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Guaiana G, Meader N, Barbui C, Davies SJ, Furukawa TA, Imai H, Dias S, Caldwell DM, Koesters M, Tajika A, Bighelli I, Pompoli A, Cipriani A, Dawson S, Robertson L. Pharmacological treatments in panic disorder in adults: a network meta-analysis. Cochrane Database Syst Rev 2023; 11:CD012729. [PMID: 38014714 PMCID: PMC10683020 DOI: 10.1002/14651858.cd012729.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND A panic attack is a discrete period of fear or anxiety that has a rapid onset and reaches a peak within 10 minutes. The main symptoms involve bodily systems, such as racing heart, chest pain, sweating, shaking, dizziness, flushing, churning stomach, faintness and breathlessness. Other recognised panic attack symptoms involve fearful cognitions, such as the fear of collapse, going mad or dying, and derealisation (the sensation that the world is unreal). Panic disorder is common in the general population with a prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions, including antidepressants and benzodiazepines. OBJECTIVES To compare, via network meta-analysis, individual drugs (antidepressants and benzodiazepines) or placebo in terms of efficacy and acceptability in the acute treatment of panic disorder, with or without agoraphobia. To rank individual active drugs for panic disorder (antidepressants, benzodiazepines and placebo) according to their effectiveness and acceptability. To rank drug classes for panic disorder (selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), mono-amine oxidase inhibitors (MAOIs) and benzodiazepines (BDZs) and placebo) according to their effectiveness and acceptability. To explore heterogeneity and inconsistency between direct and indirect evidence in a network meta-analysis. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialised Register, CENTRAL, CDSR, MEDLINE, Ovid Embase and PsycINFO to 26 May 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people aged 18 years or older of either sex and any ethnicity with clinically diagnosed panic disorder, with or without agoraphobia. We included trials that compared the effectiveness of antidepressants and benzodiazepines with each other or with a placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened titles/abstracts and full texts, extracted data and assessed risk of bias. We analysed dichotomous data and continuous data as risk ratios (RRs), mean differences (MD) or standardised mean differences (SMD): response to treatment (i.e. substantial improvement from baseline as defined by the original investigators: dichotomous outcome), total number of dropouts due to any reason (as a proxy measure of treatment acceptability: dichotomous outcome), remission (i.e. satisfactory end state as defined by global judgement of the original investigators: dichotomous outcome), panic symptom scales and global judgement (continuous outcome), frequency of panic attacks (as recorded, for example, by a panic diary; continuous outcome), agoraphobia (dichotomous outcome). We assessed the certainty of evidence using threshold analyses. MAIN RESULTS Overall, we included 70 trials in this review. Sample sizes ranged between 5 and 445 participants in each arm, and the total sample size per study ranged from 10 to 1168. Thirty-five studies included sample sizes of over 100 participants. There is evidence from 48 RCTs (N = 10,118) that most medications are more effective in the response outcome than placebo. In particular, diazepam, alprazolam, clonazepam, paroxetine, venlafaxine, clomipramine, fluoxetine and adinazolam showed the strongest effect, with diazepam, alprazolam and clonazepam ranking as the most effective. We found heterogeneity in most of the comparisons, but our threshold analyses suggest that this is unlikely to impact the findings of the network meta-analysis. Results from 64 RCTs (N = 12,310) suggest that most medications are associated with either a reduced or similar risk of dropouts to placebo. Alprazolam and diazepam were associated with a lower dropout rate compared to placebo and were ranked as the most tolerated of all the medications examined. Thirty-two RCTs (N = 8569) were included in the remission outcome. Most medications were more effective than placebo, namely desipramine, fluoxetine, clonazepam, diazepam, fluvoxamine, imipramine, venlafaxine and paroxetine, and their effects were clinically meaningful. Amongst these medications, desipramine and alprazolam were ranked highest. Thirty-five RCTs (N = 8826) are included in the continuous outcome reduction in panic scale scores. Brofaromine, clonazepam and reboxetine had the strongest reductions in panic symptoms compared to placebo, but results were based on either one trial or very small trials. Forty-one RCTs (N = 7853) are included in the frequency of panic attack outcome. Only clonazepam and alprazolam showed a strong reduction in the frequency of panic attacks compared to placebo, and were ranked highest. Twenty-six RCTs (N = 7044) provided data for agoraphobia. The strongest reductions in agoraphobia symptoms were found for citalopram, reboxetine, escitalopram, clomipramine and diazepam, compared to placebo. For the pooled intervention classes, we examined the two primary outcomes (response and dropout). The classes of medication were: SSRIs, SNRIs, TCAs, MAOIs and BDZs. For the response outcome, all classes of medications examined were more effective than placebo. TCAs as a class ranked as the most effective, followed by BDZs and MAOIs. SSRIs as a class ranked fifth on average, while SNRIs were ranked lowest. When we compared classes of medication with each other for the response outcome, we found no difference between classes. Comparisons between MAOIs and TCAs and between BDZs and TCAs also suggested no differences between these medications, but the results were imprecise. For the dropout outcome, BDZs were the only class associated with a lower dropout compared to placebo and were ranked first in terms of tolerability. The other classes did not show any difference in dropouts compared to placebo. In terms of ranking, TCAs are on average second to BDZs, followed by SNRIs, then by SSRIs and lastly by MAOIs. BDZs were associated with lower dropout rates compared to SSRIs, SNRIs and TCAs. The quality of the studies comparing antidepressants with placebo was moderate, while the quality of the studies comparing BDZs with placebo and antidepressants was low. AUTHORS' CONCLUSIONS In terms of efficacy, SSRIs, SNRIs (venlafaxine), TCAs, MAOIs and BDZs may be effective, with little difference between classes. However, it is important to note that the reliability of these findings may be limited due to the overall low quality of the studies, with all having unclear or high risk of bias across multiple domains. Within classes, some differences emerged. For example, amongst the SSRIs paroxetine and fluoxetine seem to have stronger evidence of efficacy than sertraline. Benzodiazepines appear to have a small but significant advantage in terms of tolerability (incidence of dropouts) over other classes.
