The minimally important difference in the Rhinoconjunctivitis Total Symptom Score in grass-pollen-induced allergic rhinoconjunctivitis

BACKGROUND

The minimally important difference (MID) has been defined as the smallest improvement considered worthwhile by a patient. The MID has not been estimated for the Rhinoconjunctivitis Total Symptom Score (RTSS).

METHODS

In a prospective multicentre study, patients consulting for grass-pollen-induced allergic rhinitis (AR) recorded a 15-point global rating of change scale (GRCS) score and the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score on a weekly basis and the individual symptom scores comprising the RTSS on a daily basis over two consecutive weeks. The MID in the RTSS was determined with anchor-based methods (using the GRCS and the RQLQ) and a distribution-based method [based on the RTSS' standard deviation (SD)].

RESULTS

The study population comprised 806 patients (253 children, 250 adolescents and 303 adults). During the first week of the study, the mean ± SD RTSSs for these age groups were 6.5 ± 3.3, 6.8 ± 3.4 and 7.0 ± 3.4, respectively. For an improvement of 2 points in the GRCS or 0.5 points in the RQLQ score, the regression analysis yielded MIDs in the RTSS of 1.24 ± 0.17 and 1.12 ± 0.14 in children, 1.33 ± 0.14 and 1.20 ± 0.13 in adolescents and 1.13 ± 0.14 and 0.89 ± 0.12 in adults, respectively. When applying distribution-based methods, the MID ranged from 1.09 to 1.13 (based on 0.33 SDs of the first-week RTSS) and from 1.22 to 1.40 (based on 0.5 SDs of the difference in RTSSs between the first and second weeks).

CONCLUSION

The MID in the RTSS was consistently estimated as 1.1-1.3 (and could conceivably be rounded to 1) in patients with grass-pollen-induced AR.

Meta-analyses of the efficacy and tolerability of the tricyclic antidepressant lofepramine

Lofepramine is a tricyclic antidepressant related to imipramine. Meta-analyses were carried out with respect to efficacy and tolerability by combining outcome and adverse reaction from over 20 controlled trials comparing lofepramine with other tricyclic antidepressants. Lofepramine was at least as effective as the comparators with fewer adverse effects. In particular, the risk/benefit ratio seemed superior to the comparators amitriptyline, imipramine, clomipramine, maprotiline and desipramine.

Glycosaminoglycan polysulfate in the treatment of old age dementias

1. In a multicenter, placebo-controlled, double-blind clinical trial in 155 elderly patients with cognitive decline, glycosaminoglycan polysulfate was found to be a therapeutically effective agent in the treatment of old age dementias. 2. Treatment with glycosaminoglycan polysulfate in the daily dosage of 600 LRU, administered on the basis of a divided dosage schedule for 12 weeks, was significantly superior to an inactive placebo on several outcome measures including the Wechsler Memory Scale-Russell Revision (Easy Paired Associates Learning and Immediate Visual Reproduction), Mini Mental State Examination, the Sandoz Clinical Assessment Geriatric (Cognitive Dysfunction and Depression), Hachinski Dementia Scale, Brief Psychiatric Rating Scale (Confusion and Depressive Withdrawal) and Global Improvement Scale of the Clinical Global Impression. 3. Adverse effects with glycosaminoglycan polysulfate were few and mild. The drug was equally well tolerated and equally effective in the two major dementias of old age, i.e., primary degenerative and multi-infarct. The number of abnormal laboratory test readings remained essentially unchanged from pre-treatment to post-treatment.

Efficacy of tianeptine in anxious-depressed patients: results of a controlled multicenter trial versus amitriptyline

265 adult outpatients with dysthymic disorder (DSM-III) associated with clinically manifest anxiety (according to FDA criteria) were included in a multicenter, randomized double-blind study. The trial consisted of three phases: placebo pretreatment phase and inclusion in the trial, treatment phase, placebo posttreatment phase. Patients were treated in monotherapy for 42 days with a mean dosage of 3 tablets per day corresponding to 37.5 mg/day of tianeptine or 75 mg/day of amitriptyline respectively. The following assessment instruments were used: the Montgomery and Asberg Depression Rating Scale (MADRS), the Hamilton Anxiety Rating Scale (HARS), and the Check-List for the Evaluation of Somatic Symptoms of J.D. Guelfi and C.B. Pull (CHESS 82). Analysis of MADRS total scores showed an important and rapid improvement in tianeptine and amitriptyline groups, reaching statistical significance as soon as D7. At the end of the 6-week treatment period the tianeptine group reached a decrease of 64% in the initial MADRS total score versus 69% in the amitriptyline group. 78% of patients treated with tianeptine and 83% of patients treated with amitriptyline were considered as treatment responders. There was no difference in drop-out rates between the two groups. HARS scores showed a decrease in psychic as well as somatic anxiety in both groups. The action of tianeptine on anxious-depressive symptomatology was confirmed by the concomitant improvement of global clinical rating and patients' self-rating (HSCL). Statistical comparison of all clinical rating-scale scores in patients having completed the trial failed to show any significant group differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluvoxamine and imipramine: results of a long-term controlled trial

