Case report: crowned dens syndrome in a patient with seronegative rheumatoid arthritis

Chondrocalcinosis (CC) is the one of the most common crystal pyrophosphate disease associated arthritis in the elderly. It has been shown to coexist with seronegative and seropositive rheumatoid arthritis (RA), yet mostly with seronegative RA. Among the localisation of CC, the deposition in the ligaments surrounding the odontoid process may remain asymptomatic for years or may lead to and acute severe symptomatology, which may mimic several clinical illnesses among which meningitis (fever, severe pain, acute phase reactants). This is called the 'crowned dens syndrome (CDS)', which has been reported to represent an important percentage of acute neck pain needing hospital admission in neurosurgery units. In this case, the rapid demonstration of 'crowned dens' through CT scan may allow to avoid lumbar puncture and cerebrospinal fluid examination. The coexistence of RA and CDS is very rare, and rarely reported in the literature, yet it may represent a clinical challenge. We describe here one case that while on therapy with methotrexate (MTX) and naproxen (NPX) had an acute neck pain, and peripheral arthritis flare, that responded well to colchicine given along with MTX and NPX.

A blemish on bipolar disorder: aggressive behaviour

Introduction

Many studies have searched for an association between violence and psychiatric diagnoses, without providing a confirmative result.

Objectives

We have sought to deepen this topic, analysing different aspects of aggressivity, focusing on a specific diagnosis and its particular phases of illness, and looking for a correlation between psychiatric co-diagnoses and outpatients’ visits adherence.

Methods

We studied 151 bipolar type I inpatients presenting complaint, past medical and family history; we collected information about lifetime hetero/self-aggressive behaviours, irritability, agitation, suicide attempts, alcohol, or substance abuse.

Results

The overall aggressivity in our sample resulted in 11.92% of cases, while the number of aggressive episodes during euthymia decreased to 2.64%, close to the population without psychiatric disorders. Personality disorders and alcohol abuse appeared to be the main risk factors for irritability [Fig. 1]; substance abuse for both irritability and hetero-aggressive behaviour [Fig. 2]. We observed that subjects who displayed better compliance to follow-up visits exhibited a significant lower aggressive behaviour than less adherent subjects. Moreover, our data disconfirm the common conception that correlates the presence of psychotic features to violence.

Conclusions

Studying aggressive in a bipolar population, we observed that the rare episodes of aggressiveness were condensed in active phases of illness and mainly related to alcohol or substance abuse, while violent acts during long periods of wellbeing appear in line with those of the general population. We are confident our data might be helpful in deconstructing the stigma that a psychiatric diagnosis equals to violent behaviour.

Disclosure

No significant relationships.

Clinical efficacy and tolerability of Esketamine: a case series

Introduction

Esketamine is a novel antidepressant approved by the FDA in 2019 in the form of an intranasal spray, recommended for Treatment-Resistant Depression (TRD). The intranasal spray system appears to be more manageable than intravenous ketamine infusion. It contains ketamine’s S- isomer which is four-fold more potent for the NMDA receptor.

Objectives

The aim of this case series is to describe our clinical experience in the use of Esketamine.

Methods

6 TRD patients (3 men; 3 women) were recruited in San Raffaele Turro Hospital from March 2021. All patients (2 bipolar and 4 unipolar) were diagnosed with a Major Depressive Episode according to DSM-5 criteria, resistant to at least two antidepressants. Initially, Esketamine was administrated twice weekly for one month; afterward, it was administrated once weekly for a month; finally, it was administrated once weekly or every two weeks for a month. Clinical scales (HAM-D, YMRS, SSI, HAM-A, MADRS, CADSS) were administrated to assess symptoms and sides effects before and after each administration on a weekly basis.

Results

Three patients out of six showed an improvement in depressive symptoms: two patients had remission (final HAM-D score < 8); one patient had a clinical response (final HAM-D score < 50 % respect baseline value). Three patients withdrew the treatment: two for perceived inefficacy, after 16 and 19 administrations, one for personal reasons.

Conclusions

The use of Esketamine in our TRD patients showed good effectiveness and tolerability but randomized controlled clinical trials are needed to confirm our findings.

Disclosure

No significant relationships.

Resistance or pseudo-resistance?

Introduction

Treatment-Resistant Depression continues to represent a great challenge for clinicians.

Objectives

We investigated patients with history of resistance, assessing prognostic factors, response to treatments, and remission over time.

Methods

We recruited 202 unipolar and bipolar depressed inpatients. According to anamnestic backgrounds, patients were assigned to: A) Non-resistant : responders, with no characteristics of resistance in the current episode. B) Resistant: resistant to two antidepressant trials of adequate doses and duration. C) Pseudo-resistant : non-responders, not classifiable as Resistant because of inadequate trials. During hospitalization, patients were treated by clinical judgment, following a rehabilitation program.

Results

Table 1 Non-resistant (111) Resistant (54) Pseudo-resistant (35) p-value Age 59.1±11.9 63.0±12.6 57.0±11.3 0.036* Episodes of illness 3.8±2.1 4.0±1.9 3.0±1.8 0.036* Personality disorders 27.0% 18.9% 48.6% 0.009** Therapies: 0.014** SSRI 62.4% 40.4% 69.7% SNRI 19.8% 42.3% 15.1% TCA 17.8% 17.3% 15.1% Augmentation 24.3% 38.9% 17.1% 0.05** Remission 76.5% 59.5% 81.2% CvsB:0.045** CvsA:0.587**

On the day of admission, non-responders were 44.5% of the sample, but 39.3% of them did not meet the Resistant criteria, defining the Pseudo-resistant group. Pseudo-resistant differed from others by younger age, fewer illness episodes, higher rate of personality disorders, and different therapies during hospitalization [Fig.1,2,3]. Pseudo-resistant remission rate, significantly greater than Resistant one, was comparable to Non-resistant [Tab.1]. *Kruskal-Wallis Test **Chi-Squared Test

Conclusions

This study outlines a new group of depressed patients that, apparently drug-resistant, displays the same outcome as responders when treated with first-line drugs during hospitalization, certainly taking benefit from the psychoeducational program. Quick recognition of these patients could be crucial to giving optimal care.

Disclosure

No significant relationships.

Manic switch in bipolar patients treated with electroconvulsive therapy for treatment-resistant depression: The experience at the mood disorder unit of Milan (Italy)

Introduction

Despite appropriate treatment, 30–40% of depressed patients, both unipolar and bipolar, do not achieve improvement, with high morbidity and mortality. For bipolar patients another risk is the switch into mania due to antidepressant treatment. The concern about the switch, suggests to administer antidepressants at lower doses, in combination with mood stabilizers and second generation anti-psychotics.

Objectives

We performed an observational study on a sample of 23 bipolar patients treated with ECT for severe TRD in last 3 years, in order to evaluate the risk of switch.

Methods

Twenty-three bipolar inpatients, undergoing bitemporal ECT twice/week, with MECTA spectrum device. Main demographic and clinical data collected. Hamilton rating scale for depression (HAM-D). Clinical response defined as 50% reduction of HAM-D score at the endpoint from baseline; remission as HAM-D score at the endpoint < 8. Young Mania rating scale (YMRS) weekly in order to assess switch into mania.

