Baseline anxiety effect on outcome of SSRI treatment in patients with severe depression: escitalopram vs paroxetine

OBJECTIVE

To investigate if treatment outcome for severely depressed patients depends on their baseline level of anxiety.

RESEARCH DESIGN AND METHODS

Patients with a primary diagnosis of severe major depressive disorder (n = 459) were randomised to 24 weeks of double-blind treatment with escitalopram (20 mg) or paroxetine (40 mg). Post hoc analyses of efficacy in patients with a baseline HAM-A total score < or =20 (n = 171) or >20 (n = 280) were based on analysis of covariance (ANCOVA) (ITT, LOCF).

RESULTS

At week 24, the mean change from baseline in MADRS total scores was -24.2 for escitalopram-treated patients (n = 141) and -21.5 for paroxetine-treated patients (n = 139) (p < 0.05) in high baseline anxiety patients and the mean change from baseline in HAM-A total score was -17.4 (escitalopram) and -15.1 (paroxetine) (p < 0.05). When examining the proportion of complete remitters (CGI-S = 1) after 24 weeks of treatment, there was an increasing treatment difference as a function of baseline HAM-A total score in favour of escitalopram (ITT, LOCF). There was no treatment difference in the low baseline anxiety group. Significantly more patients (p < 0.01) withdrew from the paroxetine group (31%) than from the escitalopram group (17%), partly as the result of significantly more withdrawals due to AEs (p < 0.05). Incidence of AEs and withdrawals were not related to baseline anxiety and there were no significant differences in the incidence of individual AEs with escitalopram compared to paroxetine.

LIMITATIONS

The post hoc nature of these analyses, the absence of placebo control group, and the requirement that patients should be suffering from severe depression, limit the generalisability of the results.

CONCLUSION

Patients with severe depression together with comorbid anxiety symptoms responded significantly better to treatment with escitalopram 20 mg compared with paroxetine 40 mg. Contrary to paroxetine, escitalopram maintained its efficacy with increasing baseline anxiety levels.

[Impact of psychiatric disturbances on the outcome of coronary bypass surgery]

The influence of anxiety and depression on the development and prognosis of coronary disease seems to be well established but there are few studies of the effects of these disturbances on the postoperative outcome of coronary surgery. The object of this review of the literature was to present recent data on this subject and to suggest therapeutic strategies for patients referred for coronary bypass surgery to improve their quality of life and even cardiovascular prognosis.

[Clinical impact of atypical antipsychotics: prospective 6-month study of inpatients treated with risperidone or olanzapine]

A survey of clinical and therapeutic evolution in patients treated with an atypical antipsychotic, risperidone or olanzapine, was carried out at La Colombière Psychiatric Hospital, Montpellier. This prospective observational study was conducted over 6 months. Forty-nine patients were included in the olanzapine treatment group and thirty-five in the risperidone treatment group. The Clinical Global Impression (CGI) scale was used for evaluation at day 0, 7, 30, 90 and 180 of treatment. The majority of patients were improved after 30 days of treatment, and clinical improvement was observed in about 60 per cent of patients among those treated at day 180. The main therapeutic benefit occurred in respect of positive psychotic symptoms. Patients were discharged after 30 days of treatment. The atypical antipsychotic was not used with an additional neuroleptic for all patients. Tolerance was good, particularly for olanzapine. On the other hand, according to our results, others studies have to be performed to confirm the impact of the treatment on weight gain, assessment of subjective elements such as sedation, and the direct effect of the atypical antipsychotics on primary negative symptoms.

The influence of Type A behavior pattern on the response to the panicogenic agent CCK-4

OBJECTIVES

Review of the literature equivocally suggests that subjects with Type A behavioral pattern (TABP) compared to subjects with Type B behavioral pattern display an increased sympathetic activity, a condition associated with sudden cardiac death. The objective of this study was to determine whether healthy subjects classified as Type A or Type B differed in their reactivity to the beta 1 and beta 2 receptor agonist isoproterenol and to the panicogenic agent cholecystokinin-tetrapeptide (CCK-4). By comparing reactivity to CCK-4 after pretreatment with placebo or propranolol, a beta 1 and beta 2 receptor antagonist, the role of the beta adrenergic system in the hypothesized increased response of Type A subjects to CCK-4 was also assessed.

METHODS

The study used a randomized, double-blind, placebo-controlled design. Twenty-seven Type A or B subjects were included in the study. The reactivity to isoproterenol was assessed with the CD25 of isoproterenol (i.e., the intravenous dose of isoproterenol necessary to increase the heart rate of 25 bpm). The panic symptom response and the cardiovascular response to bolus injection of 50 microg of CCK-4 was assessed in subjects pretreated with either propranolol or placebo infusions prior to the CCK-4 challenge. An additional group of subjects was recruited and these subjects received a placebo infusion pretreatment before an injection of placebo.

RESULTS

The CD25 was significantly greater in Type A subjects than in Type B subjects. No difference was found among the groups on behavioral sensitivity to the CCK-4 challenge. However, CCK-4-induced maximum increase in heart rate was greater in Type A subjects.

CONCLUSION

Our finding that Type A subjects exhibited greater CD25 of isoproterenol and greater increases in heart rate following CCK-4 administration compared to Type B subjects suggests that peripheral beta-receptor sensitivity may be increased in individuals with TABP.

Association between violent suicidal behavior and the low activity allele of the serotonin transporter gene

There is compelling evidence that serotonin system dysfunction is associated with certain behavioral disorders, such as suicidal behavior and impulsive aggression. A functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was recently identified and the presence of the short allele found to be associated with a lower level of expression of the gene, lower levels of 5-HT uptake, suicidal behavior and anxiety-related traits. We genotyped 51 West European Caucasians who had made violent suicide attempts and 139 controls of the same ethnic origin, with no history of suicidal behavior. The frequencies of the S allele and the SS genotype were significantly higher in the violent suicide attempters than in the controls. The odds ratio for the SS genotype vs the LL genotype was 3.63 (95% CI (1.27--10.40)). This suggests that a change in expression of the gene encoding the 5-HT transporter may be involved in violent suicidal behavior.

