A randomized clinical trial to assess the efficacy of trial-based cognitive therapy compared to prolonged exposure for post-traumatic stress disorder: preliminary findings.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a prevalent mental health condition that is often associated with psychiatric comorbidities and changes in quality of life. Prolonged exposure therapy (PE) is considered the gold standard psychological treatment for PTSD, but treatment resistance and relapse rates are high. Trial-based cognitive therapy (TBCT) is an effective treatment for depression and social anxiety disorder, and its structure seems particularly promising for PTSD. Therefore, we evaluated the efficacy of TBCT compared to PE in patients with PTSD. METHODS: Ninety-five patients (77.6% females) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria for PTSD were randomly assigned to receive either TBCT (n = 44) or PE (n = 51). Patients were evaluated before and after treatment, and at follow-up 3 months after treatment. The primary outcome was improvement in PTSD symptoms as assessed by the Davidson Trauma Scale (DTS). Secondary outcomes were depression, anxiety, and dysfunctional attitudes assessed by the Beck Depression/Anxiety Inventories and Dysfunctional Attitudes Scale, as well as the dropout rate. RESULTS: A significant reduction in DTS scores was observed in both arms, but no significant difference between treatments. Regarding the secondary outcomes, we found significant differences in depressive symptoms in favor of TBCT, and the dropout rate was lower in the TBCT group than the PE group. CONCLUSION: Our preliminary results suggest that TBCT may be an effective alternative for treating PTSD. Further research is needed to better understand its role and the mechanisms of change in the treatment of this disorder.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder.

BACKGROUND: Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST). METHODS: Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment. RESULTS: The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT. CONCLUSIONS: Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

Inflammatory markers changes following acceptance-based behavioral psychotherapy in generalized anxiety disorder patients: Evidence from a randomized controlled trial.

Introduction: Generalized anxiety disorder (GAD) has been associated with elevated levels of C-reactive protein (CRP) and proinflammatory cytokines. Despite robust evidence as an effective treatment for GAD, research on the effects of cognitive-behavioral therapies (CBT) in the inflammatory profile of patients with clinical anxiety has presented mixed results. Objective: The present study aimed to investigate the effect of an acceptance-based behavior therapy (ABBT) on inflammatory biomarkers and their association with anxiety levels in GAD patients in comparison to supportive therapy as an active control. Methods: Peripheral inflammatory biomarkers (CRP, IL-1ß, IL-4, IL-6, IL-10, TNF-α) were measured in 77 GAD patients who participated in a 14-week 10-session randomized clinical trial of group ABBT (experimental, n = 37) or supportive group therapy (ST: active control group, n = 40). Results: The concentrations of IL-1ß decreased in the control group and the concentrations of IL-6 increased in the experimental group from baseline to post-treatment, whereas no difference was identified in IL-4, IL-10, TNF, or CRP. Although anxiety and depression levels decreased in both treatment conditions, no correlation with inflammation markers was found for most clinical and biological variables. A negative correlation between changes in IL-6 and IL-10 and anxiety symptom score changes was identified. Conclusions: The present study results found that a short trial of acceptance-based behavior therapy did not change the proinflammatory profile which may be associated with GAD. Additional research is needed to evaluate the influence of other inflammation-related variables, longer periods of follow-up as well as the effect of supportive therapy on peripheral inflammatory biomarkers in GAD patients.

Fibromyalgia comorbid with anxiety disorders and depression: combined medical and psychological treatment.

Fibromyalgia is associated with high level of pain and suffering. Lack of diagnosis leads to onerous indirect economic costs. Recent data indicate that fibromyalgia; anxiety disorders, and depression tend to occur as comorbid conditions. They also share some common neurochemical dysfunctions and central nervous system alterations such as hypofunctional serotonergic system and altered reactivity of the hypothalamic-pituitary-adrenal axis. Conversely, functional neuroimaging findings point to different patterns of altered pain processing mechanisms between fibromyalgia and depression. There is no cure for fibromyalgia, and treatment response effect size is usually small to moderate. Treatment should be based on drugs that also target the comorbid psychiatric condition. Combined pharmacotherapy and cognitive-behavior therapy should ideally be offered to all patients. Lifestyle changes, such as physical exercise should be encouraged. The message to patients should be that all forms of pain are true medical conditions and deserve proper care.