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Affiliation(s)
| | - Nicholas Meader
- Centre for Reviews and Dissemination, University of York, York, UK
- Cochrane Common Mental Disorders, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
| | - Simon Jc Davies
- Geriatric Psychiatry Division, CAMH, University of Toronto, Toronto, Canada
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Hissei Imai
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Deborah M Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Markus Koesters
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Chemnitz, Germany
| | - Aran Tajika
- Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Irene Bighelli
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Technische Universität München Klinikum rechts der Isar, München, Germany
| | | | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Warneford Hospital, Oxford Health NHS Foundation Trust, Oxford, UK
- Oxford Precision Psychiatry Lab, Oxford Health Biomedical Research Centre, Oxford, UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Du Y, Du B, Diao Y, Yin Z, Li J, Shu Y, Zhang Z, Chen L. Comparative efficacy and acceptability of antidepressants and benzodiazepines for the treatment of panic disorder: A systematic review and network meta-analysis. Asian J Psychiatr 2021; 60:102664. [PMID: 33965693 DOI: 10.1016/j.ajp.2021.102664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/22/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This systematic review aims to assess the efficacy and acceptability of the different types of antidepressants and benzodiazepines for the treatment of panic disorder (PD) in adult patients. METHODS PubMed, Web of Science, EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) published between 1995 and 2020 on the use of antidepressants and benzodiazepines for the treatment of PD. A systematic review and network meta-analysis were performed. RESULTS 42 RCTs were included in the network meta-analysis, with a comparison of 11 interventions.Escitalopram (odds ratios OR 1.52, 95 % credible interval CI 1.09-2.10), venlafaxine (OR 1.33, 95 % CI 1.16-1.51) and benzodiazepines (OR 1.50, 95 % CI 1.29-1.75) had greater efficacy and acceptability than the placebo. Imipramine(OR 1.43, 95 % CI 1.15-1.79) was also demonstrated to be efficacious and tolerated but the results were restricted to small sample size. Moreover, paroxetine, sertraline, fluoxetine, citalopram and clomipramine (OR 1.37, 1.36, 1.45, 1.33 and 1.36, respectively) were more efficacious, although the acceptability of paroxetine and sertraline were significantly less tolerated than benzodiazepines. Notably, the efficacy of reboxetine and fluvoxamine were merely as equal as that of the placebo. OUTCOMES This is the first systematic review of antidepressants and benzodiazepines for the treatment of PD to use a network analysis. Escitalopram and venlafaxine as well as benzodiazepines may be effective choices as treatments for PD with relatively good acceptability, which still needs to be confirmed byhigh-quality RCTs.
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Affiliation(s)
- Yang Du
- Department of Psychosomatic Medicine, The Affiliated Three Gorges Hospital of Chongqing University, Chongqing, 404000, China
| | - Biao Du
- Department of Pharmacy, The Affiliated Three Gorges Hospital of Chongqing University, Chongqing, 404000, China.