Following a multicentre double-blind controlled trial comparing the effects of fluvoxamine and imipramine in depressed inpatients (M.D.E.) 39 patients continued on longer term treatment with maintenance of double-blind conditions (17 on fluvoxamine, 22 on imipramine). The results regarding the reasons for premature interruption of treatment show a slight advantage in favour of fluvoxamine. There were several significant differences in favour of fluvoxamine at the 20th week. The most common side-effects were hot flushes with imipramine and dizziness with fluvoxamine. Overall, despite the small number of patients, the results show a greater clinical tolerance to fluvoxamine than to imipramine.

Zopiclone versus nitrazepam: a double-blind comparative study of efficacy and tolerance in elderly patients with chronic insomnia

A randomized, double-blind, comparative trial of zopiclone versus nitrazepam was conducted in 74 geriatric chronic insomniac patients. Following a 7-day wash-out period, two parallel groups, successively received a placebo for 7 days, then either 7.5 mg zopiclone or 5 mg nitrazepam for another 7-day period. Efficacy on sleep was assessed by a sleep analogue scale and the Spiegel Sleep Questionnaire, residual effects by psychometric tests and tolerance by a standardized question, as well as by clinical and laboratory tests. Zopiclone and nitrazepam were more active than placebo on all tests of efficacy. In contrast with nitrazepam, zopiclone was devoid of effect on neurological function. In addition, the condition on awakening was better with zopiclone.

Pharmacological and clinical studies of cyclopyrrolones: zopiclone and suriclone

Among the non-benzodiazepine compounds which have been found to interact with the "GABA receptor-BZ receptor-chloride channel complex," the very chemically original cyclopyrrolone family has a special place. This has been demonstrated using selected pharmacological, biochemical and clinical data obtained with two cyclopyrrolones, zopiclone and suriclone, which, in addition to their capacity of displacing BZ from their sites, simultaneously possess the main pharmacological properties of BZ and well established therapeutic activities, as hypnotic and anxiolytic, respectively. However, although cyclopyrrolones recognize BZ receptor sites, their mechanism of action might not exactly fit with that of BZ. Indeed, using tritiated zopiclone and suriclone, it has been shown that they could act on sites distinct from those of BZ or could induce receptor conformational changes different from those induced by BZ.

A computerized diagnostic system for comparing alternative classification schemes of depression

The present report presents a computerized system, permitting recording of diagnostic criteria and assignment by diagnostic algorithms as proposed and intended in 7 different classification systems of depression. The potential of the procedure for comparing alternative classifications of depression is presented and discussed.

[Computer program for the processing of data collected during therapeutic trials in psychiatry]

A computer program is described which has been developed over several years and allows for the easy processing of psychiatric data gathered in clinical trials. It provides user-defined parametrization of a computer-aided data entry system, the use of the program created to input data to the computer and the data processing of the data collected either through modifications of the file created or by statistical analysis, the procedures of which have been simplified to enable its performance even by lay people.

[The Checklist for Evaluation of Somatic Symptoms (CHESS). Its use in anxious and depressive pathology. Factor structure]

The CH.E.S.S. is a new inventory for the assessment of somatic symptoms and complaints. Initialy it included 57 items (43 somatic complaints, 12 neurological signs and 2 "other symptoms"). The CH.E.S.S. was scored before treatment on two groups of patients (133 anxious and 133 depressed) with no schizophrenic or organic symptomatology. 71 somatic complaints or symptoms were identified. A principal component analysis with a subsequent Varimax rotation yelded 25 factors with 18 of clinical significance. 12 factors significantly discriminate between the two groups. Seven factors (21 items) have higher scores in depressed patients: sleep and general somatic disorders, 2) general impairment of intellectual functioning, 3) neurological, 4) neuro-muscular hypo-excitability, 5) lower limbs oedema-amimia, 6) and 7) digestive. Five factors (18 items) have higher scores in anxious patients: 1) and 2) autonomic hyperactivity, 3) neuro-muscular hyper-excitability, 4) digestive, 5) micturition disorders with limb paresthesias. According to these results the 67 items new version of the check-list (CH.E.S.S. 82) includes 51 somatic complaints or symptoms and 16 neurological signs.