Brazilian Psychiatric Association guidelines for the treatment of generalized anxiety disorder (GAD). Pharmacological and Psychotherapy approach. Perspectives.

OBJECTIVE: To combine elements of a systematic review and critical review to produce best evidence synthesis for the treatament of GAD. METHOD: There was included systematic reviews, metanalysis, and randomized controlled trials. Descriptor used was "generalized anxiety disorder", resulting in 4860 articles and 7 other studies, of which 59 were selected. RESULTS: Antidepressants and benzodiazepines are indicated, as well as pregabalin. From, atypical antipsychotics quetiapine has been studied. Cognitive behavior therapy (third wave of behavioral and cognitive therapies) as well as individual CBT proven to be effective. CONCLUSION: There is extensive literature on many effective treatments for GAD. The present work summarizes the therapeutic possibilities, emphasizing those available in the Brazil. Further studies are still needed to compare other available medications, to assess psychotherapies in more depth, new treatments and specially to assess the ideal time for maintaining therapy.

Placebo effect after prefrontal magnetic stimulation in the treatment of resistant obsessive-compulsive disorder: a randomized controlled trial.

Many patients with obsessive-compulsive disorder (OCD) do not achieve satisfactory symptom improvement with conventional treatments. Here, we evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) applied over the right dorsolateral prefrontal cortex (rDLPFC) in patients with treatment-resistant OCD. This was a double-blind randomized trial involving 30 treatment-resistant OCD outpatients, allocated to have either sham or active high-frequency rTMS (over the rDLPFC) added to their treatment regimens for 6 wk, with 6 wk of follow-up. Active rTMS consisted of 30 applications (figure-of-eight coil; 10 Hz at 110% of motor threshold; 1 session/d; 40 trains/session; 5 s/train; 25-s intertrain interval). At weeks 0, 2, 6, 8, and 12, we applied the Yale-Brown Obsessive-Compulsive Scale (YBOCS), Clinical Global Impression (CGI) scale, 14-item Hamilton Anxiety Rating Scale (HAMA-14), 17-item Hamilton Depression Rating Scale (HAMD-17), and 36-item Short-form Health Survey. The primary outcome measure was a positive response (≥ 30% improvement in YBOCS score, together with a 'much improved' or 'very much improved' CGI - Improvement scale rating). One patient in each group showed a positive response (p=1.00). For YBOCS score, there was significant effect of time (F=7.33, p=0.002) but no significant group effect or group×time interaction. In treatment-resistant OCD, active rTMS over the rDLPFC does not appear to be superior to sham rTMS in relieving obsessive-compulsive symptoms, reducing clinical severity, or improving treatment response, although there is evidence of a placebo effect.

Primary headaches in patients with generalized anxiety disorder.

Although anxiety disorders and headaches are comorbid conditions, there have been no studies evaluating the prevalence of primary headaches in patients with generalized anxiety disorder (GAD). The aim of this study was to analyze the lifetime prevalence of primary headaches in individuals with and without GAD. A total of 60 individuals were evaluated: 30 GAD patients and 30 controls without mental disorders. Psychiatric assessments and primary headache diagnoses were made using structured interviews. Among the GAD patients, the most common diagnosis was migraine, which was significantly more prevalent among the GAD patients than among the controls, as were episodic migraine, chronic daily headache and aura. Tension-type headache was equally common in both groups. Primary headaches in general were significantly more common and more severe in GAD patients than in controls. In anxiety disorder patients, particularly those with GAD, accurate diagnosis of primary headache can improve patient management and clinical outcomes.

Benzodiazepine use in Sao Paulo, Brazil.

OBJECTIVES: To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil. METHODS: 5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition. RESULTS: The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use. CONCLUSION: These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Choking phobia: full remission following behavior therapy.

