Phytophagy by the Mullein Bug (Hemiptera: Miridae) on Apples: Feeding Behavior and Fruit Damage

The zoophytophagous mullein bug, Campylomma verbasci (Meyer-Dür) (Hemiptera: Miridae), is a beneficial predator of mites and aphids, but also a pest causing damage when it feeds on apples. The aim of this study was to evaluate three different parameters of phytophagy of the mullein bug both in laboratory (phytophagous behavior) and field (fruit damage) tests: 1) apple cultivar, 2) fruit size, and 3) nymphal instar. In the laboratory, nymphs were observed individually for 15 min in Petri dishes containing agar gel and an apple fruitlet to evaluate feeding punctures of four apple cultivars, four fruit sizes, and five nymphal instars. In the orchard, nymphs were caged at bloom in sleeve cages to evaluate damage on the developing fruit of seven apple cultivars and three nymphal instars on 'Red Delicious'. The feeding punctures in the laboratory were higher on 'Red Delicious' than on 'Honeycrisp'; fruit damage in the orchard did not differ among cultivars at mid-season, but was higher on 'Red Delicious' than on 'Lobo' and 'Marshall McIntosh' at harvest. The number of feeding punctures in the laboratory was higher on 7-9 mm than on 18-20 mm size fruit for 'Red Delicious', but not for 'Honeycrisp'. The number of feeding punctures in the laboratory made by the fifth nymphal instar was higher than those made by younger nymphs, but fruit damage in the orchard did not differ among nymphal instars. Our results will help to elaborate a management chart for this insect by minimizing risks and promoting its use for biocontrol.

RÉSUMÉ

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La punaise de la molène, Campylomma verbasci (Meyer-Dür) (Hemiptera: Miridae), est un prédateur bénéfique zoophytophage des acariens et pucerons dans les vergers, mais également un ravageur causant des dommages lorsqu'il se nourrit sur les pommes. Le but de cette étude était d'évaluer trois paramètres différents sur la phytophagie de la punaise de la molène, à la fois en laboratoire (comportement phytophage) et sur le terrain (dommages aux fruits) : 1) les cultivars de pommes, 2) la taille des fruits, et 3) les stades larvaires. En laboratoire, les larves étaient observées individuellement pendant 15 min dans des boites de Petri contenant un gel d'agar et une jeune pomme afin de déterminer les piqûres de nutrition sur quatre cultivars de pommes, quatre tailles de fruit et cinq stades larvaires différents. En verger, des larves ont été encagées à la floraison dans des manchons en mousseline afin d'évaluer les dommages sur les fruits en développement. Les essais ont été effectués sur sept cultivars de pommes ainsi qu'avec trois stades larvaires sur le cultivar "Délicieuse rouge". Les piqûres de nutrition en laboratoire étaient plus nombreuses sur "Délicieuse rouge" que sur "Honeycrisp"; les dommages aux fruits en verger ne différaient pas entre les cultivars à mi-saison, mais étaient plus nombreux sur "Délicieuse rouge" que sur "Lobo" et "Marshall McIntosh" à la récolte. Les piqûres de nutrition en laboratoire étaient plus nombreuses pour la taille de fruit 7-9 mm que 18-20 mm sur "Délicieuse rouge", mais pas sur "Honeycrisp". Le nombre de piqûres de nutrition (en laboratoire) faites par les larves de stade 5 étaient plus nombreuses que celles faites par les larves plus jeunes, mais les dommages aux fruits (en verger) ne différaient pas entre les stades larvaires. Ces résultats vont aider à élaborer une charte de gestion de cet insecte en minimisant les risques et en favorisant son rôle d'agent de lutte biologique.

[In process]

Benzodiazepine hypnotics bear a higher risk of high dose dependence than benzodiazepine anxiolytics, according to a recent study in Luxemburg. This article summarizes the main indications of these molecules and the current treatment recommendations. It provides an overview of public health actions of the past and the future to reduce their excessive consumption.

[Iatrogenic psychiatric-like symptoms recognition]

INTRODUCTION

This article proposes a review of atypical multicentre studies for drug-induced movement disorders (and related psychiatric symptoms) and supersensitivity psychosis. A well-conducted antipsychotic treatment consists of regular attempts to reduce the dose by finding the minimal therapeutic dose. To achieve optimal antipsychotic treatment, it is important to distinguish psychiatric symptoms associated with drug-induced movement disorder(s) (DIMD) or supersensitivity psychosis from true relapse.

LITERATURE FINDINGS

Persistent DIMD have been found to be a predictor of supersensitivity psychosis or tardive dyskinesia (DT). DIMD-associated psychiatric symptoms can be classified into three types: directly induced by DIMD; resulting from confounding DIMD with psychiatric symptoms; and supersensitivity symptoms associated with DIMD. Without this distinction, the beneficial effects of antipsychotics are masked by emergent DIMD psychiatric symptoms (as was confounded in the CATIE study).

DISCUSSION

A constant decline in the prevalence of TD (hyperkinetic, involuntary and purposeless movement disorder) has been observed since the introduction of atypical antipsychotics. The neurotoxic effects of classical antipsychotics are well documented and their discontinuation is required. However, the risk of TD still exits with atypical antipsychotics and continued surveillance of emerging cases is very important for clinicians. Moreover, a regular evaluation of DIMD and associated psychiatric symptoms is crucial. It is important to underline the fact that DIMD persists with antipsychotics, with significantly higher total PANSS scores than in patients without DIMD.

CONCLUSION

Supersensitivity psychosis is a drug-induced psychotic relapse (6 weeks following the decrease or withdrawal of an antipsychotic). Discontinuation syndromes can produce psychiatric symptoms (and be confounded with true relapse), but can be improved more quickly after reintroduction of treatment. Interestingly, various data suggest that lower doses of antipsychotics could prevent such symptoms. Anticonvulsants can be efficient adjuvants in the treatment of psychosis. In the United States, many patients received valproate or gabapentin treatment. These adjuvants, by antikindling effect, can facilitate minimal maintenance drug treatment and be efficient for anxiety. Resistant schizophrenia can be related to supersensitivity psychosis; gabapentin and lamotrigine are effective in this case.

