Tailoring a specific medical leadership development program for faculty members: the Lyon-Ottawa experience

The development of leadership skills has been the topic of several position statements over recent decades, and the need of medical leaders for a specific training was emphasized during the COVID-19 crisis, to enable them to adequately collaborate with governments, populations, civic society, organizations, and universities. However, differences persist as to the way such skills are taught, at which step of training, and to whom. From these observations and building on previous experience at the University of Ottawa, a team of medical professors from Lyon (France), Ottawa, and Montreal (Canada) universities decided to develop a specific medical leadership training program dedicated to faculty members taking on leadership responsibilities. This pilot training program was based on a holistic vision of a transformation model for leadership development, the underlying principle of which is that leaders are trained by leaders. All contributors were eminent French and Canadian stakeholders. The model was adapted to French faculty members, following an inner and outer analysis of their specific needs, both contextual and related to their time constraints. This pilot program, which included 10 faculty members from Lyon, was selected to favor interactivity and confidence in older to favor long-term collaborations between them and contribute to institutional changes from the inner; it combined several educational methods mixing interactive plenary sessions and simulation exercises during onescholar year. All the participants completed the program and expressed global satisfaction with it, validating its acceptability by the target. Future work will aim to develop the program, integrate evaluation criteria, and transform it into a graduating training.

Interpersonal Psychotherapy for Depression in Parkinson's Disease: A Feasibility Study

Individuals living with Parkinson's disease (PD) experience interpersonal stressors that contribute to depressive risk. Interpersonal psychotherapy (IPT) emphasizes the bidirectional relationship between interpersonal stressors and mood may therefore be a suitable treatment for PD-depression. The primary aim of this study was to evaluate the feasibility of delivering 12 sessions of IPT to depressed PD patients and explore the need for modifications. A secondary aim was to obtain descriptive information about efficacy outcomes. The study used a pre-post design without a comparison group. Participants were 12 PD patients with a major depressive disorder. IPT was well accepted and tolerated by patients and required minimal modifications. Compliance with session attendance and completion of study questionnaires were excellent and treatment satisfaction was high. Depression scores declined from baseline to endpoint, with 7 patients meeting criteria for remission at endpoint. Findings are encouraging and a larger randomized controlled trial is currently underway to ascertain if IPT is an efficacious treatment for PD-depression.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Stress reactivity in healthy child offspring of parents with anxiety disorders

Several studies suggest that anxiety disorders (AD) involve dysregulation of the autonomic nervous system (ANS) and hypothalamic-pituitary (HPA) axis. However, it is unknown if alterations in these biological systems are premorbid markers of AD risk or a state-dependent feature of anxiety. This study examined ANS and HPA-axis response to a laboratory stressor in healthy child offspring of parents with (n = 55) and without (n = 98) a history of AD. High frequency heart rate variability (HF-HRV) was assessed during sitting and standing baseline conditions and during a speech task where participants remained standing. Salivary cortisol was measured at baseline and at 15, 30, 45 and 60 min post-speech. Subjective anxiety was assessed with a visual analogue scale. Children of parents with AD displayed reduced HRV and a blunted cortisol response to the speech task compared to children of non-anxious parents. No risk group effect was found for anxiety ratings. These preliminary data suggest that healthy children of anxious parents exhibit altered stress reactivity to an acute laboratory stressor. Further research is needed to confirm findings and identify mechanisms that may account for altered self-regulation processes to a stressor in children at familial risk for AD.

Feasibility and effectiveness of an online mindfulness meditation program for medical students

BACKGROUND

The need to incorporate tools to promote medical student wellness in medical education is underscored by the concerning rates of psychological distress among them. The objective of this prospective cohort study was to obtain preliminary data on the feasibility and effectiveness of an online mindfulness intervention for medical student wellness.

METHODS

A convenience sample of 52 medical students consented to participate in this study. Feasibility was assessed by ease of recruitment, number of modules completed, satisfaction with the program, and adherence to a regular meditation practice. Participants completed the Maslach Burnout Inventory, the Jefferson Scale of Empathy-medical student version, the Five Face of Mindfulness Questionnaire-short form, and the Self Compassion Scale-short form pre and post intervention.

