Non-invasive brain stimulation targets and approaches to modulate gambling-related decisions: A systematic review

INTRODUCTION

Despite intense neuroscience research on the neurobiological underpinnings of Gambling Disorder (GD) and gambling-related decision-making, effective treatments targeting these dysfunctions are still lacking. Non Invasive Brain Stimulation (NIBS) techniques, such as transcranial Direct Current Stimulation (tDCS) and Transcranial Magnetic Stimulation (TMS), selectively modulate activity of brain circuits and have the potential to reverse alterations sustaining GD symptoms. Therefore, the aim of this systematic review was to determine the impact of different NIBS interventions on gambling-related decision processes.

METHODS

We conducted a comprehensive and translational search in three online databases (MEDLINE via PubMed, Scopus, Web of Science), in accordance with the PRISMA guidelines. We included studies applying neuromodulation (TMS, tDCS) techniques in GD patients or assessing gambling-related decision-making in healthy subjects. In addition, we explored the potential impact of NIBS in drug-induced GD (e.g., Parkinson's Disease).

RESULTS

Twenty-seven studies have been included. We summarized results to detect the impact of different targets and stimulation/inhibition protocols in terms of gambling-related decision-making. The majority of both tDCS and TMS studies targeted the dorsolateral prefrontal cortex. Although heterogeneous in protocols and parameters, results from tDCS and TMS studies converge in indicating that the stimulation (instead of inhibition) of prefrontal regions could be beneficial to contrast dysfunctional gambling-related decision processes.

CONCLUSION

NIBS interventions show promise to be further tested in controlled clinical settings for the treatment of behavioral addictions. Further studies are also necessary to investigate connectivity changes and laterality issues (unilateral versus bilateral; left versus right) of NIBS application in GD.

Comorbid psychiatric diagnoses in kleptomania and pathological gambling: a preliminary comparison study

Kleptomania and pathological gambling (PG) are currently classified in the DSM IV as impulse control disorders. Impulse control disorders are characterized by an overwhelming temptation to perform an act that is harmful to the person or others. The patient usually feels a sense of tension before committing the act and then experiences pleasure or relief while in the process of performing the act. Kleptomania and PG are often associated with other comorbid psychiatric diagnoses. Forty-four pathological gamblers and 19 kleptomanics were included in this study. All enrolled patients underwent a complete diagnostic psychiatric evaluation and were examined for symptoms of depression and anxiety using the Hamilton depression rating scale and the Hamilton anxiety rating scale, respectively. In addition, the patients completed self-report questionnaires about their demographic status and addictive behavior. The comorbid lifetime diagnoses found at a high prevalence among our kleptomanic patients included 47% with affective disorders (9/19) and 37% with anxiety disorders (7/19). The comorbid lifetime diagnoses found at a high prevalence in our sample of pathological gamblers included 27% with affective disorders (12/44), 21% with alcohol abuse (9/44), and 7% with a history of substance abuse (3/44). A larger study is needed to confirm these preliminary results.

Famotidine: a supplemental drug for the treatment of schizophrenia

In an open-label study, famotidine was added to the regular neuroleptic regimen of 11 schizophrenic patients for 4 weeks. Each patient was scored weekly with SAPS, SANS, CGI and HAM-D-17 scales. The results suggest that famotidine is indeed effective as an adjunctive drug to neuroleptics in the treatment of schizophrenia.

Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead

There is growing interest in non-invasive brain stimulation (NIBS) as a novel treatment option for substance-use disorders (SUDs). Recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent FDA-approval of NIBS treatments for mental health disorders that share overlapping pathology with SUDs. As with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. Here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tES) and transcranial-magnetic (TMS) stimulation applied in SUDs. This consensus paper provides a systematic literature review on published data - emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. The goal of this effort is to provide the community with guidelines for best practices in tES/TMS SUD research. We hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.

The role of gender in association between inhibition capacities and risky decision making

BACKGROUND

Research on the association between decision making and inhibition abilities has exhibited fundamental controversies. Some authors claim that inhibition abilities are an integral part of the decision-making process, whereas others suggest that the decision-making process does not operate in close association with inhibition abilities. Can gender explain variations in risky decisions via inhibition influences?

PURPOSE

The purpose of the present study was to explore the associations between response inhibition, reflection inhibition, interference inhibition, and decision-making processes in men and women.

METHODS

To this end, 46 women and 46 men were assessed by the Go/NoGo task, a measure of response inhibition, by the Matching Familiar Figure Test, a measure of reflection inhibition; and by the Stroop task, a measure of interference inhibition.

RESULTS

No differences were detected in these measures between groups. The net score of the performance on the last section of the Iowa Gambling Task choices did not correlate with the inhibition measures in the two groups. We did not discover any significant main effects of gender on the association between these measures.

CONCLUSION

These findings do not support the hypothesis that risky decisions are due to impaired inhibitory control. Further studies are needed to identify the cognitive mechanisms involved in the tendency to make risky decisions.

Distinct Response Inhibition Patterns in Obsessive Compulsive Disorder Patients and Pathological Gamblers

Background: Obsessive-compulsive disorder (OCD) and pathological gambling (PG) are common disorders. The cognitive models of OCD and PG focus on abnormalities in response inhibition. Although, these functions have been studied in different PG and OCD samples, no study has compared the response inhibition in both. Methods: Medication-naïve OCD (n = 61) and PG subjects (n = 109) and healthy controls (n = 131) performed CPT and Go/NoGo tasks. Results: Compared to healthy controls (HC), PG and OCD groups underperformed on speed and exhibited larger time variability on the CPT and Go/NoGo task. Only in OCD patients, a positive correlation between omission errors and response time (RT) was observed in the CPT. At the Go/NoGo task, a negative correlation between false alarms and RT (a fast-errors trade-off) was significant only in the PG group. The HC group had greater sensitivity values (d') than the OCD and PG groups in the Go/NoGo task. The PG group displayed lower d' values and more conservative response criterion in the CPT. In addition, only the OCD group expressed a high switching cost compared to both the PG and HC groups in terms of the RT and d' values. Conclusions: Both the PG and OCD groups demonstrated impaired response inhibition compared to the HC group. On several measures, the OCD and PG groups showed comparable impairments, and in others these were distinct. Thus, it appears that distinct neurocognitive patterns are involved in performance of the CPT and the Go/NoGo tasks among OCD and PG subjects whose cognitive status is currently under intensive investigation.