Dysphoric mania induced by high-dose mirtazapine: a case for 'norepinephrine syndrome'?

The antidepressant mirtazapine antagonizes central presynaptic alpha2-adrenergic auto- and heteroreceptors resulting in increased central norepinephrine and serotonin activity. Histamine H2 receptors are also antagonized, as are postsynaptic serotonin 5-HT2 and 5-HT3 receptors, leading to serotonergic activity primarily via 5-HT1A receptors. Based on the case report of a patient who developed mania with higher than recommended dosage of mirtazapine, we review the literature on the atypical nature of manic symptoms with mirtazapine. Eight subjects, including those in our study, were identified as having developed mirtazapine-induced mania with atypical features, consisting of dysphoria, irritability, insomnia, psychomotor agitation and abnormal gait. Predisposing features may have included the presence of underlying brain dysfunction and certain selective serotonin reuptake inhibitor-mirtazapine combinations. Dysphoric mania with atypical features may be induced by mirtazapine, providing support for a common hypothesis such as 'central norepinephrine hyperactivity' as the basis for development of mania with mirtazapine.

Baseline toxicity of several pesticides to Hyaliodes vitripennis (Say) (Hemiptera: Miridae)

Hyaliodes vitripennis (Say) is a univoltine indigenous predacious mirid. It has been reported in several orchards where IPM programmes are used. It is a generalist, and feeds on phytophagous mites in addition to other arthropods. In Quebec, a foliar application of imidacloprid, deltamethrin or lambda-cyhalothrin is used at least once per season to manage arthropod pests such as leafhoppers and leaf-eating caterpillars. Meanwhile, several applications of metiram, flusilazole, myclobutanil and mancozeb are made to control apple scab [Venturia inaequalis (Cooke) Winter]. In laboratory trials, comparison of lethal concentrations of the three insecticides against H vitripennis nymphs and adults showed no significant difference. However, when lethal concentrations were compared between two growth stages for each insecticide, a significant difference was noted between adults and nymphs treated with lambda-cyhalothrin, adults being more susceptible than nymphs. No such difference could be detected for imidacloprid or deltamethrin. When LC50 values were compared with the manufacturer's label rates, deltamethrin and imidacloprid were toxic to the nymphs and adults, and lambda-cyhalothrin was slightly toxic to the nymphs and moderately toxic to the adults. Among the fungicides evaluated in the laboratory, myclobutanil showed moderate toxicity to adults at the manufacturer's label rate. The remaining fungicides had no toxic effects to adults or nymphs, even at four times the manufacturer's label rate.

Placebo-controlled study of gabapentin treatment of panic disorder

A randomized, double-blind, placebo-controlled, parallel-group study was conducted to evaluate the efficacy and safety of gabapentin in relieving the symptoms of panic disorder. One hundred three patients were randomly assigned to receive double-blind treatment with either gabapentin (dosed flexibly between 600 and 3,600 mg/day) or placebo for 8 weeks. No overall drug/placebo difference was observed in scores on the Panic and Agoraphobia Scale (PAS) (p = 0.606). A post hoc analysis was used to evaluate the more severely ill patients as defined by the primary outcome measure (PAS score > or = 20). In this population, the gabapentin-treated patients showed significant improvement in the PAS change score (p = 0.04). In patients with a PAS score of 20 or greater, women showed a greater response than men regardless of treatment. Adverse events were consistent with the known side effect profile of gabapentin and included somnolence, headache, and dizziness. One patient experienced a serious adverse event during the study. No deaths were reported. The results of this study suggest that gabapentin may have anxiolytic effects in more severely ill patients with panic disorder.

Effects of five insecticides used in apple orchards on Hyaliodes vitripennis (Say) (Hemiptera: Miridae)

Azinphos-methyl, carbaryl, dimethoate, phosmet and phosalone were used in apple orchards to manage apple aphid, apple maggot, woolly apple aphid and leaf eating caterpillars. Among the five insecticides evaluated, dimethoate, carbaryl and azinphosmethyl were the most toxic to the nymphs and adults of Hyaliodes vitripennis (Say) from two regions. Phosalone was the least toxic. Nymphs were more resistant than the adults. While the LC50 for dimethoate was 130 ppm for nymphs, it was 3 ppm for adults from St. Jean-Baptiste-de-Rouville. There were also significant differences in the level of resistance between the two regions where the H. vitripennis were collected. At St. Alexandre the LC50 for phosalone on nymphs was 19,250 ppm whereas, at St. Jean-Baptiste-de-Rouville it was 160,000 ppm.

Double-blind, placebo-controlled study with reboxetine in inpatients with severe major depressive disorder

The efficacy and tolerability of reboxetine, a unique selective noradrenaline reuptake inhibitor, were compared with those of placebo in a 6-week, randomized, double-blind study of hospitalized patients with a DSM-III-R diagnosis of major depressive disorder. Fifty-two patients (25 in the placebo group, 27 in the reboxetine group) were included in the efficacy analysis. Sixteen (64%) of those in the placebo group and four (15%) in the reboxetine group were withdrawn during the study because of lack of efficacy. Improvement in the mean Hamilton Rating Scale for Depression (HAM-D) total score at last assessment was significantly greater in the reboxetine group than in the placebo group (p < 0.001). Similarly, the response rate to treatment, defined as > or =50% reduction in HAM-D total score, was 74% for patients who received reboxetine compared with 20% for those who received placebo (p < 0.001). A significantly greater response with reboxetine than with placebo was seen as early as day 10 of treatment (p = 0.006). The therapeutic efficacy of reboxetine was substantiated by improvement in mean scores on the Zung Self-Rating Scale and on the Clinical Global Impression Severity of Illness and Global Improvement scales. Reboxetine was well tolerated, and only one patient in each group withdrew because of adverse events. Dry mouth, insomnia, blurred vision, sweating, and constipation were recorded more frequently in the reboxetine group than in the placebo group. There was a tendency toward orthostatic changes in the systolic blood pressure, but this was not clinically significant. This study demonstrated that reboxetine is significantly more effective than placebo in the treatment of hospitalized patients with severe major depressive disorder and is well tolerated.

