Efficacy, tolerability, and safety of oral paliperidone extended release in the treatment of schizophrenia: a 24-week, open-label, prospective switch study in different settings in Taiwan.

PURPOSE: Paliperidone extended release (ER) is an oral psychotropic treatment formulated to release paliperidone at a controlled, gradually ascending rate. We evaluated the efficacy and safety of switching to paliperidone ER in Taiwanese patients with schizophrenia who were unresponsive or intolerant to previous antipsychotic therapy. PATIENTS AND METHODS: This was a 24-week, open-label, single-arm, multicenter, Phase IV trial. Based on consulting psychiatrists' judgment, patients were deemed eligible for the switch to paliperidone ER; the switch was achieved by cross-tapering, using a recommended starting dose of 6 mg. Eligibility considerations included lack of efficacy, tolerability, and/or adherence to previous oral antipsychotic medication. RESULTS: Of the 297 enrolled patients, 178 (59.5%) completed the study. The main reasons for discontinuation included insufficient efficacy (8.7%), patient decision (8.4%), and adverse events (AEs; 6.4%). Improvements in the: Positive and Negative Syndrome Scale total score and Clinical Global Impression-Severity score were observed only in patients treated at medical centers and not in those treated at psychiatric hospitals. The most common AEs were insomnia, headache, constipation, and extrapyramidal syndrome. One or more serious AEs were reported in 11 (3.7%) patients; none resulted in death. No significant changes in body weight, plasma glucose, or lipid levels were observed. CONCLUSION: Switching to paliperidone ER was effective and well tolerated for up to 24 weeks in patients with schizophrenia who were unresponsive or intolerant to previous antipsychotic therapy. The observed differences in treatment between psychiatric hospitals and medical centers with regard to dosage and titration of paliperidone ER warrant further investigation.

Metabolic syndrome among psychiatric outpatients with mood and anxiety disorders.

BACKGROUND: Few studies have simultaneously compared the impacts of pharmacotherapy and mental diagnoses on metabolic syndrome (MetS) among psychiatric outpatients with mood and anxiety disorders. This study aimed to investigate the impacts of pharmacotherapy and mental diagnoses on MetS and the prevalence of MetS among these patients. METHODS: Two-hundred and twenty-nine outpatients (men/women = 85/144) were enrolled from 1147 outpatients with mood and anxiety disorders by systematic sampling. Psychiatric disorders and MetS were diagnosed using the Structured Clinical Interview for DSM-IV-TR and the new International Diabetics Federation definition, respectively. The numbers of antipsychotics, mood stabilizers, and antidepressants being taken were recorded. Logistic regression was used to investigate the impacts of pharmacotherapy and psychiatric diagnoses on MetS. RESULTS: Among 229 subjects, 51 (22.3%) fulfilled the criteria for MetS. The prevalence of MetS was highest in the bipolar I disorder (46.7%) patients, followed by bipolar II disorder (25.0%), major depressive disorder (22.0%), anxiety-only disorders (16.7%), and no mood and/or anxiety disorders (14.3%). The percentages of MetS among the five categories were correlated with those of the patients being treated with antipsychotics and mood stabilizers. Use of antipsychotics and/or mood stabilizers independently predicted a higher risk of MetS after controlling for demographic variables and psychiatric diagnoses. When adding body mass index (BMI) as an independent variable in the regression model, BMI became the most significant factor to predict MetS. CONCLUSION: BMI was found to be an important factor related to MetS. Pharmacotherapy might be one of underlying causes of elevated BMI. The interactions among MetS, BMI, pharmacotherapy, and psychiatric diagnoses might need further research.

Taiwan consensus of pharmacological treatment for bipolar disorder.