Paroxetine in panic disorder: clinical management and long-term follow-up

Panic disorder is one of the most common anxiety disorders and has a lifetime prevalence of 3-5%. Panic attacks can begin at any age, but commonly have their onset in early adulthood between the ages of 20 and 40 years. Naturalistic data has shown that panic disorder has a chronic and relapsing course. Panic disorder is reported to be associated with an increased risk of suicidal behavior and comorbid psychiatric diagnoses such as depression and substance abuse. Currently, recommended treatment modalities for panic disorder include the use of antidepressant pharmacotherapy and/or cognitive behavioral therapy. Paroxetine is unique among the selective serotonin reuptake inhibitors since, in addition to its effect on the CNS serotonergic neurotransmission, it also has mild noradrenergic properties demonstrated to be effective in the treatment of anxiety disorders and depression. Paroxetine treatment has the potential to cause weight gain and sexual dysfunction, primarily anorgasmia and ejaculatory dysfunction for the long term. In the short-term, treatment causes nausea, gastrointestinal disturbances, irritability, headaches and eating and sleeping difficulties. Paroxetine is an example of an selective serotonin reuptake inhibitor agent, which has been well studied in the treatment of panic disorder and is efficacious and well-tolerated. Paroxetine pharmacotherapy has been recommended to be continued for 1 year as specified in the treatment guidelines set by the American Psychiatric Association in the treatment of panic disorder.

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of 'Habit and Impulse Disorders'. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1-3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.

Response inhibition and sustained and attention in Heavy smokers versus non-smokers

BACKGROUND

Repeated nicotine administration induces neuro-adaptations associated with abnormal dopaminergic activity. These neuronal changes may contribute to impaired inhibitory control and attention deficit. However, it remains unclear whether smokers perform worse than non-smokers on tests that involve attention and control of impulsivity. The present study examined response inhibition and sustained attention capacities in a large sample of smokers and non-smokers.

METHODS

Continuous Performance Test (CPT) and Go/ NoGo computerized tasks were used as a measure of response-inhibition ability and sustained attention. Threeway repeated measures analysis of covariance was used with response time, variability of response time, number of commission errors (inappropriate responses to stimuli) and number of omission errors (missed stimuli) as dependent measures. Main effects were: group (smokers and controls), condition (CPT and Go/NoGo), and block (in each condition); gender, education, and age were used as covariates.

RESULTS AND CONCLUSIONS

Smokers, as compared to the control group, made more errors of commission in the Go/ NoGo task, reflecting impaired inhibition ability. However, we found no significant differences between the groups in our measure of sustained attention. Impaired response inhibition was found to co-occur with heavy smoking and therefore may be a potential target for the development of more effective cessation programs.

Deep transcranial magnetic stimulation for the treatment of pathological gambling

Five pathological gamblers received deep transcranial magnetic stimulation (DTMS). Evaluations included rating scales and collateral anamnesis. Despite initial improvement in ratings, collateral anamnesis demonstrated failure to respond. DTMS to the pre-frontal cortex using an H1 coil was an ineffective treatment. Our study is preliminary, and additional studies are required.

Football gambling three arm-controlled study: gamblers, amateurs and laypersons

BACKGROUND

Football (soccer) betting, as a strategic form of betting, became one of the favorite wagers for pathological gamblers. Previous studies demonstrated the psychological and biological significance of the 'illusion of control' (personal control) and 'near miss' results in gambling. In our study, we explored whether knowledge and expertise of pathological sports gamblers can ensure a successful bet.

SAMPLE AND METHODS

Participants were divided into three groups of individuals - pathological gamblers, amateurs and laypersons - and were asked to predict in advance the general result and the exact result of football matches in the European Champions League Round of 16.

RESULTS

The 165 participants included 53 pathological sports gamblers (52 males and 1 female), 78 laypersons (45 females and 33 males) and 34 amateurs (all males). After a thorough statistical analysis, we found no significant differences between the groups, no matter what kind of previous knowledge they had acquired.

CONCLUSION

This study demonstrates that the 'illusion of control' of pathological gamblers, attained by knowledge of the game and its latest data and information (especially in a strategic gamble as football betting), has no factual background. Moreover, our study demonstrates without a doubt that there is no significant difference between the male pathological sports gamblers group and the male/female laypersons group.

Tricotillomania: pathopsychology theories and treatment possibilities

The phenomenon of hair pulling has been recognized for centuries, yet the true prevalence of trichotillomania (TTM) is largely unknown and the topic has been sparsely studied. TTM is classified as an impulse-control disorder despite much debate about its etiology. In this review we summarize the different hypotheses, including impulse-control disorders, obsessive-compulsive disorders, behavioral problems and addiction, and the appropriate treatment methods. The combination of selective serotonin reuptake inhibitors and antipsychotic medications are shown to be most effective. Treatment with anti-addiction drugs seems relevant. Further research is needed to increase our knowledge regarding the etiology of TTM.

Pathological gambling: a review of phenomenological models and treatment modalities for an underrecognized psychiatric disorder

Pathological gambling (PG) is a prevalent and highly disabling impulse-control disorder. Two dominant phenomenological models for PG have been presented in the literature. According to one model, PG is included as an obsessive-compulsive spectrum disorder, while according to the second model, PG represents a form of nonpharmacologic addiction. In this article, we present an expanded conceptualization of the phenomenology of PG. On the basis of our clinical research experience and a review of data in the field, we propose 3 subtypes of pathological gamblers: the "impulsive" subtype, the "obsessive-compulsive" subtype, and the "addictive" subtype. We also review the current pharmacologic and nonpharmacologic treatment strategies for PG. A further aim of this article is to encourage awareness of the importance of improved screening procedures for the early detection of PG.

Risk-taking decisions in pathological gamblers is not a result of their impaired inhibition ability

This work investigates whether inhibition impairments influence the decision making process in pathological gamblers (PGs). The PG (N=51) subjects performed the Iowa Gambling Task (IGT as the measure of the decision making process) and two tests of inhibition: the Stroop (interference inhibition), and the Go/NoGo (response inhibition), and were compared with demographically matched healthy subjects (N=57). Performance in the IGT block 1 and block 2 did not differ between the groups, but the differences between the PGs and healthy controls began to be significant in block 3, block 4 and block 5. PGs learned the IGT task more slowly than the healthy controls and had non-optimal outcomes (more disadvantageous choices). Impaired IGT performance in PGs was not related to an inhibition ability measured by the Stroop (interference response time) and the Go/NoGo (number of commission errors) parameters. Further controlled studies with neuroimaging techniques may help to clarify the particular brain mechanisms underlying the impaired decision making process in PGs.