Guidelines for the clinical use of benzodiazepines: pharmacokinetics, dependency, rebound and withdrawal. Canadian Society for Clinical Pharmacology

Principles of benzodiazepine selection are outlined for various psychiatric indications and diverse populations (the elderly, and drug and alcohol abusers). Benzodiazepines are still among the most commonly used classes of medications, and they differ in their pharmacodynamic properties. They have varied uses as monotherapy or as adjunctive medication because of their efficacy in the treatment of conditions involving a dysfunction of the GABAergic system or where neuronal inhibition is required. In multiple therapy, benzodiazepines augment the efficacy of other drugs such as lithium in mania, antipsychotics in psychotic agitation and selective serotonin reuptake inhibitors in panic disorder. Benzodiazepines can produce dependence and tolerance in most patients; predisposed individuals are at greater risk. Short- and intermediate-beta half-life compounds carry a greater risk of rebound and withdrawal reactions, and drug dependence than long acting agents. Adverse effects include sedation, psychomotor and cognitive impairment, memory loss, potentiation of other central nervous system depressants and treatment-emergent depression. Drug potency and beta elimination half-life are reviewed and compared as pharmacokinetic variables.

A rating scale for psychotic symptoms (RSPS): part II: subscale 2: distraction symptoms (catatonia and passivity experiences subscale 3: delusions and semi-structured interview (SSCI-RSPS)

In the second paper on the Rating Scale for Psychotic Symptoms (RSPS), distraction symptoms (Subscale 2) and delusions (Subscale 3) are described. Subscale 2 includes distraction symptoms, which arise from one of two mechanisms: the symptom may arise either by loss of attentional focus (LAF) due to a competing channel of information, or by the intrusion of the competing channel into the focus of attention [attentional intrusions (AI)]. The symptom classes resulting from loss of attentional focus (LAF) include motor catatonia, negativism, and thought blocking; the attentional intrusions (AI) symptoms rated include three types of passivity experiences (Schneiderian symptoms): (1) thought insertion, (2) movements or action controlled, and (3) speech controlled by an external force. Subscale 3, consisting of delusions, is organized on the basis of content identification. Nineteen types of delusions are rated. Each item of delusional content is rated along three axes (active elaboration, persistence and active extinction) and complexity, and optionally if primary or mixed (i.e. primary with secondary elaborations). The last section of the paper includes the semi-structured interview (SCI-RSPS) for each of the items, as well as guidelines for practical application of the interview.

A rating scale for psychotic symptoms (RSPS) part I: theoretical principles and subscale 1: perception symptoms (illusions and hallucinations)

The authors present a new rating scale for the psychotic symptoms of schizophrenia and related psychoses. The scale links specific symptoms of psychopathology to dysfunction and overactivity of dopaminergic mechanisms underlying the processes of reward and selective attention. The Rating Scale for Psychotic Symptoms (RSPS) is a 44-item rating instrument with a seven-point severity scale for each item. Psychotic symptoms are classified into three groups: Pathological amplification of mental images (perception symptoms) (subscale 1), Distraction symptoms (including catatonia and passivity experiences) (subscale 2), and Delusions (subscale 3). A dimensional, rather than a categorical, conceptualization of psychosis is assumed. Rating is accomplished through a manual and a semi-structured interview (SSCI-RSPS). In this first of two papers, general issues about the construction of the scale and the derivation of symptom groups are discussed. Dopamine-mediated modification of cortico-striatal synapses is seen as being of critical importance in all three groups of symptoms. In this first paper, we present subscale I (perception symptoms), which includes both amplified perceptual images (illusions) and hallucinations. A total of seven illusions and 11 hallucinations are rated as individual items.

Metabolism of anxiolytics and hypnotics: benzodiazepines, buspirone, zoplicone, and zolpidem

1. The benzodiazepines are among the most frequently prescribed of all drugs and have been used for their anxiolytic, anticonvulsant, and sedative/hypnotic properties. Since absorption rates, volumes of distribution, and elimination rates differ greatly among the benzodiazepine derivatives, each benzodiazepine has a unique plasma concentration curve. Although the time to peak plasma levels provides a rough guide, it is not equivalent to the time to clinical onset of effect. The importance of alpha and beta half-lives in the actions of benzodiazepines is discussed. 2. The role of cytochrome P450 isozymes in the metabolism of benzodiazepines and in potential pharmacokinetic interactions between the benzodiazepines and other coadministered drugs is discussed. 3. Buspirone, an anxiolytic with minimal sedative effects, undergoes extensive metabolism, with hydroxylation and dealkylation being the major pathways. Pharmacokinetic interactions of buspirone with other coadministered drugs seem to be minimal. 4. Zopiclone and zolpidem are used primarily as hypnotics. Both are extensively metabolized; N-demethylation, N-oxidation, and decarboxylation of zopiclone occur, and zolpidem undergoes oxidation of methyl groups and hydroxylation of a position on the imidazolepyridine ring system. Zopiclone has a chiral centre, and demonstrates stereoselective pharmacokinetics. Metabolic drug-drug interactions have been reported with zopiclone and erythromycin, trimipramine, and carbamazepine. Reports to date indicate minimal interactions of zolpidem with coadministered drugs; however, it has been reported to affect the Cmax and clearance of chlorpromazepine and to decrease metabolism of the antiviral agent ritonavin. Since CYP3A4 has been reported to play an important role in metabolism of zolpidem, possible interactions with drugs which are substrates and/or inhibitors of that CYP isozyme should be considered.