| | - Yun Diao
- School of Pharmacy, North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Zubin Yin
- Department of Psychosomatic Medicine, The Affiliated Three Gorges Hospital of Chongqing University, Chongqing, 404000, China
| | - Jin Li
- Department of Psychosomatic Medicine, The Affiliated Three Gorges Hospital of Chongqing University, Chongqing, 404000, China
| | - Yunfeng Shu
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, 646000, China
| | - Zizhen Zhang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, 646000, China
| | - Lizhi Chen
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, 646000, China
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Meta-analysis of placebo group dropout in adult antidepressant trials. Prog Neuropsychopharmacol Biol Psychiatry 2020; 98:109777. [PMID: 31697973 DOI: 10.1016/j.pnpbp.2019.109777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/28/2019] [Accepted: 10/02/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Minimizing dropouts across antidepressant, placebo-controlled trials remains a major opportunity to improve the efficiency of trials. This meta-analysis investigated placebo dropout rate and its predictors in second generation antidepressant (SGA) for anxiety, depression and obsessive-compulsive disorder (OCD). METHODS A random-effects meta-analysis was performed to examine placebo group dropout rate in SGA trials for depression, anxiety and OCD using Freeman - Tukey transformation. Stratified subgroup analysis by diagnostic indication was performed to examine the dropout rate across disorders. Meta-regression was performed to identify correlates between placebo dropout rate and trial and subject characteristics. RESULTS Meta-analysis included 148 trials with 18,016 participants receiving placebo. Across antidepressant trials the overall placebo dropout rate was 25% (dropout rate ± standard error (SE) = 0.25 ± 0.01, 95% CI: 0.23-0.27, z = 23.95, p < .001) and was similar across disorders (χ2 = 1.09, df = 2, p = .58). The placebo group dropout rate was 26% in depressive disorders, 25% in anxiety disorders and 22% in OCD. Across all diagnostic indications, earlier publication year, placebo lead-in, studies conducted in a single country (instead of internationally), longer trial duration, fewer study sites, more study visits and less baseline illness severity were associated with higher placebo dropout rate. Significant predictors of placebo dropout did not replicate across disorders. CONCLUSION No significant difference was found in placebo dropout rate between internalizing disorders with overall dropout rate for placebo groups in antidepressant trials being around 25%. Placebo dropouts in trials can be minimized by reducing subject burden in trials, enrolling more severely affected subjects and foregoing placebo lead-in periods.
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Telang S, Walton C, Olten B, Bloch MH. Meta-analysis: Second generation antidepressants and headache. J Affect Disord 2018; 236:60-68. [PMID: 29715610 DOI: 10.1016/j.jad.2018.04.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/22/2018] [Accepted: 04/04/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND To assess the risk of headache associated with commonly prescribed antidepressant medications and to examine the impact of medication class, pharmacodynamics and dosage on risk of headache. METHODS We searched PubMed to identify all randomized, double-blind, placebo-controlled trials examining the efficacy of second generation antidepressant medications in the treatment of adults with depression, anxiety or obsessive-compulsive disorders. We used a fixed-effect meta-analysis to examine the pooled risk ratio of headache reported as a side-effect in adults treated with second generation antidepressants compared to placebo. We used stratified subgroup analysis and meta-regression to examine the effects of medication type, class, dosage, indication, and receptor affinity profile on the measured risk of headache. RESULTS SSRIs were associated with a significantly increased risk of headache (RR = 1.06, 95%CI = 1.00-1.13, z = 2.0, p = 0.045) when compared to placebo. There was no significant difference (test for subgroup differences χ2 = 2.2, df = 1, p = 0.14) in the risk of headache between SSRIs and SNRIs (RR = 0.97, 95%CI = 0.88-1.06, p = 0.63). There was no significant difference in the relative risk of headache with second generation antidepressants based on diagnostic indication, pharmacological properties and dosage of medications. The only antidepressants that were found to be significantly associated with increased risk of headache compared to placebo were bupropion (RR = 1.22, 95%CI = 1.06-1.41, z = 2.73, p = 0.006) and escitalopram (RR = 1.18, 95%CI = 1.01-1.37, z = 2.11, p = 0.04). LIMITATIONS The small number of studies that examined side effects within fixed-dose trials may have limited the power to examine the association between medication dosing and risk of headache. Additionally, reporting bias could potentially occur non-randomly across agents and therefore effect meta-analysis results. CONCLUSIONS Headaches reported after the initiation of second generation antidepressant medications are more likely to be coincidental than a treatment-emergent side effect of these medications.
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Affiliation(s)
| | - Celeste Walton
- Undergraduate student at Sewanee, The University of the South, Sewanee, Tennessee, USA; Summer intern at the Yale Child Study Center, New Haven, CT, USA
| | - Baris Olten
- The Yale Child Study Center, New Haven, CT, USA
| | - Michael H Bloch
- The Yale Child Study Center and the Department of Psychiatry of Yale University, New Haven, CT, USA.