Effectiveness of a second deep TMS in depression: a brief report

OBJECTIVES

Deep transcranial magnetic stimulation (DTMS) is an emerging and promising treatment for major depression. In our study, we explored the effectiveness of a second antidepressant course of deep TMS in major depression. We enrolled eight patients who had previously responded well to DTMS but relapsed within 1 year in order to evaluate whether a second course of DTMS would still be effective.

METHODS

Eight depressive patients who relapsed after a previous successful deep TMS course expressed their wish to be treated again. Upon their request, they were recruited and treated with 20 daily sessions of DTMS at 20 Hz using the Brainsway's H1 coil. The Hamilton depression rating scale (HDRS), Hamilton anxiety rating scale (HARS) and the Beck depression inventory (BDI) were used weekly to evaluate the response to treatment.

RESULTS

Similar to the results obtained in the first course of treatment, the second course of treatment (after relapse) induced significant reductions in HDRS, HARS and BDI scores, compared to the ratings measured prior to treatment. The magnitude of response in the second course was smaller relative to that obtained in the first course of treatment.

CONCLUSIONS

Our results suggest that depressive patients who previously responded well to deep TMS treatment are likely to respond again. However, the slight reduction in the magnitude of the response in the second treatment raises the question of whether tolerance or resistance to this treatment may eventually develop.

Acamprosate and Baclofen were Not Effective in the Treatment of Pathological Gambling: Preliminary Blind Rater Comparison Study

OBJECTIVES

Pathological gambling (PG) is a highly prevalent and disabling impulse control disorder. A range of psychopharmacological options are available for the treatment of PG, including selective serotonin reuptake inhibitors, opioid receptor antagonists, anti-addiction drugs, and mood stabilizers. In our preliminary study, we examined the efficacy of two anti-addiction drugs, baclofen and acamprosate, in the treatment of PG.

MATERIALS AND METHODS

Seventeen male gamblers were randomly divided into two groups. Each group received one of the two drugs without being blind to treatment. All patients underwent a comprehensive psychiatric diagnostic evaluation and completed a series of semi-structured interviews. During the 6-months of study, monthly evaluations were carried out to assess improvement and relapses. Relapse was defined as recurrent gambling behavior.

RESULTS

None of the 17 patients reached the 6-months abstinence. One patient receiving baclofen sustained abstinence for 4 months. Fourteen patients succeeded in sustaining abstinence for 1-3 months. Two patients stopped attending monthly evaluations.

CONCLUSION

Baclofen and acamprosate did not prove efficient in treating pathological gamblers.

Deep TMS in a resistant major depressive disorder: a brief report

INTRODUCTION

Repetitive transcranial magnetic stimulation (rTMS) has proven effective. Recently, a greater intracranial penetration coil has been developed. We tested the efficacy of the coil in the treatment of resistant major depression.

METHODS

Our sample included seven patients suffering from major depression who were treated using Brainsway's H1-coil connected to a Magstim rapid 2 stimulator. Deep TMS treatment was given to each patient in five sessions per week over a period of 4 weeks. Patients were treated with 120% intensity of the motor threshold and a frequency of 20 HZ with a total of 1,680 pulses per session.

RESULTS

Five patients completed 20 sessions: one attained remission (Hamilton Depression Rating Scale (HDRS)=9); three patients reached a reduction of more than 50% in their pre-treatment HDRS; and one patient achieved a partial response (i.e., the HDRS score dropped from 21 to 12). Average HDRS score dropped to 12.6 and average Hamilton Anxiety Rating Scale score dropped to 9.Two patients dropped out: one due to insomnia and the second due to a lack of response.

DISCUSSION

Compared to the pooled response and remission rates when treating major depression with rTMS, deep TMS as used in this study is at least similarly effective. Still, a severe limitation of this study is its small sample size, which makes the comparison of the two methods in terms of their effectiveness or side effects impossible. Greater numbers of subjects should be studied to achieve this aim.

CONCLUSIONS

An H1 deep TMS coil could be used as an alternative treatment for major depressive disorder.

Pathological gambling: an impulse control disorder? Measurement of impulsivity using neurocognitive tests

Pathological gambling is classified in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) and in the ICD-10 (International Classification of Disease) as an impulse control disorder. The association between impulsivity and pathological gambling remains a matter of debate: some researchers find high levels of impulsivity within pathological gamblers, others report no difference compared to controls, and yet others even suggest that it is lower. In this review we examine the relationship between pathological gambling and impulsivity assessed by various neurocognitive tests. These tests--the Stroop task, the Stop Signal Task, the Matching Familiar Figures Task, the Iowa Gambling Task, the Wisconsin Card Sorting Test, the Tower of London test, and the Continuous Performance Test--demonstrated less impulsivity in gambling behavior. The differences in performance between pathological gamblers and healthy controls on the neurocognitive tasks could be due to addictive behavior features rather than impulsive behavior.

Speed-accuracy tradeoff in decision-making performance among pathological gamblers

BACKGROUND

Pathological gambling is classified as an impulse control disorder in the DSM-IV-TR; however, few studies have investigated the relationship between gambling behavior and impulsive decision-making in time-non-limited situations.

METHODS

The subjects performed the Matching Familiar Figures Test (MFFT). The MFFT investigated the reflection-impulsivity dimension in pathological gamblers (n = 82) and demographically matched healthy subjects (n = 82).

RESULTS

Our study demonstrated that pathological gamblers had a significantly higher rate of errors than healthy controls (p = 0.01) but were not different in terms of response time (p = 0.49). We found a similar power of correlation between the number of errors and response time in both pathological gamblers and controls. We may conclude that impaired performance of our pathological gamblers as compared to controls in a situation without time limit pressure cannot be explained by a trade-off of greater speed at the cost of less accuracy.