A Canadian multicenter, double-blind study of paroxetine and fluoxetine in major depressive disorder

BACKGROUND

Recent studies have suggested clinical differences among selective serotonin reuptake inhibitors. In a 12-week randomized, multicenter, double-blind trial, the antidepressant and anxiolytic efficacy of the selective serotonin reuptake inhibitors paroxetine and fluoxetine was compared in patients with moderate to severe depression.

METHODS

A total of 203 patients were randomized to fixed doses (20 mg/day) of paroxetine or fluoxetine for the first six weeks of therapy. From week 7-12, dosing could be adjusted biweekly, as required (paroxetine 20-50 mg/day, and fluoxetine 20-80 mg/day). The mean prescribed doses were paroxetine 25.5 mg/day (range 20.0-40.2 mg/day), and fluoxetine 27.5 mg/day (range 20.0-59.5 mg/day). Emergence of motor nervousness or restlessness was assessed using the ESRS scale for akathisia.

RESULTS

Both active treatments demonstrated comparable antidepressant efficacy (HAM-D, CGI). Anxiolytic activity of the two drugs (COVI, STAI, HAM-D) was also comparable. However, paroxetine was found to be superior to fluoxetine on two subscore measures at week 1 of therapy (HAM-D Agitation item, p < 0.05; Psychic Anxiety item, p < 0.05), with no differences detected after week 2. The overall incidence of adverse effects was comparable in the two treatment groups. Constipation, dyspepsia, tremor, sweating and abnormal ejaculation were more common in paroxetine-treated subjects, whereas nausea and nervousness were more frequent in fluoxetine-treated patients. Weight loss was more common in the fluoxetine versus paroxetine group (11.88% versus 2.94%, respectively). ESRS scores for akathisia were low throughout the study and showed little change.

LIMITATIONS

Differences observed between the two drugs in antianxiety effects were limited to two measures of anxiety among several others.

DISCUSSION

The data indicate that paroxetine and fluoxetine have comparable antidepressant and anxiolytic efficacy. Paroxetine appears to produce an earlier improvement in agitation and psychic anxiety symptoms compared with fluoxetine.

Phase-IV multicentre clinical study of risperidone in the treatment of outpatients with schizophrenia. The RIS-CAN-3 Study Group

OBJECTIVE

Since most clinical trials of atypical antipsychotics have been conducted in hospitalized patients, a Phase-IV, multicentre, 8-week, open-label, flexible-dose study was performed to assess the efficacy and safety of risperidone in outpatients with schizophrenia.

METHOD

Three hundred and thirty patients with a Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) diagnosis of schizophrenia were enrolled at 61 Canadian sites. Upon trial entry, the patients had their neuroleptic and antiparkinsonian drugs discontinued, and treatment with risperidone was initiated at a dose of 2 mg daily, then increased by 2 mg daily on each of the 2 following days until the initial target dose of 6 mg daily was reached on day 3. No further titration was allowed until day 14, after which the dose could be increased or decreased.

RESULTS

During the stabilization phase (days 14-56), the dose was unchanged in 44% of the patients, increased in 24%, decreased in 23%, and titrated both up and down in 9% of the patients. In the efficacy-evaluable population (n = 292), treatment with risperidone produced substantial (-26.4) and significant (P = 0.0001) improvement in the total Positive and Negative Syndrome Scale (PANSS) score. At the end of the study (week 8), 85% of patients were classified as clinically improved according to an a priori definition (that is, 20% or more decrease from baseline in total PANSS score). On their last study visit, 75% of patients reported their experience with risperidone as better than their previous neuroleptic therapy. Risperidone was generally well tolerated. The adverse events reported by more than 5% of the patients were insomnia, nausea, headache, somnolence, dizziness, fatigue, anxiety, vomiting, and ejaculation disorder. Seventy-four percent of the reported treatment-related adverse events were recorded during the first 2 weeks of the trial, possibly because of the discontinuation of prior neuroleptic and antiparkinsonian drugs followed by immediate upward titration of risperidone. However, only 8.5% of adverse events were reported to have occurred during week 3, and only 0.8% of adverse events were reported for week 8. Risperidone treatment produced significant improvements over baseline in the incidence and severity of extrapyramidal symptoms (EPS). A slight but statistically significant increase in body weight was observed.

CONCLUSIONS

The results of this open-label, Phase-IV trial in a large population of outpatients with schizophrenia found that risperidone was superior to the neuroleptics that patients had previously taken in terms of efficacy and severity of EPS. Our results suggest the use of risperidone at lower doses in outpatients with schizophrenia.

Foliar Sprays with Steinernema carpocapsae against Early-season Apple Pests

Persistence and field efficacy of the entomopathogenic nematode Steinernema carpocapsae A11 strain applied by foliar sprays were evaluated against the apple sawfly Hoplocampa testudinea and the plum curculio Conotrachelus nenuphar, two early-season pests in Quebec apple orchards. From 1992 to 1995, bioassays with Galleria mellonella larvae were conducted to assess the persistence of S. carpocapsae on leaves, flower clusters, and twigs up to 4 days after evening application. S. carpocapsae juveniles remained infective on apple leaves 24, 42, 98, and 24 hours after application in 1992, 1993, 1994, and 1995, respectively. In bioassays, the percentage of G. mellonella mortality was consistently higher on leaves (average = 84%), intermediate on flower clusters (73%), and lower on twigs (43%) for all application dates. In 1992 and 1993, single nematode sprays applied every 2 to 3 days from early May to mid-June on apple tree limbs reduced primary damage caused by H. testudinea by 98% and 100%, respectively, but none of the treatments was effective in 1994. In 1993 and 1994, multiple border-row sprays were applied against C. nenuphar adults with a commercial hand-gun applicator in an insecticide-free orchard. At harvest, plum curculio damage in the nematode-treated orchard reached 5% and 55% in 1993 and 1994, respectively, as compared to 80% and 85% in an adjacent insecticide-free orchard. In a second experiment performed in 1994, multiple broadcast sprays with a commercial orchard sprayer caused no significant effect on plum curculio damage (nematode = 28%; control = 31%). Although some efficacy of canopy sprays of nematodes was detected against early-season apple pests, the inconsistent results and high application costs preclude their use as a sole control tactic against these pests in commercial apple orchards.