Bipolar disorder is an important psychiatric disorder with different disease phases. The pharmacological treatment is complicated, and is updated frequently as new research evidence emerges. For the purpose of international collaboration, research, and education, the Taiwan consensus of pharmacological treatment for bipolar disorders was initiated by the Taiwanese Society of Biological Psychiatry and Neuropsychopharmacology (TSBPN) - the Bipolar Chapter, which was established in August 2010 and approved as a member of International Society of Bipolar Disorder. TSBPN is the country member of the World Federation of Societies of Biological Psychiatry (WFSBP). The development of the Taiwan consensus for bipolar disorder was mainly based on the template of WFSBP Guidelines, with references to other international guidelines including the Canadian Network for Mood and Anxiety Treatments, and British Association for Psychopharmacology. We have also added Taiwanese experts' experience, Taiwan national health insurance data, and the indications for the pharmacological treatment of bipolar disorder given by the Taiwan Department of Health, to emphasize the balance between efficacy and safety, and to make this consensus a concise, empirical, and important reference for clinical psychiatric practice.

CYP1A2 genetic polymorphisms are associated with early antidepressant escitalopram metabolism and adverse reactions.

AIM: The liver CYP1A2 enzyme may metabolize antidepressant escitalopram (S-CIT) to S-desmethylcitalopram (S-DCIT) and S-didesmethylcitalopram (S-DDCIT). This study tested whether genetic polymorphisms in the CYP1A2 gene are associated with the treatment responses to S-CIT. MATERIALS & METHODS: Ten SNPs in CYP1A2 were selected and genotyped in 158 patients under S-CIT treatment. The serum levels of S-CIT and its metabolites were measured by HPLC. RESULTS: CYP1A2 SNPs rs2069521, rs2069526, rs4646425 and rs4646427 are significantly associated with the metabolic ratios of S-DDCIT/S-DCIT (p = 0.002, 0.018, 0.008 and 0.004, respectively) at week 2 of treatment. Carriers of the allele types associated with higher S-DDCIT/S-DCIT ratios had more severe side effects. CONCLUSION: These results suggest that genetic variants in CYP1A2 may be indicators for S-CIT metabolism and that the fast metabolizers may experience more severe adverse reactions in the early stages of S-CIT treatment. Original submitted 27 December 2012; Revision submitted 15 May 2013.

Comparison of escitalopram and paroxetine in the treatment of major depressive disorder.

This is a single-blind, parallel, flexible-dose study to compare the efficacy and tolerability of escitalopram and paroxetine in the treatment of patients with major depressive disorder. We recruited 399 patients from the outpatient clinics of five hospitals in northern Taiwan. Patients were administered either escitalopram (10-30 mg) or paroxetine (20-40 mg) according to the judgment of clinicians. These patients were assessed using the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety at weeks 0, 1, 2, 4, 6, and 8. A total of 302 patients fulfilled the evaluation criteria and were included in a statistical analysis. We found that escitalopram induced more significant symptom reduction and response rate in terms of the mean HAM-D scores at week 6 (P<0.05) and week 8 (P<0.05) than paroxetine, but that there were no significant differences between the two groups in the remission rate. Escitalopram induced significantly less frequency of adverse effects of weakness (P<0.01), nausea and vomiting (P<0.001), drowsiness (P<0.01) as well as somnolence (P<0.01) than paroxetine, although all these side effects were mild and tolerable. However for a more definitive result, future prospective trials with the inclusion of a placebo group and a double-blind design are needed. In patients who did not have severe depression (HAM-D score at baseline<21), but not in severely depressed patients, escitalopram was statistically superior to paroxetine, as shown by the mean change in the HAM-D score.

The interaction between dopamine transporter function, gender differences, and possible laterality in depression.

The Dopamine Transporter (DAT) can reflect the general state of striatal dopamine activity. This current study examined the role of DAT in depressed patients before and after bupropion treatment. Twenty-three patients with major depression were treated with bupropion for 8 weeks. Before and after the treatment, they and 20 normal subjects received the radioligand (99m)Tc-TRODAT-1 single photon emission tomography scan (SPECT). Subjects were assessed with the Hamilton Depression Rating Scale. All DAT images were spatially normalized to an averaged brain template, and the specific binding ratios of the striatum, caudate, and putamen were calculated according the formulae of: [region counts] / [occipital counts] - 1. Depressed patients had greater DAT availability on both sides of the striatum. DAT binding was significantly decreased in the striatum after bupropion treatment. Women had higher initial and final DAT binding in the right and left caudate when compared to depressed men. DAT binding decreased in all areas of the brain in women after successful antidepressant treatment, but only in the right caudate of men. Depressed patients had a greater availability of DAT; it was decreased after bupropion treatment.Women seemed to have more DAT availability.