CONCLUSIONS

The results of our study showed that pathological gamblers tend to make more errors but do not exhibit quicker responses as compared to the control group. Diminished MFFT performance in pathological gamblers as compared to controls supports findings of previous studies which show that pathological gamblers have impaired decision-making. Further controlled studies with a larger sample size which examine MFFT performance in pathological gamblers are necessary to confirm our results.

[Depressive disorders in elderly: treatment possibilities rather than pharmacotherapy]

Treatment of depression is one of the most challenging issues in adult populations. In adults, response rates to classic treatments are lower than expected. The effectiveness of different treatment strategies could be related to age, sex and physical conditions of the patients. The side-effect profile in adult population affects pharmacological interventions. The aim of this review is to present the non-pharmacological treatment strategies in the adult population. However, possible treatment strategies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS) were less frequently studied in this population. ECT was found to be the most effective treatment procedure for depression of adults. There were only a few double-blind sham (placebo) controlled studies with demonstrated effectiveness of TMS. DBS lacks double-blind studies of this invasive treatment method. ECT seems to be the gold standard for the treatment of resistant patients in this population but the side-effect profile of ECT in this sensitive population will be discussed. Double-blind sham controlled studies with larger samples are necessary to confirm preliminary results with TMS and DBS.

Go-no-go performance in pathological gamblers

Previous neuropsychological studies demonstrated various deficits of impulse control in pathological gamblers (PGs). However, there are limited data available on response-inhibition impairment among PGs. The present study attempted to assess response inhibition in untreated PGs (N=83), in comparison with normal subjects (N=84). Go/no-go and target-detection conditions of a computerized task were used as a measure of response-inhibition ability. A repeated measures analysis of covariance (ANCOVA-RM) was used with response time, variability of response time, and number of false alarms and misses as dependent measures; group (PG and controls) as the between-subjects measure; condition (target detection or go/no-go) and time slice (first and second in each condition) as repeated measures within-subject factors; and educational level as a covariate. Our results showed that PGs were significantly more impaired in both target detection and go/no-go task performance than controls. The PGs had significantly more false alarms and misses than controls, and they were slower and less consistent in their responses.

Pathological gambling: an update on neuropathophysiology and pharmacotherapy

Neurobiological research has shown the potential involvement of serotonergic, dopaminergic and opioid dysfunction in the pathophysiology of pathological gambling. In this review, we present current theories of the neuropathology of pathological gambling, paying particular attention to the role of the neural circuitry underlying motivation, reward, decision-making and impulsivity. This review also presents a literature review of current pharmacological treatment strategies for pathological gambling, such as selective serotonin reuptake inhibitors (SSRIs), opioid receptor antagonists, anti-addiction drugs and mood stabilizers, and also discusses the role of nonpharmacological interventions.A hypothetical model of the clinical subtypes of pathological gambling is presented, e.g. the impulsive subtype, the obsessive-compulsive subtype and the addictive subtype. This model attempts to integrate current knowledge in the field of pathological gambling regarding neuropathology, psychiatric co-morbidity, family history, genetics, course of illness, gender and response to pharmacological treatment. Finally, it is proposed that the existence of possible clinical subtypes of pathological gambling may provide a potential framework for matching the various subtypes with specific pharmacotherapies.

Prevalence of self-reported specific phobia symptoms in an Israeli sample of young conscripts

Specific phobia is a very prevalent disorder with high comorbidity rates. The aim of this study was to assess prevalence of specific phobia symptoms in a sample of Israeli young adults. Eight hundred fifty young Israeli soldiers participated in the study. Measures included a questionnaire on specific phobias and a socio-demographic questionnaire. Data on eight specific fears representing DSM-IV-TR specific phobias were analyzed to evaluate prevalence of phobic symptoms and find potential socio-demographic correlates. Prevalence of fears and specific phobic symptoms was 49.1 and 8.7%, respectively. Most frequent phobic symptoms were from animals, being alone, heights, injury and closed places. The following variables were accompanied by more phobic symptoms: male gender, role of mechanic, not having completed the matriculation exams, lack of friends and romantic relationships, therapy prior to enlistment or during the military service and having received psychotropic drugs in the past. Based on a stepwise regression analysis, the following variables contributed significantly to the prediction of phobic symptoms: lack of friends and romantic relationships, school absenteeism and role of mechanic. Our findings corroborate results from other studies in the Western world regarding the high prevalence of specific phobia symptomatology, as well as its distribution and socio-demographic correlates.

Dual psychiatric diagnosis and substance abuse in pathological gamblers: a preliminary gender comparison study

BACKGROUND

Pathological Gambling (PG) is a highly prevalent and disabling impulse control disorder. Recent studies have consistently shown that PG patients have responded well to treatment with SSRI's, mood stabilizers, and opioid antagonists. These findings have supported the observation that PG is strongly associated with both mood and anxiety disorders as well as substance abuse. The aim of the study is to evaluate the comorbid psychiatric diagnoses in our sample.

METHODS

Thirty-six female, and forty-two male PG's were enrolled in our study. A comprehensive psychiatric diagnostic evaluation was performed on all patients, and patients were screened for symptoms of depression and anxiety using the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Yale-Brown Obsessive Compulsive Scale, and the Frost Multidimensional Perfectionism Scale. In addition, the patients completed self-report questionnaires about their demographic status and substance abuse.

RESULTS

The majority of patients were married with full or part-time employment. The study results demonstrated that PG in males is correlated with substance and alcohol abuse. Diagnoses, which were prevalent among our cohort of female PG's included major depression, affective disorders, anxiety disorders, and eating disorders.

CONCLUSION

In our sample of PGs, the men and women had different patterns of psychiatric comorbidity. The different patterns of psychiatric comorbidity seen in our male versus female PG's raises the question of whether the underlying etiopathology in PG may differ according to gender.