The effects of risperidone on the five dimensions of schizophrenia derived by factor analysis: combined results of the North American trials

BACKGROUND

In two double-blind trials conducted in North America, 513 patients with chronic schizophrenia received risperidone, haloperidol, or placebo. In the present study, combined data from the two trials were analyzed.

METHOD

Patients were randomly assigned to receive placebo, fixed doses of risperidone (2, 6, 10, and 16 mg/day) or 20 mg/day of haloperidol for 8 weeks. Factor analysis of scores on the Positive and Negative Syndrome Scale (PANSS) produced five dimensions (negative symptoms, positive symptoms, disorganized thought, uncontrolled hostility/excitement, and anxiety/depression), similar to the five dimensions of previous factor-analytic studies of PANSS data.

RESULTS

Mean changes (symptom reductions) in PANSS factor scores from baseline to treatment Weeks 6 and 8 were significantly greater in patients receiving 6-16 mg/day of risperidone than in patients receiving placebo or haloperidol. The advantages of risperidone were greatest for negative symptoms, uncontrolled hostility/excitement, and anxiety/depression. Even at the lowest dose, 2 mg/day, risperidone was significantly (p < or = .05) superior to haloperidol in reducing negative symptoms. The differences in outcomes between risperidone and haloperidol on PANSS scores were not related to extrapyramidal symptoms.

CONCLUSION

Risperidone produced significantly (p < or = .05) greater improvements than haloperidol on all five dimensions. The large between-group differences on negative symptoms, hostility/excitement, and anxiety/depression suggest that risperidone and other serotonin/dopamine antagonists have qualitatively different effects from those of conventional antipsychotic agents.

Economic and health state utility determinations for schizophrenic patients treated with risperidone or haloperidol

The current study uses utility analysis to assess economic and quality-of-life benefits of risperidone in patients with chronic schizophrenia. A retrospective analysis was performed on Positive and Negative Syndrome Symptoms (PANSS) data obtained from the published Canadian multicenter risperidone trial (part of the North American trial). Cluster analysis applied to endpoint PANSS scores, including all patients (N = 135), identified three clusters representing 130 patients with mild, moderate, and severe symptomatology. A narrative health state profile was written for each cluster, and 100 psychiatric nurses from Washington, DC, were asked to assign preference ratings to each one using linear analog and standard gamble (SG) methods. Mean utility values (confidence interval 95%) obtained from the SG ratings for the three health state profiles were 0.61 +/- 0.069 (mild); 0.36 +/- 0.073 (moderate); and 0.29 +/- 0.071 (severe). The mild health state (including the majority of risperidone 6 mg-treated patients) was rated by nurses to have a 0.25 +/- 0.0501 greater utility than the moderate health state (composed of the majority of haloperidol-treated patients). The results of these utility evaluations (SG) by the nurses were related to the clinical outcome for three of the six drug treatment groups (N = 65) by multiplying the percentage of patients in each of the three clusters, both at baseline and end-point, who were receiving risperidone 6 mg/day, haloperidol, or placebo, by the utility value for the health state assigned to that cluster. The gain in utility for risperidone-treated patients was 2.6 times higher (0.125) compared with haloperidol-treated patients (0.049), and 7 times higher compared with placebo (-0.021). After multiplying the gain in utility of each treatment by the remaining expected life span for men and women, it was found that risperidone-treated patients obtained more than twice as many quality-adjusted years as haloperidol patients. The incremental drug treatment cost divided by the incremental benefit of risperidone versus haloperidol was found to yield a favorable, generally accepted cost-utility ratio.

Moclobemide versus fluoxetine in the treatment of major depressive disorder in adults

The objective of the present study was to compare the safety and efficacy of moclobemide versus fluoxetine in adult patients with major depressive disorder. The design of the study was a multicenter, double-blind, comparative, and randomized trial. A 1- to 2-week single-blind placebo washout phase was followed by 6 weeks of double-blind treatment with moclobemide or fluoxetine. A total of 150 patients were enrolled in the study. There were 128 patients eligible to be randomized, with 66 patients receiving moclobemide and 62 patients receiving fluoxetine. At the termination of the study, patients in the moclobemide group were receiving a mean dose of 440 mg +/- 123 mg, while the mean dose in the fluoxetine group was 35 mg +/- 8 mg. No significant treatment differences were found for any of the efficacy parameters. Headache and nausea were the most frequently reported adverse events in both treatment groups. Headache and blurred vision were reported significantly more often (P < 0.05) in the fluoxetine group, whereas significantly more dry mouth was reported (P < 0.05) in the moclobemide group. These results provide supporting evidence of the comparable efficacy of moclobemide and fluoxetine and the better tolerability of moclobemide when used in the treatment of major depressive disorder.

Potentiation of fluoxetine by aminoglutethimide, an adrenal steroid suppressant, in obsessive-compulsive disorder resistant to SSRIs: a case report

1. The role of serotonin in the aetiology of obsessive compulsive disorder (OCD) has been established through considerable indirect evidence (Landry and Chouinard, 1990). The strongest evidence comes from the fact that drugs known to be serotonin-selective reuptake inhibitors (SSRIs) have been found to be useful in the pharmacotherapy of OCD (Landry and Chouinard, 1990). 2. The authors investigated a new treatment approach by adding an adrenal steroid suppressant to a SSRI, fluoxetine, in the case of a severe obsessive-compulsive patient who was drug-resistant to clomipramine and SSRIs. 3. We found that the combination of aminoglutethimide 250 mg qid and fluoxetine 40 mg die significantly improved the patient's condition. Moreover, during a four and a half year period, each time we tried to decrease either fluoxetine or the steroid suppressant, the patient started to relapse, suggesting that the adrenal steroid suppressant had a potentiating effect on the SSRI.