Mineralocorticoid receptor antagonist spironolactone prevents chronic corticosterone induced depression-like behavior.

High level of serum corticosteroid is frequently associated with depression, in which a notable HPA (hypothalamus-pituitary-adrenal) axis hyperactivity is often observed. There are two types of corticosteroid receptors expressed in the hippocampus that provide potent negative feedback regulation on the HPA axis but dysfunction during depression, i.e. the glucocorticoid receptor (GR) and the mineralocorticoid receptor (MR). The balance between hippocampal MR and GR during chronic stress plays an important role in the occurrence of depression. The aim of this study is to explore if chronic corticosterone administration would induce depression-like behavior and affect the expression and function of hippocampal MR and GR, in addition to assess whether manipulation of corticosteroid receptors would modulate depressive behaviors. Hence, mice were treated with corticosterone (40 mg/kg) for 21 days followed by assessment in a battery of depression-like behaviors. The results show that chronic corticosterone-treated animals displayed an increased immobility time in a forced-swimming test, decreased preference to sucrose solution and novel object recognition performance, and enhanced hippocampal serotonin but decreased MR expression in both hippocampus and hypothalamus. On the other hand, co-administration of MR antagonist, spironolactone (25mg/kg, i.p. × 7 days) in corticosteroid-treated animals reduced immobility time in a forced-swimming test and improved performance in a novel object recognition test. In conclusion, we demonstrate that chronic corticosterone treatment triggers several depression-like behaviors, and in parallel, down-regulates MR expression in the hippocampus and hypothalamus. Administration of an MR antagonist confers an anti-depressant effect in chronic corticosterone-treated animals.

Premenstrual dysphoric disorder in East Asia: a review of the literature.

OBJECTIVE: Fluctuations in ovarian steroids during specific phases of the reproductive cycle, such as pre-menstruation, have been hypothesized to contribute to women's increased vulnerability to depression. This current study's goal is to summarize the literature regarding Premenstrual Dysphoric Disorder (PMDD) in the East Asian countries of Taiwan, China (including Hong Kong and Macau), Japan, and Korea. METHOD: A Pubmed and Chinese Electronic Periodical Service (CEPS) literature review was conducted using the key words "Premenstrual Dysphoric Disorder" along with "Japan," rea," "Taiwan," "Hong Kong," and "Macau." Using these criteria, 17 articles were found. Three articles were excluded because they did not involve PMDD in the aforementioned countries. In addition to this search, an article found in a review of the research on reproductive mental health disorders in China was utilized. That review contained one article regarding PMDD with an English language abstract, which was utilized in this current article. RESULTS: The rates of PMDD in East Asia (1.3-2.8%) appear to be lower than that seen in the Western literature (3-8%). Many of the risk factors for PMDD were the same in the Eastern and Western literature, although some key differences were found. The few studies on treatment of PMDD in East Asia have shown positive results. CONCLUSIONS: The rates of PMDD appear to be lower in East Asia, though reasons for this result are discussed. Few studies have been conducted examining the efficacy of psychotropic medications commonly used to treat PMDD in this population.

Antenatal depression in East Asia: a review of the literature.

This current study's goal is to summarize the literature regarding Antenatal Depression (AD) in the East Asian countries of Taiwan, China (including Hong Kong and Macau), Japan, and Korea. The main search utilized a Pub med Chinese Electronic Periodical Service (CEPS) literature review using keywords 'AD', and 'Prenatal Depression' with searches for 'Japan', 'Korea', 'Taiwan', 'Hong Kong' and Macau'. The rates of AD in East Asia appear to be relatively close to those in the Western literature, although certain studies showed slightly decreased rates. Many of the risk factors for AD were the same in the Eastern and Western literature. These risk factors included demographic factors such as younger age, smoking, low education and income, and unemployment. Other risk factors were physical symptoms such as menstrual pains and nausea. Finally, psychological factors such as a poor response to the pregnancy, poor spousal support, and poor family support were associated with AD. With regard to treatment, there were no studies examining the administration of psychotropic medications for AD. The literature from East Asia both confirmed many Western findings and made unique contributions to the literature on AD. The treatment of AD in East Asia appears to be an entity which, despite its morbidity, has not been adequately studied.