Suicide attempts and the tryptophan hydroxylase gene

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme of serotonin synthesis. In this case-control study, we investigated whether the TPH gene was a susceptibility factor for suicidal behavior. Seven polymorphisms spanning the entire gene were studied in a case-control study including 231 individuals who had attempted suicide and 281 controls. Significant associations were found between variants in introns 7, 8 and 9 (chi(2) = 11.2, df = 1, P< 0.0008 for the allele distribution; these loci are in complete linkage disequilibrium) and in the 3' noncoding region (chi(2) = 30.94, P = 0.0014) and suicide attempt. The association was strongest for subjects who had attempted suicide by violent means and who had a history of major depression. No significant association was observed between suicide attempts and polymorphisms in the promoter, intron 1 and intron 3. The results presented here, and those of previous studies, suggest that a genetic variant of the 3' part of the TPH gene may be a susceptibility factor for a phenotype combining suicidal behavior, mood disorder and impulsive aggression.

Outcomes in a referral cohort of patients with anxiety disorders

This study describes 6- and 12-month outcomes in a referral cohort with anxiety disorders and identifies treatment and prognostic factors related to these outcomes. Patients were recruited at three general hospital clinics, two psychologist-run clinics, and one psychiatric hospital clinic. Outcomes included severity of symptoms, physical and mental health status, and subjective global change in problem severity. Of 254 patients eligible for follow-up, 165 (65.0%) completed a follow-up questionnaire. Methods of treatment included consultation with return to the primary care physician (38.2%); or continued treatment at the clinic, with medications (16.4%), psychotherapy (22.4%), or both (23.0%). Both severity of symptoms and mental health status improved but remained abnormal at follow-up. In multiple logistic regression, subjective global improvement was related to a diagnosis of panic disorder only, treatment with psychotherapy, and type of referral. Change over time in symptom severity was related to clinic type, and change over time in mental health was related to clinic type and duration of previous treatment.

[Abuse of and dependence on zolpidem: a report of seven cases]

Zolpidem is an hypnotic drug that belongs to the imidazopyridine family. Its chemical structure is different from that of benzodiazepines though both type of drugs bind specifically to the same site of the GABA-A macromolecular complex: the omega 1 benzodiazepine receptor. This mechanism of action could be responsible for the predominantly hypnotic properties of zolpidem and its reduced liability to induce dependence in comparison with benzodiazepines. Yet, several cases of zolpidem abuse and dependence have been published recently. We report seven cases, from which three are detailed, of zolpidem abuse and/or dependence. These patients did not suffer from sedative effects of this drug despite important doses. We even noticed stimulating and euphorising effects in two of these patients, an effect that may explain at least in part the dependence to zolpidem. We will discuss the clinical similarities existing between zolpidem and benzodiazepines' effects. Furthermore we will discuss a molecular genetic hypothesis that may explain the differential effect of a specific benzodiazepine ligand on its receptors.

Relationships between trait and state anxiety and the central benzodiazepine receptor: a PET study

The central benzodiazepine receptor (cBZr) has long been implicated in anxiety disorders on the basis of: (i) the well-known anxiolytic and anxiogenic properties of cBZr agonists and inverse agonists, respectively; (ii) a possibly reduced sensitivity to benzodiazepines in anxious subjects; and (iii) a putative endogenous ligand. Thus, two main hypothesis have been advanced, namely changes in the concentration or properties of the latter, and changes in the GABAA complex conformation, which contains the cBZr. Neither postmortem studies nor appropriate animal models are available to investigate these ideas. We have used positron emission tomography (PET) to measure both the density and affinity of the cBZr in multiple brain regions in unmedicated patients and age- and sex-matched healthy volunteers, and have looked for differences between groups as well as correlations between cBZr parameters and state and trait anxiety scores. We studied 10 unmedicated patients (sex ratio 1 : 1; mean age: 39 years), prospectively recruited using DSM III-R criteria, and 10 age- and gender-matched healthy unmedicated volunteers. Thanks to a PET procedure using two successive administrations of 11C-flumazenil (at high and low specific radioactivity) and previously validated by us, we estimated the Bmax, Kd and bound : free (B/F) ratios in 11 neocortical areas and in the cerebellum. Before and after the PET session, anxiety scores from Spielberger's and Covi's scales were obtained. There was no statistically significant difference in Bmax, Kd or B/F-values between the two groups for any region. Across the two groups, there were only a few marginally significant anxiety-score-PET correlations, suggesting chance findings. This is the first fully quantitative study to report on the relationships between cBZr parameters and anxiety. Using two independent approaches (i.e. group comparison and across-group correlations), we found no evidence for a link between anxiety trait or state and the cBZr in neocortex or cerebellum in this sample. These findings, if confirmed by studies on larger samples, have implications for the pharmacotherapy of anxiety disorders, and will need to be considered when designing new neurobiological models of anxiety.

CCK4-induced panic in healthy subjects II: neurochemical correlates

Cholecystokinin tetrapeptide (CCK4) induces symptoms similar to those of panic attack. The present study investigated the effects of CCK4 administration on catecholaminergic system. In this double blind, randomised, crossover experiment, 16 healthy subjects received injections of either 25 microg of CCK4 or placebo on two separate occasions. Platelet and plasma catecholamine concentrations were assessed before the administration and compared to post-injection values. The results clearly show that both plasma and platelet concentrations of catecholamines are significantly affected by CCK4. Plasma norepinephrine (NE) and epinephrine (EPI) raised significantly above baseline in the immediate post-CCK4 period, while in plasma dopamine (DA), the significant increases were delayed. In the platelets, significant post-CCK4 increases of NE and EPI concentrations were observed with a delay of several minutes. In summary, we have demonstrated that, in healthy subjects, CCK4 increases peripheral concentrations of catecholamines in both plasma and platelets, with the most consistent changes occurring in platelet NE and plasma EPI concentrations.

CCK4-induced panic in healthy subjects I: psychological and cardiovascular effects

Sixteen healthy subjects participated in a crossover, double blind, and placebo-controlled study, designed to assess simultaneously the psychological and cardiovascular effects of cholecystokinin tetrapeptide (CCK4). Following an i.v. injection of 25 microg of CCK4, 44 percent of subjects experienced symptoms that fulfilled the DSM-IV criteria for a panic attack while no one panicked with placebo. CCK4 induced a significantly greater number and higher intensity of panic-like symptoms than placebo. A significant increase in state anxiety was observed in the period after CCK4 injection; this increase was significantly larger than the non-specific anxious reaction to placebo. CCK4 also affected cardiovascular signs. Both heart rate and mean blood pressure significantly increased after administration of CCK4. Again, these increases were significantly higher than those seen after placebo injection. We conclude that, in healthy subjects, CCK4 induces panic-like reaction characterized by a number of somatic, cognitive and emotional symptoms, which are accompanied by increases in heart rate and blood pressure.