RESULTS

The convenience sample was recruited within a two-month period. Forty-five participants completed at least one of seven modules. Descriptive statistics (mean±standard deviation) revealed that the mean number of modules completed was 4.85±2.7. Mean satisfaction with the modules was 7.07±1.1 out of 10. Adherence to a regular formal meditation practice was poor; the average amount of formal meditation practice per module was 34.14±27.44 minutes. Self-compassion and the "observe and describe" facets of mindfulness practice significantly statistically increased from baseline, but no such change was observed for levels of burnout and empathy.

CONCLUSION

The present study indicates that an online mindfulness meditation program may be of interest to medical students. The results did not provide any evidence that the program was effective but we believe further research and development is warranted.

Predictors of etiological beliefs about panic disorder and impact of beliefs on treatment outcomes

Little is known about the beliefs people with panic disorder (PD) have about their illness and how these beliefs might influence treatment outcome. This study explored demographic and clinical predictors of etiological beliefs about PD and the impact these beliefs have on treatment response. The sample included 251 outpatients with PD who participated in a randomized placebo-controlled trial of treatments for PD. Regression analyses revealed that sex, duration of PD and family history of psychiatric illnesses predicted biological etiological beliefs, previous history of psychotherapy predicted environmental etiological beliefs, and age, impaired functioning, and measures of "fear of fear" predicted multiple etiological beliefs about PD. Etiological beliefs predicted more severe symptoms at 12 weeks post-treatment, irrespective of the type of treatment received, but had no effect on attrition, treatment adherence or treatment-related adverse effects This study contributes to the sparse literature on etiological beliefs about PD. Results are preliminary and further research is needed to understand more fully the factors that shape etiological beliefs about PD, whether these beliefs change over the course of illness, and the impact etiological beliefs have on treatment outcome.

Preliminary Investigation of a Mindfulness-Based Intervention for Social Anxiety Disorder That Integrates Compassion Meditation and Mindful Exposure

OBJECTIVES

This study evaluated the feasibility and initial efficacy of a 12-week group mindfulness-based intervention tailored for persons with social anxiety disorder (MBI-SAD). The intervention includes elements of the standard mindfulness-based stress reduction program, explicit training in self-compassion aimed at cultivating a more accepting and kinder stance toward oneself, and use of exposure procedures to help participants practice responding mindfully to internal experiences evoked by feared social situations.

METHODS

Participants were randomly assigned to the MBI-SAD (n = 21) or a waitlist (WL) (n = 18) control group. Feasibility was assessed by the number of participants who completed at least 75% of the 12 weekly group sessions. Primary efficacy outcomes were clinician- and self-rated measures of social anxiety. Other outcomes included clinician ratings of illness severity and self-rated depression, social adjustment, mindfulness, and self-compassion.

RESULTS

The MBI-SAD was acceptable and feasible, with 81% of participants attending at least 75% of sessions. The MBI-SAD fared better than WL in improving social anxiety symptom severity (p ≤ 0.0001), depression (p ≤ 0.05), and social adjustment (p ≤ 0.05). The intervention also enhanced self-compassion (p ≤ 0.05), and facets of mindfulness (observe and aware; p ≤ .05). MBI-SAD treatment gains were maintained at 3-month follow-up.

CONCLUSIONS

These preliminary findings suggest that an MBI that integrates explicit training in self-compassion and mindful exposure is a feasible and promising intervention for social anxiety disorder. The next step is to compare the MBI-SAD to the gold standard of cognitive-behavior therapy to determine equivalence or noninferiority and to explore mediators and moderators of treatment outcome.

A pilot feasibility study of a peer-led mindfulness program for medical students

BACKGROUND

Mindfulness meditation has gained momentum in medical circles for bolstering wellbeing and other facets of professionalism. This study evaluated the feasibility and benefits of a peer-led mindfulness meditation program (MMP) on medical student wellness and professionalism.

METHOD

Pre-clerkship students were recruited and randomized to the 8-week MMP or wait-list. Feasibility outcomes included ease of recruitment, program attendance and homework compliance. Other outcomes included self-reported psychological distress, empathy, self-compassion, mindfulness, altruism and program satisfaction.

