Diagnostic dilemmas presented by patients with anxiety and depression

Anxiety disorders: Treatments, models, and circuitry mechanisms

Anxiety disorders are one of the most prevalent mental health conditions worldwide, imposing a significant burden on individuals affected by them and society in general. Current research endeavors aim to enhance the effectiveness of existing anxiolytic drugs and reduce their side effects through optimization or the development of new treatments. Several anxiolytic novel drugs have been produced as a result of discovery-focused research. However, many drug candidates that show promise in preclinical rodent model studies fail to offer any substantive clinical benefits to patients. This review provides an overview of the diagnosis and classification of anxiety disorders together with a systematic review of anxiolytic drugs with a focus on their targets, therapeutic applications, and side effects. It also provides a concise overview of the constraints and disadvantages associated with frequently administered anxiolytic drugs. Additionally, the study comprehensively reviews animal models used in anxiety studies and their associated molecular mechanisms, while also summarizing the brain circuitry related to anxiety. In conclusion, this article provides a valuable foundation for future anxiolytic drug discovery efforts.

Efeitos biopsicos sociais e psiconeuroimunológicos do câncer sobre o paciente e familiares

Durante as duas últimas décadas, têm sido ressaltados os problemas somáticos, psíquicos e sociais de pacientes com câncer, bem como têm sido focalizadas, no âmbito do estudo oncolágico, as teorias hiopsicossociais e psiconeuroimunológicas. O presente trabalho apresenta considerações clínicas sobre esses aspectos, ressaltando-se o impacto que o câncer provoca sobre os pacientes e seus familiares. O câncer e seus tratamentos constituem uma fonte de estresse, capaz de desencadear desordens de ajustamento nestes indivíduos. A mensuração da qualidade de vida  deve ser incorporada aos estudos clínicos, porque a sua inclusão tende a melhorar as indicações terapêuticas. Os relatos de pacientes sobre sintomas somáticos são associados, principalmente, às suas preocupações emocionais e sociais mais do que ao seu estado geral de saúde. A equipe responsável pelos pacientes deve compreender a dinâmica envolvida no binômio família-paciente e conhecer a influência que os fatores psicossociais exercem sobre ele. A falha do reconhecimento dessa influência e, conseqüentemente, o prejuízo provocado no suporte psicossocial da família irão privar os pacientes do conforto, amor, suporte e companheirismo de que eles precisarão através do curso da sua doença. Os médicos devem ser capazes de identificar e estimular circunstâncias que facilitem o processo de adaptação de seus pacientes. O tratamento psicológico, em pelo menos alguma extensão, sempre é benéfico.

Use of antidepressive agents as a possibility in the management of periodontal diseases: A systematic review of experimental studies

Antidepressant agents have anti-inflammatory functions that could be interesting as adjuvants in periodontal therapy. The aim of the present study was to analyze the effect of antidepressive drugs in the management of periodontal disease. The MEDLINE, Scopus, Embase, LILACS, and SciELO databases were searched. To be included, the studies had to be experimental studies; randomized, controlled; double-blinded; or blinded studies. A total of 565 articles were initially searched, of which five were selected for the systematic review. All studies used rats, and three different drugs were evaluated: tianeptine, venlafaxine, and fluoxetine. Two of these studies evaluated the effect of antidepressive agents in rats submitted to both ligature-induced periodontitis and depression models, showing that depressive rats had greater alveolar bone loss (ABL). Only the venlafaxine study was not able to find any significant ABL reduction in the group that used this antidepressive drug. The other four studies showed statistically-significant differences, favoring the group with the antidepressant agent. Treatments that are able to modulate the brain-neuroendocrine-immune system could be used as an adjuvant to periodontal disease management. However, studies on humans and animals are scarce, limiting the conclusion of a positive effect in the present systematic review.

