Nocturnal urinary cortisol excretion over a randomized controlled trial with paroxetine vs. placebo combined with relaxation training or aerobic exercise in panic disorder.

INTRODUCTION: Data on basal hypothalamo-pituitary-adrenomedullary (HPA) function over controlled treatment trials with serotonergic drugs in anxiety disorders are still rare. METHODS: 29 patients with panic disorder participating in a 10 week randomized, controlled trial (paroxetine vs. placebo with exercise or relaxation; N=60) collected urine for cortisol excretion over 3 consecutive nights before start and before termination of the treatment episode. Urinary cortisol was measured by radioimmunoassay. Efficacy measures were the Clinical Global Impression Scale (CGI) and the Panic and Agoraphobia Scale (P&A). 83% were female (p<.05 vs. males). 55% received additional aerobic exercise, and 45% relaxation. 55% received paroxetine treatment, and 45% placebo. Significantly fewer males received placebo treatment (p<.05). RESULTS: All subjects improved significantly. Cortisol excretion did not differ between treatment groups or at pre-/post measurements. Females showed a significantly higher variability of cortisol excretion compared to males, at pre-(p<.005) and post (p=.015) assessments. Males displayed a trend to lower basal HPA function at end of treatment (p=.08). HPA variability after treatment showed a trend to be higher in the paroxetine (p=.052) -who clinically improved significantly better- compared to the placebo group. No relationship between HPA activity and treatment response or with exercise was detected. DISCUSSION: HPA function shows significant gender differences, with females having a higher HPA function variability. Future studies on HPA function in treatment trials should address gender and medication effects.

[Etiology of initially unexplained confusion of excitability in deadly nightshade poisoning with suicidal intent. Symptoms, differential diagnosis, toxicology and physostigmine therapy of anticholinergic syndrome]. / Atiologisch zunächst unklare Verwirrtheit und Exzitation im Verlauf einer Tollkirschenvergiftung mit suizidaler Absicht. Symptomatik, Differentialdiagnose, Toxikologie und Physostigmin-Therapie des anticholinergen Syndroms.

HISTORY AND ADMISSION FINDINGS: After a walk in a wood a 55-year-old teacher was admitted to the emergency unit of a university hospital because of somnolence and excitability. Her rectal temperature was 37.8 degrees C, she had sinus tachycardia (rate of 130/min) but no other significant findings. INVESTIGATIONS: With the exception of C-reactive protein (10 mg/dl), MCV (101 fl), MCH (34 pg) and arterial blood gases (pH 7.483, pCO2 35.5 mmHg, base excess 5.1 mmp/l) laboratory tests were within normal limits. Qualitative screening of serum for benzodiazepines, barbiturates and antidepressives was negative. Neurological examination, including lumbar puncture and cranial computed tomography were noncontributory. TREATMENT AND COURSE: 10 hours after admission the patient developed signs of an anticholinergic syndrome with mydriasis, dry mouth, tachycardia, hot skin and an atonic bladder. Physostigmine 2 mg completely reversed the neurological and mental symptoms. After gas chromatography, mass-spectrometry of a urine sample showed an atropine molecular fragment with a molecular weight of 271. At intervals of 3 to 5 hours the recurrence of confusion and excitability required 4 further i.v. injection of physostigmine. The patient subsequently became accessible to psychiatric examination and reported that during the walk she had swallowed 8-10 berries of deadly nightshade with suicidal intent. CONCLUSION: In case of excitability and confusion as well as somnolence or coma of uncertain aetiology an anticholinergic syndrome caused by ingestion of atropine-containing plants or psychoactive drugs (phenothiazines, butyrophenones, tri- or tetracyclic antidepressants) should be included in the differential diagnosis. If there are suggestive clinical findings (tachycardia, somnolence, coma or threatened respiratory arrest, physostigmine should be given if there are no contraindications.

What treatments do patients with panic disorder and agoraphobia get?

In a retrospective study 100 patients with DSM-III-R/ICD-10 panic disorder and agoraphobia (PDA) were interviewed about the psychopharmacological, psychological and 'alternative' treatments they had received in the course of their illness. Patients gave global statements about how satisfied they were with the various treatments they had experienced. Many patients received treatments that have never been investigated under controlled conditions. The most common drug treatments, in descending order, were: 48% benzodiazepines, 42% tricyclic antidepressants, 32% herbal preparations, 29% neuroleptics, 7% selective serotonin reuptake inhibitors and 6% beta blockers. Of the drug prescriptions, 63% were according to international standards. Of the neuroleptics, two-thirds (63.3%) were prescribed by nonpsychiatric physicians, and only one-third by psychiatrists (33.3%). Tricyclic antidepressants were prescribed more often by psychiatrists (64.7%) than by non-psychiatrists (31.4%). Among psychological treatments, autogenic training (43% of the patients) and psychodynamic therapy (33%) were used far more frequently than behavioural/cognitive therapy (20%). These results confirm the underutilisation of available effective treatments for panic disorder (e.g. tricyclic antidepressants or behavioural therapy) and the overutilisation of treatments without proven efficacy (e.g. herbal preparations or autogenic training). Patients were most satisfied with treatments that have been proven effective in controlled studies. Among drug treatments, benzodiazepines, selective serotonin inhibitors and tricyclic antidepressants were favoured (mean on a 0-4 scale indicating effectiveness: 2.6, 2.6 and 2.4). Neuroleptics (1.4), beta-blockers (1.0) and herbal preparations (0.9) were not rated highly effective by the patients. Among psychological treatments, patients were more satisfied with behavioural/cognitive therapy (2.6) than with psychodynamic therapies (1.5).(ABSTRACT TRUNCATED AT 250 WORDS)