RESULTS

The MMP decreased levels of stress and enhanced mindfulness, self-compassion and altruism from baseline to post-study. Changes were not significant for the wait-list condition. Although satisfaction with the MMP was high compliance was suboptimal.

CONCLUSIONS

A peer-led MMP is feasible and may be a promising approach to enhance medical student wellbeing. Further research is needed to explore strategies to improve program compliance in this student population.

A new leadership curriculum: the multiplication of intelligence

The authors propose a new model of leadership for the clinical setting. The authors' research suggests that there is latent intelligence inside business and educational organizations because many leaders operate in a way that shuts down the intelligence of others. Such leaders are classified as "Diminishers." In the clinical setting this behavior creates a hidden curriculum in medical education, passing on unprofessional patterns of behavior to future physicians. Other leaders, however, amplify intelligence, produce better outcomes, and grow talent. These leaders are classified as "Multipliers." The authors suggest that Multiplier leadership should become the standard leadership practice in medical schools. Case studies of a Multiplier and a Diminisher are presented and illustrate the positive effect these leaders can have on medical education and health organizations.

A multifaith spiritually based intervention versus supportive therapy for generalized anxiety disorder: a pilot randomized controlled trial

OBJECTIVES

We have previously reported that a multifaith spiritually based intervention (SBI) may have efficacy in the treatment of generalized anxiety disorder (GAD). This randomized pilot trial tested whether the SBI had greater efficacy than a nonspecific control condition in GAD.

METHOD

Twenty-three participants with GAD of at least moderate severity were randomized to 12 individual sessions of the SBI (n = 11) or supportive psychotherapy (SP)--our control condition (n = 12).

RESULTS

Intent-to-treat analysis revealed the SBI fared better than SP in decreasing blind clinician ratings of anxiety and illness severity and self-report worry and intolerance of uncertainty, with large between-group effect sizes. The SBI also produced greater changes in spiritual well-being. Results remained the same when supplementary analyses were performed on the completer sample. Treatment gains were maintained at 3-months follow-up.

CONCLUSIONS

This small pilot trial demonstrates that a nondenominational SBI has greater efficacy than a rigorous control in improving symptoms of GAD and enhancing spiritual well-being. These results are encouraging and further research on the efficacy of the SBI and its underlying mechanisms is warranted.

Parental bonds in children at high and low familial risk for panic disorder

A rejecting and overprotective parenting style is considered to be an important risk factor for the development of anxiety disorders. This study examined the role of perceived parental bonding as a potential environmental risk factor for panic disorder (PD) in unaffected offspring with parental PD. Children with a biological parent with PD (n = 71) and children of parents with no psychiatric history (n = 80) participated in the study. Results indicate that high risk children do not perceive their parents as being more protective and less caring than low risk controls. The optimal bonding type (high care, low protection) was the most frequently reported parenting style across groups. The constraining type of maternal bonding (high care, high protection) was less frequently reported by high risk children (p < 0.05). Overall, these data suggest that parental PD does not compromise the parent-child bonds in never-ill offspring.

Neuronal network of panic disorder: the role of the neuropeptide cholecystokinin

Panic disorder (PD) is characterized by panic attacks, anticipatory anxiety and avoidance behavior. Its pathogenesis is complex and includes both neurobiological and psychological factors. With regard to neurobiological underpinnings, anxiety in humans seems to be mediated through a neuronal network, which involves several distinct brain regions, neuronal circuits and projections as well as neurotransmitters. A large body of evidence suggests that the neuropeptide cholecystokinin (CCK) might be an important modulator of this neuronal network. Key regions of the fear network, such as amygdala, hypothalamus, peraqueductal grey, or cortical regions seem to be connected by CCKergic pathways. CCK interacts with several anxiety-relevant neurotransmitters such as the serotonergic, GABA-ergic and noradrenergic system as well as with endocannabinoids, NPY and NPS. In humans, administration of CCK-4 reliably provokes panic attacks, which can be blocked by antipanic medication. Also, there is some support for a role of the CCK system in the genetic pathomechanism of PD with particularly strong evidence for the CCK gene itself and the CCK-2R (CCKBR) gene. Thus, it is hypothesized that genetic variants in the CCK system might contribute to the biological basis for the postulated CCK dysfunction in the fear network underlying PD. Taken together, a large body of evidence suggests a possible role for the neuropeptide CCK in PD with regard to neuroanatomical circuits, neurotransmitters and genetic factors. This review article proposes an extended hypothetical model for human PD, which integrates preclinical and clinical findings on CCK in addition to existing theories of the pathogenesis of PD.

