Comparison of the Treatment with Paroxetine and Reboxetine in Panic Disorder: A Randomized, Single-Blind Study

Comparative efficacy and acceptability of antidepressants and benzodiazepines for the treatment of panic disorder: A systematic review and network meta-analysis

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.

Pharmacological Therapy in Panic Disorder: Current Guidelines and Novel Drugs Discovery for Treatment-resistant Patient

Panic disorder (PD) being one of the most intensively investigated anxiety disorders is considered a heterogeneous psychiatric disease which has difficulties with early diagnosis. The disorder is recurrent and usually associated with low remission rates and high rates of relapse which may exacerbated social and quality of life, causes unnecessary cost and increased risk for complication and suicide. Current pharmacotherapy for PD are available but these drugs have slow therapeutic onset, several side effects and most patients do not fully respond to these standard pharmacological treatments. Ongoing investigations indicate the need for new and promising agents for the treatment of PD. This article will cover the importance of immediate and proper treatment, the gap in the current management of PD with special emphasis on pharmacotherapy, and evidence regarding the novel anti-panic drugs including the drugs in developments such as metabotropic glutamate (mGlu 2/3) agonist and levetiracetam. Preliminary results suggest the anti-panic properties and the efficacy of duloxetine, reboxetine, mirtazapine, nefazodone, risperidone and inositol as a monotherapy drug. Apart for their effectiveness, the aforementioned compounds were generally well tolerated compared to the standard available pharmacotherapy drugs, indicating their potential therapeutic usefulness for ambivalent and hypervigilance patient. Further strong clinical trials will provide an ample support to these novel compounds as an alternative monotherapy for PD treatment-resistant patient.

Toward a personalized therapy for panic disorder: preliminary considerations from a work in progress

Although several treatment options for panic disorder (PD) are available, the best intervention for each individual patient remains uncertain and the use of a more personalized therapeutic approach in PD is required. In clinical practice, clinicians combine general scientific information and personal experience in the decision-making process to choose a tailored treatment for each patient. In this sense, clinicians already use a somehow personalized medicine strategy. However, the influence of their interpretative personal models may lead to bias related to personal convictions, not sufficiently grounded on scientific evidence. Hence, an effort to give some advice based on the science of personalized medicine could have positive effects on clinicians' decisions. Based on a narrative review of meta-analyses, systematic reviews, and experimental studies, we proposed a first-step attempt of evidence-based personalized therapy for PD. We focused on some phenomenological profiles, encompassing symptoms during/outside panic attacks, related patterns of physiological functions, and some aspects of physical health, which might be worth considering when developing treatment plans for patients with PD. We considered respiratory, cardiac, vestibular, and derealization/depersonalization profiles, with related implications for treatment. Given the extensiveness of the topic, we considered only medications and some somatic interventions. Our proposal should be considered neither exhaustive nor conclusive, as it is meant as a very preliminary step toward a future, robust evidence-based personalized therapy for PD. Clearly much more work is needed to achieve this goal, and recent technological advances, such as wearable devices, big data platforms, and the application of machine learning techniques, may help obtain reliable findings. We believe that combining the efforts of different research groups in this work in progress can lead to largely shared conclusions in the near future.

Management of Treatment-Resistant Panic Disorder

PURPOSE OF REVIEW

Purpose of Review Management of treatment-resistant (TR) panic disorder (PD) is an unresolved issue. In this paper, we provide a brief summary of previous findings, an updated (2015-2017) systematic review of pharmacological/non-pharmacological studies, and our personal perspective on this topic.

RECENT FINDINGS

Recent Findings We found a very limited number of recent findings. Quetiapine extended-release augmentation has not been found to be beneficial, in comparison to placebo, in non-responders to previously recommended pharmacotherapy. In non-responders to cognitive behavioral therapy (CBT), switching to paroxetine/citalopram has been found to be more effective than continuing CBT. Acceptance and commitment therapy (ACT) has shown some improvement in patients' resistance to previous psychological/pharmacological interventions compared with a waiting-list condition.

SUMMARY

Summary Previous and recent findings regarding the treatment of TR PD suffer from several methodological limitations. Available studies provide insufficient evidence to support the use of medications alternative to the recommended medications; the efficacy of ACT needs confirmation with more rigorous methodology. Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy, while switching to pharmacotherapy may help non-responders to CBT. We discuss our personal perspective on the definition of "treatment resistance" as it relates to PD and provide personalized intervention strategies to increase favorable clinical outcomes based on our clinical expertise and review of experimental studies on the pathophysiology of PD.