Results

Thirteen (56.5%) females, 10 (43.5%) males, mean age 60.1 ± 10.3 years. Mean age at onset 35.5 ± 13.6 years. Mean number of episodes: 7.1 ± 3.6. Mean duration of current episode: 33.4 ± 24.9 weeks. Mean HAM-D basal score: 30.0 ± 5. Each patient underwent a cycle of ECT (mean No. 6.7 ± 3.3). Pharmacological treatment was administered upon clinical need. Response rate 87%, remission rate 43.5%. Three out of 23 (13.04%) patients had transient hypomanic switch, spontaneous recovery within 7 days after the last ECT.

Conclusions

Our experience confirms that ECT is a powerful antidepressant, especially in patients with severe long-lasting depression, refractory to treatment. ECT is also a safe procedure: no adverse effects were reported. The manic switch rate is comparable with antidepressant drugs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A symptom-specific analysis of the effect of high-frequency left or low-frequency right transcranial magnetic stimulation over the dorsolateral prefrontal cortex in major depression

BACKGROUND

We have investigated the efficacy of high-frequency left (HFL) versus low-frequency right (LFR) repetitive transcranial magnetic stimulation (rTMS) in depression, focusing on specific symptoms as possible predictors of outcome for these two different types of stimulation.

METHOD

Seventy-four outpatients with a major depressive episode treated with an adequate antidepressant dosage for at least 4 weeks were included in our study and randomly assigned to two different groups: HFL or LFR rTMS. The Hamilton Rating Scale for Depression (HAM-D) items were pooled into 6 factors to evaluate specific symptoms as possible predictors of response.

RESULTS

Twenty-one out of 32 patients (65.6%) and 24 out of 42 patients (57.1%) were responders in the HFL and LFR groups, respectively. No significant difference in response rate was observed. Considering the whole sample, we found an inverse correlation between activity and HAM-D score reduction and a significant positive relation between somatic anxiety and outcome. An inverse correlation between psychic anxiety and HAM-D score reduction emerged considering the HFL group. In the LFR group, there was a significant negative relationship between baseline activity and the outcome.

CONCLUSION

These findings support the hypothesis that LFR rTMS could be as effective as HFL rTMS and more suitable for patients with a higher anxiety degree, particularly in bipolar patients.

Response to SSRIs and role of the hormonal therapy in post-menopausal depression

The aim of this study is to prospectively evaluate the antidepressant response to SSRIs in depressed post-menopausal women with or without hormonal therapy (HT), and to analyze the possible influence of basal serum levels of gonadotropins and sexual hormones on the antidepressant response. 170 post-menopausal women with a depressive episode (DSM-IV criteria)--47 on HT and 123 not on HT--started the treatment with an SSRI. Depressive symptoms were assessed at baseline and 7 weeks thereafter by raters blind to treatment regimen. Response rates were 63.2% in the group without HT and 83.7% in the HT group (p=0.013). An inverse correlation emerged between the basal levels of LH and the improvement in HRSD scores (p=0.001) in the group without HT. In conclusion, HT appeared to improve the antidepressant response to SSRIs. Furthermore, in post-menopausal women, LH basal levels may be taken into account as possible predictor of response.

A double-blind, randomised, controlled clinical trial of acetyl-L-carnitine vs. amisulpride in the treatment of dysthymia

AIM

Evaluation of the effect of acetyl-L-carnitine (ALCAR) vs. amisulpride measured by total Hamilton Depression Rating Scale score (HAM-D(21)) in patients with pure dysthymia (DSM IV). Two hundred and four patients were randomised and treated with ALCAR 500 mg b.i.d. or amisulpride 50 mg u.i.d. in a double-blind study, for 12 weeks.

RESULTS

A solid improvement of HAM-D(21) was observed in both treatment groups throughout the study. The results did not disclose statistically significant differences between treatments, although the confidence interval for the non-inferiority of the primary end-point exceeded the pre-established limit of 2 by 0.46 points. According to a non-inferiority margin of 3 (considered acceptable by recent published data) the primary end-point could have been fully satisfied. CDRS, MADRS and CGI, employed to further measure the clinical outcome, reported similar results in both treatment groups. The greater tolerability of ALCAR is of clinical relevance considering the chronicity of dysthymia, which often requires prolonged treatment.

Staging of pelvic endometriosis based on MRI findings versus laparoscopic classification according to the American Fertility Society

BACKGROUND

Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offers a prognosis to patients. We compared a staging system of pelvic endometriosis based on magnetic resonance imaging (MRI) findings with the American Fertility Society (AFS) laparoscopic classification.

METHODS

Forty-four consecutive females with clinically suspected endometriosis underwent MRI examination to demonstrate the presence of endometriomas and pelvic implants. Laparoscopy was performed within 2 weeks. An MRI score was developed to classify endometriosis into four classes comparable to those of AFS laparoscopic staging. Concordance between MRI and laparoscopic classification was evaluated with kappa statistics.

RESULTS

Laparoscopy confirmed 60 of 61 endometriomas detected by MRI. Implants were discovered in 20 of 44 patients with MRI and in 23 of 44 with laparoscopy. MRI detected 50 endometrial implants of 65 detected by laparoscopy (76.9%). With regard to endometriosis staging, we obtained a concordance between MRI and AFS classification in 42 of 44 patients (kappa = 0.913).

CONCLUSION

Although MRI has limitations such as suboptimal depiction of small implants and adhesions, this technique is very useful to guide laparoscopy. Moreover, the optimal concordance (95%) between our proposed MRI staging and the AFS laparoscopic classification demonstrated a new advantage of MRI in preoperative staging of endometriosis.

Pseudomesotheliomatous angiosarcoma of the chest wall and pleura

Angiosarcoma is a rare soft tissue sarcoma that usually occurs in deep soft tissues, breast, spleen, liver, and bone. Primary thoracic parietal localization of angiosarcoma is rare and prognosis is poor. In this report, we present the CT and PET features of a patient with pseudomesotheliomatous angiosarcoma of the chest wall and pleura, which, to the best of our knowledge, have not previously been described.

Staging of pelvic endometriosis using magnetic resonance imaging compared with the laparoscopic classification of the American Fertility Society: a prospective study

PURPOSE

To introduce a staging of pelvic endometriosis based on Magnetic Resonance Imaging (MRI) features, compared with the American Fertility Society (AFS) laparoscopic classification.

MATERIALS AND METHODS

Thirty-five consecutive females with clinically suspected endometriosis underwent MRI examination using TSE T1, T2W, and SE FAT-SAT T1W sequences, to demonstrate the presence of endometriomas and pelvic implants. Laparoscopy was performed within two weeks (mean 8 days) of the examination. A radiologist experienced in pelvic pathology evaluated the presence of endometriomas and implants and calculated a score to classify endometriosis in four classes, comparable with those of AFS laparoscopic staging. The MRI score was based on size, edges, wall thickness, septations, signal intensity on T2-weighted images of endometriomas and presence of pelvic implants. The concordance between MRI and laparoscopic classification was evaluated using k-statistics.