Differences in saccadic eye movements in subjects at high and low risk for panic disorder

BACKGROUND

Panic disorder (PD) has a strong genetic component showing high heritability rates and familial aggregation. Moreover, there is evidence for associations between parental PD and patterns of psychopathology. So far, little is known about possible endophenotypes representing premorbid vulnerability markers in high-risk subjects for PD. In the present study, we investigated saccadic eye movement (SEM) as an index of CNS inhibitory function in subjects at high risk for PD.

METHODS

132 healthy children at high and low familial risk for PD were included in the study. Basal SEM parameters were obtained using an electro-oculography (EOG) based system measuring peak saccadic eye velocity (pSEV), latency and accuracy. Moreover, with regard to self rating scales, state-trait-anxiety (STAI-C), childhood behavioral inhibition (CSRI), and anxiety sensitivity (CASI) were assessed.

RESULTS

There was a significant overall difference for basal SEM parameters across groups as revealed by MANCOVA (F7,118=2.184, p=.040). A significant influence was found for the covariate age, while gender and puberty status had no influence on SEM. High-risk (HR) subjects showed significantly lower pSEV. Moreover, levels of state and trait anxiety were higher in HR children (F1=5.429, p=.021).

DISCUSSION

In our sample, measurement of pSEV allowed discrimination between children at high and low risk for PD. Since these results argue for possible alterations of saccadic function in high risk subjects, differences in underlying neurobiological mechanisms might be discussed as a possible endophenotype of PD.

CCK-B receptor gene and response to cholecystokinin-tetrapeptide in healthy volunteers

Recent investigations suggest that genes that confer risk for panic disorder (PD) may moderate response to panicogenic agents in healthy volunteers. Given the potential role of the central cholecystokinin receptor (CCKBR) (CT) polymorphism alleles 26 and 27 in PD, the present study attempted to discern if these alleles moderated panicogenic sensitivity to the CCKBR agonist, CCK-tetrapeptide (CCK-4), in healthy volunteers. The study group consisted of 92 men and women with no personal or family history of psychiatric illness. Participants provided blood samples for genotyping of the CCKBR alleles and they received a 25 μg bolus injection of CCK-4. Behavioral, cardiovascular and hormonal responses to the peptide were assessed and analyzed with adjusted linear regression models. Carriers of the CCKBR alleles tended to have higher levels of pre-challenge anxiety and significantly higher levels of anxiety sensitivity and introversion than those without the alleles. However, they did not exhibit an enhanced panicogenic response to CCK-4. Overall, our findings do not demonstrate a role of these alleles in modulating CCK-4's panicogenicity. The significant association between the risk alleles and anxiety-related personality traits is intriguing and further exploration of this association is merited.

Predictors of treatment acceptance and of participation in a randomized controlled trial among women with anorexia nervosa

OBJECTIVE

This study aimed to identify predictors of acceptance of intensive treatment and of participation in a randomized controlled trial (RCT) among women with anorexia nervosa (AN).

METHOD

Participant data were drawn from a tertiary care intensive treatment programme including a previously published RCT. Women with AN (N = 106) were offered intensive treatment, and 69 were approached to participate in an RCT of olanzapine's efficacy as an adjunctive treatment for AN. AN subtype and pretreatment psychological variables were used to predict acceptance of intensive treatment and RCT participation.

RESULTS

AN binge purge subtype and higher depression and body dissatisfaction predicted intensive treatment acceptance. No variable predicted RCT participation among treatment acceptors.

DISCUSSION

Clinicians may focus on enhancing motivation or use a stepped care approach to increase intensive treatment acceptance especially among women with AN-restricting type and among all those with AN who have lower levels of distress.

A randomized trial of sertraline, self-administered cognitive behavior therapy, and their combination for panic disorder

BACKGROUND

Self-administered cognitive behavior therapy (SCBT) has been shown to be an effective alternative to therapist-delivered treatment for panic disorder (PD). However, it is unknown whether combining SCBT and antidepressants can improve treatment. This trial evaluated the efficacy of SCBT and sertraline, alone or in combination, in PD.