A cross-sectional study of parkinsonism and tardive dyskinesia in lithium-treated affective disordered patients

BACKGROUND

The purpose of this study was to investigate the prevalence of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD) in affective disordered patients treated with lithium and to study the association of these symptoms with medication and other factors.

METHODS

This cross-sectional study was carried out in all consenting outpatients attending an affective disorders clinic in a psychiatric hospital. The study sample consisted of 130 stable outpatients: 110 with bipolar disorder, 18 with unipolar (major) depression, and 2 with atypical affective disorder. At the time of evaluation, 110 patients were receiving lithium, 37 in combination with antidepressants and 19 with neuroleptics, and 40 had a history of neuroleptic treatment during the previous 6 months. The patients were assessed with the Extrapyramidal Symptom Rating Scale (ESRS) for parkinsonism, akathisia, dystonia, and TD. The prevalence of these symptoms was calculated for all patients and by current lithium and neuroleptic intake. Multiple linear regression analysis was used to investigate the relationship between the ESRS subscale scores and gender, age, diagnosis, and medication type.

RESULTS

The prevalence of tremor was 20.8%; hypokinetic parkinsonism, 7.7%; akathisia, 4.6%; dystonia, 3.8%; and TD, 9.2%. Tremor was associated with lithium and neuroleptic intake; hypokinesia was associated with neuroleptic treatment and age; and TD was associated with neuroleptic, lithium, and tricyclic intake and age. Seven of 51 patients taking lithium but without a history of neuroleptic treatment during the previous 6 months presented symptoms of TD.

CONCLUSION

The combination of lithium and neuroleptics was associated with a high prevalence of EPS. The presence of TD in lithium-treated patients not treated with neuroleptics for at least 6 months is consistent with the hypothesis that lithium may exacerbate the vulnerability of affective disordered patients to dyskinesias.

A 1 year double-blind placebo-controlled fixed dose study of sertraline in the treatment of obsessive-compulsive disorder

The objective of this study was to evaluate the safety and efficacy, over a 1 year treatment period, of three dose levels of sertraline and placebo in the treatment of non-depressed adult out-patients with obsessive-compulsive disorder (OCD). Following 1 week of single-blind placebo washout, patients (n = 325) from 11 sites following identical protocols were randomly assigned to 12 weeks of double-blind treatment with one of three fixed doses of sertraline (50, 100 or 200 mg) or placebo. At the end of 12 weeks, treatment responders (including placebo patients) were offered an additional 40 weeks of double-blind treatment at their assigned doses. Efficacy measures were the Yale-Brown Obsessive Compulsive Scale, the NIMH Global Obsessive Compulsive Scale, Clinical Global Impressions of Severity of Illness and Global Improvement and the Maudsley Obsessive Compulsive Inventory. Patients in the pooled sertraline group showed greater improvement than placebo-treated patients on all efficacy measures, based on the endpoint analyses. Moreover, pairwise comparisons at endpoint revealed a significant effect on all three investigator-rated scales in patients receiving 50 or 200 mg of sertraline; in the 100 mg group, there was a significant effect on the NIMH Global Obsessive Compulsive Scale only. Patients completing 3 months of sertraline treatment exhibited excellent toleration and sustained improvement during an additional 40 weeks of therapy. Results support the safety, efficacy and tolerability of daily doses of 50-200 mg of sertraline in the long-term treatment of patients with OCD.

Double-blind parallel comparison of three dosages of sertraline and placebo in outpatients with obsessive-compulsive disorder

BACKGROUND

Anecdotal evidence suggests patients with obsessive-compulsive disorder (OCD) are treated with selective serotonin uptake inhibitors at dosages significantly higher than those used with depressed patients. The current study examined the efficacy, safety, and optimal dosing strategy of sertraline in patients with OCD.

METHODS

Three hundred twenty-four nondepressed outpatients with OCD from 11 sites followed identical protocols using a double-blind parallel design. Following 1 week of single-blind placebo, patients were randomly assigned to 12 weeks of treatment with one of three fixed dosages of sertraline (50, 100, or 200 mg/d) or placebo.

RESULTS

Sertraline patients exhibited significantly greater improvement (P < .05) at end point than placebo patients on all three main efficacy measures in the 50-mg/d and 200-mg/d groups and on one measure in the 100-mg/d group. The placebo response was larger in this population of subjects with OCD than in those previously studied. Adverse experiences were common in the sertraline and placebo groups and appeared to be dose-related in the sertraline-treated patients.

CONCLUSIONS

Results support the safety and efficacy of daily dosages of 50, 100, and 200 mg of sertraline in the short-term treatment of patients with OCD.

The psychotropic effects of inhibitors of steroid biosynthesis in depressed patients refractory to treatment

Twenty patients, diagnosed as suffering from treatment-resistant major depression, were treated with one or more drugs that decrease corticosteroid biosynthesis. Nine were psychotic, 11 nonpsychotic. Seventeen completed the treatment (8 psychotic, 9 nonpsychotic); 13 responded (5 psychotic, 8 nonpsychotic; 11 responded completely (i.e., a drop in the Hamilton Depression Scale of at least 50%, to < or = 15), and 2 responded partially. The mean age of the responders (45.2 +/- 12.6 years) did not differ significantly from that of the nonresponders (48.7 +/- 12/3). Data were analyzed in the following categories; (1) the presence or absence of psychosis, (2) response or nonresponse to treatment, and (3) the drug(s) used (aminoglutethimide, ketoconazole, or a combination of either of these with metyrapone). The patients improved over time on the Hamilton Depression Scale independent of the medication used. Responders demonstrated improvement in mood, insomnia, anxiety, diurnal variation, paranoia and obsessive compulsiveness. Nonpsychotics responded better than psychotics.