RESULTS

Laparoscopy confirmed 47/48 endometriomas, ranging in size from 10 to 62 mm, detected by MRI, with only one false positive due to an hemorrhagic corpus luteum. Nevertheless, 2 intra-ovarian endometriomas were detected by laparoscopy only thanks MRI guidance. Implants were discovered in 17/30 patients with MRI, laparoscopically in 18/30. MRI detected 46 endometrial implants out of 57 detected by laparoscopy (80.7%): 17/46 implants were directly confirmed by laparoscopy, 29/46 were indirectly confirmed by the presence of adhesions. As regards staging, there was agreement between the MRI and AFS classification in 33/35 patients with only two case of discordance (K= 0,892).

CONCLUSIONS

Although MRI has limitations such as suboptimal depiction of small implants and adhesions, this technique is very useful for guiding laparoscopy. Moreover, the high level of agreement (96.6%) between the MRI staging proposed in this paper and laparoscopic classification demonstrates a further advantage of the use of MRI in the preoperative staging of endometriosis.

Detection of liver metastases: comparison of gadobenate dimeglumine-enhanced and ferumoxides-enhanced MR imaging examinations

PURPOSE

To compare gadobenate dimeglumine (Gd-BOPTA)-enhanced magnetic resonance (MR) imaging with ferumoxides-enhanced MR imaging for detection of liver metastases.

MATERIALS AND METHODS

Twenty consecutive patients known to have malignancy and suspected of having focal liver lesions at ultrasonography (US) underwent 1.0-T MR imaging with gradient-recalled-echo T1-weighted breath-hold sequences before, immediately after, and 60 minutes after Gd-BOPTA injection. Subsequently, MR imaging was performed with turbo spin-echo short inversion time inversion-recovery T2-weighted sequences before and 60 minutes after ferumoxides administration. All patients subsequently underwent intraoperative US within 15 days, and histopathologic analysis of their resected lesion-containing specimens was performed. Separate qualitative analyses were performed to assess lesion detection with each contrast agent. Quantitative analyses were performed by measuring signal-to-noise and contrast-to-noise ratios (CNRs) on pre- and postcontrast Gd-BOPTA and ferumoxides MR images. Statistical analyses were performed with Wilcoxon signed rank and Monte Carlo tests.

RESULTS

Sensitivity of ferumoxides-enhanced MR imaging was superior to that of Gd-BOPTA-enhanced MR imaging for liver metastasis detection (P <.05). Ferumoxides MR images depicted 36 (97%) of 37 metastases detected at intraoperative US, whereas Gd-BOPTA MR images depicted 30 (81%) metastases during delayed phase and 20 (54%) during dynamic phase. All six metastases identified only at ferumoxides-enhanced MR imaging were 5-10 mm in diameter. There was a significant increase in CNR between the lesion and liver before and after ferumoxides administration (from 3.8 to 6.8, P <.001) but not before or after Gd-BOPTA injection (from -4.8 to -5.5, P >.05).

CONCLUSION

Ferumoxides-enhanced MR imaging seems to be superior to Gd-BOPTA-enhanced MR imaging for liver metastasis detection.

Combined treatment, TACE and RF ablation, in HCC: preliminary results

PURPOSE

The aim of this study was to assess the effectiveness of a combination of percutaneous radiofrequency thermal ablation (RF), stop-flow and transcatheter arterial chemo-embolisation (TACE) in the treatment of hepatic neoplasms.

MATERIALS AND METHODS

From December 1997 to September 2000, 34 patients with hepatocellular carcinoma (HCC) underwent radiofrequency thermoablation treatment. The choice of method was based on the type of lesion (HCC vs metastasis) and the following dimensional criteria: 1. RF without stop-flow associated with the injection of diagnostic Lipiodol in the case of a single nodule with a maximum diameter smaller than 3 cm; 2. RF with stop-flow of the hepatic artery associated with TACE in the case of a single nodule with a diameter greater than 3 cm; 3. RF with stop-flow of the hepatic artery associated with TACE in the case of 2-3 nodules, a subdivision was made into 2 groups according to the volume: smaller or greater than 80 ml.

RESULTS

10 out of 34 patients affected by HCC with a diameter smaller than 3cm, treated only with RF, demonstrated 100% necrosis in the follow-up period, which varied between 6 and 24 months (average 10 months). The remaining 24 patients affected by HCC and treated with RF associated with stop-flow and TACE showed responses related to the volume of the tumour: 1. patients with a single nodule with a diameter of 3-5 cm showed 100% necrosis; 2. patients affected by multifocal HCC with a maximum of 3 nodules and/or total tumour mass smaller than 80 ml, for a total of 9 lesions, showed 95% necrosis; 3. patients affected by multifocal HCC with more than 3 nodules (total mass less than 40% of liver volume) or tumour mass greater than 80ml, for a total of 13 lesions, showed 90% necrosis. In the group of patients affected by multiple nodules with volumes smaller than 80ml, the technique did not show complete effectiveness, thus these patients cannot be considered cured. Such aspects are even clearer in the more advanced stages.

CONCLUSIONS

In our case study, radiofrequency proved effective with lesions up to 3cm in diameter. By reducing thermal dispersion, the association of the stop-flow technique with radiofrequency ablation, determines a greater volume of necrosis, which allows effective treatment of single nodules with a diameter of up to 5cm and/or multiple nodules. The association with TACE: 1. provided a way to highlight and treat lesions not recognizable through other imaging techniques; 2. increased the accumulation of lipid contrast in the tissue surrounding the lesion and in the vessels not occluded by thermal ablation in the lesions with diameters greater than 3 cm; 3. enabled further treatment of tumour residue possibly left untouched by thermal ablation in large tumours; 4. increased the amount of Lipiodol accumulated in normal tissue surrounding the lesion, made evident through the comparison of the dimensions of the nodule's blush between angiography and Lipiodol CT.

cAMP signaling pathway in depressed patients with psychotic features

Abnormalities in protein kinase A (PKA) and Rap1 have recently been reported in depressed patients. The aim of the present study was to investigate the levels of these proteins in platelets from untreated unipolar and bipolar depressed patients with psychotic features. The levels PKA and Rap1 were assessed by Western blot analysis and immunostaining in 37 drug-free patients and 29 healthy subjects. Both unipolar and bipolar patients with psychotic depression have significantly lower levels of platelet regulatory type I and higher levels of catalytic subunits of PKA than controls, whereas the levels of regulatory type II were higher only in psychotic unipolar patients. No significant differences were found in the immunolabeling of both Rap1 and actin among groups. These findings support the idea that besides nonpsychotic depression, abnormalities of PKA could be linked, albeit in a somewhat different way, with psychotic depression.

Advances in imaging for pancreatic disease

Pancreatic imaging is an essential tool in the early diagnosis and staging of pancreatic disease. This review analyzes the most recent advances in pancreatic imaging. The specific modalities discussed include helical computed tomography (HCT) and multislice CT (MSCT), CT angiography, magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET). At present, MSCT is generally viewed as the most efficient modality for initial detection and staging of pancreatic carcinoma, with an accuracy rate of about 95% to 97% for initial detection and virtually 100% for staging. CT is also the initial imaging modality used in evaluation of acute pancreatitis. However, recently, MRI has been viewed increasingly as a more precise diagnostic tool in this subgroup of patients. MRCP has been accepted as the primary imaging technique in the diagnosis of chronic pancreatitis. PET imaging, on the other hand, has an increasing role in the staging of pancreatic carcinoma, for which it may be the modality of choice in detection of extrapancreatic metastasis.