OBJECTIVE: A phobic behavior pattern is learned by classical and operant conditioning mechanisms. The present article reviews the main determinants of choking phobia etiology and describes the behavior therapy of an adult patient. METHOD: Psychoeducation, functional analysis, and graded exposure to aversive stimuli were used to treat the patient, after extensive psychiatric and psychological assessment. Ingesta and anxiety levels were measured along treatment and at follow-up. RESULTS: A multiple assessment baseline design was used to demonstrate the complete remission of symptoms after seven sessions, each of them exposing the patient to a different group of foods. CONCLUSION: Psychoeducation and exposure were critical components of a successful choking phobia treatment.

Abuse liability of intra-nasal midazolam in inhaled-cocaine abusers.

Intra-nasally instilled benzodiazepines have been proposed for acute anxiety episodes. However, routes with faster absorption may increase abuse liability. This study compared abuse liability of intra-nasal midazolam between subjects with a history of intra-nasal drug abuse and non-psychiatric subjects on a single-blind randomized controlled trial. Thirty-one inhaled-cocaine abusers and 34 normal volunteers received either 1 mg intra-nasal midazolam or active placebo. Visual analogue scales assessing desire to repeat the experience (ER) and Experience Liking (EL) assessed abuse liability. Profile analysis for repeated measures showed a significant effect of time over ER (F([5,57])=3.311, p=0.011) and EL (F([5,57])=3.947, p=0.004), diagnostic group (cocaine abusers scoring higher on both - F([5,57])=5.229, p=0.026; F([5,57])=4.946, p=0.030), regardless of the administered substance. It is concluded that the intra-nasal route does not seem to pose risks for non-psychiatric individuals, but it may represent a risk in itself for subjects with a history of drug abuse through this path.

Personality traits and treatment outcome in obsessive-compulsive disorder.

OBJECTIVE: Comorbidity with personality disorders in obsessive-compulsive patients has been widely reported. About 40% of obsessive-compulsive patients do not respond to first line treatments. Nevertheless, there are no direct comparisons of personality traits between treatment-responsive and non-responsive patients. This study investigates differences in personality traits based on Cloninger's Temperament and Character Inventory scores between two groups of obsessive-compulsive patients classified according to treatment outcome: responders and non-responders. METHOD: Forty-four responsive and forty-five non-responsive obsessive-compulsive patients were selected. Subjects were considered treatment-responsive (responder group) if, after having received treatment with any conventional therapy, they had presented at least a 40% decrease in the initial Yale-Brown Obsessive Compulsive Scale score, had rated "better" or "much better" on the Clinical Global Impressions scale; and had maintained improvement for at least one year. Non-responders were patients who did not achieve at least a 25% reduction in Yale-Brown Obsessive Compulsive Scale scores and had less than minimal improvement on the Clinical Global Impressions scale after having received treatment with at least three selective serotonin reuptake inhibitors (including clomipramine), and at least 20 hours of cognitive behavioral therapy. Personality traits were assessed using Temperament and Character Inventory. RESULTS: Non-responders scored lower in self-directedness and showed a trend to score higher in persistence than responders did. CONCLUSION: This study suggests that personality traits, especially self-directedness, are associated with poor treatment response in obsessive-compulsive patients.

Concomitant treatment with sertraline and social skills training improves social skills acquisition in social anxiety disorder: A double-blind, randomized controlled trial.

OBJECTIVES: To examine whether: (1) sertraline (SER) + psychotherapy is superior to psychotherapy alone; (2) group cognitive-behavioural therapy (GCBT) is superior to group psychodynamic therapy (GPT) and (3) SER+GCBT or SER+GPT is superior to Placebo (PLA)+GCBT or PLA+GPT in social anxiety disorder (SAD). METHODS: A double-blind randomized controlled trial. Participants were assigned either to: SER+GCBT (n = 34); SER+GPT (n = 36); PLA+GCBT (n = 36) or PLA+GPT (n = 41) for 20 weeks. SER (or PLA) was administered at doses from 50 to 200 mg/d. Primary measures were both categorial: remission (CGI score≤2), response of social symptoms (≥50% reduction in Scale of Avoidance and Social Discomfort (SASD)); and continuous: reduction of SASD and Multidimensional Scale of Social Expression(M-MSSE). RESULTS: SER exhibited better improvement of social anxiety symptoms rate than PLA (25.73% vs. 9.46%, P < .05). Neither GCBT differed from GPT (12.33% vs. 22.54%, P = .11) nor SER+GCBT from PLA+GCBT (17.65% vs. 7.69%, P = .20). However, SER+GPT was superior to PLA+GPT (33.33%, vs. 11.43%, P < .05). M-MSSE had superior improvement for SER+GCBT vs PLA+GCBT (P < .01) but not for SER+GPT vs. PLA+GPT (P = .80). SASD scores improvement were greater for SER than PLA (P < .01) and for SER+GCBT vs. PLA+GCBT (P < .05), but neither GCBT differed from GPT(P = .60) nor SER+GPT differed from PLA+GPT (P = .09). CONCLUSIONS: In overall, SER+psychotherapy was superior to psychotherapy alone. SER potentiated GCBT by enhancing social skills acquisition. TRIAL REGISTRATION: ISRCTN 57551461.