Pharmacologic treatments effective in both generalized anxiety disorder and major depressive disorder: clinical and theoretical implications

OBJECTIVE

To review the efficacy of anxiolytics (alprazolam and azapirones) in major depressive disorder (MDD) and that of antidepressants in generalized anxiety disorder (GAD), thereby exploring the possible theoretical and clinical implications of this efficacy.

METHOD

A Medline literature search was performed for the period January 1980 to September 1997 of randomized, double-blind comparison studies between anxiolytics and antidepressants in the acute treatment of adult patients with either MDD or GAD.

RESULTS

Alprazolam, at doses double those generally recommended for anxiety disorders, appears to be as effective as tricyclic antidepressants (TCAs) in the acute treatment of mild to moderate MDD. Alprazolam was also found to have a more rapid onset of action than to TCAs, particularly for the improvement of anxiety, somatization, and insomnia. Two azapirones (buspirone and gepirone) also have demonstrated a modest acute antidepressant effect in preliminary studies, albeit only in a depressed outpatient sample with considerable anxiety at baseline. Finally, various antidepressant drugs (imipramine, trazodone, paroxetine) were shown to have, at the least, comparable efficacy to benzodiazepines (BZDs) in the acute treatment of GAD.

CONCLUSIONS

The nonspecificity of treatment response suggests that GAD and MDD are 1) different expressions of a similar disorder with a common neurobiological substrate, 2) discrete diagnostic entities that respond to independent pharmacological effects of the same drugs, or 3) a combination of the two (heterogeneity hypothesis). The most relevant clinical finding is the efficacy of antidepressants in the acute treatment of GAD.

Effect of aging on cholecystokinin-induced panic

OBJECTIVE

Epidemiologic surveys have found that the incidence and prevalence of panic disorder decline in later life. The goal of this study was to determine whether aging has an effect on healthy subjects' responses to the panicogenic agent cholecystokinin tetrapeptide (CCK-4).

METHOD

The study used a double-blind, placebo-controlled design: 40 subjects 20-35 years old and 40 subjects 65 years old or older were randomly assigned to receive an intravenous bolus of either 50 micrograms of CCK-4 or normal saline.

RESULTS

When given CCK-4, older subjects had significantly fewer and less intense symptoms of panic, shorter duration of symptoms, and less of an increase in heart rate than did younger subjects.

CONCLUSIONS

This study found an age-related change in responsiveness to CCK-4. Further research to delineate the mechanism of this change is warranted.

Use of health services for anxiety disorders: a multisite study in Quebec

OBJECTIVE

We investigated patient characteristics and use of services for anxiety disorders among patients seeking care from participating clinicians at 7 anxiety clinics in Quebec: 3 general hospital clinics, 3 psychologist-run clinics, and one psychiatric hospital clinic.

METHODS

Persons eligible for the study were those who were visiting the clinics for the first time, had a current diagnosis of an anxiety disorder, and could communicate in French or English. Subjects recruited through advertisements were excluded. Data, collected by a self-administered questionnaire, included demographics, treatment history, use of services for anxiety, and the Beck Anxiety Inventory (BAI).

RESULTS

The sample comprised 235 subjects: 146 seen at 3 general hospital clinics, 54 at 3 psychologist-run clinics, and 35 at a psychiatric hospital clinic. There were statistically significant differences by clinic type in the prevalence of specific anxiety diagnoses, BAI score, referral source, antidepressant use, and use of services. High-intensity use (10 or more consultations during the previous year) was reported by 23.4% of the sample for medical services and 19.6% for mental health services. Multiple logistic regression identified variables associated with high-intensity use of medical services (higher BAI score, 1 to 4 years since first sought treatment, and less than 12 years of education) and high-intensity use of mental health services (clinic type, obsessive-compulsive disorder [OCD], and 5 or more years since first sought treatment).

CONCLUSIONS

The patient populations seen at different types of anxiety clinics differ in several respects, including referral source, previous treatment, and severity of symptoms. Regardless of type of clinic, patients with a longer time since they first sought treatment use more services, particularly mental health services. Those with less education use more medical services than those with greater education.

Mixed anxiety and depression: from theory to practice

The 10th International Classification of Disease (ICD-10) introduced the concept of mixed anxiety-depression to define patients presenting both anxiety and depressive symptoms of limited number and/or intensity, not sufficiently severe to fulfill criteria for a specific diagnosis of depressive or anxiety disorder. Epidemiologic surveys have shown that these patients may display significant levels of functional impairment, have unexplained somatic symptoms and a high use of nonpsychiatric medical care, have long-lasting symptoms, and are at risk for more severe psychiatric disorders. A DSM-IV field trial concluded that patients with affective-symptoms not meeting thresholds for DSM-III-R disorders were at least as common as patients with anxiety or mood disorders, and that their symptoms were associated with significant distress or impairment. Although some of these patients present residual symptoms from previous psychiatric episodes and may request treatment specific to these conditions, it is not known if those without a psychiatric history could benefit from pharmacologic or psychological treatments usually used in mild outpatient cases.

Elevated plasma levels of neuropeptide Y in patients with panic disorder

OBJECTIVE

Neuropeptide Y is a pancreatic polypeptide closely associated with noradrenergic activity both in the central and peripheral nervous systems. The objective of this study was to assess plasma neuropeptide Y-like immunoreactivity in panic disorder.

METHOD

Radioimmunoassays were performed in 12 patients with DSM-III-R panic disorder and two groups of normal comparison subjects (N = 22 and N = 16).

RESULTS

Markedly higher plasma neuropeptide Y-like immunoreactivity was found in patients with panic disorder.

CONCLUSIONS

Higher plasma neuropeptide Y-like immunoreactivity suggests that this peptide may be implicated in the etiology or expression of symptoms of panic disorder.