Color Doppler sonography of hepatic artery reconstruction in liver transplantation

PURPOSE

The purpose of this study was to evaluate the Doppler spectral waveforms in the hepatic artery after liver transplantation and hepatic artery reconstruction by end-to-end anastomosis or aortohepatic bypass. The peak systolic velocities (PSVs), end-diastolic velocities (EDVs), and resistance indices (RIs) between the 2 reconstruction groups were compared to establish normal post-transplantation values.

METHODS

We retrospectively reviewed the Doppler sonograms and the sonographic reports from 48 patients who had undergone liver transplantation, 30 with end-to-end arterial anastomoses and 18 with aortohepatic bypasses. All aortohepatic bypasses had been performed using the infrarenal technique. All sonographic examinations had been performed 3-6 months after transplantation in patients with no clinical sign of transplant failure and whose liver function test results more normal. We compared the mean hepatic artery PSVs, EDVs, and RIs of the 2 groups.

RESULTS

Doppler spectral analysis allowed the detection of 2 types of arterial flow, a low-resistance pattern in the end-to-end anastomosis group and a high-resistance pattern with low diastolic flow in the infrarenal bypass group. The mean PSV +/- standard deviation (SD) was 57 +/- 16 seconds in the end-to-end anastomosis group and 62 +/- 16 cm/second in the infrarenal bypass group. The mean EDV +/- SD was 25 +/- 14 cm/second in the end-to-end anastomosis group and 12 +/- 4 cm/second in the infrarenal bypass group. The RIs ranged from 0.33 to 0.71 (mean +/- SD, 0.58 +/- 0.13) in the patients with end-to-end anastomoses and from 0.70 to 0.87 (mean +/- SD, 0.77 +/- 0.06) in those with infrarenal bypasses. The difference in the mean RIs between the 2 groups was statistically significant (p < 0.05).

CONCLUSIONS

Spectral waveform and RI are associated with the length and caliber of the type of hepatic artery anastomosis used. End-to-end anastomoses are short and have a uniform small caliber; aortohepatic bypasses are longer and have a progressively by smaller caliber. We must be cognizant of the method of anastomosis used when examining patients for complications after liver transplantation because the method used affects the resulting spectral waveform and RI.

Long-term treatment with citalopram in patients with highly recurrent forms of unipolar depression

The authors evaluated the efficacy and safety of citalopram in a 28-month study in 48 inpatients with highly recurrent forms of unipolar depression. The patients, who each had at least one depressive episode during the 18 months preceding the index episode, were openly treated with citalopram, 40 mg/day. Thirty-six of the patients had a stable response to citalopram and continued treatment as outpatients for 4 months. No relapses were observed. At the time of recovery, 32/36 subjects received maintenance treatment with citalopram (40 mg) for an additional 24 months. At the end of the study, 11/32 patients experienced a single new recurrence.

No association between dopamine D(2) and D(4) receptor gene variants and antidepressant activity of two selective serotonin reuptake inhibitors

The possible association of the dopamine receptor D(2) (Ser 311Cys) and D(4) exon 3 (48 base pair repeat) gene variants with the antidepressant activity of selective serotonin reuptake inhibitors (SSRIs) was investigated in a sample of 364 inpatients affected by a major depressive episode treated with fluvoxamine, 300 mg/day (n=266), or paroxetine, 20-40 mg/day (n=98). The severity of depressive symptoms was assessed weekly with the Hamilton Rating Scale for Depression. Dopamine receptor D(2) (DRD2) and dopamine receptor D(4) (DRD4) allelic variants were determined in each subject by polymerase chain reaction. We observed that DRD2 and DRD4 variants were not associated with response to SSRI treatment. Possible stratification factors, such as sex, diagnosis, presence of psychotic features, depressive symptoms at baseline, paroxetine and fluvoxamine plasma levels, and pindolol augmentation did not significantly influence the observed results. The investigated DRD2 and DRD4 gene variants therefore do not seem to play a major role in the antidepressant activity of SSRIs, at least in the present sample.

Tryptophan hydroxylase gene associated with paroxetine antidepressant activity

The possible association of the A218C tryptophan hydroxylase (TPH) gene variant with the antidepressant activity of paroxetine was investigated in a sample of 121 inpatients affected by a major depressive episode and treated with paroxetine 20-40 mg with either placebo or pindolol in a double blind design for 4 weeks. The severity of depressive symptoms was weekly assessed with the Hamilton Rating Scale for Depression. TPH allelic variants were determined in each subject using a PCR-based technique. TPH*A/A and TPH*A/C variants were associated with a poorer response to paroxetine treatment when compared to TPH*C/C (P=0.005); this difference was not present in the pindolol augmented group. Other variables, such as sex, diagnosis, presence of psychotic features, severity of depressive symptomatology at baseline and paroxetine plasma level, were not associated with the outcome. TPH gene variants are therefore a possible modulator of paroxetine antidepressant activity.

Influence of tryptophan hydroxylase and serotonin transporter genes on fluvoxamine antidepressant activity

The aim of the present study was to test a possible effect of the A218C tryptophan hydroxylase (TPH) gene variant on the antidepressant activity of fluvoxamine in a sample of major and bipolar depressives, with or without psychotic features. Two hundred and seventeen inpatients were treated with fluvoxamine 300 mg and either placebo or pindolol in a double blind design for 6 weeks. The severity of depressive symptoms was weekly assessed with the Hamilton Rating Scale for Depression. TPH allelic variants were determined in each subject by using a PCR-based technique. No significant finding was observed in the overall sample as well as in the pindolol group, while TPH*A/A was associated with a slower response to fluvoxamine treatment in subjects not taking pindolol (P = 0.001). This effect was independent from the previously reported influence of 5-HTTLPR polymorphism. If confirmed, these results may shed further light on the genetically determined component of the response to pharmacological treatments, thus helping the clinician to individualize each patient's therapy according to their genetic pattern.

Factors affecting fluvoxamine antidepressant activity: influence of pindolol and 5-HTTLPR in delusional and nondelusional depression

BACKGROUND

It has been recently reported that the short variant of the serotonin transporter (5-HTT) gene-linked functional polymorphic region (5-HTTLPR) influences the antidepressant response to certain selective serotonin reuptake inhibitors. The aim of the present study was to test this finding in a sample of major and bipolar depressives, with or without psychotic features.

METHODS

One hundred fifty-five inpatients were treated with fluvoxamine 300 mg and either placebo or pindolol in a double-blind design for 6 weeks. The severity of depressive symptoms was weekly assessed with the Hamilton Rating Scale for Depression. Allelic variation of 5-HTTLPR in each subject was determined using a polymerase chain reaction-based technique.