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Bighelli I, Castellazzi M, Cipriani A, Girlanda F, Guaiana G, Koesters M, Turrini G, Furukawa TA, Barbui C. Antidepressants versus placebo for panic disorder in adults. Cochrane Database Syst Rev 2018; 4:CD010676. [PMID: 29620793 PMCID: PMC6494573 DOI: 10.1002/14651858.cd010676.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Panic disorder is characterised by repeated, unexpected panic attacks, which represent a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes, and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. It is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, the National Institute for Health and Care Excellence (NICE) and the British Association for Psychopharmacology consider antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). Several classes of antidepressants have been studied and compared, but it is still unclear which antidepressants have a more or less favourable profile in terms of effectiveness and acceptability in the treatment of this condition. OBJECTIVES To assess the effects of antidepressants for panic disorder in adults, specifically:1. to determine the efficacy of antidepressants in alleviating symptoms of panic disorder, with or without agoraphobia, in comparison to placebo;2. to review the acceptability of antidepressants in panic disorder, with or without agoraphobia, in comparison with placebo; and3. to investigate the adverse effects of antidepressants in panic disorder, with or without agoraphobia, including the general prevalence of adverse effects, compared to placebo. SEARCH METHODS We searched the Cochrane Common Mental Disorders' (CCMD) Specialised Register, and CENTRAL, MEDLINE, EMBASE and PsycINFO up to May 2017. We handsearched reference lists of relevant papers and previous systematic reviews. SELECTION CRITERIA All double-blind, randomised, controlled trials (RCTs) allocating adults with panic disorder to antidepressants or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently checked eligibility and extracted data using a standard form. We entered data into Review Manager 5 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details and settings. Primary outcomes included failure to respond, measured by a range of response scales, and treatment acceptability, measured by total number of dropouts for any reason. Secondary outcomes included failure to remit, panic symptom scales, frequency of panic attacks, agoraphobia, general anxiety, depression, social functioning, quality of life and patient satisfaction, measured by various scales as defined in individual studies. We used GRADE to assess the quality of the evidence for each outcome MAIN RESULTS: Forty-one unique RCTs including 9377 participants overall, of whom we included 8252 in the 49 placebo-controlled arms of interest (antidepressant as monotherapy and placebo alone) in this review. The majority of studies were of moderate to low quality due to inconsistency, imprecision and unclear risk of selection and performance bias.We found low-quality evidence that revealed a benefit for antidepressants as a group in comparison with placebo in terms of efficacy measured as failure to respond (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.66 to 0.79; participants = 6500; studies = 30). The magnitude of effect corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 7 (95% CI 6 to 9): that means seven people would need to be treated with antidepressants in order for one to benefit. We observed the same finding when classes of antidepressants were compared with placebo.Moderate-quality evidence suggested a benefit for antidepressants compared to placebo when looking at number of dropouts due to any cause (RR 0.88, 95% CI 0.81 to 0.97; participants = 7850; studies = 30). The magnitude of effect corresponds to a NNTB of 27 (95% CI 17 to 105); treating 27 people will result in one person fewer dropping out. Considering antidepressant classes, TCAs showed a benefit over placebo, while for SSRIs and serotonin-norepinephrine reuptake inhibitor (SNRIs) we observed no difference.When looking at dropouts due to adverse effects, which can be considered as a measure of tolerability, we found moderate-quality evidence showing that antidepressants as a whole are less well tolerated than placebo. In particular, TCAs and SSRIs produced more dropouts due to adverse effects in comparison with placebo, while the confidence interval for SNRI, noradrenergic reuptake inhibitors (NRI) and other antidepressants were wide and included the possibility of no difference. AUTHORS' CONCLUSIONS The identified studies comprehensively address the objectives of the present review.Based on these results, antidepressants may be more effective than placebo in treating panic disorder. Efficacy can be quantified as a NNTB of 7, implying that seven people need to be treated with antidepressants in order for one to benefit. Antidepressants may also have benefit in comparison with placebo in terms of number of dropouts, but a less favourable profile in terms of dropout due to adverse effects. However, the tolerability profile varied between different classes of antidepressants.The choice of whether antidepressants should be prescribed in clinical practice cannot be made on the basis of this review.Limitations in results include funding of some studies by pharmaceutical companies, and only assessing short-term outcomes.Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.
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Affiliation(s)
- Irene Bighelli
- Klinikum rechts der Isar, Technische Universität MünchenDepartment of Psychiatry and PsychotherapyIsmaningerstr. 22MunichGermany
| | - Mariasole Castellazzi
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | | | - Giuseppe Guaiana
- Western UniversityDepartment of PsychiatrySaint Thomas Elgin General Hospital189 Elm StreetSt ThomasONCanadaN5R 5C4
| | | | - Giulia Turrini
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Corrado Barbui
- University of VeronaDepartment of Neuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
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Bighelli I, Borghesani A, Barbui C. Is the efficacy of antidepressants in panic disorder mediated by adverse events? A mediational analysis. PLoS One 2017; 12:e0178617. [PMID: 28575031 PMCID: PMC5456299 DOI: 10.1371/journal.pone.0178617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/16/2017] [Indexed: 11/18/2022] Open
Abstract
It has been hypothesised that the perception of adverse events in placebo-controlled antidepressant clinical trials may induce patients to conclude that they have been randomized to the active arm of the trial, leading to the breaking of blind. This may enhance the expectancies for improvement and the therapeutic response. The main objective of this study is to test the hypothesis that the efficacy of antidepressants in panic disorder is mediated by the perception of adverse events. The present analysis is based on a systematic review of published and unpublished randomised trials comparing antidepressants with placebo for panic disorder. The Baron and Kenny approach was applied to investigate the mediational role of adverse events in the relationship between antidepressants treatment and efficacy. Fourteen placebo-controlled antidepressants trials were included in the analysis. We found that: (a) antidepressants treatment was significantly associated with better treatment response (ß = 0.127, 95% CI 0.04 to 0.21, p = 0.003); (b) antidepressants treatment was not associated with adverse events (ß = 0.094, 95% CI -0.05 to 0.24, p = 0.221); (c) adverse events were negatively associated with treatment response (ß = 0.035, 95% CI -0.06 to -0.05, p = 0.022). Finally, after adjustment for adverse events, the relationship between antidepressants treatment and treatment response remained statistically significant (ß = 0.122, 95% CI 0.01 to 0.23, p = 0.039). These findings do not support the hypothesis that the perception of adverse events in placebo-controlled antidepressant clinical trials may lead to the breaking of blind and to an artificial inflation of the efficacy measures. Based on these results, we argue that the moderate therapeutic effect of antidepressants in individuals with panic disorder is not an artefact, therefore reflecting a genuine effect that doctors can expect to replicate under real-world conditions.