[Treatment of generalized anxiety: new pharmacologic approaches]

First defined as a residual diagnostic category in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Generalized Anxiety Disorder (GAD) was until recently one of the least studied and least clearly conceptualized of the anxiety disorders. The clinical definition of GAD has however improved up to the fourth edition of the DSM where the disorder is now characterized as a chronic state of apprehensive expectation and uncontrollable worry concerning multiple daily life events or activities and accompanied with at least 3 symptoms belonging to a list of six common manifestations of psychic or motor tension. Clinical research demonstrating the stability and the specificity of somatic symptoms clearly support the validity of the diagnosis of GAD despite possible difficulties in the differential diagnosis with other chronic conditions or axis II disorders such as dysthymia or mixed anxiety-depressive disorder. After benzodiazepines (BZD) and 5-HT1A agonists like buspirone, several other types of new anxiolytic drugs have been developed for the treatment of GAD. Partial agonists at GABA-BZD receptor sites may offer the advantage of a better efficacy vs side-effects ratio over classical BZDs; however, systematic comparative clinical trials will have to demonstrate the clinical relevance of the encouraging results obtained with these drugs, at the experimental level, during studies in healthy volunteers and during the first placebo-controlled trials. Furthermore, the recent description of GABA-receptor's subunits clearly suggest that the development of drugs acting at this level and devoided of psychomotor or withdrawal side-effects is a target that is worth pursuing. On the other hand, the development of 5-HT2 and 5-HT3 antagonists is also of interest for the treatment of GAD since it could provide new anxiolytic drugs without these side-effects and thus easier to administer on a long-term basis corresponding to the chronicity of GAD. However, it will also be important to know if wether or not the efficacy of these new drugs, like that of buspirone, is associated with some effects on depressive symptomatology, develops only progressively over time and is different in previous BZD users compared to GAD patients who did not receive BZD before the new drug. Among these drugs in development for GAD, the most likely to reach the market in a near future are a BZD partial agonist (abecarnil), 5-HT1A agonists like ipsapirone and 5-HT3 antagonists like ondansetron. However, another area of new developments concerning the drug treatment of GAD is the use of antidepressants, which have demonstrated efficacy in this indication even in patients without depressive features or panic attacks symptoms. Considering the chronic nature of GAD, these drugs, like those acting on the 5-HT-system, would be more adapted than BZD for the long-term management of this condition. If confirmed by clinical trials involving antidepressants other than tricyclics, the efficacy of these drugs in GAD may suggest that common neurobiological mechanisms are involved in the pathogenesis of both anxiety and depressive disorders. Despite the potential interest of these new treatments of GAD, recent years have shown that the development of new anxiolytic drugs often appears limited by high-rates of placebo response in numerous clinical trials. This phenomenon may be related--in part--to the increasingly sophisticated designs used in such trials, such as extensive diagnostic workups, repeated evaluations and inclusion criteria selecting the less severe types of anxiety. As emphasized by other authors, much more research needs to be done to establish what effects various ways of conducting a trial have on the trial's results in order to facilitate the emergence of new psychopharmacological approaches in the treatment of GAD.

Mixed anxiety and depression: diagnostic issues

Mixed anxiety and depression (MAD) is a new diagnostic category introduced in the ICD-10 classification for patients seen mainly in primary care settings. These patients are defined as those suffering from symptoms of anxiety and depression of limited and equal intensity accompanied by at least some autonomic features, who do not qualify for specific diagnosis of anxiety or depressive disorders and are independent of stressful life events. The validity of this clinical entity is presently under investigation in the DSM-IV-MAD field trial. Cases of mixed anxiety and depression, however, are not limited to those meeting the criteria of this new "subsyndromal" category. Many patients fulfilling criteria for either depressive or anxiety disorders may also respectively present symptoms, syndromes, or a diagnosis of anxiety or depression. It is still not known whether anxious and depressive symptoms are two different expressions of the same psychopathologic underlying process. Tyrer's recent description of a "general neurotic syndrome" is an attempt to reunify syndromes separated in our present classifications. In this comprehensive approach, anxiety, depression, or MAD states are associated at different times with specific personality features and considered as expressing different levels of overreactivity to various stressful situations. This hypothesis would explain the close relationship existing between these two categories of symptoms and the common efficacy of some psychopharmacologic agents for both anxiety and depressive disorders.

[Hemispheric functional specialization and anxiety. Focus on an evaluation procedure]

Observations of brain-lesioned patients and experimental psychology studies have shown that the influence of the specific functioning of the two hemispheres of the brain on the regulation of emotional behaviour appears to be unequal and suggests a functional specialization of the right hemisphere for the expression and comprehension of the affective components of behaviour. However, the extension of this hypothesis to include all emotional experiences remains controversial. The observed superiority of the left hemisphere in the perception of positive emotions and the predominance of the right hemisphere in the treatment of negative emotions would appear to favour a joint and complementary participation of both cerebral hemispheres in emotional experiences. In the case of affective disorders, and particularly in anxiety symptoms, the hypothesis of a dysfunctioning of the right hemisphere is similarly questioned: while all metabolic studies corroborate this hypothesis, experimental psychological studies suggest the existence of a preferential involvement of one or the other hemisphere in relation to individual differences such as the "trait" anxiety score. Moreover, the few studies which have been undertaken with healthy volunteers raise the problem of their extrapolation to pathological situations. In view of the potential interest in the neuropsychological evaluations of subjects with different forms of pathological anxiety, we have developed an experimented with two tests aimed at evaluating the differential activity of the two hemispheres of the brain. These two tests, constructed on a "mirror-image" model from the specifications of a functional hemispheric specialization, are supposed to involve cognitive strategies pinpointing preferentially one hemisphere or the other.(ABSTRACT TRUNCATED AT 250 WORDS)

Central benzodiazepine receptors in human brain: estimation of regional Bmax and KD values with positron emission tomography

Studies of central benzodiazepine receptors in the human brain in vivo are now possible using positron emission tomography (PET) and [11C]flumazenil. With the aim of measuring Bmax and Kd in brain regions, we used a two-injection [11C]flumazenil (at high and low specific radioactivity, respectively) pseudo-equilibrium paradigm to evaluate, in seven unmedicated healthy volunteers, the relative merits of three 'reference' structures (pons, hemispheric white matter and corpus callosum) in which the free radioligand concentration in brain tissue was estimated 15-40 min after i.v. injection of the radioligand. By means of high-resolution PET, the Bmax and Kd were calculated for each subject in 18 gray matter structures, based on a two-point Scatchard plot. We found that the use of the corpus callosum as reference often resulted in spurious Bmax and Kd values. The pons was the best reference structure because it provided satisfactory Bmax values (closest to in vitro data) and most consistent Kd values, and was the region easiest to sample on PET images. The pattern of regional Bmax was consistent with that expected from in vitro studies, with values highest in the cerebral cortex, intermediate in the cerebellum, and lowest in the striatum and the thalamus. The Kd values were uniform among regions and were consistent with earlier in vitro and in vivo data. This work documents the feasibility of estimating Bmax and Kd of central benzodiazepine receptors in multiple brain regions for clinical research.