Efficacy of adjunctive treatments added to olanzapine or clozapine for weight control in patients with schizophrenia: a systematic review and meta-analysis

Objectives. This study was conducted to review systematically adjunctive treatments for weight reduction in patients with schizophrenia and compare efficacies of clinical trials through meta-analysis, so as to provide effective clinical guideline regarding weight control for patients taking atypical antipsychotics. Methods. Candidate clinical trials were identified through searching the Cochrane Central Register of Controlled Trials, PubMed, and PsycINFO. Fourteen randomized clinical trials were included for systematic review and meta-analysis from 132 potential trials. The Comprehensive Meta-Analysis version 2 was used for meta-analysis. Results. Difference in means and significances from meta-analyses regarding weight control by adjunctive treatments showed that topiramate, aripiprazole, or sibutramine was more effective than metformin or reboxetine. Psychiatric evaluations did not show statistically significant changes between treatment groups and placebo groups except topiramate adjunctive treatments. Adverse effects regarding adjunctive therapies were tolerable and showed statistically no significances compared to control groups. Conclusion. Though having several reports related to exacerbation of psychiatric symptoms, topiramate and aripiprazole are more efficacious than other medications in regard to weight reduction and less burden of critical adverse effects as well as being beneficial for clinical improvement.

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.

An explorative study on metacognition in obsessive-compulsive disorder and panic disorder

OBJECTIVE

To test the hypothesis that dysfunctional metacognitions might be a general vulnerability factor for anxiety disorder, metacognitive beliefs among patients with obsessive-compulsive disorder (OCD), patients with panic disorder (PD), and healthy subjects (HS) were studied. Correlations between metacognitive beliefs, OCD, and PD symptoms were also investigated.

METHODS

Patients with OCD (n = 114), patients with PD (n = 119), and HS (n = 101) were assessed with the Metacognition Questionnaire (MCQ).

RESULTS

Patients with OCD and those with PD scored significantly higher than HS on the MCQ in 2 dimensions: negative beliefs about worry concerning uncontrollability and danger as well as beliefs about the need to control thoughts dimensions. No difference in MCQ scores was observed between the OCD and PD groups. The former 2 MCQ dimensions were positively correlated with the degree of indecisiveness in patients with OCD, whereas the MCQ negative beliefs about worry positively correlated with the average intensity of anticipatory anxiety in patients with PD.

CONCLUSIONS

The presence of dysfunctional metacognitions in both patients with OCD and those with PD suggests that such beliefs can represent not only generic vulnerability factors for anxiety disorders but also elements that contribute to maintaining the disorder, as evidenced by their associations with aspects of OCD and PD symptoms.

Evidence-based pharmacotherapy of panic disorder: an update

The evidence-based pharmacotherapy of panic disorder continues to evolve. This paper reviews data on first-line pharmacotherapy, evidence for maintenance treatment, and management options for treatment-refractory patients. A Medline search of research on pharmacotherapy was undertaken, and a previous systematic review on the evidence-based pharmacotherapy of panic disorder was updated. Selective serotonin reuptake inhibitors remain a first-line pharmacotherapy of panic disorder, with the serotonin noradrenaline reuptake inhibitor venlafaxine also an acceptable early option. Temporary co-administration of benzodiazepines can be considered. Maintenance treatment reduces relapse rates, but further research to determine optimal duration is needed. For patients not responding to first-line agents several pharmacotherapy options are available, but there is a notable paucity of data on the optimal choice.

Antianxiety medications for the treatment of complex agoraphobia: pharmacological interventions for a behavioral condition

BACKGROUND

Although there are controversial issues (the "American view" and the "European view") regarding the construct and definition of agoraphobia (AG), this syndrome is well recognized and it is a burden in the lives of millions of people worldwide. To better clarify the role of drug therapy in AG, the authors summarized and discussed recent evidence on pharmacological treatments, based on clinical trials available from 2000, with the aim of highlighting pharmacotherapies that may improve this complex syndrome.

METHODS

A systematic review of the literature regarding the pharmacological treatment of AG was carried out using MEDLINE, EBSCO, and Cochrane databases, with keywords individuated by MeSH research. Only randomized, placebo-controlled studies or comparative clinical trials were included.

RESULTS

After selection, 25 studies were included. All the selected studies included patients with AG associated with panic disorder. Effective compounds included selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, selective noradrenergic reuptake inhibitors, and benzodiazepines. Paroxetine, sertraline, citalopram, escitalopram, and clomipramine showed the most consistent results, while fluvoxamine, fluoxetine, and imipramine showed limited efficacy. Preliminary results suggested the potential efficacy of inositol; D-cycloserine showed mixed results for its ability to improve the outcome of exposure-based cognitive behavioral therapy. More studies with the latter compounds are needed before drawing definitive conclusions.