A comparative study of zopiclone and flunitrazepam in insomniacs seen by general practitioners

A double-blind crossover trial was conducted in 42 outpatients of either sex in order to obtain information on the properties of 7.5 mg of zopiclone in a general practice setting compared with 2 mg of flunitrazepam. Each patient went through two periods of treatment, each period lasting 10 days. A comparison of the effect of the drugs showed a significant difference with regard to effectiveness and sleep latency favoring flunitrazepam. When patient's preferences were analyzed there was a highly significant difference favoring flunitrazepam both for effectiveness and tolerance. The side effects from both drugs were generally mild.

Effects of hypnotics on memory

The influence on memory of 7.5 mg zopiclone, given in single and repeated doses was compared with that of 2 mg flunitrazepam, 5 mg nitrazepam and placebo. Compared with placebo, all three drugs induced some impairment of memory especially after the first day of administration. Effects were more pronounced for the two benzodiazepines and more marked for flunitrazepam. There was one report of an anterograde amnestic episode after flunitrazepam.

Comparison of nitrazepam and zopiclone in psychiatric patients

This investigation compares the effects of single and double doses of nitrazepam (5 and 10 mg) and zopiclone (7.5 and 15 mg) and placebo for 1 night in 40 psychiatric patients. The results indicate that zopiclone is an active hypnotic compound, comparable in its effects to those of nitrazepam, the higher dosage being best adapted to the type of patients included in the study.

Pharmacokinetics and metabolism of zopiclone

Pharmacokinetics and metabolism of a new hypnotic, zopiclone (ZD), were studied under the following conditions: (1) rats and dogs were given oral doses of the molecule, 14C-labeled either on the side chain or on the pyrrolopyrazine nucleus; (2) rats, rabbits and dogs were given increasing oral doses of the cold compound; (3) human subjects in various physiopathological situations--young and elderly healthy volunteers, patients with liver or renal impairments, nursing mothers--were given single or repeated doses, p.o. or i.v. (range 3.5-15 mg). ZD is rapidly and efficiently absorbed: its oral bioavailability was greater than 75% in all species except rats, where a first-pass effect of about 65% was recorded. Plasma protein binding is about 45%. The radioactive material rapidly diffuses from the vascular compartment, with a marked affinity for the brain. Plasma kinetics of ZD are generally well described by a two-compartment open model; in man, terminal half-life is 4-5 h; total body clearance is large (300 ml/mn), renal clearance very low (10 ml/min). The relationship between doses and concentrations, doses and urinary excretion of unchanged compound and major metabolites was linear in all species, except rabbits. The major metabolic routes involve decarboxylation affecting more than 50% of dose (rats and dogs), N-demethylation and N-oxidation--more than 30% as N-desmethyl and N-oxide derivatives in urine (humans). Due to intensive metabolism, only 7-10% of the dose is recovered in urine and feces as unchanged compounds (all species). In nursing mothers, milk and plasma kinetics of ZD are similar with a milk/plasma ratio around 0.80. In human volunteers, plasma half-life of ZD increases with age, while patients with liver or renal impairments show little or no modification of pharmacokinetic parameters.

A double-blind controlled clinical trial comparing fluvoxamine with imipramine

1 The effects of fluvoxamine to a maximum of 300 mg daily were compared with those of imipramine to a maximum of 200 mg daily, in 151 patients with primary major depression. 2 Four weeks of treatment with fluvoxamine resulted in 67.2% improvement (+/- s.d. 21.6) on the Hamilton Rating Scale for Depression (26 items). Treatment with imipramine showed 62.1% improvement (+/- s.d. 29.5) on this scale. 3 Fluvoxamine had no untoward effects on the cardiovascular system, while imipramine produced systematic increases in the postural fall in blood pressure. Dry mouth, nausea, daytime somnolence and tremor were seen with fluvoxamine treatment, while imipramine was associated with dry mouth, daytime somnolence, dizziness and tremor. 4 We conclude that fluvoxamine seems to have the same general antidepressant efficacy as imipramine. It was not associated with any safety problems and was generally well tolerated.