Factors associated with low bone density among women with major depressive disorder.

OBJECTIVE: Previous studies have suggested that depression might be associated with low bone mineral density (BMD) in women with depression. The aim of this study was to investigate the association between the BMD of women with major depressive disorder and correlated factors. METHOD: This prospective cross-sectional study explored the association between bone density and major depressive disorder in women. One hundred women diagnosed with major depressive disorder were enrolled. The diagnoses were made by board-certificated psychiatrists using the Mini International Neuropsychiatric Interview (MINI). The Beck Depression Inventory (BDI) was administered. The bone density of the hip was measured with dual X-ray densitometry (DEXA) using a Hologic Delphi QDR-2000 densitometer. RESULTS: We found age, family history of osteoporosis, consumption of coffee, and consumption of tea to be associated with low BMD in single-variate analysis. Depression was also related to BMD, in that the worse the depression, the lower the BMD. Multi-variate analysis by linear regression revealed an equation of BMD = 0.91 - 0.004 x (severity of depression) + 0.07 x (tea consumption)--0.06 x (family history of osteoporosis)--0.04 x age. CONCLUSION: These results suggest that depression is associated with lower BMD, and the associated factors should be considered in depressive women. The findings of this research may be useful for improving the care of women with major depressive disorder in terms of developing appropriate and effective care plans.

The role of consulting psychiatrists for obstetric and gynecologic inpatients.

BACKGROUND: The purpose of this study was to investigate the consultation psychiatry service to the Obstetrics and Gynecology Department in a general hospital, focusing on referral patterns and consultation recommendations. METHOD: A retrospective review of the medical charts and consultation records of obstetric and gynecological patients referred for psychiatric consultation from Dec. 2003 to Nov. 2009 was performed. RESULTS: One hundred and eleven patients were referred during the 6-year period, a psychiatric referral rate of 0.11% among 99,098 obstetric and gynecologic admissions. Obstetric and gynecologic consultations comprised 0.64% of all psychiatric consultations. The most common reasons for referral were depression (52.25%), past psychiatric history (31.53%), insomnia (29.73%) and confusion (24.32%). The most common DSM-IV psychiatric diagnoses were depressive disorder (37.84%), schizophrenia and other psychoses (20.72%), delirium (17.12%) and adjustment disorder (10.81%). The most frequent physical diagnoses of referred patients were neoplasms (72.97%), infectious diseases (42.34%) and complications of pregnancy and puerperium (17.12%). Recommendations included pharmacological intervention (89.19%) and psychological management (72.07%). CONCLUSION: The psychiatric referral rate of obstetric and gynecological inpatients was relatively low compared with that of other departments. More collaboration and liaison between gynecologists and consultation psychiatrists may provide better care for obstetric and gynecological inpatients.

ABCB1 gene polymorphisms are associated with the severity of major depressive disorder and its response to escitalopram treatment.

OBJECTIVE: ATP-binding cassette, sub-family B (MDR/TAP), member 1 (ABCB1) is a drug transporter protein expressed on the epithelial cells of the intestine and the endothelial cells of the blood-brain barrier. Intestinal ABCB1 actively transports drugs from the cell membrane and prevents them from entering the blood stream whereas the blood-brain barrier ABCB1 prevents drugs from entering the central nervous system. In this study, we tested whether genetic polymorphisms within the ABCB1 gene are associated with the severity of depression and the effectiveness of the antidepressant, escitalopram (S-CIT), in treating major depressive disorder (MDD). METHODS: Twenty single nucleotide polymorphisms in the ABCB1 gene were selected and genotyped in 100 MDD patients who had undergone S-CIT treatment continuously for 8 weeks. The serum concentrations of S-CIT and its metabolites (S-desmethylcitalopram and S-didesmethylcitalopram) were then measured at weeks 2, 4, and 8. RESULTS: The ABCB1 genotypes of rs1922242 (P=0.0028) and rs1202184 (P=0.0021) showed significant association with the severity of depressive symptoms as assessed by the Hamilton Rating Scale for Depression adjusted with Hamilton Rating Scale for Anxiety. The haplotype block, rs1882478-rs2235048-rs2235047-rs1045642-rs6949448 (from intron 27 to intron 26), of ABCB1 was found strongly associated with the remission rate (global P=0.003, d.f.=69) in which haplotype T-T-T-C-C was associated with a slower remission rate on S-CIT treatment (P=0.001). The haplotypes may not be indicators of the severity of depression or anxiety. CONCLUSION: Our findings suggest that single nucleotide polymorphisms in the ABCB1 gene may be indicators of the severity of depression and of the likely S-CIT treatment remission response in MDD.