CONCLUSION

No studies have been specifically oriented toward evaluating the effect of drugs on AG; in the available studies, the improvement of AG might have been the consequence of the reduction of panic attacks. Before developing a "true" psychopharmacology of AG it is crucial to clarify its definition. There may be several potential mechanisms involved, including fear-learning processes, balance system dysfunction, high light sensitivity, and impaired visuospatial abilities, but further studies are warranted.

The role of central noradrenergic dysregulation in anxiety disorders: evidence from clinical studies

The nature of the noradrenergic dysregulation in clinical anxiety disorders remains unclear. In panic disorder, the predominant view has been that central noradrenergic neuronal networks and/or the sympathetic nervous system was normal in patients at rest, but hyper-reactive to specific stimuli, for example carbon dioxide. These ideas have been extended to other anxiety disorders, which share with panic disorder characteristic subjective anxiety and physiological symptoms of excess sympathetic activity. For example, Generalized Anxiety Disorder is characterized by chronic free-floating anxiety, muscle tension, palpitation and insomnia. It has been proposed that there is chronic central hypersecretion of noradrenaline in Generalized Anxiety Disorder, with consequent hyporesponsiveness of central post-synaptic receptors. With regards to other disorders, it has been suggested that there is noradrenergic involvement or derangement, but a more specific hypothesis has not been enunciated. This paper reviews the evidence for noradrenergic dysfunction in anxiety disorders, derived from indirect measures of noradrenergic function in clinical populations.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision

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.

Disability and treatment of specific mental and physical disorders across the world

BACKGROUND

Advocates of expanded mental health treatment assert that mental disorders are as disabling as physical disorders, but little evidence supports this assertion.

AIMS

To establish the disability and treatment of specific mental and physical disorders in high-income and low- and middle-income countries.

METHOD

Community epidemiological surveys were administered in 15 countries through the World Health Organization World Mental Health (WMH) Survey Initiative.

RESULTS

Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to the commonly occurring physical disorders included in the surveys. This pattern held for all disorders and also for treated disorders. Disaggregation showed that the higher disability of mental than physical disorders was limited to disability in social and personal role functioning, whereas disability in productive role functioning was generally comparable for mental and physical disorders.

CONCLUSIONS

Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.

A randomized controlled trial of venlafaxine ER and paroxetine in the treatment of outpatients with panic disorder

RATIONALE

Few randomized, placebo-controlled trials have evaluated the comparative efficacy and tolerability of more than one pharmacological agent for panic disorder.

OBJECTIVES

The primary objective of this study was to compare the efficacy and tolerability of venlafaxine extended release (ER) with placebo in treating panic disorder. Secondary objectives included comparing paroxetine with venlafaxine ER and placebo.

METHODS

Outpatients aged > or =18 years (placebo, n = 157; venlafaxine ER 75 mg, n = 156; venlafaxine ER 225 mg, n = 160; paroxetine, n = 151), with a primary diagnosis of panic disorder (+/-agoraphobia) based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for > or =3 months were randomly assigned to receive venlafaxine ER (titrated to 75 mg/day or 225 mg/day), paroxetine (titrated to 40 mg/day), or placebo for 12 weeks. The primary efficacy measure was the percentage of patients free of full-symptom panic attacks (> or = four symptoms) at endpoint. Key secondary outcomes included the Panic Disorder Severity Scale (PDSS) mean score change and response.

RESULTS

At endpoint, all active treatment groups showed a significantly (P < 0.01) greater proportion of patients free of full-symptom panic attacks, compared with placebo, and were superior (P < 0.05) on most secondary measures. The venlafaxine ER 225 mg group had significantly (P < 0.05) greater mean PDSS score improvement than the paroxetine group (-12.58 vs -11.87) and a significantly higher proportion of patients free of full symptom panic attacks (70.0 vs 58.3%). Both drugs were generally well tolerated.

CONCLUSION

Venlafaxine ER 75 mg/days and 225 mg/days and paroxetine 40 mg/day were both well tolerated and effective for short-term treatment of panic disorder.

Attenuating effect of reboxetine on appetite and weight gain in olanzapine-treated schizophrenia patients: a double-blind placebo-controlled study

RATIONALE

Search for safe and effective strategies to diminish weight gain associated with second generation antipsychotics (SGAs) is imperative. In the present study, we sought to replicate our preliminary findings, which indicated that coadministration of the selective norepinephrine reuptake inhibitor reboxetine attenuates olanzapine-induced weight gain.