Use of the Beck Anxiety and Depression Inventories for Primary Care with Medical Outpatients

The effectiveness of the Beck Anxiety (BAI-PC) and Depression (BDI-PC) Inventories for Primary Care for discriminating 56 primary care patients with and without revised, third edition Diagnostic and Statistical Manual of Mental Disorders ( DSM-III-R) diagnosed anxiety and mood disorders was studied. The Anxiety and Mood modules from the Primary Care Evaluation of Mental Disorders (PRIME-MD) were used to establish diagnoses. The coefficient alphas for the BAI-PC and BDI-PC were, respectively, .90 and .88. A BAI-PC cutoff score of 5 and above yielded the highest clinical efficiency (82%) with 85% sensitivity and 81% specificity for identifying patients with and without panic, generalized anxiety, or both disorders, whereas a BDI-PC cutoff score of 6 and above afforded the highest clinical efficiency (92%) with 83% sensitivity and 95% specificity for detecting patients with and without major depressive disorders. The use of these instruments to screen primary care patients before conducting extensive diagnostic evaluations with them was discussed.

Self-report measures of anxiety: are they suitable for older adults?

OBJECTIVES

To assess the performance of four self-report measures of anxiety in an older adult population.

METHOD

Forty older adults with current or previous anxiety symptoms completed four self-report measures of anxiety (Beck Anxiety Inventory, State Trait Anxiety Inventory, Hospital Anxiety and Depression Scale and Visual Analogue Scale) and received an independent diagnostic assessment and rating of anxiety severity. After a minimum of four months, participants were re-assessed on all measures.

RESULTS

The self-report measures most suited for anxiety screening and assessing severity when compared to the independent assessment were the Beck Anxiety Inventory (BAI), the anxiety scale from the Hospital Anxiety and Depression Scale (HADS-A) and State Trait Anxiety Inventory-Trait form (STAI-T). However, participants made an unacceptably high number of errors using the STAI-T, making the BAI and HADS-A the most suitable measures for older adults. The Visual Analogue Scale (VAS) performed poorly in both screening and measuring severity. All self-report measures were poor at detecting change as evaluated by the independent assessment.

CONCLUSION

There was no single measure that performed adequately in screening, measuring severity and monitoring changes, suggesting that measures may need to be adapted if they are to be used in an older adult population. The lack of appropriately designed self-report measures with adequate normative data for older people presents a barrier to future research.

Relationship of clinical depression to periodontal treatment outcome

BACKGROUND

Depression has been associated with periodontal disease; however, its relationship to periodontal treatment outcome (PTO) has not been investigated.

METHODS

Data were obtained by chart abstraction and computer databases on 1,299 health maintenance organization (HMO) patients aged 30 to 64 who had concurrent medical, dental, and pharmacy benefits, and who had an initial periodontal examination during 1996, 1997, or 1998. Depression (yes/no) was the main independent variable and was determined by presence of any diagnosis code for depression on the patient record. PTO was determined by the difference in percent of sites with probing depth (PD) > or = 5 mm between the initial and 1-year post-treatment periodontal exams. Sub-median periodontal treatment outcome (SMPTO) was defined as a reduction in fewer than the median percent of sites (7.33%) with PD > or = 5 mm. Information on sociodemographics, periodontal therapy, calculus and plaque, number of remaining teeth, smoking, antidepressant medications, and diabetes were collected.

RESULTS

A total of 697 patients had a periodontal exam at both baseline and follow-up. Of these, 12.2% had depression. In a multivariable logistic model, depression (odds ratio [OR] 2.16, 95% confidence interval [Cl] 1.12 to 4.16) and 4-month recall treatment (OR 2.34, Cl 1.46 to 3.75) were associated with SMPTO, while percent of sites at baseline with PD > or = 5 mm (OR 0.93, Cl 0.91 to 0.94), number of remaining teeth at baseline (OR 0.94, Cl 0.89 to 0.99), and number of teeth lost during the study period (OR 0.75, Cl 0.58 to 0.96) were negatively associated. Periodontal surgery, age, gender, smoking, plaque, calculus, diabetes, and antidepressant medication were not significant in the model.

CONCLUSION

Clinical depression may have a negative effect on periodontal treatment outcome in this group model HMO population.

A Review of the Diagnosis, Pharmacologic Treatment, and Economic Aspects of Anxiety Disorders

As many as 1 in 4 Americans will experience an anxiety disorder at some point in their lives, and many will also suffer the depression, substance abuse, distressing physical signs, and socioeconomic problems that often accompany these disorders when left untreated. Anxiety disorders can be detected using simple screening tools in the physician's office. Early and effective treatment with appropriate medication can significantly reduce the psychic and physical symptoms of anxiety, lowering the overall costs of the disorder to the health care system and society. Many drugs offer safe and effective relief of anxiety symptoms with few side effects or drug-drug interactions, and some offer symptomatic relief within 1 to 2 weeks.