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Affiliation(s)
- Irene Bighelli
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Anna Borghesani
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, Guaiana G, Koesters M, Barbui C. Antidepressants and benzodiazepines for panic disorder in adults. Cochrane Database Syst Rev 2016; 9:CD011567. [PMID: 27618521 PMCID: PMC6457579 DOI: 10.1002/14651858.cd011567.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND A panic attack is a discrete period of fear or anxiety that has a rapid onset, reaches a peak within 10 minutes and in which at least four of 13 characteristic symptoms are experienced, including racing heart, chest pain, sweating, shaking, dizziness, flushing, stomach churning, faintness and breathlessness. Panic disorder is common in the general population with a lifetime prevalence of 1% to 4%. The treatment of panic disorder includes psychological and pharmacological interventions. Amongst pharmacological agents, antidepressants and benzodiazepines are the mainstay of treatment for panic disorder. Different classes of antidepressants have been compared; and the British Association for Psychopharmacology, and National Institute for Health and Care Excellence (NICE) consider antidepressants (mainly selective serotonin reuptake inhibitors (SSRIs)) as the first-line treatment for panic disorder, due to their more favourable adverse effect profile over monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). In addition to antidepressants, benzodiazepines are widely prescribed for the treatment of panic disorder. OBJECTIVES To assess the evidence for the effects of antidepressants and benzodiazepines for panic disorder in adults. SEARCH METHODS The Specialised Register of the Cochrane Common Mental Disorders Group (CCMDCTR) to 11 September 2015. This register includes relevant randomised controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950-), Embase (1974-) and PsycINFO (1967-). Reference lists of relevant papers and previous systematic reviews were handsearched. We contacted experts in this field for supplemental data. SELECTION CRITERIA All double-blind randomised controlled trials allocating adult patients with panic disorder to antidepressants or benzodiazepines versus any other active treatment with antidepressants or benzodiazepines. DATA COLLECTION AND ANALYSIS Two review authors independently checked eligibility and extracted data using a standard form. Data were entered in RevMan 5.3 using a double-check procedure. Information extracted included study characteristics, participant characteristics, intervention details, settings and outcome measures in terms of efficacy, acceptability and tolerability. MAIN RESULTS Thirty-five studies, including 6785 participants overall (of which 5365 in the arms of interest (antidepressant and benzodiazepines as monotherapy)) were included in this review; however, since studies addressed many different comparisons, only a few trials provided data for primary outcomes. We found low-quality evidence suggesting no difference between antidepressants and benzodiazepines in terms of response rate (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.67 to 1.47; participants = 215; studies = 2). Very low-quality evidence suggested a benefit for benzodiazepines compared to antidepressants in terms of dropouts due to any cause, even if confidence interval (CI) ranges from almost no difference to benefit with benzodiazepines (RR 1.64, 95% CI 1.03 to 2.63; participants = 1449; studies = 7). We found some evidence suggesting that serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs (when looking at the number of patients experiencing adverse effects). We failed to find clinically significant differences between individual benzodiazepines. The majority of studies did not report details on random sequence generation and allocation concealment; similarly, no details were provided about strategies to ensure blinding. The study protocol was not available for almost all studies so it is difficult to make a judgment on the possibility of outcome reporting bias. Information on adverse effects was very limited. AUTHORS' CONCLUSIONS The identified studies are not sufficient to comprehensively address the objectives of the present review. The majority of studies enrolled a small number of participants and did not provide data for all the outcomes specified in the protocol. For these reasons most of the analyses were underpowered and this limits the overall completeness of evidence. In general, based on the results of the current review, the possible role of antidepressants and benzodiazepines should be assessed by the clinician on an individual basis. The choice of which antidepressant and/or benzodiazepine is prescribed can not be made on the basis of this review only, and should be based on evidence of antidepressants and benzodiazepines efficacy and tolerability, including data from placebo-controlled studies, as a whole. Data on long-term tolerability issues associated with antidepressants and benzodiazepines exposure should also be carefully considered.The present review highlights the need for further higher-quality studies comparing antidepressants with benzodiazepines, which should be conducted with high-methodological standards and including pragmatic outcome measures to provide clinicians with useful and practical data. Data from the present review will be included in a network meta-analysis of psychopharmacological treatment in panic disorder, which will hopefully provide further useful information on this issue.