RESULTS

5-HTTLPR short variant was associated with a poor response to fluvoxamine treatment, independently from the recorded clinical variables. More specifically, the diagnosis, the presence of psychotic features, and the severity of depressive symptomatology did not influence this association. Conversely, pindolol augmentation may ameliorate the rate of response in 5-HTTLPR short variant subjects, thus reducing the difference in the response rate among the genotype variants.

CONCLUSIONS

If confirmed, these results may improve patient care by helping the clinician to individualize treatment according to the patient's genetic 5-HTTLPR pattern.

Increased 5-hydroxytryptamine-2 receptor binding in the frontal cortex of depressed patients responding to paroxetine treatment: a positron emission tomography scan study

The changes in aminergic receptors elicited by antidepressant treatments have been extensively examined in the brain of experimental animals using radioligand and molecular techniques. However, there is a very limited direct information regarding the changes effected by such treatments in the human brain, as well as its relationship to clinical improvement. Using positron emission tomography (PET) scanning, the authors examined the cortical 5-Hydroxytryptamine-2A (5-HT2A) receptor binding of [18F]fluoro-ethyl-spiperone after a 4-week treatment with the selective serotonin reuptake inhibitor paroxetine. [18F]fluoro-ethyl-spiperone labels 5-HT2A receptors in the cortex and dopamine D2 receptors in the basal ganglia. A binding index (BI) was calculated in the frontal cortex and the basal ganglia (mostly caudate-putamen) by reference to cerebellum. Thirty-seven inpatients with major depression with a mean +/- SD score on the 21-item Hamilton Rating Scale for Depression (HAM-D-21) of 26.3 +/- 4.3 at admission were treated with paroxetine 40 mg/day. After 4 weeks of treatment, the BI in the frontal cortex of remitted patients (HAM-D-21 score = 4.7 +/- 4.0; N = 20) was significantly greater than the score in nonresponder patients (HAM-D-21 score = 21.2 +/- 4.0; N = 17) (BI = 0.54 +/- 0.15 and 0.41 +/- 0.17, respectively; p < 0.02). No such difference was observed in the basal ganglia (5.45 +/- 1.11 and 5.39 +/- 0.82, respectively; p = 0.85). The significant difference in cortical BI persisted when age was used as covariate (p < 0.016). These data suggest that clinical improvement in patients treated with paroxetine is associated with an increase in the density of 5-HT2A receptors in the frontal cortex.

Protein kinase A and Rap1 levels in platelets of untreated patients with major depression

We have recently reported altered levels of protein kinase A and Rap1 in patients with bipolar disorder. The purpose of the current investigation was to assess the levels of these proteins in platelets from untreated euthymic and depressed patients with major unipolar depression. Platelets were collected from 45 drug-free unipolar patients (13 euthymic and 32 depressed) and 45 healthy subjects. The levels of protein kinase A and Rap1 were assessed by Western blot analysis, immunostaining and computer-assisted imaging. The immunolabeling of the regulatory subunit type II of protein kinase A and that of Rap1 was significantly lower in untreated depressed patients compared with untreated euthymic patients and healthy subjects. No significant differences were found in the immunolabeling of both the regulatory type I and the catalytic subunits of protein kinase A among groups. Levels of the regulatory subunit type II of protein kinase A and Rap1 are altered in platelets of unipolar depressive patients. These findings may provide new insight about the relationship between components of cAMP signaling and affective disorders.

Will a second prophylactic treatment with a higher dosage of the same antidepressant either prevent or delay new depressive episodes?

Fifty-seven highly recurrent unipolar patients, excluded from previous long-term studies with selective serotonin reuptake inhibitors (SSRIs) after they experienced a new recurrence, were acutely treated with the full dosage of the SSRIs they were on. Fifty-one of them (89.5%) had a sustained response and entered into the 4-month continuation therapy. During this phase, no relapse was observed. At the end of it, all patients gave their written informed consent to be enrolled in a 24-month long-term therapy, maintaining the same treatment dosage of fluvoxamine 300 mg/day, sertraline 150 mg/day, or paroxetine 40 mg/day. At the end of the study, 28 out of the 51 outpatients (54.9%) showed a further recurrence. Nevertheless, second recurrences observed during this second maintenance therapy were less severe than first recurrences, decreasing from 25.1+/-3.4 to 21.6+/-3.3 (P<0.0001), respectively. Considering the clinical characteristics of patients, we found that a high number of prior depressive episodes and an early age at onset of illness may predict a bad outcome. Moreover, patients with a longer duration of euthymia during a first maintenance period are less likely to have a new episode of depression.

Four-year follow-up study of sertraline and fluvoxamine in long-term treatment of unipolar subjects with high recurrence rate

We prolonged from 24 to 48 months a follow-up study of unipolar subjects with high recurrence rate treated with fluvoxamine (N=25) and sertraline (N=22). During the two-year additional period a significant risk of recurrences was observed during the third year of follow-up, without differences in the two long-term therapy groups. During the fourth year no patients showed new episodes of illness.

Patterns of symptom improvement during antidepressant treatment of delusional depression

We assessed the pattern of changes in depressive symptoms in delusional depressed inpatients treated openly with 300 mg/day of fluvoxamine for 6 weeks. We studied 59 inpatients affected by bipolar (n=23) and major depressive (n=36) disorders with psychotic features (DSM-IV) who showed complete responses to fluvoxamine treatment. Responses were evaluated using the Hamilton Rating Scale for Depression (HAMD-21, divided into: Core, Activity, Psychic anxiety, Somatic anxiety and Delusion clusters) administered at baseline and weekly until the 6th week. Random Regression Model (RRM) analysis was used to investigate the longitudinal time course of HAMD clusters. HAMD depressive symptom clusters decreased in a parallel manner from baseline to the end of the 6-week trial. The RRM analysis revealed no significant difference between HAMD clusters and the time course of the total HAMD score during treatment. Our data indicate that there is a simultaneous decrease in depressive symptoms during antidepressant treatment of delusional depressives.

Altered Rap1 endogenous phosphorylation and levels in platelets from patients with bipolar disorder

Previous studies have reported abnormalities either in the cAMP-dependent endogenous phosphorylation or in the levels of Rap1 in platelets from bipolar patients. One limitation of these findings was that they come from different groups of patients in independent studies. To overcome this limitation, we designed the present study in which both these biochemicals parameters were assessed in the same cohort of euthymic bipolar patients and healthy subjects. The results showed that the cAMP-dependent phosphorylation of Rap1 was significantly higher in platelets of bipolar patients with respect to healthy subjects. Furthermore, immunoblotting experiments revealed that also the levels of Rap1 were significantly higher in bipolar patients than in control subjects, thus supporting that the abnormal phosphorylation can be ascribed to the increased levels of Rap1. Taken together the results of the present study further support that downstream components of the cAMP signal cascade could be involved in the pathophysiology of bipolar disorders.

Abnormalities of cAMP signaling in affective disorders: implication for pathophysiology and treatment

OBJECTIVE

During the last decade, much attention has been given to the role of signal transduction pathways in affective disorders. This review describes the possible role of the cAMP signaling in such disorders.