Acute hormonal changes after IV citalopram and treatment response in OCD.

RATIONALE: Serotonergic pharmacological challenges have failed to produce consensual results in patients with obsessive-compulsive disorder (OCD), suggesting a heterogeneous 5-hydroxytryptamine (5-HT) activity in this disorder. OBJECTIVES: The aim of this study was to compare the neuroendocrine response to a serotonergic challenge in OCD patient responders (RP) and nonresponders (NR) to serotonin reuptake inhibitors treatment and healthy volunteers. MATERIALS AND METHODS: Thirty OCD treatment NR, 30 RP, and 30 controls (CN) matched for sex and age were included. Each subject received 20 mg of intravenous citalopram. Prolactin, cortisol, and growth hormone plasma concentration were measured at times-20, 0, 20, 40, 60, 80, 100, 120, 140, and 160 min after the onset of citalopram infusion. RESULTS: Citalopram did not induce anxiety or OCD symptoms in patients. Citalopram was associated with stronger prolactin response in the CN group (maximal percentage variation [max%Delta] = 65.76 +/- 105.1) than in NR (max%Delta = 17.41 +/- 31.06) and RP groups (max%Delta = 15.87 +/- 31.71; p = 0.032; Friedman chi (2) = 6.87; df = 2). On the other hand, cortisol response did not differ between CN and RP groups and was blunted in the NR group (NR max%Delta = 20.98 +/- 58.14 vs RP max%Delta = 47.69 +/- 66.94; CN max%Delta = 63.58 +/- 88.4; p = 0.015; Friedman chi (2) = 8.60; df = 2). CONCLUSIONS: Compared to CN, both treatment RP and NR patients showed blunted prolactin response to citalopram, but only NR patients showed an attenuated cortisol response, suggesting a more disrupted central serotonergic transmission in this group.

[Psychiatric comorbidities decrease quality of life in chronic migraine patients]. / Comorbidade psiquiátrica diminui a qualidade de vida de pacientes com enxaqueca crônica.

INTRODUCTION: Chronic migraine is a common, debilitating condition affecting quality of life and social functioning with significant impact. Migraine is highly comorbid with anxiety and mood disorders, but little is known about psychiatric comorbidities impact in the migraine patient quality of life. METHOD: Fifty patients with chronic migraine diagnosed according to the International Headache Society (2004) were interviewed and met diagnostic criteria for mental disorders, according to the structured interview SCID-I/P and were evaluated by the SF-36 Health Survey questionnaire. Patients were divided in the following groups: chronic migraine with both mood and anxiety disorders, with only anxiety disorders, with generalized anxiety disorder, with only a mood disorder, and without psychopathology. The scores in the group without psychopathology were compared with the other groups. All eight domains of the SF-36 scale were compared in those groups. RESULTS: Significantly lower (p<0.05) quality of life was found on all eight SF-36 domains for CM psychiatric comorbidity patients compared to no-co morbidity patients. On the SF-36 General Health domain alone, quality of life was not significantly lower for all four CM psychiatric comorbidity groups. On the SF-36 Physical Aspects domain alone, quality of life was not significantly lower only for the Anxiety Disorders group. CONCLUSION: Chronic migraine comorbidity with mental disorder is a significant factor affecting patients' quality of life.