Effects of risperidone in tardive dyskinesia: an analysis of the Canadian multicenter risperidone study

In the Canadian multicenter, double-blind clinical trial of risperidone, 135 hospitalized chronic schizophrenic patients were randomly assigned to one of six parallel treatment groups for 8 weeks: risperidone, 2, 6, 10, or 16 mg/day; haloperidol, 20 mg/day; or placebo. Risperidone (6 to 16 mg)-treated patients showed significantly (p < 0.05) lower dyskinetic scores than those receiving placebo, whereas in haloperidol- and placebo-treated patients, no significant differences for dyskinetic symptoms were noted. To explore the antidyskinetic effect of risperidone, a post hoc analysis was performed on two selected patient samples: (1) patients meeting Research Diagnosis Criteria (RDC) for tardive dyskinesia (TD) at baseline or during double-blind treatment (N = 49) and (2) patients with RDC TD and with a Clinical Global Impression (CGI) Severity of dyskinesia score > or = 5 (at least moderately severe) (N = 48). The composition of the two subsamples was found to be almost identical because all but one of the patients with RDC TD (N = 49) were members of the group with at least moderately severe TD (N = 48). Analysis of four parameters (Extrapyramidal Symptom Rating Scale-dyskinesia total score, CGI severity of dyskinesia, buccolinguomasticatory [BLM] factor score, and extremities [choreoathetoid factor] score confirmed the antidyskinetic effect that was noted in the intent-to-treat analysis, which included all patients, whether they had RDC TD or not. Results indicated that risperidone at 6 mg/day had the most beneficial effect on TD, especially on the BLM syndrome, without inducing significant parkinsonism while treating psychotic symptoms. This antidyskinetic effect was greater than with either placebo or haloperidol.

A path-analytical approach to differentiate between direct and indirect drug effects on negative symptoms in schizophrenic patients. A re-evaluation of the North American risperidone study

The hypothesis that differences in drug effects of risperidone and haloperidol on negative symptoms in schizophrenia are secondary to effects on positive, extrapyramidal, and depressive symptoms was investigated by means of an analysis of the data from the USA-Canada risperidone double-blind randomized clinical trial of 523 chronic schizophrenic patients. Regression analyses in the total sample and within treatment groups confirmed a strong relationship between changes in negative symptoms and the other variables studied (R2 = 0.50-0.51, p < 0.001). Only depressive symptoms did not contribute significantly to these results (p > 0.10). Path analysis showed that the greater mean change (p < 0.05) of negative symptoms with risperidone compared to haloperidol could not be fully explained by correlations with favourable effects on positive and extrapyramidal symptoms. The relationship between shift in extrapyramidal symptoms and shift in negative symptoms failed to reach statistical significance; however, there was a clear tendency in the expected direction in both treatment groups.

Dopamine D4 receptor variant, D4GLYCINE194, in Africans, but not in Caucasians: no association with schizophrenia

Because antipsychotic drugs selectively block dopamine receptors and since dopamine D4 receptors are elevated sixfold in postmortem schizophrenia brain, we searched for possible abnormalities in the coding region of the genomic DNA sequence for the dopamine D4 receptor in control and schizophrenia tissues. The DNA sequence for the first 250 bases of exon 3 of this receptor was examined in the genomic DNA from 296 control individuals and 58 schizophrenics. Twenty-three out of 183 control blacks (12.6%) and 3 out of 24 (12.5%) schizophrenic blacks revealed a replacement of T by G, predicting a substitution of valine by glycine at amino acid position 194. The identical prevalence of 12.5% indicates that the variant is not associated with schizophrenia. The amino acid replacement occurs one amino acid away from a serine amino acid which is critical for the attachment of dopamine. None of the 147 Caucasians (113 controls; 34 schizophrenics) revealed this variant, termed D4GLYCINE194.

A double-blind controlled study of intramuscular zuclopenthixol acetate and liquid oral haloperidol in the treatment of schizophrenic patients with acute exacerbation

We carried out a 9-day double-blind clinical trial comparing intramuscular zuclopenthixol acetate with liquid oral haloperidol in the treatment of 40 newly admitted schizophrenic patients with acute exacerbation. A parallel-group design was used with stratification by sex. Zuclopenthixol acetate (50 to 150 mg) was given intramuscularly every 3 days, whereas liquid haloperidol (10 to 30 mg daily) was given orally three times a day, with supplementary doses of each medication given under double-blind conditions when needed for agitation. No other sedative drugs, including benzodiazepines, were administered. The mean daily dose was 18.9 mg for haloperidol as compared with a mean dose per 3 days of 117.6 mg for zuclopenthixol. The two treatments were found to be equally efficacious on the Brief Psychiatric Rating Scale and Clinical Global Impression Scale. Both drugs induced similar extrapyramidal side effects. However, more tremors were associated with zuclopenthixol as was a tendency for tardive dyskinesia to be unmasked at the end of the injection interval. Sedation was higher with zuclopenthixol acetate than with haloperidol. Serum creatinine phosphokinase levels were not significantly increased after zuclopenthixol injections. The results of this trial suggest that zuclopenthixol acetate given intramuscularly every second to third day offers an alternative to conventional liquid oral haloperidol in the management of acute schizophrenia.

Elevated dopa decarboxylase activity in living brain of patients with psychosis

The hypofrontality theory of the pathogenesis of schizophrenia predicts that cortical lesions cause psychosis. During a search for abnormalities of catecholaminergic neurotransmission in patients with complex partial seizures of the mesial temporal lobe, we discovered an increase of the rate of metabolism of an exogenous dopa tracer (6-[18F]fluoro-L-dopa) in the neostriatum of a subgroup of patients with a history of psychosis. When specifically assayed for this abnormality, patients with schizophrenia revealed the same significant increase of the rate of metabolism in the striatum. The finding is consistent with the theory that a state of psychosis arises when episodic dopamine excess is superimposed on a trait of basic dopamine deficiency in the striatum. The finding is explained by the hypothesis that cortical insufficiency, a proposed pathogenetic mechanism of both disorders, causes an up-regulation of the enzymes responsible for dopa turnover in the neostriatum as well as the receptors mediating dopaminergic neurotransmission.