METHODS

Among the components of cAMP signaling, this review focuses on the cAMP-dependent phosphorylation system. We analyzed the basic components of the cAMP-dependent phosphorylation system and the preclinical evidence supporting their involvement in the biochemical action of antidepressants and mood stabilizers. The clinical data available until now, concerning the possible link between the cAMP-dependent phosphorylation system and the pathophysiology of affective disorders, are also reviewed.

RESULTS

The studies herein presented demonstrated that the levels and the activity of cAMP-dependent protein kinase are altered by antidepressants and mood stabilizers. Furthermore. these medications are able to modify the phosphorylation state, as well as the levels of some of the cAMP-dependent protein kinase substrates. More recently, clinical studies have reported abnormalities in the cAMP-dependent phosphorylation system in both peripheral cells and the postmortem brain of patients with affective disorders.

CONCLUSIONS

Overall, these studies support an involvement of cAMP signaling in affective disorders. The precise knowledge of the findings has the potential to improve the understanding of pharmacotherapy and to provide directions for the development of novel biochemical and genetic research strategies on the pathogenesis of affective disorders.

Venlafaxine versus fluvoxamine in the treatment of delusional depression: a pilot double-blind controlled study

BACKGROUND

Previous studies have reported the efficacy of selective serotonin reuptake inhibitors as monotherapy in the treatment of delusional depression. The clinical efficacy of venlafaxine, a serotonin-norepinephrine reuptake blocker, has been demonstrated in the treatment of patients with moderate-to-severe depression, but, to date, no evidence is available about its use in depressed patients with psychotic features.

METHOD

Under double-blind conditions, 28 hospitalized patients who met DSM-IV criteria for major depression, severe with psychotic features, were randomly assigned to receive fluvoxamine or venlafaxine, 300 mg/day, for 6 weeks. Severity was evaluated using the Hamilton Rating Scale for Depression (HAM-D) and the Dimensions of Delusional Experience Rating Scale (DDERS) administered at baseline and every week thereafter. Side effects were also recorded. Clinical response was defined as a reduction of the scores in the 21-item HAM-D to 8 or below and in the DDERS to 0.

RESULTS

At study completion, the response rates were 78.6% (N = 11) and 58.3% (N = 7) for fluvoxamine and venlafaxine, respectively. No significant difference was found between drugs (Fisher exact test, p = .40). Analysis of covariance on HAM-D scores did not reveal a significantly different decrease of depressive symptomatology between the 2 treatment groups (p = .14). Treatment response appeared to be unrelated to the demographic and clinical characteristics recorded. The overall safety profile of both fluvoxamine and venlafaxine was favorable.

CONCLUSION

The results of this pilot double-blind trial show that fluvoxamine is useful in the treatment of delusional depression and suggest that venlafaxine may also be an effective compound in the treatment of this disorder. The latter finding, although promising, warrants further replication in a larger sample of patients.

Early onset of lithium prophylaxis as a predictor of good long-term outcome

The recurrence rates during lithium preventive treatment were investigated in a sample of 270 Mood Disorder subjects subdivided according to their onset time for lithium prophylaxis as very early (within 5 years from the onset of illness), early (6-10 years), late (11-20 years) and very late (more than 21 years). 131 subjects of the sample followed for 4 years prolonged the observation for a further period of 8 years. Results indicated that beginning lithium therapy within the first ten years of illness predicts better preventive outcomes than beginning prophylaxis later, both in major depression, recurrent and bipolar patients.

Two-year maintenance treatment with citalopram, 20 mg, in unipolar subjects with high recurrence rate

BACKGROUND

The efficacy of citalopram, 20 to 60 mg/day, in relapse prevention in major depression was demonstrated in 6-month placebo-controlled studies. The authors tested the efficacy of citalopram, 40 mg/day, in relapse prevention over a 4-month period and citalopram, 20 mg/day, in recurrence prevention over a 24-month period.

METHOD

Fifty inpatients with recurrent major depressive disorder (DSM-IV criteria) who had had at least one depressive episode during the 18 months preceding the index episode were openly treated with citalopram, 40 mg/day. Thirty-six subjects had a stable response to citalopram and remained in the continuation treatment with citalopram, 40 mg/day, for 4 months as outpatients. At the time of recovery, 32 patients gave their written informed consent before entering the 24-month maintenance period with citalopram, 20 mg/day. They were evaluated monthly by trained psychiatrists on the basis of the 21-item Hamilton Rating Scale for Depression. Every 3 months, patients were given the Sheehan Disability Scale, a self-rating instrument, to assess their psychosocial adjustment.

RESULTS

No relapse was observed in the 4-month continuation period. Sixteen (50%) of 32 patients who entered the 24-month maintenance period had a new recurrence. Patients with recurrence showed a persistent moderate disability on Sheehan Disability Scale score, while no further differences were highlighted in clinical and demographic characteristics between patients with and without recurrence.

CONCLUSION

In agreement with previous findings, these data suggest that a full dose of antidepressant is strongly recommended in prophylactic therapy of patients with recurrent major depression. Moreover, it appears that psychosocial impairment may increase the risk of recurrence, thus conditioning a poor outcome.

Abnormalities of cyclic adenosine monophosphate signaling in platelets from untreated patients with bipolar disorder

BACKGROUND

Abnormalities in the cyclic adenosine monophosphate (cAMP)-dependent phosphorylation system have been recently reported in patients with bipolar disorder. We evaluated the immunoreactivity of the regulatory and catalytic subunits of cAMP-dependent protein kinase (protein kinase A) and 1 of its substrates, Rap1, in platelets from untreated euthymic, manic, and depressed patients with bipolar disorder and healthy subjects.

METHODS

Platelets were collected from 112 drug-free patients with bipolar disorder (52 euthymic, 29 depressed, and 31 manic) and 62 healthy subjects. The levels of cAMP-dependent protein kinase and Rap1 were assessed by Western blot analysis, immunostaining, and computer-assisted imaging.

RESULTS

The immunolabeling of the catalytic subunit of cAMP-dependent protein kinase was significantly different among groups (P<.001), with higher values in untreated depressed and manic patients with bipolar disorder compared with untreated euthymic patients with bipolar disorder and healthy subjects. No significant differences were found in the immunolabeling of the regulatory subunits (type I and type II) of cAMP-dependent protein kinase. The immunolabeling of Rap1 was significantly higher (P<.001) in untreated euthymic, depressed, and manic patients than in healthy persons.

CONCLUSIONS

Levels of Rap1 and the catalytic subunit of cAMP-dependent protein kinase are altered in the platelets of bipolar patients. These findings may provide clues toward understanding the involvement of cAMP signaling in the pathogenesis of bipolar disorder.

Worsening of delusional depression after sleep deprivation: case reports

Five patients (three bipolars and two unipolars) affected by a major depressive episode with psychotic features were treated with total sleep deprivation (TSD) without concurrent psychotropic medication. After TSD we observed a worsening in psychotic as well as in depressive symptoms as rated on the Dimension of Delusional Experience Rating Scale and on Hamilton Rating Scale for Depression, respectively. TSD is known to markedly enhance the activity of brain monoaminergic pathways. Given the interaction between brain serotonergic and dopaminergic systems in delusional depression, it is possible that an enhancement in dopaminergic activity may be responsible of the symptomatological worsening in delusional depressives observed after TSD.