[Panic disorder and microcirculation. Controlled study of capillaries in anxiety disorders]

However varied the clinical descriptions of anxiety, a sizeable proportion is always allotted to the cardiovascular aspect. One is reminded of Krishaber's cerebral-cardiac neuropathy and Brissaud's conception of anxiety. The implication of the heart in anxiety disorders, especially paroxystic disorder, i.e. panic attacks (PA) is important. Cardiovascular symptoms (tachycardia, increased systolic blood pressure, chest pain) are among the most frequent manifestations of panic; furthermore, recent studies suggest that male panic disorder (PD) patients have an increased mortality risk from cardiovascular diseases. It is with this implication in mind that we undertook this study, the main aim of which was to confirm the existence of an abnormal microcirculation, characteristic of PD, taking the form of an excess number of twisted capillaries. Abnormal capillaries had been described previously in non-controlled studies of patients with psychiatric disorders diagnosed as neurasthenia, neurosis, neurovegetative disorders and more recently as neurocirculatory asthenia, a syndrome similar to PD. This led us to undertake a study of the total number of capillaries observed by photomicrography (capillaroscopy) in the supra-ungueal fold of the fingers of both hands (except thumbs), comparing the number of twisted capillaries of 16 subjects suffering from panic disorder with or without agoraphobia according to the DSM III-R criteria, with those of 16 healthy volunteers matched for age and sex and 14 subjects suffering from other anxiety disorders (10 of them fulfilling criteria for generalized anxiety disorders).(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for hypothalamo-growth hormone dysfunction in panic disorder: profile of growth hormone (GH) responses to clonidine, yohimbine, caffeine, glucose, GRF and TRH in panic disorder patients versus healthy volunteers

Given the abrupt and time-limited nature of daytime-awake and nocturnal-sleep panic attacks, several chemical and neuroendocrine challenge tests have been employed to investigate the neurobiology of "spontaneous" panic attacks. Previously we demonstrated that panic disorder patients have blunted growth hormone (GH) responses to clonidine, an alpha 2-adrenergic agonist. However, the mechanism of this blunted response and the role of hypothalamic-GH dysfunction, if any, remains unclear. To further delineate the status of hypothalamic-GH function in panic disorder, we review the literature and present original data on the GH responses to a number of different chemical and neuroendocrine challenge paradigms. Although stress-mediated increases in GH are thought to be a common correlate of stress in humans, our findings indicate that panic disorder patients have significantly blunted GH responses to clonidine, yohimbine, growth-hormone releasing factor, and caffeine compared to normal control subjects. A similar trend was noted in the delayed rise in GH after glucose challenge. There was no difference in the rate of abnormal GH responses to thyrotropin-releasing hormone in panic disorder compared to normal control subjects. No drug or neuroendocrine challenge, even if associated with marked increases in anxiety, produced a significantly enhanced GH response compared to normal control subjects. These findings provide support for a hyporesponsive hypothalamic-GH system in panic disorder. These observations, combined with preliminary observations from our clinic of short stature in several cases of prepubescent children with anxiety disorders, also underscore the need for assessing early growth patterns in individuals with panic disorder. Strategies for investigating the site(s) of possible neurotransmitter or hypothalamic-GH-somatomedin dysfunction are discussed.

[Benzodiazepines in the treatment of anxiety]

During the last ten years, the treatment of anxiety disorders has changed considerably. Cognitive-behavioural therapies and new chemotherapies have been added to benzodiazepine therapy and psychotherapy which for a long time had been the only treatment of these frequent and invalidating disorders. Recent reports of possible drawbacks in prolonged benzodiazepine therapy provide another reason to reconsider the indications of these drugs now that other drugs are available. Benzodiazepines remain the treatment of choice for recent anxiety states requiring some degree of sedation and rapid relief, but their long-term administration should be reserved to patients who did not respond to other treatments. The authors propose several guidelines for a better prescription of these anxiolytic agents and for more rational indications taking into account the advantages of other available treatments.

Compared efficacy of prazepam and clomipramine in major depression with anxiety: a multicenter controlled study

The efficacy of antidepressants is well established in major depressions, especially those with melancholic features. However, some anxiolytics also appear to have antidepressant properties at least for outpatients. 118 outpatients (25 males, 93 females, age: 18-60) with major depression according to DSM-III criteria, neither melancholic nor suicidal, reaching at least 27 on Montgomery and Asberg depression rating scale (MADRS) and 19 on Hamilton anxiety rating scale (HARS) accepted to participate this double blind study carried out by 15 G.P.s coordinated by 3 psychiatrists. After a one week placebo wash-out-single-blind period, they were randomly, double blind, assigned to one of the two following groups: PR treated with prazepam (30-60 mg), a benzodiazepine anxiolytic or CL treated clomipramine, an imipramine antidepressant (75-150 mg). Patients were evaluated at days 0, 7, 14, and 28, using MADRS, HARS, Clinical Global Impression and Hopkins symptoms check list 58. In addition, G.P.s had to meet monthly for a case discussion group.