Safety and tolerability considerations: tricyclic antidepressants vs. selective serotonin reuptake inhibitors

OBJECTIVE

An important consideration in the choice of an antidepressant is its safety and tolerability.

METHOD

We present a review of literature, clinical trials and meta-analyses regarding the safety and tolerability of the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitors (SSRIs) in depressed patients.

RESULTS

The SSRIs have a very favourable side-effect profile compared to the TCAs and are associated with fewer treatment discontinuations. Unlike the TCAs, they do not cause anticholinergic, hypotensive or sedating reactions, and are not associated with impaired cognitive function. Their most common side-effects (nausea, vomiting, nervousness, insomnia, headache and sexual dysfunction) are usually mild and typically disappear as treatment continues. The SSRIs also exhibit lower toxicity and lower lethality when taken in an overdose situation. Although the safety profiles of the principal SSRIs appear to be comparable, there is some data showing important differences in the severity and frequency of specific adverse events.

CONCLUSION

The SSRIs have a more favourable safety profile than the TCAs in both acute and long-term treatment of major depression.

Treatment of depression with associated anxiety: comparisons of tricyclic antidepressants and selective serotonin reuptake inhibitors

OBJECTIVE

Evidence indicates that alleviating anxiety symptoms early in the treatment of depression improves treatment compliance, limits treatment discontinuations and contributes to a positive treatment outcome. Because of their sedating effects, the tricyclic antidepressants (TCAs) have historically been the first-choice agent in treating comorbid depression and anxiety. However, a growing body of evidence suggests that the selective serotonin reuptake inhibitors (SSRIs) can also be suitable therapy.

METHOD

We reviewed literature regarding the use of TCAs and SSRIs in depressed patients with comorbid anxiety.

RESULTS

SSRIs are at least as effective as TCAs in the treatment of both overall depression as well as anxiety symptoms. TCAs can cause significant and sometimes unacceptable side effects which limit their therapeutic potential. SSRIs, on the other hand, have little or no effect on cholinergic, histaminergic or adrenergic receptors, and have a very favourable tolerability profile.

CONCLUSION

The traditional selection of antidepressants based on the presence or absence of anxiety has little scientific support. In considering the overall risk:benefit ratio, SSRIs should be the first line treatment for depression with associated anxiety.

Anxiety disorders: a review of tricyclic antidepressants and selective serotonin reuptake inhibitors

OBJECTIVE

Anxiety disorders are the most common mental health disorders. While the older tricylic antidepressants (TCAs) are efficacious in the treatment of many anxiety disorders, recent studies with fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have emphasized the role of serotonin in the aetiology of these conditions.

METHOD

We reviewed the efficacy, safety and tolerability of TCAs and SSRIs in the treatment of the most common anxiety disorders, specifically, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder.

RESULTS

Both the TCA and SSRI antidepressants are effective in treating a wide variety of anxiety disorders. SSRIs, due to their greater safety and tolerability, should be the preferred choices in treating anxiety disorders in those instances where TCAs and SSRIs are considered equally effective. In the cases of OCD and social phobia, SSRIs are almost always preferable given that the TCAs do not appear effective in these disorders.

CONCLUSION

Further research is needed on the naturalistic long-term use of the TCAs and SSRIs in the treatment of anxiety disorders.

Estrogen desensitizes 5-HT(1A) receptors and reduces levels of G(z), G(i1) and G(i3) proteins in the hypothalamus

The present study investigated whether estrogen would desensitize hypothalamic serotonin(1A) (5-HT(1A)) receptors by examining the neuroendocrine response to 8-OH-DPAT, a 5-HT(1A) agonist. Rats were ovariectomized, allowed to recover for 5 days, then given 2 daily injections of estradiol benzoate or vehicle (10 microg/day, s.c.). Twenty-four hours after the second injection, rats were challenged with a sub-maximal dose of 8-OH-DPAT (50 microg/kg, sc) or saline 15 min prior to sacrifice. 8-OH-DPAT produced a significant increase in plasma oxytocin, ACTH and corticosterone levels in ovariectomized rats. While estrogen treatment for 2 days did not alter basal hormone levels, it did significantly reduce the magnitude of oxytocin, ACTH and corticosterone responses to 8-OH-DPAT. The reduction in hormone responses was accompanied by a significant reduction in hypothalamic levels of G(z), G(i1) and G(i3) proteins (by 50%, 30% and 50%, respectively). These findings suggest that a reduction in these G proteins may contribute to the mechanisms underlying estrogen-induced desensitization of 5-HT(1A) receptors. The desensitization of 5-HT(1A) receptors has been suggested to underlie the therapeutic effects of antidepressant 5-HT uptake inhibitors (SSRIs). Thus, the present results suggest that estrogen or estrogen-like substances in combination with SSRIs may prove effective in developing novel therapeutic strategies for neuropsychiatric disorders in women.

