development of clinical worsening in OCD patients discontinuing SRI medication following successful EX/RP treatment.

0152 Insomnia Severity and Daytime Complaints: What is to be Learned When These Domains are Discordant?

Introduction

If illness severity and daytime dysfunction are construed as categorical entities, it is possible to conceptualize the relationship between these variables in terms of a 2x2 matrix where the resultant cells represent a concordant dimension (quadrants 2 & 4 [high-high and low-low]) and a discordant dimension (quadrants 1 & 3 [high-low and low-high]). The question for the present analysis was, what percentage of subjects populate each quadrant and is it the case that the discordant dimension contains only a small percentage of subjects?

Methods

Illness severity and daytime dysfunction data was collected from individuals with sleep continuity complaints in archival/community-based sample (N = 4680; 60% female; Ages 18–89) (www.sleeplessinphilly.com). Illness severity was operationalized as Total Wake Time (TWT; [SL+WASO+EMA=TWT]) and daytime dysfunction was operationalized as the composite score of six daytime symptoms items. Median splits were calculated for each variable and subjects were typed accordingly (HH, LL, HL, & LH).

Results

Surprisingly, the sample was relatively equally distributed into the two dimensions; 38% and 23% for the concordant dimension and 13% and 26% for discordant dimension.

Conclusion

The 39% of subjects in the discordant groups might be thought of as complaining good sleepers (LH) and noncomplaining poor sleepers (HL). Other investigators have identified the LH subjects as individuals with “insomnia identity”. Alternatively, it is possible to characterize the whole dimension as being related to a mismatch between the individual’s sleep need and sleep ability. Those who need a lot, may suffer a lot, in the face of only a little (LH) whereas those who need a little, may suffer only a little, in the face of a lot (HL).

Support

 

0351 Sleep Continuity, Sleep-Related Daytime Dysfunction, and Problem Endorsement: Do These Vary Concordantly by Age?

Introduction

It is well documented that sleep continuity (i.e., SC [ability to initiate and/or maintain sleep]) worsens with age. It is unclear whether problem endorsement and/or daytime dysfunction show similar age-related trends. Accordingly, an analysis was undertaken to assess whether initial, middle, and/or late insomnia all exhibit age related change and whether problem endorsement and/or daytime dysfunction show comparable age-related changes.

Methods

The study utilized a cross-sectional group design in an archival/community dataset (www.sleeplessinphilly.com). This dataset (N=932) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints. Participants were categorized as: Young Adults (18-29 years); Adults (30-44 years); Middle Age Adults (45-64 years); and Older Adults (65-89 years). Age groups were matched to the Older Adults group (n=233) by sex, race, and BMI. ANOVAs with Bonferroni corrections (alpha = .001), and contingency analyses were performed to assess for age group differences.

Results

It was found that, as expected, SC worsens with age but that this was limited to middle and late insomnia. Further, problem endorsement increased with age (except for SL) but sleep-related daytime dysfunction did not (except for concentration issues).

Conclusion

These results have several implications. Methodologically speaking, when evaluating the effects and/or correlates of SC, it may be wise to concomitantly assay “is this a problem for you” and “does this affect your daytime function”, as SC can occur without perceived daytime consequences, especially in older adults. Conceptually speaking, the observed discordance requires further exploration. In the past, it has been argued that sleep need is reduced in older adults. While this is a reasonable hypothesis (no need, no functional consequence), it remains to be demonstrated that older adults require less sleep.

Support

 

1109 Broadly Assessing Sleep Complaints In A Sample Of Patients With ADHD

Introduction

It is commonly observed in clinical settings that patients with ADHD regularly present with comorbid “sleep disturbances”. In the absence of broad based sleep disorders assessments, it is thought that this represents Delayed Sleep Phase Disorder (DSPD). Recently, a surveillance study was undertaken in a university-based, outpatient specialty clinic for adults with ADHD, by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain which sleep disorders symptoms are common in this clinical cohort.

Methods

SDS-CL-25 data were collected in 150 subjects (93/57 male/female, mean age 32.8, age range 18-79). The SDS-CL-25 is a 25 item instrument developed to screen for 13 sleep disorders at one time (Sleep Dx symptoms are endorsed on Likert-scales; 0 [never] 4 [&gt;5x/week]). For the purposes of this study, the percentage of subjects endorsing frequent symptomatology (sum of the percent of endorsements for columns 3 & 4)was calculated per symptom. Sums of &gt;20% were considered, a priori, to be of clinical significance.