RESULTS

groups were comparable at day 0. A highly significant improvement of MADRS and HARS scores (p less than 0.001) was observed in the total population. For the completer population evolution was also significantly positive in all the parameters studied but, considering MADRS and HSCL scores, a difference in favor of CL is observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Beta-blocking drugs and anxiety. A proven therapeutic value]

The therapeutic value of propranolol and other beta-adrenergic receptor blockers in anxiety disorders is reviewed. The potential side-effects of benzodiazepines, eg psychomotor impairment and dependance, suggest that the main indicators of these compounds are the acute anxiety states and the short term treatment of anxiety disorders requiring sedation. Thus, other psychotropic drugs may be of potential value in the treatment of these disorders. The results of the placebo-controlled studies reviewed here strongly suggest that propranolol is useful in the treatment of anxiety disorders, especially those: 1) characterized by the presence of somatic symptoms related to increased adrenergic tone; 2) of moderate intensity and/or seen in general practice; 3) of recent onset and not fulfilling DSM III criteria for specific chronic anxiety disorders. Propranolol and other beta-blockers may also be useful in the prevention of performance anxiety such as the fear of speaking in public or specific social phobias when limited in number in the same patients. Average therapeutic doses range from 20 to 40 mg, once to three times a day; the clinical efficacy of beta-blockers administered for periods longer than 4 weeks remains to be demonstrated. The potential impairment of cognitive functions by propranolol is still a matter of controversy as well as its ability to induce depressive states in predisposed patients. Furthermore, the efficacy of beta-blockers that do not cross the blood-brain barrier in the treatment of anxiety raises unresolved questions concerning the mode of action (central vs peripheric) of these medications. In short, beta-blocking agents, and especially propranolol, should be considered as potential therapeutic agents in the pharmacological treatment of anxiety disorders besides benzodiazepines, antidepressant compounds and the newer azapirones, eg buspirone.

Striatal D2 dopaminergic receptors assessed with positron emission tomography and [76Br]bromospiperone in untreated schizophrenic patients

Striatal D2 dopaminergic receptors of 12 drug-free schizophrenic patients and 12 normal subjects were investigated with positron emission tomography and [76Br]bromospiperone. Patients were classified according to DSM-III criteria, and their clinical symptoms were rated according to Andreasen's negative and positive symptom scales. The ratio of striatal to cerebellar radioactivity was taken as an index of striatal D2 dopamine receptor density. There was no significant difference between the control subjects and the overall schizophrenic group and no significant relationship between this index and the symptom ratings. However, state-dependent variables could partly account for the striatal D2 receptor density variability.

Anxiety disorders in a French general psychiatric outpatient sample. Comparison between DSM-III and DSM-IIIR criteria

In a general psychiatric outpatient sample (n = 1271) gathered through a cross-national French survey, anxiety and somatoform syndromes were assessed according to DSM-III and DMS-III-revised criteria. Lifetime and one-month prevalence rates in this population are provided and the high level of comorbidity between the anxiety syndromes is noted. The patient symptom profiles for panic syndrome, simple attacks, agoraphobia and generalized anxiety are displayed. The conspicuous consequences of the modifications brought in by the Revision-anticipatory anxiety in panic syndrome, and restricted period criteria for generalized anxiety- are discussed, with the conclusion that more field study assessment is required before further revision.

Substantial rise in sparteine metabolic ratio during haloperidol treatment

A sparteine test was carried out in 14 patients suffering from acute schizophrenic psychoses before and 1-2 times during oral haloperidol treatment in doses of 10-40 mg day-1. In patients classified as extensive metabolisers (sparteine MR less than 20 before treatment), haloperidol treatment resulted in a rise in sparteine MR that correlated with the serum-haloperidol concentration both within and between patients. At the highest serum haloperidol concentrations (60-80 nM) an increase in sparteine MR by a factor 15-50 was seen, but no patients were transformed into phenotypically poor metabolisers. The steady state concentration of haloperidol on the initial standard dose of 10 mg day-1 was the same in one patient classified as a sparteine poor metaboliser (MR = 112) as in eleven patients classified as extensive metabolisers (MR:0.22-1.47).

Caffeine withdrawal affects central adenosine receptors but not benzodiazepine receptors

The effects of chronic caffeine administration on both adenosine and benzodiazepine receptors were studied in mouse brain membranes. Animals were fed on a diet enriched with caffeine (600 mg/kg diet) for 15 days and sacrificed 2, 4, 8 and 15 days after withdrawal. Compared with controls fed on a regular diet, animals receiving a caffeine-enriched diet showed an increase in the number of brain adenosine receptors labeled with [3H]-DPX in both the cerebellum and forebrain regions. This up-regulation was still significant 15 days after withdrawal in the cerebellum but not in the forebrain, where the number of adenosine receptors returned to control levels within 8 days following withdrawal. Benzodiazepine receptors labeled by [3H]-B-CCE were not influenced by chronic caffeine diet or withdrawal.

Behavioral and physiologic effects of short-term and long-term administration of clonidine in panic disorder

We evaluated the behavioral and physiologic effects of clonidine hydrochloride, a centrally active alpha 2-adrenergic agonist, in two separate studies of patients with panic disorder. In the first study, intravenous clonidine (2 micrograms/kg) and placebo were administered on a blind basis to 12 patients with panic disorder and ten normal controls. Clonidine produced significantly greater decrements in anxiety at one hour in the patients with panic disorder than in the controls. The changes in pulse, blood pressure, and ratings of sleepiness did not differ significantly between patients and controls. In the second study, oral clonidine was administered to 18 patients in a double-blind, flexible-dose treatment trial averaging ten weeks in duration. While anxiolytic effects were noticed in some patients, these effects did not persist in the group as a whole. These two studies indicate that while clonidine has short-term anxiolytic effects in patients with panic disorder, these effects do not persist with long-term administration in most patients.

Buspirone and diazepam: comparison of subjective, psychomotor and biological effects

The effects of oral buspirone (BUS, 10 mg) and diazepam (DZP, 10 mg) were studied in 12 healthy women volunteers using subjective ratings, objective tests of psychomotor and cognitive functions and urinary dosage of catecholamine output. Drugs were randomly administered to the same subjects, in a crossover, double-blind study, each drug administration being separated by at least 1 week. BUS subjective effects were less severe than those of DZP and not accompanied by feelings of sleepiness that characterized DZP sedative effects. Furthermore, BUS did not impair psychomotor functioning while DZP induced both an impairment of central sensory processing and, to a lesser extent, an impairment in delayed memory.