Elevated serum cholesterol levels in women with premenstrual dysphoric disorder.

OBJECTIVES: To study the association of premenstrual serum total cholesterol level (TC) with premenstrual dysphoric disorder (PMDD). METHOD: The premenstrual serum cholesterol levels of 34 patients with PMDD and 20 normal controls were measured, and the rates ofhypercholesterolemia in the 2 groups were compared. RESULTS: The mean of the premenstrual cholesterol level of the study group was 180.82 +/- 34.47 mg/dL, while that of the control group was 162.45 +/- 21.29 mg/dL (t = 2.152, df = 52, p = 0.036). The prevalence of premenstrual hypercholesterolemia (serum total cholesterol > 200 mg/dL) was 23.53% (8/34) in the PMDD group and zero in the normal control group (chi-square = 5.524, df = 1, p = 0.019). CONCLUSION: The results showed elevated premenstrual serum cholesterol in PMDD and implied a new direction of research to further explore the etiology of PMDD. It is suggested that the pathophysiology of premenstrual dysphoric disorder may be similar to that of anxiety disorders.

Sleep quality, fatigue, and related factors among perimenopausal women in Taipei City.

BACKGROUND: Sleep disturbances and fatigue are two of the most common complaints in perimenopausal women. PURPOSE: The purpose of this study was to explore sleep quality, fatigue, and related factors among perimenopausal women. METHODS: A cross-sectional correlation survey was conducted. Data were collected through purposive sampling conducted from January to April 2008 at gynecological clinics and perimenopausal support groups in Taipei City. Informed consent was obtained from patients. RESULTS: Eighty-five women with a mean age of 52.73 years were recruited. The total score for sleep quality was 7.71 ± 4.66, and 62.4% of women were identified as poor sleepers. The mean score of perimenopausal fatigue was 3.02 ± 2.41, indicating mild fatigue. Results showed that the quality of sleep among perimenopausal women was significantly affected by factors including long-term drug use, hormone and/or nutritional supplement consumption, perimenopausal status, and tendency toward anxiety and/or depression (t = 5.43, p < .01; t = -3.15, p < .01; t = -3.33, p < .001; F = 4.33, p < .05; F = 20.20 and 12.73, p < .001.). Fatigue and perimenopausal disturbances were related to sleep quality (r = .63 and .61, p < .01), and 43% of sleep quality variance was explained by fatigue and depression. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: It is crucial to assess sleep quality in perimenopausal women who complain of fatigue and/or depression. In addition, health providers should integrate assessments of factors of significant influence on the sleep quality of perimenopausal women (e.g., fatigue; long-term drug, hormone, and/or nutritional supplements use; menopausal status, and tendency toward anxiety and/or depression).

CYP1A2 genetic polymorphisms are associated with treatment response to the antidepressant paroxetine.