Stroop performance in pathological gamblers

Pathological gambling is a relatively prevalent psychiatric disorder that typically leads to severe family, social, legal, and occupational problems and is associated with a high rate of suicide attempts. Understanding the neurobiological basis of pathological gambling is a current focus of research, and emerging data have demonstrated that pathological gamblers may have impaired decision-making because of an inability to inhibit irrelevant information. In this study, we examined pathological gamblers by using the Stroop Color-Word Test, a neurocognitive task used to assess interference control. The "reverse" variant of the Stroop Color-Word Test was administered to a cohort of medication-free pathological gamblers (n=62) and a cohort of age-matched controls (n=83). In the reverse variant of the Stroop task, subjects are asked to read the meaning of the word rather than name the ink color. The reverse Stroop task was chosen because it highly discriminates ability to inhibit interference in a population of psychiatric patients. In our study, performance on the reverse Stroop task in the pathological gamblers was significantly slower and less accurate than in the healthy subjects. A new finding in our study was that for pathological gamblers, the average reaction time in the neutral condition (where the color names are displayed in black letters) was slower than the average reaction time in the incongruent condition (where the meaning of the color name and the color of the printed letters are different). This controlled study extends previous findings by showing that performance on the Stroop task is impaired in a sample of medication-free pathological gamblers.

Recurrence of Panic Disorder During Pregnancy

OBJECTIVES

The aim of this naturalistic follow-up study was to examine the effect of pregnancy as a predicting factor of relapse in patients with panic disorder (PD).

METHODS

Eighty-five female patients with PD (between the ages of 20 and 35 years) were included in this study. They were divided into 2 groups based on whether the onset of PD had been during pregnancy (PD-pregnancy [PD-P]) or whether the onset of PD had been while not pregnant (PD-nonpregnant [PD-NP]). Patients were treated with paroxetine up to 40 mg/day for 12 months, and the full responders were tapered off their medication and were monitored for an additional 6 years. Treatment response was assessed using the Panic Self-Questionnaire (PSQ) with full response being defined as "0" panic attacks. Assessments using the PSQ were made at baseline and every 4 weeks for the first twelve months. During the 6-year drug-free follow-up period, patients were assessed using the PSQ every 3 months. Relapse was defined as the occurrence of a panic attack in any phase of the study. The effect of group membership (PD-P vs. PD-NP) and new pregnancies as risk factors for relapse were explored.

RESULTS

Sixty-eight patients completed the 6-year follow-up, and each of the study groups (PD-P and PD-NP) was composed of 34 patients. Twenty-six of 34 (76.6%) patients in the PD-P group had another pregnancy, and 15/26 (57%) in this group experienced a relapse during the subsequent pregnancy. Three of 8 (37%) PD-P patients experienced a relapse without pregnancy. Among the second group (PD-NP), 18/34 (52.9%) became pregnant and 8/18 (44.4%) experienced a relapse at the time of pregnancy, whereas 4/16 (25%) experienced a relapse while not pregnant. Patients who relapsed during pregnancy had a more severe relapse (as defined by the severity of the PSQ score) compared with nonpregnant relapsers.

CONCLUSIONS

Our naturalistic follow-up study demonstrated that pregnancy might confer an increased risk of relapse in PD. Moreover, when compared with patients who develop PD while not pregnant (PD-NP), patients who develop PD during pregnancy (PD-P) appear to have a higher risk of relapse at the time of a subsequent pregnancy (P < 0.001).

Current and emerging somatic treatment strategies in psychotic major depression

Psychotic major depressive disorder (MDD) is a mood disorder characterized by severe affective and neurovegetative symptoms together with the presence of delusions and/or hallucinations. It is a common disorder seen in a quarter of consecutively admitted depressed patients and is often associated with severe symptomatology, increased suicide risk, poor acute response to antidepressants and poor acute and long-term treatment outcome. It is possible that poor response in psychotic depression is caused by the fact that we have yet to identify the most efficacious treatment protocol for psychotic MDD. Multiple studies have shown that modifications in the treatment paradigm may increase treatment efficacy in psychotic MDD. It has been generally accepted that, during the acute treatment phase, antidepressant-antipsychotic drug combination therapy is more effective than either treatment alone, although this strategy has recently been challenged. The question of the optimal duration of pharmacotherapy in order to prevent relapse and improve long-term (i.e., 5-year) outcome is a focus of current investigation. This article will review currently recommended treatment strategies for the acute, continuation and maintenance phases of therapy. In particular, it will address the role of newer-generation antidepressants, the role of second-generation antipsychotics, the use of mood stabilizers and indications for electroconvulsive therapy. Other possible treatment strategies such as transcranial magnetic stimulation, vagus nerve stimulation, deep-brain stimulation and glucocorticoid receptor antagonists will be discussed. Current recommendations for the prevention of relapse and improvement of long-term outcome will be reviewed.

Pathological gambling: comorbid psychiatric diagnoses in patients and their families

OBJECTIVES

Pathological gambling is a highly prevalent and disabling impulse control disorder. Recent studies have consistently demonstrated that pathological gamblers respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings have supported the observation that pathological gambling is associated with anxiety and mood spectrum disorders as well as addictive disorders.

METHODS

Fifty-two male pathological gamblers and their first-degree relatives (n=93) completed a semi-structured DSM-IV-based diagnostic interview as well as a series of data collection instruments including the South Oaks Gambling Scale, the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for Anxiety, the Yale-Brown Obsessive-Compulsive Scale, and the Young Mania Rating Scale. The study subjects and their first-degree relative were compared to demographically matched normal controls (n=96).

RESULTS

We found higher prevalence of alcohol, substance abuse, problematic gambling, depression, and anxiety disorders in the pathological gamblers and their first-degree relatives than in the control group. In particular, the scores on the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for Anxiety, and the Yale-Brown Obsessive-Compulsive Scale were higher in the study group than in the control group.

CONCLUSIONS

Our finding of a high prevalence of psychiatric comorbidity in pathological gamblers and their families raises the question of the proper classification of pathological gambling in the DSM-IV. Furthermore, the pattern of psychiatric disorders seen in the first-degree relatives can lead to new insights about the etiopathology of pathological gambling.

Sustained-release bupropion versus naltrexone in the treatment of pathological gambling: a preliminary blind-rater study

BACKGROUND

Pathological gambling (PG) is a relatively common and highly disabling impulse control disorder. A range of psychotherapeutic agents, including selective serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists, has been shown to be effective in the treatment of PG. The use of selective serotonin reuptake inhibitors and opioid antagonists for PG is consistent with the observation that PG shares features of both the obsessive-compulsive spectrum disorders and addictive disorders. The aim of the study is to compare the effectiveness of sustained-release bupropion versus naltrexone in the treatment of PG.