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Affiliation(s)
- Irene Bighelli
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Carlotta Trespidi
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Mariasole Castellazzi
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
| | - Andrea Cipriani
- University of OxfordDepartment of PsychiatryWarneford HospitalOxfordUKOX3 7JX
| | - Toshi A Furukawa
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐ku,KyotoJapan606‐8501
| | - Francesca Girlanda
- University of VeronaDepartment of Public Health and Community Medicine, Section of PsychiatryPoliclinico "G.B.Rossi"Piazzale L.A. Scuro, 10VeronaItaly37134
| | - Giuseppe Guaiana
- Western UniversityDepartment of PsychiatrySaint Thomas Elgin General Hospital189 Elm StreetSt ThomasONCanadaN5R 5C4
| | - Markus Koesters
- Ulm UniversityDepartment of Psychiatry IILudwig‐Heilmeyer‐Str. 2GuenzburgGermanyD‐89312
| | - Corrado Barbui
- University of VeronaNeuroscience, Biomedicine and Movement Sciences, Section of PsychiatryVeronaItaly
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8
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Rutherford BR, Bailey VS, Schneier FR, Pott E, Brown PJ, Roose SP. INFLUENCE OF STUDY DESIGN ON TREATMENT RESPONSE IN ANXIETY DISORDER CLINICAL TRIALS. Depress Anxiety 2015; 32:944-57. [PMID: 26437267 PMCID: PMC4922308 DOI: 10.1002/da.22433] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/05/2015] [Accepted: 09/12/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The influence of study design variables and publication year on response to medication and placebo was investigated in clinical trials for social anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder (PD). METHOD Hierarchical linear modeling determined whether publication year, treatment assignment (medication vs. placebo), study type (placebo-controlled or active comparator), study duration, and the number of study visits affected the mean change associated with medication and placebo. RESULTS In the 66 trials examined, the change associated with both medication and placebo increased over time (t = 4.23, df = 39, P < .001), but average drug-placebo differences decreased over time (t = -2.04, df = 46, P = .047). More severe baseline illness was associated with greater drug-placebo differences for serotonin norepinephrine reuptake inhibitors (SNRIs, t = 3.46, df = 106, P = .001) and selective serotonin reuptake inhibitors (SSRI, t = 10.37, df = 106, P < .001). Improvement with medication was significantly greater in active-comparator studies compared to placebo-controlled trials (t = 3.41, df = 39, P = .002). A greater number of study visits was associated with greater symptom improvement in PD trials relative to SAD (t = 2.83, df = 39, P = .008) and GAD (t = 2.16, df = 39, P = .037). CONCLUSIONS Placebo response is substantial in SAD, GAD, and PD trials, and its rise over time has been associated with diminished drug-placebo differences. Study design features that influence treatment response in anxiety disorder trials include patient expectancy, frequency of follow-up visits, and baseline illness severity.
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Affiliation(s)
- Bret R Rutherford
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York,Correspondence to: Bret R. Rutherford, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, 1051 Riverside Drive, Box 98, New York, NY 10032.
| | | | - Franklin R. Schneier
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York
| | - Emily Pott
- New York State Psychiatric Institute, New York, New York
| | - Patrick J. Brown
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York
| | - Steven P. Roose
- Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, New York
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9
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Erburu M, Cajaleon L, Guruceaga E, Venzala E, Muñoz-Cobo I, Beltrán E, Puerta E, Tordera R. Chronic mild stress and imipramine treatment elicit opposite changes in behavior and in gene expression in the mouse prefrontal cortex. Pharmacol Biochem Behav 2015; 135:227-36. [DOI: 10.1016/j.pbb.2015.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/28/2015] [Accepted: 06/01/2015] [Indexed: 01/22/2023]
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10
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Altamura AC, Caldiroli A, Buoli M. Pharmacokinetic evaluation of fluvoxamine for the treatment of anxiety disorders. Expert Opin Drug Metab Toxicol 2015; 11:649-60. [DOI: 10.1517/17425255.2015.1021331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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11
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Mochcovitch MD, Nardi AE. Selective serotonin-reuptake inhibitors in the treatment of panic disorder: a systematic review of placebo-controlled studies. Expert Rev Neurother 2010; 10:1285-93. [PMID: 20662754 DOI: 10.1586/ern.10.110] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The selective serotonin-reuptake inhibitors are widely used in clinical practice in the treatment of panic disorder (PD). This article undertakes an up-to-date, systematic review of the published double-blind, placebo-controlled, randomized, short-term studies with currently available selective serotonin-reuptake inhibitors in the treatment of PD. Sertraline, paroxetine, citalopram, escitalopram, fluoxetine and fluvoxamine have all been proven to be superior to pill-placebo, although the placebo effect has been shown to be extremely important in patients with PD. The authors also explore the anxiolytic mechanism of action of this antidepressant drug class and the preclinical studies that are being developed to clarify the etiopathogenic mechanisms of PD and, more precisely, the role of the serotoninergic system in this pathogenesis. These steps are considered fundamental for the improvement of pharmacological treatment of PD.