Risperidone and clozapine in the treatment of drug-resistant schizophrenia and neuroleptic-induced supersensitivity psychosis

1. Supersensitivity psychosis (SSP) has emerged as a potential side effect of long-term neuroleptic therapy similar to tardive dyskinesia (TD). 2. Six schizophrenic patients with SSP, considered to be drug-resistant, were treated with risperidone, while another 5 were treated with clozapine. 3. The 6 risperidone-treated patients (all women) were rated on the Clinical Global Impression Improvement Scale as at least very much improved. Among the 5 clozapine-treated patients, all 4 men were found to have a marked response to clozapine, while the female patient was judged to be minimally improved. 4. It is hypothesized that not only TD but also SSP arise from destruction of cholinergic interneurons in the striatum as a consequence of prolonged neuroleptic administration. Thus, the drug-induced parkinsonism, which was proposed as mediating the antipsychotic effect of dopamine D2 blocking drugs, depends on the integrity of these cholinergic neurons. If these neurons are destroyed, drugs such as haloperidol lose their therapeutic effect. 5. In contrast, atypical neuroleptics like clozapine and risperidone reduce dopamine release in the striatum independently of prior production of extrapyramidal symptoms and, in this way, may be effective in psychotic illnesses unresponsive to classical anti-D2 neuroleptics. 6. In the present sample of patients, it is worth noting that schizophrenic men were good responders to clozapine. In comparison, risperidone was found to be efficacious in schizophrenic women.

A Canadian multicentre placebo-controlled study of a fixed dose of brofaromine, a reversible selective MAO-A inhibitor, in the treatment of major depression

In a 6-week double-blind study, 220 patients with major depression (mostly outpatients) were randomly assigned to receive a fixed dose of brofaromine 150 mg daily (n = 111) or placebo (n = 109) after a 1-week single-blind placebo washout. Except for the HAM-D sleep items, brofaromine was superior to placebo on measures of depression as determined by the four methods of assessing drug efficacy: (1) psychiatric symptom rating (HAM-D 17-item less the three sleep items); (2) self-rating scale (Beck Depression Inventory); (3) Clinical Global Assessment of Efficacy; and (4) drop-out rate due to lack of efficacy. Most commonly reported adverse events with brofaromine were: headache, nausea, dizziness and sleep disturbance. Brofaromine was found to be an effective antidepressant, superior to placebo with a good tolerability profile.

CGP 25454A, a novel and selective presynaptic dopamine autoreceptor antagonist

N-(diethylamino-ethyl)-4-chloro-5-cyano-2-methoxy-benzamide-hydrochlo rid e (CGP 25454A) is a new benzamide derivative now in clinical trials in patients with major depression. Here we describe some basic neurochemical and behavioural properties in animal experiments. In vitro, CGP 25454A increased the field-stimulated [3H]- and [14C]-overflow from rat striatal slices preloaded with [3H]dopamine and [14C]choline, indicating that CGP 25454A was able to enhance the release of both dopamine (DA) and acetylcholine (ACh). However, CGP 25454A was 12.9 times more potent in increasing, by 1/6 of the apparent maximal increase, the release of [3H]DA than that of [14C]ACh. In vivo, CGP 25454A increased [3H]spiperone binding to receptors of the D2 family in rat striatum by 90-110% (ED50: 13 mg/kg i.p.). As a similar increase in [3H]spiperone binding was found with a variety of agents which increase the synaptic concentration of endogenous DA, the effect of CGP 25454A most probably reflects an enhanced release of DA under in vivo conditions. At 30-100 mg/kg, CGP 25454A inhibited [3H]spiperone binding in the pituitary of the same animals as a result of a blockade of postsynaptic DA receptors. This dual mode of action was also apparent in terms of behavioral changes. At doses as low as 5-10 mg/kg, CGP 25454A produced a weak stimulation, suggested by a trend of increased spontaneous rearing and corroborated by a significant potentiation of the elevated rearing induced by (+)-amphetamine. By contrast, at doses of 30-100 mg/kg, it exerted clear-cut sedative and neuroleptic-like properties.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of venlafaxine, trazodone, and placebo in major depression

A double-blind, placebo-controlled trial was undertaken to compare the safety and efficacy of venlafaxine and trazodone in patients with major depression. Two hundred twenty-five patients entered an initial 6-week treatment phase, and 149 completed it. Ninety-six patients who were responders continued in a 1-year, double-blind, long-term phase during which they received the same medication and doses they had during the short-term phase. Both active treatments were significantly more effective than placebo on some measures during the short-term study, but venlafaxine produced more improvement in the cognitive disturbance and retardation factors on the Hamilton Rating Scale for Depression. Trazodone was more effective against the sleep disturbance factor. Patients on venlafaxine were most likely to enter the long-term phase and to remain in the trial longest. The side effect profiles of the three treatment groups were compared. Venlafaxine was most likely to cause nausea, whereas trazodone was associated with the most dizziness and somnolence.

Clonazepam in the treatment of panic disorder: a double-blind, placebo-controlled trial investigating the correlation between clonazepam concentrations in plasma and clinical response

Thirty-two outpatients with a DSM-III diagnosis of panic disorder or agoraphobia with panic attacks were randomly assigned to 4 weeks of treatment with clonazepam or placebo, after a 1-week placebo washout period. Twenty-nine patients entered the double-blind phase of the study and were eligible for intent-to-treat analysis. Clonazepam-treated patients experienced significantly fewer panic attacks, and these were of lesser intensity and short duration than those in placebo-treated patients (p < 0.001). Clonazepam was also superior to placebo with respect to symptoms of anxiety and depression (p < 0.001). The mean dose of clonazepam at week 4 was 2.2 mg (standard deviation, 0.7 mg). There was significant (p < 0.05) correlation between drug concentration in plasma and decrease in the global measure of the severity of panic disorder (r = 0.68); similar trends were seen for the decreases in frequency (r = 0.60) and severity (r = 0.55) of panic attacks, but not between concentration in plasma and decline in generalized anxiety. The most common adverse event was drowsiness, which occurred in 9 of 13 clonazepam-treated patients.