METHODS

Thirty-six male pathological gamblers were enrolled in our study. A comprehensive psychiatric diagnostic evaluation was performed at baseline on all patients, and patients were screened for symptoms of gambling, depression, and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Clinical Global Impression-Severity Scale. In addition, the patients completed self-report questionnaires about their demographic status. Patients were randomized in 2 groups and received either naltrexone (n = 19) or sustained-release bupropion (n = 17) for 12 weeks in a parallel fashion. Treatment response was monitored using the Clinical Global Impression-Improvement Scale which was performed at weeks 2, 4, 8, and 12. Patients were also assessed for the presence of gambling behavior via an unstructured interview, which was also performed at weeks 2, 4, 6, 8, and 12. Raters were blind to the study treatment.

RESULTS

The majority of patients responded well to the drug treatment. Twelve of 17 patients in the sustained-release bupropion group completed the 12-week study, and 13 of 19 naltrexone patients completed the study. Nine (75%) of the 12 completers were rated as full responders in the sustained-release bupropion group versus 10 (76%) of 12 in the naltrexone group. Three (25%) of 12 completers in the bupropion group were rated as partial responders. In the naltrexone group, 3 (23%) of 13 completers were rated as partial responders. Full response was defined as the absence of gambling for a 2-week duration together with improvement on the Clinical Global Impression-Improvement Scale. Partial response was defined as a decrease in the frequency of gambling behavior and a decrease in the amount of money spent on gambling.

CONCLUSION

This preliminary study shows that sustained-release bupropion may be effective as naltrexone in the treatment of PG. Further studies are needed to confirm our findings.

Topiramate Versus Fluvoxamine in the Treatment of Pathological Gambling

Pathologic gambling (PG) is a highly prevalent and disabling impulse control disorder. Recent studies have demonstrated that PG patients respond well to treatment with SSRIs, mood stabilizers, and opioid antagonists. These findings support the idea that PG and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders. Pilot studies have shown topiramate to be effective in the treatment of specific disorders of impulse control. The aim of the study is to compare the effectiveness of topiramate versus fluvoxamine in the treatment of PG. Thirty-one male PGs were assigned in a randomized fashion to receive either topiramate (15/31) or fluvoxamine (16/31) pharmacotherapy for 12 weeks. A comprehensive psychiatric diagnostic evaluation was performed on all patients, and all patients were evaluated for symptoms of gambling, depression, and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Yale-Brown Obsessive Compulsive Symptoms Scale, and the Clinical Global Impression-Improvement Scale. The rating scales were administered at baseline and at the 12-week endpoint. In addition, the patients completed self-report questionnaires about their demographic status. Twelve of the 15 patients from the topiramate group completed the 12-week treatment. Nine of the 12 topiramate completers reported full remission of gambling behavior, and 3 completers had a partial remission. The CGI-improvement score was significantly better for the topiramate group at the 12-week visit as compared with baseline (F = 10.5, P < 0.01, df = 2.31). In the fluvoxamine treatment group 8/16 patients completed the study, and 6/8 fluvoxamine completers reported a full remission, and the remaining 2/8 fluvoxamine completers reported a partial remission. The fluvoxamine group showed improvement in the CGI-improvement score at week 12, although this difference was not significant (F = 3.7, P < 0.08, df = 2.31). Topiramate and fluvoxamine monotherapy may be effective in the treatment of pathologic gambling.

Kleptomania After Head Trauma

The purpose of this paper is to add to the growing number of reports about kleptomania occurring in relation to brain injury as well as to present the authors' findings regarding treatment strategies. The authors present two case reports of patients who developed the new onset of kleptomania after closed head trauma. Both patients had comorbid psychiatric symptoms associated with the kleptomania. Antidepressant monotherapy was not beneficial in reducing kleptomania in either patient. Kleptomanic behavior was successfully treated in both patients, however, through combination treatment using an antidepressant agent together with adjunctive cognitive behavioral therapy or adjunctive naltrexone. In one patient, single photon emission tomography showed a perfusion deficit in the left temporal lobe. Various hypotheses regarding this finding and the etiopathology of kleptomania are discussed. Review of current work in the field suggests that kleptomania is a heterogeneous disorder that shares features of both impulse and addiction disorders as well as affective spectrum disorders.

Three year naturalistic outcome study of panic disorder patients treated with paroxetine

BACKGROUND

This naturalistic open label follow-up study had three objectives: 1) To observe the course of illness in Panic Disorder patients receiving long-term versus intermediate-term paroxetine treatment, 2) To compare the relapse rates and side-effect profile after long-term paroxetine treatment between patients with Panic Disorder and Panic Disorder with Agoraphobia, 3) To observe paroxetine's tolerability over a 24 month period.

METHODS

143 patients with panic disorder (PD), with or without agoraphobia, successfully finished a short-term (ie 12 week) trial of paroxetine treatment. All patients then continued to receive paroxetine maintenance therapy for a total of 12 months. At the end of this period, 72 of the patients chose to discontinue paroxetine pharmacotherapy and agreed to be monitored throughout a one year discontinuation follow-up phase. The remaining 71 patients continued on paroxetine for an additional 12 months and then were monitored, as in the first group, for another year while medication-free. The primary limitation of our study is that the subgroups of patients receiving 12 versus 24 months of maintenance paroxetine therapy were selected according to individual patient preference and therefore were not assigned in a randomized manner.

RESULTS

Only 21 of 143 patients (14%) relapsed during the one year medication discontinuation follow-up phase. There were no significant differences in relapse rates between the patients who received intermediate-term (up to 12 months) paroxetine and those who chose the long-term course (24 month paroxetine treatment). 43 patients (30.1%) reported sexual dysfunction. The patients exhibited an average weight gain of 5.06 kg. All patients who eventually relapsed demonstrated significantly greater weight increase (7.3 kg) during the treatment phase.

CONCLUSIONS

The extension of paroxetine maintenance treatment from 12 to 24 months did not seem to further decrease the risk of relapse after medication discontinuation. Twenty-four month paroxetine treatment is accompanied by sexual side effects and weight gain similar to those observed in twelve month treatment.

Comorbid cannabis use and panic disorder: short term and long term follow-up study

OBJECTIVES

The aim of the study was to compare the treatment of panic disorder in patients with or without cannabis use according to response, relapse and side effects.