Faster onset of action of fluvoxamine in combination with pindolol in the treatment of delusional depression: a controlled study

This double-blind, controlled study was undertaken to investigate whether the addition of pindolol could improve the therapeutic response to fluvoxamine of depressed patients with psychotic features. After a 1-week placebo run-in period, 72 patients received fluvoxamine 300 mg/day in combination with placebo or pindolol 7.5 mg/day. At study completion, 28 (80%) of 35 patients treated with fluvoxamine plus placebo and 29 (80.5%) of 36 patients treated with fluvoxamine plus pindolol were categorized as responders (reduction of their score on the 21-item Hamilton Rating Scale for Depression to 8 or less and on the Dimension for the Delusional Experience Rating Scale to 0). In the third and fourth weeks, the response rates were significantly superior in the fluvoxamine plus pindolol group (p = 0.0001, p = 0.023, respectively). Treatment response seemed to be unrelated to the demographic and the clinical characteristics recorded. No significant difference was found comparing plasma levels of fluvoxamine between groups, thus excluding a pharmacokinetic interaction. Other than mild nausea and sedation in a few patients, treatments were well tolerated. No medically significant adverse events occurred. Depressed patients with psychotic features who were administered pindolol experienced a more rapid improvement during fluvoxamine treatment. Thus, the combination of fluvoxamine with pindolol may be a useful pharmacologic strategy in the treatment of this disorder. A rapid clinical response in such patients is of relevance in clinical practice as well as in economic fields, given the direct and indirect costs of depression.

Polymorphism within the promoter of the serotonin transporter gene and antidepressant efficacy of fluvoxamine

Depression with psychotic features has been shown to respond to selective serotonin reuptake inhibitors (SSRIs). The serotonin transporter (5-HTT) is a prime target for SSRIs. A functional polymorphism within the promoter region of the 5-HTT gene, leading to different transcriptional efficiency, was recently reported. We tested the hypothesis that allelic variation of the 5-HTT promoter could be related to the antidepressant response to fluvoxamine and/or augmentation with pindolol (a serotonin autoreceptors antagonist) which has been suggested as an augmentation therapy for nonresponders. One hundred and two inpatients with major depression with psychotic features were randomly assigned to treatment with a fixed dose of fluvoxamine and either placebo or pindolol for 6 weeks. Depression severity was assessed once a week using the Hamilton Depression Rating Scale. Allelic variation in each subject was determined using a PCR-based method. Data were analyzed with a three-way repeated measures analysis of variance. Both homozygotes for the long variant (l/l) of the 5-HTT promoter and heterozygotes (l/s) showed a better response to fluvoxamine than homozygotes for the short variant (s/s). In the group treated with fluvoxamine plus pindolol all the genotypes acted like l/l treated with fluvoxamine alone. Fluvoxamine efficacy in delusional depression seems to be related to allelic variation within the promoter of the 5-HTT gene. Even though other factors may be implicated, genotyping at 5-HTT promoter may represent a promising tool to individualize the pharmacological treatment of depression.

Effects of lithium on cAMP-dependent protein kinase in rat brain

We have investigated the effects of lithium treatment on cAMP-dependent protein kinase in discrete brain areas of rat by using photoaffinity labeling as well as western blotting. Lithium administered for 5 weeks resulted in a significant increase of the cAMP binding to the 52 kDa cAMP-receptor in the soluble, but not in the particulate, fractions of both hippocampus and frontal cortex. Moreover, immunoblotting experiments revealed that chronic lithium treatment significantly increased the immunoreactivity against the regulatory and the catalytic subunits of the cAMP-dependent protein kinase in the soluble fraction of both brain areas. In contrast, no appreciable effect was observed in the particulate fractions. Short-term lithium treatment induced a significant increase in the immunolabeling of the catalytic subunits in the soluble fraction of both areas; whereas, the regulatory subunits and the actin were unchanged. In the particulate fractions, short-term lithium treatment did not elicit any substantial modification. Taken together, the results of the present study add to the growing evidence indicating that components of the cAMP signalling could play a crucial role in the biochemical action of lithium.

Dose-response efficacy of paroxetine in preventing depressive recurrences: a randomized, double-blind study

BACKGROUND

The authors evaluated and compared the efficacy of 20 mg versus 40 mg of paroxetine in a randomized, double-blind, parallel-group study during a maintenance period of 28 months.

METHOD

Ninety-nine inpatients with recurrent, unipolar depression (DSM-IV criteria) who had at least 1 depressive episode during the 18 months preceding the index episode were openly treated with paroxetine 40 mg/day. Seventy-two subjects had a stable response (Hamilton Rating Scale for Depression score < 8) to paroxetine treatment and remained in the continuation treatment as outpatients for 4 months. At the time of recovery, 68 patients were randomly assigned to 1 of the 2 maintenance treatment groups: paroxetine 20 mg or paroxetine 40 mg daily.

RESULTS

Sixty-seven patients completed the 28-month follow-up period. Seventeen (51.5%) of 33 patients in the 20-mg paroxetine regimen had a single recurrence compared with 8 (23.5%) of 34 subjects in the 40-mg dose regimen (chi2 = 5.56, p = .018).

CONCLUSION

These data suggest that a full dose of paroxetine is recommended in unipolar patients who are at high risk for recurrent depressive episodes.

cAMP-dependent phosphorylation system after short and long-term administration of moclobemide

Accumulating evidence suggested that signal transduction cascade including protein phosphorylation is implicated in the neurochemical action of antidepressant agents. Clinical data indicated that moclobemide, a short acting and reversible inhibitor of monoamino oxidase type. A, is an effective antidepressant medication. However, little is known about the intracellular effects of this compound. Thus, in the present study we assessed the binding of cAMP to cAMP-dependent protein kinase (PKA) in rat cerebral cortex following short and long-term administration of moclobemide. The results showed that 21 days of treatment with moclobemide significantly increased the specific [32P]-cAMP covalent binding into the soluble 52-54 kDa cAMP-receptor. This effect was not seen following 1, 5 and 12 days of treatment. These findings suggest that PKA could be implicated in the biochemical effects of moclobemide.

How long should pindolol be associated with paroxetine to improve the antidepressant response?

A double-blind study was undertaken to investigate the period of treatment with the beta-adrenoreceptor/5-hydroxytryptamine 1A (5-HT1A) antagonist pindolol required to enhance the antidepressant effects of paroxetine. After 1 week of a placebo run-in period, 63 untreated major depressive inpatients were randomly assigned to three different groups. Group 1 received paroxetine (20 mg/day) plus placebo (4 weeks). Group 2 received paroxetine (20 mg/day) plus pindolol (7.5 mg/day) for 1 week and placebo for 3 weeks. Group 3 received both active treatments for the entire duration of the study (4 weeks). Clinical response was defined as a reduction of the score in the Hamilton Rating Scale for Depression (HAM-D) to 8 or below. Also, to preliminarily examine whether beta-adrenoreceptor blockade was involved in the action of pindolol, another group of 10 inpatients was treated in an open-label manner with paroxetine (20 mg/day) plus 50 mg/day of the beta-adrenergic antagonist metoprolol, devoid of significant affinity for 5-HT1A receptors. At endpoint, the incidence of treatment-emergent side effects did not significantly differ among the three groups. After 1 and 2 weeks of treatment, the two groups treated with paroxetine plus pindolol displayed a significantly greater response rate than the group treated with paroxetine plus placebo. At study completion, only the patients treated with pindolol for the entire period showed a significantly greater response rate (p = 0.05). HAM-D score were also significantly lower at endpoint in patients treated with the combination for 4 weeks (p = 0.00003). The group of patients treated with paroxetine and metoprolol exhibited a side-effect profile comparable to that of paroxetine alone. Response rates were also comparable. These findings support the efficacy of pindolol, but not of metoprolol, in accelerating the antidepressant effect of paroxetine and suggest that the administration of pindolol for the entire period of the acute treatment may increase the efficacy of paroxetine.