Results

Patients endorsed: increased fatigue (59%); SL or WASO or EMA’s &gt;30 minutes (40%; 26%; 21%, respectively); late preferred time to bed (31%); work & school limits sleep opportunity (30%); variable time to and out of bed (27%); and snoring (21%). The average percent endorsement was 15% (range 0-59%).

Conclusion

These results suggest that, consistent with clinical observations, adult patients diagnosed with ADHD frequently endorse late preferred time to bed, variable sleep wake schedules, work/school limitations on sleep opportunity, and sleep onset problems that are accompanied by daytime fatigue. This constellation of symptoms is consistent with the notion that patients with ADHD tend to have comorbid DSPD. The high prevalence of middle and late insomnia was unexpected and suggests that Insomnia Disorder (proper) may also be a feature of ADHD.

Support

No support was provided for this abstract.

1111 Do Sleep Disorder Symptom Endorsements Differ Between ADHD Subtypes?

Introduction

To date, research on differences in sleep complaints between patients with different subtypes of ADHD has been mixed. On balance, the evidence tends towards ADHD-Combined Presentation (ADHD-C) being associated with more severe sleep and sleep-related daytime complaints than ADHD-Primarily Inattentive (ADHD-I). In order to further assess this issue a surveillance study was undertaken in an active ADHD clinic by adding a comprehensive sleep disorders screener (SDS-CL-25) to the clinical intake procedures. These data were used to ascertain whether the two subtypes differ for any of 13 sleep disorders symptoms.

Methods

Subjects (n = 132; 83 male, 49 female, mean age 32.8, age range 18-79), presenting to the clinic for evaluation for ADHD were given the SDS-CL-25. The SDS-CL-25 is a 25-item instrument developed to screen for multiple sleep disorders at one time (problems are endorsed on a Likert-scale; 0 = never and 4 = more than 5x/week). Endorsements greater than 3x/week were counted as positive for the symptom and less than three days per week was considered negative.

Percent per group was compared using Chi Square Analyses. Cumulative morbidity means were also analyzed using t-tests. The subtype, ADHD-I (n=71) and ADHD-C (N=61), was established using EMR records.

Results

No significant differences between patients with ADHD-I and ADHD-C were detected.

Conclusion

The lack of finding in the present analysis may reflect a lack of difference or a failure to detect differences based on the small sample sizes or lack of statistical control for likely confounders (age, sex, illness severity or chronicity, SES status, etc.). Analyses are ongoing.

Support

No support was provided for this abstract.

Yohimbine enhancement of exposure therapy for social anxiety disorder: a randomized controlled trial

BACKGROUND

Preclinical and clinical trials suggest that yohimbine may augment extinction learning without significant side effects. However, previous clinical trials have only examined adults with specific phobias. Yohimbine has not yet been investigated in the augmentation of exposure therapy for other anxiety disorders.

METHODS

Adults (n = 40) with a DSM-IV diagnosis of social anxiety disorder were randomized to placebo or yohimbine HCl (10.8 mg) 1 hour before each of four exposure sessions. Outcome measures were collected at baseline, each treatment session, posttreatment, and 1-month follow-up.

RESULTS

Yohimbine was well tolerated. Yohimbine augmentation, relative to placebo augmentation, resulted in faster improvement and better outcomes on self-report measures of social anxiety disorder severity (Liebowitz Social Anxiety Scale, d = .53) and depressed mood severity (Beck Depression Inventory, d = .37) but not on the clinician-rated measures (Clinical Global Impressions-Severity Scale, d = .09; Clinical Global Impressions-Improvement Scale, d = .25). Between-group differences on the Liebowitz Social Anxiety Scale were moderated by the level of fear reported at the end of an exposure exercise (end fear), such that the advantage of yohimbine over placebo was only evident among patients who reported low end fear.

CONCLUSIONS

The results provide moderate support for yohimbine as a therapeutic augmentation strategy for exposure therapy in social anxiety disorder, one that may be especially effective when coupled with successful exposure experiences. Beneficial effects for yohimbine were readily evident for self-report measures but not for clinician-rated outcomes of social anxiety severity and improvement.