MATERIALS AND METHODS

66 panic disorder (PD) patients were included in our study. All the subjects met the DSM-IV diagnosis of panic disorder (n=45) or panic disorder with agoraphobia (n=21). Twenty four patients experienced their first panic attack within 48 h of cannabis use and then went on to develop PD. All the patients received pharmacologic treatment with paroxetine (gradually increased up to 40 mg/d). A masked rater that was blind to the group allocation, assessed patients in order to rate anxiety symptoms and medication side effects. Relapse was defined as the occurrence of a single panic attack after remission of panic symptoms. The instruments were administered at baseline and also at the 4, 8 and 12 weeks visits and at the 1 year visit.

RESULTS

The two groups responded equally well to paroxetine treatment as measured at the 8 weeks and 12 months follow-up visits. There were no significant effects of age, sex and duration of illness as covariates with response rates between the two groups. Also PD or PDA diagnosis did not affect the treatment response in either group. There were no significant differences in weight gain, sexual side effects or relapse rates between patients according to gender or comorbid diagnosis.

SUMMARY

Acute cannabis use can be associated with the onset of panic attacks and panic disorder, and panic disorder which develops after cannabis use is responsive to pharmacotherapy.

Kleptomania: comorbid psychiatric diagnosis in patients and their families

OBJECTIVES

Kleptomania, defined by DSM-IV as the inability to resist the impulse to steal objects which are not needed for personal use or for their monetary value, may reflect a form of obsessive-compulsive spectrum disorder and/or affective spectrum disorder.

METHODS

Twenty-one kleptomanic patients and 57 first-degree relatives completed a semistructured DSM-IV-based interview and questionnaires. Questionnaires are: the HDRS-17 (the Hamilton Rating Scale for Depression), the HARS (Hamilton Rating Scale for Anxiety), the Y-BOCS (Yale-Brown Obsessive Compulsive Scale), the YMRS (Young Mania Rating Scale). The two groups were compared to demographically matched normal controls (n = 64).

RESULTS

We found a high prevalence of affective and anxiety disorders in our sample of kleptomanic patients and their first-degree relatives. In addition, the scores on the HDRS, HARS, and Y-BOCS were significantly higher in the study group than in the control group.

CONCLUSIONS

Our finding of a high prevalence of psychiatric comorbidity in kleptomanic patients could lead to the development of new treatment strategies for this disorder. Furthermore, the pattern of psychiatric disorders seen in the first-degree relatives can lead to new insights about the nosology and etiopathology of kleptomania.

Cognitive behavioral group therapy in panic disorder patients: the efficacy of CBGT versus drug treatment

The aim of our study was to evaluate the effectiveness of Cognitive Behavioral Group Therapy (CBGT) in the treatment of Panic Disorder (PD) and to compare the treatment outcome of CBGT versus Paroxetine pharmacotherapy. Fifty seven patients referred to our anxiety disorder clinic for the treatment of PD were randomly allocated to receive either CBGT or Paroxetine. Follow up was done by a masked rater after four and twelve weeks of treatment in order to compare the efficacy of CBGT versus Paroxetine. CBGT and Paroxetine were both effective in the short-term treatment of PD. Assessments at weeks four and twelve of treatment showed no statistically significant differences between the two groups in terms of treatment outcome. Treatment with CBGT alone for the acute phase of PD appears to be equally efficacious to treatment with Paroxetine alone. Our study shows that CBGT produced beneficial results, for it was associated with a reduction in the number and frequency of panic attacks and with an improved feeling of well-being.

Motor-evoked potential amplitudes elicited by transcranial magnetic stimulation do not differentiate between patients and normal controls

Transcranial magnetic stimulation (TMS) applied over the motor cortex depolarizes neurons and leads to motor-evoked potentials (MEP). To assess cortico-spinal excitability we compared the motor threshold (MT) and the averaged MEP amplitude generated by TMS in patients with major depression (MD) and matched controls. Nineteen patients, who where participants in a protocol comparing the antidepressant effects of rTMS with those of ECT, and thirteen age- and gender-matched normal controls were studied. MT was similar between patients and normal controls. The MEP amplitude response was significantly increased by rTMS, however, the magnitude of the response was similar in patients and normal controls. Correlations between the averaged MEP amplitude and age revealed that older subjects demonstrated significantly lower responses at all time-points. We conclude that cortico-spinal excitability is increased following rTMS, however, differences between patients and normal controls were not apparent with the paradigm used.

Repetitive transcranial magnetic stimulation is effective following repeated courses in the treatment of major depressive disorder--a case report

Repetitive transcranial magnetic stimulation (rTMS) is a relatively new treatment modality for psychiatric patients. rTMS was demonstrated to be effective in the treatment of depression. However, longitudinal outcome studies have not yet been published. Relapse rates are higher in depressed patients and most of them do not respond to the same treatment with similar success. In this report we present a patient, who experienced relapse with the various conventional drug treatments, but responded well to rTMS at three different points in time.

Transcranial magnetic stimulation in the treatment of depression

OBJECTIVE

Transcranial magnetic stimulation (TMS) is a noninvasive and easily tolerated method of altering cortical physiology. The authors evaluate evidence from the last decade supporting a possible role for TMS in the treatment of depression and explore clinical and technical considerations that might bear on treatment success.

METHOD

The authors review English-language controlled studies of nonconvulsive TMS therapy for depression that appeared in the MEDLINE database through early 2002, as well as one study that was in press in 2002 and was published in 2003. In addition, the authors discuss studies that have examined technical, methodological, and clinical treatment parameters of TMS.

RESULTS

Most data support an antidepressant effect of high-frequency repetitive TMS administered to the left prefrontal cortex. The absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. Technical parameters possibly affecting treatment success include intensity and duration of treatment, but these suggestions require systematic testing.

CONCLUSIONS

TMS shows promise as a novel antidepressant treatment. Systematic and large-scale studies are needed to identify patient populations most likely to benefit and treatment parameters most likely to produce success. In addition to its potential clinical role, TMS promises to provide insights into the pathophysiology of depression through research designs in which the ability of TMS to alter brain activity is coupled with functional neuroimaging.

A randomized controlled comparison of electroconvulsive therapy and repetitive transcranial magnetic stimulation in severe and resistant nonpsychotic major depression

BACKGROUND

Studies published over the past few years suggest that transcranial magnetic stimulation (TMS) may have significant antidepressant actions. In a previous report, we compared electroconvulsive therapy (ECT) and repetitive TMS (rTMS) and found ECT to be superior for psychotic major depression (MD); however, ECT and rTMS had similar results in nonpsychotic MD. We now report on a controlled randomized comparison of ECT and rTMS in patients with nonpsychotic MD.