Long-term treatment of geropsychiatric depressed patients with venlafaxine

Twenty-eight psychiatric patients older than 65 years with major depression with high probability of recurrence were enrolled in a 24-month open label clinical trial aimed at evaluating the long-term efficacy and safety of venlafaxine. All patients completed the acute phase of the study; 21 were responders and entered the follow-up period. During the continuation phase no relapse was observed. During the maintenance period, 20% of the patients had a single new recurrence. No significant side effects were observed. The results demonstrate that venlafaxine is both effective and safe in the long-term treatment of major depression in geropsychiatric patients.

Long-term treatment of psychotic (delusional) depression with fluvoxamine: an open pilot study

The aim of this open pilot study was to evaluate the efficacy of fluvoxamine in the continuation as well as in the maintenance therapy of delusional depression. Thirty patients with recurrent, unipolar depression (DSM-IV criteria) were selected who had at least one depressive episode during the 18 months preceding the delusional depressive index episode and were treated with fluvoxamine 300 mg/day. Twenty-five of them had a sustained response to this short-term treatment and agreed to enter into the 30-month follow up study. All participants completed the follow up period. No relapse was observed during the 6 months of continuation therapy. During the further 24 months of maintenance therapy, 80% of the patients remained well, whereas 20% (five out of 25) had a single recurrence. Based on these observations, fluvoxamine might be a promising drug for long-term therapy of delusional depression. Further controlled studies are required to confirm this finding.

A double-blind study of long-term treatment with sertraline or fluvoxamine for prevention of highly recurrent unipolar depression

BACKGROUND

We evaluated and compared the efficacy and safety of sertraline and fluvoxamine in a randomized, double-blind, parallel-group study during a follow-up of 24 months.

METHOD

Sixty-four patients with recurrent, unipolar depression (DSM-IV criteria) who had at least one depressive episode during the 18 months preceding the index episode were accepted into the trial. Patients were randomly assigned to one of the two long-term treatment groups and evaluated monthly by trained psychiatrists, blinded to treatment option, on the basis of the Hamilton Rating Scale for Depression.

RESULTS

All patients completed the 24-month follow-up period. Sertraline and fluvoxamine showed an equal efficacy in preventing new recurrences. In fact, there was no significant difference in survival rates between the two medication groups: 7 sertraline-treated patients (21.9%) and 6 fluvoxamine-treated patients (18.7%) had a single new recurrence (z = 0.14; p = .88). Moreover, recurrence observed during maintenance therapies was less severe and/or of shorter duration than index episodes.

CONCLUSION

Long-term treatment with sertraline or fluvoxamine has been shown to be effective for prevention of highly recurrent unipolar depression. The high tolerability of these compounds, together with their prophylactic effectiveness, has an important role in improving the quality of life of these patients.

Differential effects of lithium on platelet protein phosphorylation in bipolar patients and healthy subjects

In the present study we have investigated the cAMP-dependent phosphorylation system in platelets of euthymic bipolar patients and healthy volunteers before and after 15 days of lithium treatment. The results showed that 15 days of lithium treatment enhanced the basal and the cAMP-stimulated 32P incorporation in the 22 and 38 kDa phosphoproteins in bipolar patients, but not in healthy subjects. Moreover, we provided further evidence of increased phosphorylation in the 22 kDa platelet phosphoprotein in untreated euthymic bipolar patients when compared with controls. Overall, these findings suggest an implication of protein phosphorylation in the biochemical action of lithium and in the pathophysiology of bipolar disorder.

Double-blind controlled trial of sertraline versus paroxetine in the treatment of delusional depression

OBJECTIVE

In this study the authors evaluated the efficacy and the tolerability of sertraline and paroxetine in the treatment of delusional depression.

METHOD

Under double-blind conditions, 46 hospitalized patients who met the DSM-III-R criteria for major depression with psychotic features were treated with sertraline or paroxetine for 6 weeks.

RESULTS

The response rates were 75% and 46% for sertraline and paroxetine, respectively. The dropout rate was substantial (41%) in the paroxetine group and was attributable to side effects.

CONCLUSIONS

Selective serotonin reuptake inhibitors administered alone are useful in the treatment of delusional depression.

Abnormal pattern of platelet APP isoforms in Alzheimer disease and Down syndrome

OBJECTIVE

To determine if changes in levels of amyloid precursor protein (APP) isoforms in periphery are associated with Alzheimer disease and Down syndrome.

DESIGN

After subjects were grouped according to diagnosis, APP isoform levels in platelets were compared.

SETTING

University medical center.

SUBJECTS

Ten patients who fulfilled diagnostic criteria for probable Alzheimer disease, 22 healthy volunteers, and 7 elderly (mean age, 42.7 years) and 7 young (mean age, 19.0 years) patients with Down syndrome.

MAIN OUTCOME MEASURES

The levels of APP isoforms were evaluated by means of Western blot analysis and immunostaining of whole platelets.

RESULTS

The ratio between the 130- and the 106- to 110-kd APP isoforms was markedly lower in patients with Alzheimer disease and in elderly patients with Down syndrome than in control subjects. In young patients with Down syndrome, the ratio did not significantly differ from that in control subjects.

CONCLUSIONS

A consistent alteration in platelet APP isoforms has been found in Alzheimer disease and Down syndrome. Further studies will determine whether this alteration could provide a peripheral biochemical marker of the disorder and whether it could intervene in the pathogenesis of Alzheimer disease.

Inhibitory effect of lithium on cAMP dependent phosphorylation system

The aim of the present study was to assess the direct effect of lithium on cAMP dependent phosphorylation. The results show that lithium, but not rubidium, at therapeutic and high concentrations significantly decreases the cAMP stimulated MAP2 endogenous phosphorylation in microtubule fraction. An inhibitory effect of lithium has also been found using purified heat stable microtubule proteins phosphorylated by the catalytic subunit of PKA. These data suggest a direct effect of lithium on the cAMP dependent protein kinase.

Fluvoxamine and lithium in long-term treatment of unipolar subjects with high recurrence rate

We prolonged from 24 to 36 months a follow-up study of unipolar subjects with a high probability of recurrence treated with fluvoxamine (n = 32) or lithium (n = 32). During the extra observation period, two patients developed mania and were excluded from the study. There were no further recurrences in either the lithium or the fluvoxamine group. In our sample, previous prescriptions of tricyclics seem to predict a worse prognosis.