Anxiety and Depression: Optimizing Treatments

Properly diagnosing and treating patients with anxiety, depression, or both is a challenging aspect of practicing medicine in the primary care setting. Patients often present with somatic complaints rather than classic psychiatric symptoms. In addition, there is significant overlap between anxiety and depression in this patient population. Comorbid anxiety and depression is often more resistant to pharmacologic treatment, and patients with coexisting disorders have a poorer medical prognosis than do patients with either disorder alone. Fortunately, many new therapies are available to assist the clinician in managing these patients. The newer antidepressants, in particular, are playing an increasingly important role in the treatment of both anxiety disorders alone and comorbid anxiety and depression. These new choices enable our goal of treatment to encompass not only improvement but also sustained complete remission. Of the newer agents, the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been studied quite extensively in these patient populations. The specific profiles of individual agents may assist the clinician in individualizing treatment. Characteristics such as robust efficacy, speed of onset of activity, the potential for drug-drug interactions, dose response, and tolerability are important considerations in optimizing treatment.

Early depressive symptoms in cancer patients receiving interleukin 2 and/or interferon alfa-2b therapy

PURPOSE

Depressive symptomatology is frequently associated with interleukin (IL)-2 and interferon alfa-2b (INFalpha-2b) therapy in cancer patients. The objective of the present study was to evaluate the depressive and anxiety symptoms induced by IL-2 and/or INFalpha-2b in cancer patients during the first days of cytokine immunotherapy.

PATIENTS AND METHODS

The study included 48 patients with renal cell carcinoma or melanoma. Patients were treated either with subcutaneous IL-2, alone (n = 20) or in combination with INFalpha-2b (n = 6); or with INFalpha-2b alone, administered subcutaneously at a low dose (n = 8) or intravenously at a high dose (n = 14). Depressive symptoms were evaluated using the Montgomery and Asberg Depression Rating Scale (MADRS), and anxiety symptoms were evaluated using the Covi scale. Evaluations were performed just before initiation of treatment (day 1) and on days 3 and 5 of treatment.

RESULTS

Patients treated with IL-2 alone or in association with INFalpha-2b had significantly higher MADRS scores after 5 days of cytokine therapy, and patients who received both cytokines had increased scores on day 3. In contrast, patients treated with INFalpha-2b alone did not have varying MADRS scores during the course of treatment. Cytokine therapy had no effect on anxiety, except in patients treated with IL-2 in combination with INFalpha-2b. In these patients, the enhancement in anxiety scores that was observed on day 5 was mainly attributable to increased somatic complaints.

CONCLUSION

IL-2 and INFalpha-2b have differential effects on mood, and IL-2 therapy induces depressive symptoms early in treatment.

Measurement of anxiety in transgenic mice

A wide range of approaches has been used to study anxiety in mice. All presuppose that aversive stimuli, such as foot shock or novelty, induce a central state of fear, which can be quantified through specific behavioural and physiological measures. This review discusses the validity of the various approaches in terms of their similarity to different human anxiety disorders, their ability to detect compounds which modulate human anxiety, and their relevance to animal defensive processes. The most commonly used models of anxiety suitable for screening transgenic and knockout mice are discussed, with an emphasis placed on controlling for factors which could confound results. As all models used to date have limitations and no single paradigm adequately models all aspects of anxiety, this review recommends the use of a broad range of anxiety models in order to provide a comprehensive characterisation of the behavioural phenotype of transgenic mice.

Persisting symptoms and carers' views of outcome after subarachnoid haemorrhage

OBJECTIVE

To report the outcome of aneurysmal subarachnoid haemorrhage (SAH) in terms of subjective symptoms and carers' perspective over a period of two years.