AIM: Paroxetine is a drug of choice in the treatment of major depressive disorder (MDD). Its metabolism has recently been reported to be mediated through the CYP enzymes 1A2 and 2D6. In our current study, we tested whether genetic polymorphisms in CYP1A2 are associated with the treatment efficacy and side effects of paroxetine. MATERIALS & METHODS: A total of 241 MDD patients who had taken paroxetine continually for 8 weeks were recruited, and their steady state paroxetine concentrations were measured at weeks 2, 4 and 8. The genotypes of these patients were then assessed for the presence of nine SNPs, which were selected from either the HapMap Chinese ethnic group, the literature report or through their functional role in the CYP1A2 gene. RESULTS: The allele types for SNPs rs4646425 (permutation p = 0.03), rs2472304 (permutation p = 0.01) and rs2470890 (permutation p = 0.004) demonstrated significant associations with paroxetine treatment remission at week 8. Response rates in the Hamilton Rating Scale for Depression (HAM-D) and for The Hamilton Rating Scale for Anxiety (HAM-A) were significantly associated with the SNPs rs4646425 (p = 0.0126 and 0.0088 for HAM-D and HAM-A, respectively) and rs4646427 (p = 0.0067 and 0.0196 for HAM-D and HAM-A, respectively). The inducible SNP rs762551 had a significant association with paroxetine dose at week 4 (permutation p = 0.012). We did not find an association between these SNPs and the side effects or serum concentrations of paroxetine. CONCLUSION: Genetic variants in the CYP1A2 region may be indicators of treatment response in MDD patients to paroxetine.

Conversion paralysis after surgery for lumbar disc herniation.

OBJECTIVE: New neurologic deficit after spinal surgery is a rare complication that must be promptly diagnosed and treated to reduce the risk of permanent neurologic disability. SUMMARY OF BACKGROUND DATA: A 37-year-old woman underwent left laminotomy and L5-S1 diskectomy for the treatment of L5-S1 disc herniation. She was found to be normal after recovery from anesthesia but loss of muscle power in the left lower limb after 1 h. METHODS: Surgical exploration was performed; no obvious hemorrhage or compression because of hematoma was observed. After the exploration, the muscle power recovered but deteriorated after 10 h. RESULTS: Re-exploration did not yield any specific findings. In view of the normal electrophysiological and anatomic findings, a psychiatric evaluation confirmed the diagnosis of conversion paralysis with major depression disorder. CONCLUSION: Normal somatosensory-evoked potentials or motor-evoked potentials in a patient denying sensation of stimuli offer objective evidence of the psychogenic nature of the para/tetraplegia. This report describes a case in which psychopathology interfered with the outcome of a frequently used procedure for a well-defined, chronic, painful condition.

Genetic polymorphisms of cytochrome P450 enzymes influence metabolism of the antidepressant escitalopram and treatment response.

AIMS: The antidepressant escitalopram (S-CIT) is metabolized by the cytochrome-P450 (CYP) enzymes CYP 2D6, 2C19 and 3A4. This study evaluated the impact of CYP2D6, 2C19 and 3A4 genetic polymorphisms on plasma concentrations of S-CIT and patient treatment response. MATERIALS & METHODS: A total of 100 patients diagnosed with major depressive disorder were recruited to the study and their depression symptoms were assessed using the Hamilton Depression Rating Scale. The genetic polymorphisms *4, *5 and *10 on CYP2D6, *2, *3 and *17 on CYP2C19, and *18 on CYP3A4 were selected based on their function and respective allele frequencies in Asian populations. Polymorphisms were analyzed using the SNPstream genotyping system, PCR and direct sequencing methods. The steady-state serum concentrations of S-CIT and its metabolites S-desmethylcitalopram and S-didesmethylcitalopram were analyzed by HPLC. According to semiquantitative gene dose (SGD) and gene dose (GD) models for allele combinations of these polymorphisms, CYP2D6 was clustered into intermediate (0.5, 1 and 1.5 SGD) and extensive (2 SGD) metabolizers, while CYP2C19 was clustered into poor (0 GD) and extensive (1 and 2 GDs) metabolizers. RESULTS: The group of patients with intermediate CYP2D6 metabolism (0.5 SGD) had a significantly higher frequency of remitters from major depressive disorder during the 8-week treatment (p = 0.0001). Furthermore, CYP2C19 poor metabolizers had significantly higher S-CIT serum levels than did extensive metabolizers at weeks 2, 4 and 8 (p < 0.05). The allele frequencies in CYP3A4*18 and CYP2C19*17 were too low to permit further subgroup analyses. CONCLUSION: Our results suggest that the genetic polymorphisms in CYP2C19 may be influencing S-CIT serum concentrations, and that specific CYP2D6 polymorphisms may be predicting patient treatment outcomes based on gene dosage analyses.