Drug-alcohol interactions on psychomotor skills: zopiclone and flunitrazepam

Interaction between alcohol and zopiclone or flunitrazepam as well as the residual effects of both these hypnotics were studied in 20 normal male volunteers who received each 3 of 6 different drug and drink combinations according to a balanced incomplete block design as follows: placebo, zopiclone (7.5 mg), or flunitrazepam (2 mg) was administered double-blind in identical capsules at 23.00 h, and 0.5 g/kg body weight of alcohol or placebo alcohol was given at 08.30 h the following morning. Psychomotor skills of the volunteers were measured before drinking and 30 min, 1.5 h and 2.5 h after it. As compared with placebo, zopiclone had no residual effects, while flunitrazepam had some effects on standing steadiness, tracking, and flicker recognition. Alcohol alone had a non-significant effect on skills, and the combination zopiclone plus alcohol behaved as alcohol alone. Flunitrazepam plus alcohol impaired significantly standing steadiness, tracking, and reactive skills when compared with all other treatments. Time anticipation and hand and foot proprioception were not affected by any treatment. The results suggest that flunitrazepam, unlike zopiclone, has residual effects and interacts with alcohol in the morning following overnight ingestion of the drug.

Polygraphical sleep recordings in insomniac patients under zopiclone or nitrazepam

Zopiclone, a new hypnotic with an original chemical structure, was compared in a sleep laboratory study with nitrazepam according to a double-blind, parallel group randomized design. Zopiclone (7.5 mg) and nitrazepam (5 mg) were each given for 14 nights to 5 insomniacs; a placebo washout period of 4 nights and a placebo withdrawal period of 10 nights were included in the design. Both drugs were found to be immediately and lastingly effective. Some slight insomnia rebound was found with nitrazepam, but not with zopiclone. Stage 2 was decreased, slow wave sleep (SWS) increased, and rapid eye movement unchanged by both drugs: however, only nitrazepam increased rapid eye movement latency. The differences between the effects of the drugs were quite limited. However, 3 out of 50 comparisons favoured zopiclone and none nitrazepam.

Studies on the dependence-inducing potential of zopiclone and triazolam

We carried out a randomized double-blind study. This was a crossover design with two periods of 2 days each with one compound (either zopiclone or triazolam). The next 2 days of active trial periods the patients were allowed to choose the preferred coloured capsule of which both neither the patients nor the investigators knew about its real contents. 40 volunteers were chosen from our patients suffering from chronic alcoholism who just finished their detoxification. There were given coloured coded capsules, each of them containing either 0.25 mg triazolam or 3.75 mg zopiclone. The capsules should be swallowed when patients felt a desire for alcohol. The maximal dosage was 8 capsules per day (2.0 mg triazolam and 30 mg zopiclone). There was a significant difference of degrees of freedom and probability at a level of 0.0005 for the items of the Addiction Research Centre Inventory and a level of 0.0005 for the items of the 'profile of mood states'. None of the volunteers developed a special desire for zopiclone after withdrawal of the medication.

A double-blind controlled multicenter trial comparing butriptyline with amitriptyline

77 primary depressive in-patients aged 18-70 years (mean = 46/47 years) were assigned randomly to experimental and control groups and treated in double-blind conditions in ten centers. Butriptyline and amitriptyline were both administered with an identical increasing schedule, up to 150 mg daily in the first week and a flexible schedule for the last 3 weeks of trial. Mean daily doses were 145 mg butriptyline and 142 mg amitriptyline after 2 weeks, and 77.5 mg amitriptyline and butriptyline after 4 weeks. Nitrazepam (5-10 mg) and haldol (5 mg) were also allowed, only if necessary. Symptomatology and antidepressant efficacy were assessed using the rating scales of Hamilton, Overall, BPRS, CGI and a side effect checklist. After initial comparison of the two treatment groups, the results showed that the antidepressant effects were significantly better with butriptyline on the number of dropouts, on the total score and on the following factors of the Overall Depression Scale: depression, guilt, anxiety, somatization and somatic complaints. Frequency of haldol prescription was significantly lower with butriptyline than with amitriptyline. The overall frequency of side effects and of autonomic symptoms did not differ in the two groups. The effects on other parameters (hematological and biochemical variables, ECG and EEG) were similar for both drugs. In conclusion, butriptyline has the same indications as amitriptyline but shows a better antidepressant efficacy at the same dosage.

Placebo use in clinical trials on psychotropic drugs in France

The use of placebos is often justified in therapeutic drug testing. They may be employed in order to compare their effects with those of a so-called active treatment, to compare two active medications, in double-blind comparisons of two drugs of different appearance (double-dummy technique) or to carry through initial washout periods. Although the scientific justification for this procedure is hardly contestable, the methodological difficulties and demands must be considered. The clinical use of placebo comparison poses a true ethical dilemma which increases with the effectiveness of psychotropic drugs. Placebos were used relatively rarely in France before 1978 as a general review of 120 controlled psychotropic drug trials published in French shows. Various precautions undertaken in drug testing designs respond, nevertheless, to both ethical and methodological demands in the majority of the cases. Examples are given regarding the testing of major or minor tranquilizers and antidepressive drugs.