Misinterpretation of the Borg's Rating of Perceived Exertion Scale by patients with panic disorder during ergospirometry challenge.

INTRODUCTION: The most widely used instrument to measure perceived exertion or exercise intensity is the Borg's Rating of Perceived Exertion (RPE) Scale. Panic attacks are aversive experiences that may be triggered by bodily sensations such as palpitations, breathlessness or dizziness due to increasing autonomic distress, prior sensitisation to panic and fear conditioning. The consequence is catastrophic interpretation of bodily sensations of arousal in general, which can lead to misinterpretation of exertion or exercise intensity. PURPOSE: To verify the effectiveness of the Borg's RPE Scale as a measure of perceived effort in panic disorder subjects. METHODS: The study enrolled 72 subjects: the control group (C, healthy sedentary subjects, n=30) and patients with panic disorder (PD, n=42). All subjects were submitted to an ergospirometry challenge. Perceived exertion RPE scores and heart rate at 90% VO2max were compared between groups. RESULTS: Patients with PD showed lower levels of maximal oxygen consumption, when compared with C group [VO2max (mL/kg/min): PD=29.42±6.50xC=34.51±5.35; Student's t-test=-3.51; p <0.05]. Furthermore, among PD subjects, the maximum heart rate during ergospirometry challenge was lower than expected [predict max HR (bpm)=200.85±6.33xheart rate test (bpm)=178.86±7.28; Z=-5.64; p<0.05]. Perceived exertion, as measured by RPE, was also overestimated in relation to heart rate at 90% of maximum oxygen consumption compared with controls (RPE90%VO2max: PD=18.93±0.55xC=16.67±0.60; U=8.00; Z=7.42; p<0.05). CONCLUSIONS: The present study findings suggest that the Borg's RPE Scale may not be an appropriate measure of subjective exertion among subjects with panic disorder performing a cardiopulmonary exercise test.

Impact of post-traumatic stress disorder on oral health.

BACKGROUND: The stress experienced as an intense and traumatic event can increase the odds of orofacial pain, affect the biomechanics of masticatory system and compromise the periodontal health. This study was conducted to investigate the impact of post-traumatic stress disorder (PTSD) on oral health. METHODS: A case-control study with a convenience sample was designed. Probing pocket depth (PPD), clinical attachment level (CAL), bleeding on probing, and plaque were recorded at 6 sites per tooth. A visual analog scale (VAS) was used to evaluate the pain after probing. The Research Diagnostic Criteria for Temporomandibular Disorders Axis II (RDC/TMD Axis II) and Structured Clinical Interview (DSM-IV) were also applied. The final sample comprised 38 PTSD patients and 38 controls. RESULTS: Patients with PTSD had a higher degree of chronic pain, more depression and nonspecific physical symptoms (including and excluding pain) compared with the control group (Fisher exact test p < 0.001, and Chi-squared test, p < 0.001, < 0.001, < 0.001, respectively). Patients with PTSD also had more pain after periodontal probing compared with controls (Mann-Whitney, p = 0.037). The prevalence of sites with CAL or PPD ≥ 4, ≥ 5, ≥ 6 were not different between the groups. Age was associated with moderate periodontitis (multivariable logistic regression model, OR = 3.33, 95% CI = 1.03-10.75, p = 0.04). LIMITATION: The severity of PTSD precluded an ample sample size. CONCLUSIONS: Patients with PTSD presented a worse RDC/TMD Axis II profile, more pain after periodontal probing, and no difference related to periodontal clinical parameters. More studies are needed to confirm these findings.

Phobias, other psychiatric comorbidities and chronic migraine.

BACKGROUND: Comorbidity of chronic migraine (CM) with psychiatric disorders, mostly anxiety and mood disorders, is a well-recognized phenomenon. Phobias are one of the most common anxiety disorders in the general population. Phobias are more common in migraineurs than non-migraineurs. The clinical profile of phobias in CM has never been studied. METHOD: We investigated the psychiatric profile in 56 patients with CM using the SCID I/P interview. RESULTS: Lifetime criteria for at least one mental disorder was found in 87.5% of the sample; 75% met criteria for at least one lifetime anxiety disorder and 60.7% of our sample fulfilled DSM-IV criteria for lifetime phobic avoidant disorders. Mood and anxiety scores were higher in phobic patients than in non-phobic CM controls. Number of phobias correlated with higher levels of anxiety and depression. CONCLUSION: Phobias are common in CM. Its recognition may influence its management. Early treatment may lead to better prognosis.