Striatal dopamine receptor occupancy during and following withdrawal from neuroleptic treatment: correlative evaluation by positron emission tomography and plasma prolactin levels

The percentage occupation of striatal dopamine D2 receptors has been evaluated in 25 patients using 76Br-bromospiperone positron emission tomography (PET) and prolactin plasma levels (PRL) during oral neuroleptic treatment (11 studies), 1-90 days following discontinuation of such treatment (16 studies), and 1-120 days after last intramuscular administration of depot neuroleptics (nine studies). The PET-estimated occupation was highly significantly correlated in a sigmoid-like fashion to the logarithm of the chlorpromazine-equivalent dose of oral neuroleptics (suggesting a strict dose-occupation relationship during oral neuroleptic treatment and supporting the D2-mediated hypothesis of neuroleptic action), while PRL was weakly related to daily dosage. Following withdrawal, return to normal receptor availability, as estimated by PET, occurred within 5-15 days (suggesting that protracted effects of neuroleptics after withdrawal are not due to sustained D2 receptor occupation), but PRL values fell even more rapidly. Efficient treatment with depot neuroleptics resulted in marked PET-estimated D2 receptor occupation, stable over the whole 4-week drug-administration interval, suggesting that longer intervals could be appropriate; PRL values bore no relationship to PET-estimated occupation, indicating variable intersubject tolerance to neuro-endocrine dopamine blockade. Overall, PET was much more sensitive than PRL to estimate striatal D2 receptor occupation in vivo.

[Caffeine and EEG mapping: effects of visuo-spatial task in healthy volunteers]

A group of 10 subjects, normal volunteers (6 men, 4 women), mean age 27.2 years, right-handers, has been selected for a double-blind study of caffeine effects (400 mg per os) versus placebo. One week delay separated the two EEG sessions quantified by spectral analysis. During each session (16 EEG channels, common reference), each subject was recorded four times: 2.5 min, in eyes-closed condition, under diffuse attention, followed by 2.5 min, during a visuo-spatial task ("eyes open" condition: presentation of a picture). These two EEG recordings were obtained before the oral administration and repeated 1 hr after the administration of caffeine or placebo. Individual and group results presented globally: 1) an increase in mean frequencies of alpha activity in "eyes closed" condition, and of delta activity in "eyes open" condition; 2) a decrease of alpha activity amplitudes (both RMS and % values) in both conditions; 3) a decrease of total RMS amplitudes in "eyes closed" condition; 4) an increase of relative % amplitudes for beta 2% fast activity in the "eyes open condition". These results characterize the psycho-stimulant effects of caffeine, especially over the left temporal area which was confirming an initial statistical hypothesis of specific cerebral local activation. The non-parametric permutation tests of Fisher, were not always reaching statistical significance for the same EEG channel quantified by one of the 17 analyzed spectral parameters, except on the left temporal area. During the visuo-spatial task, the decrease in alpha amplitudes (RMS and %) was also statistically significant, but over larger areas: over left and right temporal, central and parietal regions. In both conditions, eyes closed and eyes open, the alpha RMS amplitude was also decreased over the right anterior frontal area.

[Buspirone: pharmacological and clinical properties of the first member of a new anxiolytic drug family]

Buspirone is a new anxiolytic agent with an original chemical structure. Its activity in doses of 15 to 30 mg per day has been demonstrated in patients presenting with manifestations of generalized anxiety. Its mode of action is still imperfectly known; in animals, it influences several neuromediator systems but does not act on benzodiazepine receptors. Its main pharmacokinetic features are: complete absorption when given orally, short half-life (4 to 8 h), reduced plasma clearance in patients with hepatic cirrhosis or renal impairment and no major interaction with most of the other psychotropic drugs. Controlled clinical studies have provided evidence of its anxiolytic properties; against anxiety symptoms buspirone has proved more effective than placebo and as effective as several reference benzodiazepine derivatives, with a lesser incidence of sedative effects. However, it is not effective in the treatment of benzodiazepine withdrawal. Gastrointestinal disorders and moderate headache have been reported in less than 10 p. 100 of the patients treated. Administered acutely, buspirone does not seem to alter cognitive mechanisms. Unlike benzodiazepines, it does not potentiate the effects of alcohol and does not lead to drug-dependence. Its usefulness in panic disorders, anxious-depressive states and obsessional symptoms remains to be determined.

In vivo assay for neuroleptic receptor binding in the striatum. Positron tomography in humans

Using PET, we investigated the potency in six patients of therapeutic doses of neuroleptic drugs for preventing specific binding of trace doses of intravenously administered 76Br-labelled bromospiperone to corpus striatum in vivo. Measured receptor occupancy showed a clear-cut dose-dependent saturation curve with increasing daily oral dose of neuroleptics, indicating the validity and reliability of the method when used as an in vivo radioreceptor assay. Following drug withdrawal in eight patients, recovery to normal or supranormal receptor availability occurred in a matter of days. The results demonstrate an approach that may help resolve controversies about, and design better strategies for, neuroleptic treatment schedules.

Plasma adenosine levels: measurement in humans and relationship to the anxiogenic effects of caffeine

The effects of caffeine on plasma adenosine were examined in eight healthy normal volunteers. Subjects were randomly administered on 4 separate days, in a double-blind fashion, either placebo or three different doses of caffeine (240, 480, and 720 mg). Adenosine concentrations, measured by high performance liquid chromatography, were in the micromolar range when samples were drawn into tubes containing dipyridamole to prevent adenosine reuptake by red blood cells. Plasma adenosine levels did not change after caffeine administration. The effects of caffeine on anxiety were related to changes in plasma caffeine but not plasma adenosine levels. The potential interest of caffeine as a chemical model of anxiety is discussed.

[Acute anxiety attacks and phobia. Historical aspects and clinical manifestations of the agoraphobia syndrome]

This article describes the evolution of the concept of agoraphobia since its initial description in 1871 until its inclusion in the most recent american diagnostic classifications. In most cases, agoraphobia appears to be secondary to the occurrence of repeated panic attacks, that may also lead to the development of chronic generalized anxiety or hypochondriac syndromes. The main clinical, biological and therapeutic features of panic disorders, a clinical entity that is part of the previous syndromes, are reviewed and discussed according to the most recent studies. Panic disorders appear to be distinct from mood disorders but their relationship to other anxiety disorders is still a matter of controversy.