[Clinical evaluation of pipothiazine and its palmitic ester in the therapy of schizophrenia]

20 schizophrenic patients presenting with an acute episode were treated first, whilst hospitalized, by a single oral dose of pipotiazine, then, when their symptomatology had been controlled, thus allowing their discharge, by a monthly injection of pipotiazine palmitate for 6 months. The patients were assessed with a CGI and the BPRS. The tablets provided control of the symptoms of most patients as early as the second week of treatment, the improvement bearing particularly on thought disorder, concept disorganization, excitation, anxiety, depression, tension and somatic symptoms. This led to an improvement in activities and sociability. Injections not only provided the prevention of relapses but even an improvement over the already obtained results which allowed these patients to insert themselves in the community. Adverse effects were infrequent and easily controlled. There were no abnormal modifications of the vital signs and laboratory tests. Pipotiazine appears as an extremely useful drug for countries in which the psychiatric treatment network is still being constructed.

[Factorial analysis of the Hamilton depression scale, II]

A factorial analysis (principal components with Varimax rotation) was performed on 85 ratings of the Hamilton Depression Rating Scale obtained in 1979-1980 on inpatients with a major depressive illness. Using a replicable statistical technique, 4 factors were obtained. These factors do not overlap with those obtain on a similar sample with a similar technique nor with those obtained by other authors. It thus appears that there is no such thing as a factorial structure of this scale.

[Factorial structure of the Hamilton depression scale. I]

A development version (N I M H 67) of the Hamilton depression rating scale with 26 items was scored on 125 depressed inpatients recently hospitalized for a major non schizophrenic depressive illness. The data were obtained before any antidepressant treatment or after an adequate wash out period. A principal component factorial analysis with Varimax rotation was used. Computer simulations showed that only 2 factors were really outside the non significant range. A criterion is defined to allow the choice of an optimal saturation threshold for inclusion of an item in a factor. It assigns 25 of the 26 items of the scale to one of 2 independent factors: depression and anxiety-somatization.

[A double-blind comparison between mianserin and imipramine (author's transl)]

Fifty-four depressed patients aged 18 to 65 years were treated for 4 weeks with a daily dose of either 60 mg mianserin or 150 mg imipramine in a double-blind controlled trial. The results which were measured on the Hamilton rating scale, on the Beck and on the Overall rating scale, on the brief psychiatric rating scale (BPRS) and on a global rating scale, did not show any significant difference relative to the antidepressive efficiency of both products. The frequency of side-effects however was significantly lower in the mianserin group than in the imipramine group.

[Prediction test of nomifensine prescription from symptomatic pre-therapeutic status (author's transl)]

Heighty two outpatients, suffering from reactive or neurotic depression have been treated with a daily 100 mg dose of nomifensine. The symptomatic status before treatment was appreciated by a self-rating scale, the Hopkins Symptoms Check List (HSCL). At the end of the study, the patient again filled out this same rating scale, and also a seven-score amelioration questionnaire. The investigator filled out this same questionnaire and a fourscore global impression scale. We tried to find out if by appreciating initial symptoms with the HSCL, it was possible to predict which patients would be responders to the treatment. The only highly significant result was obtained with a discriminant analysis, which combines 22 items of the pre-therapeutic HSCL and with which it is possible to predict the amelioration measured by the difference between the total pre- and post-therapeutic HSCL notations. The authors point out to the interest of this method in psychopharmacology.

A double-blind multicentre trial comparing mianserin with imipramine

1. Fifty-four depressive in-patients aged 18-45 yr, were treated at random, in double-blind conditions, with mianserin 60 mg daily or imipramine 150 mg daily in three divided doses for 4 weeks. Nitrazepam and diazepam were also allowed if necessary. 2. There was no significant difference in antidepressant efficacy between the two groups, as assessed by the rating scales of Hamilton, Beck and Overall, the Brief Psychiatric Rating Scale, and a global clinical rating. 3. The overall frequency of side-effects was significantly lower with mianserin than with imipramine. Autonomic symptoms increased in severity during treatment with imipramine, but not with mianserin. 4. the patients treated with imipramine had a fall in blood pressure which was not observed during mianserin treatment.