MATERIALS AND METHOD

Fifty-nine patients hospitalized for first-episode DSM-IV schizophrenic disorder participated in this randomized double-blind study. Reboxetine (4 mg/day; 31 patients) or placebo (29 patients) was coadministered with olanzapine (10 mg/day) for 6 weeks. Analysis was by intention-to-treat.

RESULTS

Nine patients in each group prematurely discontinued the trial. Olanzapine/reboxetine-treated patients showed a significantly lower increase in body weight (mean = 3.31 kg, SD = 2.73) than their olanzapine/placebo-treated counterparts (mean = 4.91 kg, SD = 2.45). Significantly fewer olanzapine/reboxetine-treated patients gained at least 7% of their initial weight, the cutoff for clinically significant weight gain (6 [19.4%] of 31 patients vs 13 [46.4%] of 28 patients). Seven (22.6%) olanzapine/reboxetine-treated patients compared to only one patient (3.6%) in the olanzapine/placebo group revealed no weight change or even modest weight loss. Appetite increase was significantly lower in the olanzapine/reboxetine than olanzapine/placebo group and was correlated with attenuation of weight gain. Reboxetine addition was safe and well tolerated.

CONCLUSIONS

The results confirm that coadministration of reboxetine promotes a clinically meaningful attenuation of olanzapine-induced weight gain in schizophrenia patients. If substantiated in long-term studies, along with behavioral management and diet counseling, reboxetine may have a clinical utility in controlling SGA-induced weight gain.

Management of panic disorder

Selective serotonin reuptake inhibitors are the first-line treatment for panic disorder. They are effective and well tolerated. Although tricyclic antidepressants are equally effective, they are less well tolerated than the selective serotonin reuptake inhibitors. Monoamine oxidase inhibitors can be efficacious but have a range of unwanted effects that preclude their use as first-line treatments. Benzodiazepines should be reserved for short-term use and for treatment-resistant patients who do not have a history of dependence and tolerance. Also, they can be combined with selective serotonin reuptake inhibitors in the first weeks of treatment to tide the patient over before the onset of the response. Cognitive behavioral therapy is the psychologic treatment of first choice. The methods of combining drug and nondrug treatments need careful and thorough exploration.

Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

Persistence, Switching, and Discontinuation Rates Among Patients Receiving Sertraline, Paroxetine, and Citalopram

STUDY OBJECTIVE

To compare persistence, switching, and discontinuation rates among patients taking brand-name selective serotonin reuptake inhibitors (SSRIs).

DESIGN

Retrospective cohort study. Data Source. Protocare Sciences managed care database.

PATIENTS

A total of 14,933 patients with depression, posttraumatic stress disorder, or social anxiety disorder whose prescriptions for brand-name SSRIs were filled from January 1, 1999-June 30, 2002.

MEASUREMENTS AND MAIN RESULTS

A total of 5598 patients received sertraline, 4131 citalopram, and 5204 paroxetine. Adherence status was categorized as persistence, switching (from one SSRI to another SSRI), and discontinuation. Persistence was determined based on the number of days' supply of the prescribed drug, with a minimum of 15 days to refill. Survival analyses using life-table survival curves and Cox proportional hazard models were conducted. Age, sex, and copayment were covariates in the Cox proportional models. Sensitivity analysis with a longer time to refill was performed to determine whether the results were sensitive to the algorithm for determining adherence. Compared with patients receiving sertraline and citalopram, those receiving paroxetine had lower rates of persistence (23.79% vs 25.96% for sertraline [p = 0.0093] and 26.56% for citalopram [p = 0.0022]) and higher rates of switching (3.55% vs 3.32% for sertraline [p = 0.5076] and 2.78% for citalopram [p = 0.0359]) and discontinuation (72.66% vs 70.72% for sertraline [p = 0.0258] and 70.66% for citalopram [p = 0.0334]). Survival curves showed that persistence rates with sertraline and citalopram were significantly greater than with paroxetine (p<0.05, log-rank and Wilcoxon tests). Age was an independent predictor of persistence; male sex and copayment were not. The comparisons across SSRIs were robust in the sensitivity analysis that varied the time to refill allowed.

CONCLUSION

Differences in the persistence rates were noted among patients receiving three brand-name SSRIs, with patients receiving paroxetine having lower persistence than those receiving sertraline and citalopram. Observed differences in persistence across SSRIs were not sensitive to model specifications. Prescription of SSRIs that demonstrate better adherence would benefit both the patient and the health care system.