Platelet [3H]imipramine binding in patients with panic disorder

[3H]imipramine binding to platelets was measured in 17 drug-free panic disorder patients and 14 healthy controls. No difference in Bmax or Kd values was found between the two groups. Patients with a past history of major melancholic depression or severe agoraphobia had similar binding parameters as panic disorder patients without a history of depression or severe agoraphobia.

[Lithium]

Lithium salts are used in psychiatry, for their sedative properties in states of agitation and, above all, for their ability to prevent recurring manic and depressive episodes in manic-depressive psychosis. In addition to manic-depressive psychosis, lithium is used as an antidepressant and the treatment of aggressive behaviors. Pharmacologic characteristics of lithium are incompletely elucidated; a few sedative and antiaggressive properties have been demonstrated in animals, but lithium fits into none of the known classes of psychoactive agents. Following absorption into the body, lithium does not bind to proteins. Penetration through the blood-brain barrier is poor. Elimination is mainly through the kidneys. Penetration of lithium into cells seems to vary across individuals. Lithium has a number of neurochemical effects, including stabilization of the number and sensitivity of monoaminergic receptors, which may be the mechanism for the drug's therapeutic properties. The main rule of lithium treatment is to achieve serum levels between 0.6 and 1 nM/l. Before starting a patient on lithium, tests are needed, especially to assess renal function: patients with renal failure are at risk for accumulation of lithium with toxic side effects. Most of the side effects are minor. The only serious risk is hyperlithemic intoxication that may cause mental confusion, coma and death. Lithium may induce malformations if given during the first trimester of pregnancy. The only true contraindications to lithium are renal failure, treatment by thiazide diuretics, and organic brain disease.

Basic and clinical aspects of adenosinergic neuromodulation

Adenosine and the methylxanthines have marked and opposite effects on behavior both of which are now thought to be mediated by cell surface adenosine receptors present in brain. These receptor sites have now been characterized using simple radioreceptor ligand binding techniques. Pharmacologic, autoradiographic and behavioral studies involving adenosine and the methylxanthines strongly suggest a neuromodulatory role for adenosine and indicate that adenosinergic neurons constitute an important central nervous system depressant system. A key component of the adenosinergic system is the adenosine uptake site which represents the inactivation mechanism for receptor mediated adenosine action. The adenosine uptake site can be identified as distinct from the adenosine receptor using a specific ligand. The two key components of the adenosine system, i.e., the receptor and uptake site, can therefore be studied using simple binding techniques. This should facilitate the development of new drugs specific for each system. Adenosine agonists can be expected to have sedative, anticonvulsant and anxiolytic actions whereas adenosine antagonists such as caffeine have stimulant and anxiogenic properties. Adenosine uptake blockers should have pharmacologic actions similar to adenosine agonists. The adenosinergic system, therefore, offers unique opportunities for developing new and potentially useful clinical agents.

Longitudinal course of panic disorder: clinical and biological considerations

The longitudinal course of panic disorder and its associated symptoms were investigated in thirty-eight patients. The temporal relationships among panic attacks, generalized anxiety, agoraphobia and depression are described. Similar and different biological alterations in the tricyclic-responsive disorders of primary depression and panic disorder are reviewed and discussed.

Transient sensory, cognitive and affective phenomena in affective illness. A comparison with complex partial epilepsy

Behavioural changes have often been noted in patients with epilepsy. This study investigated the converse phenomenon--the occurrence of transient sensory, cognitive and affective changes resembling those described by epileptics, in affectively ill patients. Forty-four patients with affective illness, 37 with complex partial seizures, and 30 hypertensive controls were interviewed to determine the lifetime occurrence of these phenomena. Such symptoms occurred frequently in association with episodes of affective illness and epilepsy, but were rare in controls. Visual, auditory, olfactory and epigastric symptoms, illusions, jumbled thoughts and amnesia were common to both epilepsy and affective illness. Greater numbers of symptoms were associated with better response to lithium and tricyclic antidepressants. Transient sensory, cognitive, and affective phenomena may be more common in affective illness and other psychiatric conditions than is generally recognised, and may be clues to the underlying pathophysiology of these conditions.

Increased sensitivity to caffeine in patients with panic disorders. Preliminary evidence

The results of a caffeine consumption inventory indicated that patients with panic anxiety disorder, but not affectively ill patients or normal controls, had levels of self-rated anxiety and depression that correlated with their degree of caffeine consumption. In addition, this self-report survey suggested that patients with panic disorder had an increased sensitivity to the effects of one cup of coffee. This apparent sensitivity to caffeine was also documented by the observation that more patients with panic disorder reported the discontinuation of coffee intake due to untoward side effects than controls. These results, based on self-reports, suggest that the hypothesis that patients with panic disorder are more reactive to caffeine should be directly tested using caffeine challenges and that the mechanisms underlying caffeine's effects on anxiety should be further explored.

The sleep of patients with panic disorder: a preliminary report

Electroencephalographic sleep recordings were compared in patients with panic disorder and normal controls. Correlation coefficients of standard sleep parameters versus ratings of anxiety, depression, and panic attack frequency were calculated in the panic-anxious patients. Overall findings are discussed in the context of previous sleep studies in patients with depressive, anxiety, and obsessive-compulsive disorders.

Effects of chronic caffeine on brain adenosine receptors: regional and ontogenetic studies

The effect of chronic caffeine treatment on three different binding sites in five brain areas of mice is characterized. The sites studied were the adenosine receptor, using [3H] diethylphenylxanthine, the benzodiazepine receptor, using [3H] diazepam and the adenosine uptake site, using [3H] nitrobenzylthioinosine. Significant increases were only observed in adenosine receptors with the greatest degree of change seen in the cerebellum and brain stem at both 16 and 23 days of caffeine treatment. The lack of significant effects of chronic caffeine on benzodiazepine receptors and adenosine uptake sites indicates that the caffeine effect is specific. The effect of chronic caffeine treatment on the ontogeny of adenosine receptors was also studied with the result showing a significantly accelerated development of the receptor in the caffeine treated animals. The adult adenosine receptor levels were 20-30% higher than those observed in control animals. The observed alterations in adenosine receptor number which occur as a consequence of caffeine consumption may underlie some of the behavioral effects of this cortical stimulant as well as provide insights concerning the mechanisms of tolerance to and dependence on caffeine.