DESIGN

Forty-four consecutive patients admitted to a Regional Neurosurgical Unit and who survived aneurysmal SAH were invited for outpatient assessment at 6, 12 and 24 months post haemorrhage.

MEASURES

The Glasgow Outcome Scale (GOS) was used to measure global outcome; the Hospital Anxiety and Depression Scale (HAD) to screen for affective symptoms; the Head Injury Symptom Checklist (HISC) to detect symptoms commonly reported after head trauma; and information was collected from a close friend or relative of the patient using the Relative's Questionnaire (RQ).

RESULTS

GOS outcome was significantly related to the severity of the original haemorrhage, as classified by the World Federation of Neurological Surgeons (WFNS) Grading Scale, on admission to hospital. However, even in cases where patients had made a good recovery according to the GOS, a variety of problems were frequently reported by patients and relatives, and many of these persisted for the duration of the study. The three most common and persistent symptoms were tiredness (63%, 59% and 59% at 6, 12 and 24 months respectively), memory disturbance (50%, 52% and 56%) and passivity (61%, 47% and 46%). In contrast, the prevalence of disturbed mood, as reported using the HAD, was similar to that of the general population.

CONCLUSIONS

Studies of outcome following SAH should address these subtle disturbances, and information pertaining to potential long-term problems should be provided to patients and relevant others.

Cognitive and psychosocial outcome following moderate or severe traumatic brain injury

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relative's Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.

Review of the results from clinical studies on the efficacy, safety and tolerability of mirtazapine for the treatment of patients with major depression

Mirtazapine is a presynaptic alpha-2 antagonist that has dual action by increasing noradrenergic and serotonergic neurotransmission. The enhancement of serotonergic neurotransmission is specifically mediated via 5-HT1 receptors because mirtazapine is a postsynaptic serotonergic 5-HT2 and 5-HT3 antagonist. In addition, mirtazapine has only a weak affinity for 5-HT1 receptors and has very weak muscarinic anticholinergic and histamine (H1) antagonist properties. As a consequence of its unique pharmacodynamic properties, mirtazapine is an effective, safe and well-tolerated addition to the antidepressant armamentarium. Mirtazapine is well absorbed from the gastrointestinal tract following oral administration, and it is extensively metabolized in the liver to four metabolites via demethylation and hydroxylation, followed by glucuronide conjugation. The unconjugated desmethyl metabolite is pharmacologically less active than the parent compound. Mirtazapine lacks auto-induction of hepatic isoenzymes. Although mirtazapine is a substrate of P450 isoenzymes 1A2, 2D6 and 3A4, in vitro studies show that it is not a potent inhibitor or inducer of any of these enzymes. Mirtazapine has been evaluated in a worldwide clinical development program involving approximately 4500 patients. Controlled clinical trials involving almost 2800 mirtazapine-treated patients have demonstrated the compound to be effective for the treatment of moderate-to-serve major depression. Mirtazapine was consistently superior to placebo, and equivalent in efficacy to the tricyclic antidepressants amitriptyline, doxepin and clomipramine, but with an improved tolerability profile. Mirtazapine has shown a rapid onset of action in patients with predominantly severe depressive illness in a comparative study against fluoxetine. Mirtazapine has a unique tolerability profile, since the specific postsynaptic 5-HT2 and 5-HT3 receptor blockade of mirtazapine provides early antidepressant effects without causing unwanted serotonin-related side-effects. Transient somnolence, hyperphagia and weight gain are the most commonly reported adverse events, which may be attributed to the antihistaminic (H1) activity of mirtazapine at low doses. Somnolence, the most commonly reported side-effect, appears to be less frequent at higher dosages. Mirtazapine also demonstrates important anxiolytic and sleep-improving effects, which may be related to its pharmacodynamic properties. In addition, mirtazapine does not appear to be associated with sexual dysfunction. Mirtazapine has shown no significant cardiovascular adverse effects at multiples of 7 to 22 times the maximum recommended dose. Mirtazapine is a unique addition to the antidepressant armamentarium as first-line therapy in patients with major depression and symptoms of anxiety/agitation or anxiety/somatization or complaints of insomnia and as a useful alternative in depressed patients who do not adequately respond to or are intolerant of tricyclic antidepressants or serotonin-specific reuptake inhibitors.