METHODS

Forty patients with nonpsychotic MD referred for ECT were included. Electroconvulsive therapy was performed according to established protocols. Repetitive TMS was performed over the left dorsolateral prefrontal cortex at 90% motor threshold. Patients were treated with 20 sessions (five times per week for 4 weeks) of 10-Hz treatments (1200 pulses per treatment-day) at 90% motor threshold. Response to treatment was defined as a decrease of at least 50% in the Hamilton Rating Scale for Depression (HRSD) score, with a final HRSD equal or less than 10 points and a final Global Assessment of Function Scale rating of 60 or more points.

RESULTS

The overall response rate was 58% (23 out of 40 patients responded to treatment). In the ECT group, 12 responded and eight did not; in the rTMS group, 11 responded and nine did not (chi2 =.10, ns). Thus, patients responded as well to either ECT or rTMS.

CONCLUSIONS

This study adds to the growing literature supporting an antidepressant effect for rTMS. This study is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder.

Topiramate for the treatment of kleptomania: a case series and review of the literature

Kleptomania--the inability to resist the impulse to steal objects, not for personal use or monetary gain--is currently classified in psychiatric nomenclature as an impulse control disorder. There is no standard pharmacologic therapy for this disorder. If kleptomania was considered a form of obsessive-compulsive disorder, treatments used for this spectrum, including serotonin reuptake inhibitors (SSRI), other antidepressants, opioid receptor antagonist medications, and mood stabilizers, could be logically tested. Topiramate is currently used for the treatment of patients with affective and compulsive eating disorders. This report documents three kleptomanic patients who responded well to topiramate given either alone or in combination with SSRIs.

Psychoeducation in panic disorder patients: effect of a self-information booklet in a randomized, masked-rater study

The aim of our study was to evaluate the effectiveness of a self-information booklet (SIB) in decreasing anxiety and panic attacks in Panic Disorder (PD) patients. Eighty-four patients attending an outpatient clinic due to panic disorder were randomly chosen to receive paroxetine with/without a friendly-designed brochure. Follow-up was done by a masked rater after 1, 3,and 12 weeks in order to evaluate whether the co-administration of paroxetine and the brochure (Group A) had a beneficial effect over the administration of paroxetine alone (Group B). After 3 weeks of therapy, Group A patients had significantly greater improvement and lower scores on the Hamilton Anxiety Scale, the Panic Self Questionnaire, and the Visual Analog Scale. After 12 weeks, the differential improvement was not statistically significant and both groups had improved as compared to baseline. The administration of a psychoeducational brochure (SIB) to PD patients at the initiation of therapy had beneficial effects during the first weeks of treatment. Although this effect fades away, the role of the SIB is overstressed in its ability to increase well being and compliance, and reduce anxiety and panic attacks.

Right prefrontal rTMS treatment for refractory auditory command hallucinations - a neuroSPECT assisted case study

Auditory command hallucinations probably arise from the patient's failure to monitor his/her own 'inner speech', which is connected to activation of speech perception areas of the left cerebral cortex and to various degrees of dysfunction of cortical circuits involved in schizophrenia as supported by functional brain imaging. We hypothesized that rapid transcranial magnetic stimulation (rTMS), by increasing cortical activation of the right prefrontal brain region, would bring about a reduction of the hallucinations. We report our first schizophrenic patient affected with refractory command hallucinations treated with 10 Hz rTMS. Treatment was performed over the right dorsolateral prefrontal cortex, with 1200 magnetic stimulations administered daily for 20 days at 90% motor threshold. Regional cerebral blood flow changes were monitored with neuroSPECT. Clinical evaluation and scores on the Positive and Negative Symptoms Scale and the Brief Psychiatric Rating Scale demonstrated a global improvement in the patient's condition, with no change in the intensity and frequency of the hallucinations. NeuroSPECT performed at intervals during and after treatment indicated a general improvement in cerebral perfusion. We conclude that right prefrontal rTMS may induce a general clinical improvement of schizophrenic brain function, without directly influencing the mechanism involved in auditory command hallucinations.

The efficacy of reboxetine in the treatment-refractory patients with panic disorder: an open label study

BACKGROUND AND OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) are currently the first-line treatment for panic disorder, although up to 30% of patients either do not respond to SSRIs or withdraw due to adverse events. Reboxetine, a selective norepinephrine reuptake inhibitor (selective NRI), is effective in treating depression and may alleviate depression-related anxiety. This study aimed to investigate the efficacy of reboxetine in the treatment of patients with panic disorder who did not respond to SSRIs.

METHOD

In this 6-week, open-label study, 29 adult outpatients with panic disorder who had previously failed to respond to SSRI treatment received reboxetine 2 mg/day, titrated to a maximum of 8 mg/day over the first 10 days. Efficacy was assessed using the Panic Self-Questionnaire (PSQ), the Hamilton Rating Scale for Anxiety (HAM-A), the 17-item Hamilton Rating Scale for Depression (HRSD) and the Global Assessment of Functioning (GAF) Scale.

RESULTS

The 24 patients who completed the study responded well to reboxetine treatment. Significant improvement (p < 0.001) was observed in the number of daily panic attacks, and on the scales measuring anxiety, depression and functioning. Reboxetine was generally well tolerated. Five patients withdrew due to adverse events.

CONCLUSIONS

Reboxetine appears to be effective in the treatment of SSRI-refractory panic disorder patients and warrants further clinical investigation.

Monitoring the response to rTMS in depression with visual analog scales

Visual analog scales (VAS) administered on a daily basis provide a fast and reliable method for assessing clinical change during transcranial magnetic stimulation (TMS). We treated 40 patients with major depression with TMS and assessed their clinical condition with VAS. Response to TMS was defined with the Hamilton rating scale for depression and the Global assessment of function scale. Nineteen patients of 40 were responders to TMS (when the whole sample was considered) whereas 17 of 29 responded when only the non-psychotic patients were considered. Patients who eventually responded to TMS demonstrated early changes in the VAS scores. We conclude that monitoring with VAS scores can detect early response to TMS.