Help-seeking behavior in Taiwanese woman with menopause-related mood symptoms.

BACKGROUND: Typical menopause-related symptoms sometimes mimic cardiovascular illnesses or other physical problems. It is essential to understand the help-seeking behaviors of menopausal women. METHODS: A total of 181 subjects were recruited from our menopause-related mood clinic. A questionnaire which included patient data and help-seeking questions was used. All help-seeking information was documented in chronological order up to register in the menopause-related mood clinic. RESULTS: The average latency from the onset of menopausal symptoms to seeking evaluation at our specialty clinic was 16.8 +/- 27.7 months. The first contact was a gynecologist (28.2%), general practitioner (15.5%), cardiologist (6.1%), and psychiatrist (6.1%). The most common contacts were gynecologists (37.0%), followed by general practitioners (28.2%), psychiatrists (16.0%), and cardiologists (11.6%). CONCLUSIONS: Gynecologists, general practitioners, cardiologists, and general psychiatristsare all potential gatekeepers for menopausal women. It is important to increase the public's understanding of menopause and improve cooperation between the various providers of women's mental health to cut medical insurance costs and improve the quality of care.

Effective treatment of premenstrual violence in major depression: augmentation with aripiprazole.

Premenstrual exacerbation of major depression is not uncommon. Premenstrual phase-related violence has also been reported. Serotonergic antidepressants, used both continuously and with increased dosage in the late luteal phase, are believed to be effective for major depressive disorder with premenstrual exacerbation. Adding a second medication for non-responder treatment is another treatment option. We present a 38-year-old woman suffering from major depression with premenstrual exacerbation of irritability and uncontrollable violence. The premenstrual exacerbation did not respond to increasing doses of selective serotonin reuptake inhibitor (SSRI) but a combination of an SSRI and late luteal phase aripiprazole was effective for her premenstrual violence. The serotonergic property of aripiprazole provides a synergic effect to SSRI for relieving premenstrual exacerbation of depression. The role of dopamine D2 as a partial agonist might further add to the effective alleviation of aggression and violence. An antidepressant with aripiprazole augmentation may be a treatment strategy for refractory premenstrual exacerbation and violence. Large-scale double blind placebo-controlled studies to verify efficacy are warranted.

Six-month paroxetine treatment of premenstrual dysphoric disorder: continuous versus intermittent treatment protocols.

AIMS: Several trials have proved the efficacy of selective serotonin re-uptake inhibitors (SSRI) in the treatment of premenstrual dysphoric disorder (PMDD) in Western society. The SSRI can be administered continuously throughout the entire cycle or intermittently from ovulation to the onset of menstruation (luteal phase). The purpose of the present study was to compare continuous and intermittent paroxetine treatment in oriental PMDD women during 6 months follow up. METHODS: Thirty-six subjects were evaluated and drug free for two menstrual cycles, and they received daily paroxetine (20 mg) for two further full cycles. They were then randomly divided into continuous or intermittent treatment groups (n = 16, 14) over the next four cycles. Responses were assessed every 2 weeks. Outcome measures included scores on the Prospective Record of the Impact and Severity of Menstrual Symptomatology (PRISM) calendar, Hamilton Rating Scale for Depression/Anxiety (HAMD/HAMA), and the Clinical Global Impression scale (CGI). RESULTS: All these women had significant improvements in the HAMA, HAMD, CGI, and PRISM calendar. The rate of response to paroxetine treatment lay between 50% and 78.6% in the continuous-treatment group, and 37.5-93.8% in the intermittent-treatment group, as determined at the study end-point. Limitations of the present study included the open-label design and the incorporation of a limited sample size. CONCLUSIONS: The present results indicate that paroxetine is effective in both continuous and intermittent treatment of oriental PMDD women, and that the effects of active treatment lasted for six consecutive treatment menstrual cycles.