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Affiliation(s)
- Marina Dyskant Mochcovitch
- Federal University of Rio de Janeiro, National Institute for Translational Medicine, Rio de Janeiro, Brazil.
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12
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Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision. World J Biol Psychiatry 2009; 9:248-312. [PMID: 18949648 DOI: 10.1080/15622970802465807] [Citation(s) in RCA: 420] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Gottingen, Gottingen, Germany.
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13
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Abstract
Agoraphobia with panic disorder is a phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs. During the last half-century, agoraphobia has been thought of as being closely linked to the recurring panic attack syndrome, so much so that in most cases it appears to be the typical development or complication of panic disorder. Despite the high prevalence of agoraphobia with panic disorder in patients in primary-care settings, the condition is frequently under-recognised and under-treated by medical providers. Antidepressants have been demonstrated to be effective in preventing panic attacks, and in improving anticipatory anxiety and avoidance behaviour. These drugs are also effective in the treatment of the frequently coexisting depressive symptomatology. Among antidepressant agents, SSRIs are generally well tolerated and effective for both anxious and depressive symptomatology, and these compounds should be considered the first choice for short-, medium- and long-term pharmacological treatment of agoraphobia with panic disorder. The few comparative studies conducted to date with various SSRIs reported no significant differences in terms of efficacy; however, the SSRIs that are less liable to produce withdrawal symptoms after abrupt discontinuation should be considered the treatments of first choice for long-term prophylaxis. Venlafaxine is not sufficiently studied in the long-term treatment of panic disorder, while TCAs may be considered as a second choice of treatment when patients do not seem to respond to or tolerate SSRIs. High-potency benzodiazepines have been shown to display a rapid onset of anti-anxiety effect, having beneficial effects during the first few days of treatment, and are therefore useful options for short-term treatment; however, these drugs are not first-choice medications in the medium and long term because of the frequent development of tolerance and dependence phenomena. Cognitive-behavioural therapy is the best studied non-pharmacological approach and can be applied to many patients, depending on its availability.
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Affiliation(s)
- Giulio Perugi
- Department of Psychiatry, University of Pisa, Pisa, Italy.
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Abstract
The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.
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Affiliation(s)
- Michel Bourin
- Neurobiology of Anxiety and Depression, Faculty of Medicine, BP 53508, 44035 Nantes Cedex 1, France.
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15
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Abstract
OBJECTIVE To compare the short-term efficacy of selective serotonin reuptake inhibitors (SSRIs) vs. tricyclic antidepressants (TCAs) in the treatment of panic disorder (PD) a meta-analysis was conducted. METHOD Included were 43 studies (34 randomized, nine open), pertaining to 53 treatment conditions, 2367 patients at pretest and 1804 at post-test. Outcome was measured with the proportion of patients becoming panic-free, and with pre/post Cohen's d effect sizes, calculated for four clinical variables: panic, agoraphobia, depression, and general anxiety. RESULTS There were no differences between SSRIs and TCAs on any of the effect sizes, indicating that both groups of antidepressants are equally effective in reducing panic symptoms, agoraphobic avoidance, depressive symptomatology and general anxiety. Also the percentage of patients free of panic attacks at post-test did not differ. The number of drop-outs, however, was significantly lower in the group of patients treated with SSRIs (18%) vs. TCAs (31%). CONCLUSION SSRIs and TCAs are equal in efficacy in the treatment of panic disorder, but SSRIs are tolerated better.
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Affiliation(s)
- A Bakker
- Sint Lucas Andreas Hospital, Amsterdam, The Netherlands.
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16
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Díez-Quevedo C, Rangil T, Sánchez Planell L. [Agoraphobia]. Med Clin (Barc) 2002; 119:60-5. [PMID: 12084372 DOI: 10.1016/s0025-7753(02)73314-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Crisanto Díez-Quevedo
- Unidad de Psiquiatría, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
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17
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Perna G, Bertani A, Caldirola D, Gabriele A, Cocchi S, Bellodi L. Antipanic drug modulation of 35% CO2 hyperreactivity and short-term treatment outcome. J Clin Psychopharmacol 2002; 22:300-8. [PMID: 12006901 DOI: 10.1097/00004714-200206000-00011] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Carbon dioxide (CO2) inhalation induces acute anxiety and panic attacks in patients with Panic Disorder (PD). Anti-panic drugs decrease CO2 reactivity after the first days of treatment; however, the clinical meaning of this finding has not yet been established. This study investigated the effects of treatment with tricyclic antidepressants and selective serotonin re-uptake inhibitors (SSRIs) on CO2 reactivity and compared the relationships between 35% CO2 hyperreactivity modulation and short-term clinical outcome. One hundred twenty-three patients with PD with or without agoraphobia who were hyperreactive to CO2 were randomly assigned to treatment groups with imipramine, clomipramine, paroxetine, sertraline, or fluvoxamine. A double-blind, randomized design was applied. Each patient received the 35% CO2 challenge on days 0, 7, and 30. The severity of clinical symptomatology was measured on days 0 and 30. Decreased hyperreactivity to 35% CO2 in all five treatment groups was already evident after the first week. The decrease in CO2 reactivity at the end of treatment was proportional to the degree of clinical improvement. Multiple regression analyses showed that the decrease in CO2 reactivity after the first week was a significant predictor for good clinical outcome after one month. The results of this study confirm evidence that psychoactive drugs effective in the treatment of PD decrease CO2 hyperreactivity. They also suggest that precocious modulation of CO2 reactivity might fairly reliably predict short-term clinical outcome in patients with "respiratory" PD.