The putative catalytic role of higher serotonin bioavailability in the clinical response to exposure and response prevention in obsessive-compulsive disorder.

OBJECTIVE:: Exposure and response prevention (ERP) is effective to treat obsessive-compulsive disorder (OCD), but the lack of tolerance to the aversion nature of exposure techniques results in a high drop-out rate. There have been reports of a generic stress endurance effect of serotonin (5-HT) in the central nervous system (CNS) which might be explained by suppression of defensive fixed action patterns. Previous studies have proposed that higher baseline 5-HT concentration and slow decrease in concentration during drug treatment of OCD were predictors of good clinical response to 5-HT reuptake inhibitors. The objective of this study was to investigate whether pre-treatment platelet rich plasma (PRP) 5-HT concentration is associated with latency of treatment response and final response to an ERP protocol for obsessive-compulsive disorder (OCD). METHODS:: Thirty adult and treatment-free OCD patients were included in an 8-week, 16-session ERP protocol. 5-HT concentration was determined at baseline and after treatment. Patients with a reduction ≥30% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at the end of ERP were defined as responders. RESULTS:: A positive correlation between baseline 5-HT concentration and reduction of symptoms on the Y-BOCS was observed after 4 weeks. Baseline 5-HT concentration was not correlated with clinical response after 8 weeks of ERP, possibly due to the similar though delayed clinical response of patients with lower (compared to those with higher) baseline 5-HT concentration. Patients with higher 5-HT baseline concentration also showed more improvement in depressive symptoms with treatment. CONCLUSION:: The present results partially support the hypothesis of a stress endurance effect of 5-HT in OCD patients. According to the literature, fast onset responders possibly have more or larger 5-HT containing neurons, higher endogenous 5-HT synthesis or lower monoamine oxidase activity; all these hypotheses remain to be investigated.

Depression in chronic migraine: severity and clinical features.

INTRODUCTION: Chronic migraine (CM) is a common medical condition affecting 2.4% of the general population. Depression is one of the most frequent comorbid disorders in CM. METHOD: Seventy patients diagnosed with chronic migraine were studied. All patients evaluated filled out the Beck Depression Inventory (BDI). Depression severity was divided into none or minimal depression, mild, moderate, and severe. RESULTS: BDI ranged from 4 to 55, mean 21 +/- 10.7. Moderate or severe depression, were present in 58.7% of the patients. Some degree of depression appeared in 85.8% of patients. The BDI scores correlated with pain intensity (p = 0.02). Severe depression was more frequent in patients with comorbid fibromyalgia and in patients reporting fatigue. CONCLUSION: The BDI is an easy tool to access depression in CM patients. Suicide risk assessment is needed in CM patients. Patients with fibromyalgia and fatigue are at even higher risk for severe depression.

Clomipramine demethylation rate is important on the outcome of obsessive-compulsive disorder treatment.

The aim of this study was to investigate the influence of demethylation rate on the outcome of obsessive-compulsive disorder patients treated with clomipramine. Eighteen patients meeting the DSM-IV criteria for obsessive-compulsive disorder received 150-300 mg of clomipramine daily in a single-blind design for 12 weeks. The patients were evaluated with the Clinical Global Impression scale and the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Clinical assessment and serum measurements of clomipramine and desmethylclomipramine were carried out at baseline and after 3, 6, 8, 10, and 12 weeks. A greater improvement in Clinical Global Impression scale rating was associated with a lower desmethylclomipramine/daily dose and the total clomipramine and desmethylclomipramine/daily dose. Moreover, an improved response on the YBOCS-obsession score was associated with higher serum levels of clomipramine and the total clomipramine and desmethylclomipramine/daily dose. Patients with a greater reduction in baseline YBOCS rating had a lower desmethylclomipramine/clomipramine ratio. These data suggest that a lower demethylation rate correlates with better clinical outcome.