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Affiliation(s)
- Giampaolo Perna
- The Anxiety Disorder Clinical and Research Unit, Department of Neuropsychiatric Sciences, University of Milan, Istituto Scientifico Ospedale San Raffaele, Italy.
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18
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Asnis GM, Hameedi FA, Goddard AW, Potkin SG, Black D, Jameel M, Desagani K, Woods SW. Fluvoxamine in the treatment of panic disorder: a multi-center, double-blind, placebo-controlled study in outpatients. Psychiatry Res 2001; 103:1-14. [PMID: 11472786 DOI: 10.1016/s0165-1781(01)00265-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Serotonergic mechanisms have been implicated in panic disorder, and several preliminary studies suggest that fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), is helpful in its treatment. This 8-week double-blind parallel-group study compared fluvoxamine with a placebo in 188 patients with DSM-III-R defined panic disorder with or without agoraphobia. Efficacy assessments included a Daily Panic Attack Inventory, the Sheehan Disability Scale, the Clinical Anxiety Scale and the Clinical Global Impression Scale. When compared with the placebo, fluvoxamine produced highly significant improvements in most measures of the frequency and severity of panic disorder and in the more global aspects of disability and distress. Significant improvement was evident as early as week 1 for some panic variables. Fluvoxamine is a potent anti-panic agent with a relatively rapid onset of action.
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Affiliation(s)
- G M Asnis
- Department of Psychiatry, Albert Einstein College of Medicine, Montefiore Medical Center, 111 E. 210th Street, Bronx, New York, NY 10467-2490, USA.
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19
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Kasper S, Resinger E. Panic disorder: the place of benzodiazepines and selective serotonin reuptake inhibitors. Eur Neuropsychopharmacol 2001; 11:307-21. [PMID: 11532386 DOI: 10.1016/s0924-977x(01)00100-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article reviews the efficacy of the benzodiazepines and the selective serotonin reuptake inhibitor class of antidepressant in the treatment of panic disorder. The benzodiazepine alprazolam has been used successfully in the treatment of panic disorder, but its long-term use presents problems with dependence. Since panic may be mediated by a dysfunction of serotonin neuronal pathways, there is a rationale for treatment with antidepressants that modulate serotonergic systems. In clinical trials, members of the SSRI class of antidepressant reduced panic attack frequency to zero in 36-86% of patients and were well tolerated over long-term administration, all important factors in ensuring patient compliance. In addition, antidepressants are preferable to benzodiazepines in the treatment of panic and comorbid depression, of which there is a high prevalence among panic disorder patients. This review emphasises the need for long-term treatment of this chronic and disabling condition with a therapy that is well tolerated and provides complete and sustained recovery from panic attacks, and resolution of anticipatory anxiety.
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Affiliation(s)
- S Kasper
- Department of General Psychiatry, University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
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20
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Kent JM, Coplan JD, Gorman JM. Clinical utility of the selective serotonin reuptake inhibitors in the spectrum of anxiety. Biol Psychiatry 1998; 44:812-24. [PMID: 9807637 DOI: 10.1016/s0006-3223(98)00210-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The selective serotonin reuptake inhibitors (SSRIs) are now being employed in the treatment of the full spectrum of anxiety disorders. In comparative trials, the SSRIs are proving to be equal or superior in efficacy to traditional antianxiety medications. Due to their favorable side effect profile, safety, and tolerability, they are rapidly replacing older agents in the treatment of anxiety. Neuroanatomical pathways that may be important in the antianxiety effect of the SSRIs are outline and discussed, followed by a review of the clinical evidence supporting the efficacy of this class of medications in the treatment of anxiety disorders.
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Affiliation(s)
- J M Kent
- Department of Clinical Psychobiology, New York State Psychiatric Institute, NY 10032, USA
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Apter JT. Evolving treatment of panic disorder. J Psychosom Res 1998; 44:181-2. [PMID: 9483473 DOI: 10.1016/s0022-3999(97)00287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- J T Apter
- Princeton Biomedical Research, NJ 08540, USA
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