METHOD

Patients (n=251) were randomized to 12 weeks of either placebo drug, placebo drug plus SCBT, sertraline, or sertraline plus SCBT. Those who improved after 12 weeks of acute treatment received treatment for an additional 12 weeks. Outcome measures included core PD symptoms (panic attacks, anticipatory anxiety, agoraphobic avoidance), dysfunctional cognitions (fear of bodily sensations, agoraphobic cognitions), disability, and clinical global impression of severity and improvement. Efficacy data were analyzed using general and generalized linear mixed models.

RESULTS

Primary analyses of trends over time revealed that sertraline/SCBT produced a significantly greater rate of decline in fear of bodily sensations compared to sertraline, placebo/SCBT and placebo. Trends in other outcomes were not significantly different over time. Secondary analyses of mean scores at week 12 revealed that sertraline/SCBT fared better on several outcomes than placebo, with improvement being maintained at the end of continuation treatment. Outcome did not differ between placebo and either sertraline monotherapy or placebo/SCBT. Moreover, few differences emerged between the active interventions.

CONCLUSIONS

This trial suggests that sertraline combined with SCBT may be an effective treatment for PD. The study could not confirm the efficacy of sertraline monotherapy or SCBT without concomitant medication or therapist assistance in the treatment of PD.

Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Anorexia nervosa is associated with high mortality, morbidity, and treatment costs. Olanzapine, an atypical antipsychotic, is known to result in weight gain in other patient populations. The objective of this trial was to assess the efficacy of olanzapine in promoting weight gain and in reducing obsessive symptoms among adult women with anorexia nervosa.

METHOD

The study was a double-blind, placebo-controlled, 10-week flexible dose trial in which patients with anorexia nervosa (N=34) were randomly assigned to either olanzapine plus day hospital treatment or placebo plus day hospital treatment.

RESULTS

Compared with placebo, olanzapine resulted in a greater rate of increase in weight, earlier achievement of target body mass index, and a greater rate of decrease in obsessive symptoms. No differences in adverse effects were observed between the two treatment conditions.

CONCLUSIONS

These preliminary results suggest that olanzapine may be safely used in achieving more rapid weight gain and improvement in obsessive symptoms among women with anorexia nervosa. Replication, in the form of a large multicenter trial, is recommended.

Fetal gender and postpartum depression in a cohort of Chinese women

To examine the relationship between fetal gender and postpartum depression, we conducted a cohort study in Changsha, Hunan, China between September 2004 and January 2005. Women aged 18-40 years with their first live birth of a singleton infant who came to hospital for postpartum examination at 6 weeks after childbirth were invited to participate. Women with known psychiatric disorders or a history of psychiatric disorders were excluded. Data on demographic and clinical information were collected. Postpartum depression was assessed by the Chinese version of the Edinburgh Postnatal Depression Scale. Fifty-two women (17.3%) were found to have postpartum depression. The rate of postpartum depression in women who gave birth to a female infant was 24.6% while the rate in those women who gave birth to a male infant was 12.2%. The relative risk for postpartum depression of women who gave birth to a female infant as compared with those who gave birth to a male was 2.89, after adjusting for potential confounding by maternal age, education level, family income, living condition, gravidity, number of prenatal care visits, and mode of delivery. We conclude that the risk of postpartum depression is increased in Chinese women who give birth to a female infant as compared to those who gave birth to a male infant. We speculate that this is associated with the negative reactions of family members towards the birth of a female baby.

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

Mindfulness-based stress reduction (MBSR) has been reported to reduce anxiety in a broad range of clinical populations. However, its efficacy in alleviating core symptoms of specific anxiety disorders is not well established. We conducted a randomized trial to evaluate how well MBSR compared to a first-line psychological intervention for social anxiety disorder (SAD). Fifty-three patients with DSM-IV generalized SAD were randomized to an 8-week course of MBSR or 12 weekly sessions of cognitive-behavioral group therapy (CBGT). Although patients in both treatment groups improved, patients receiving CBGT had significantly lower scores on clinician- and patient-rated measures of social anxiety. Response and remission rates were also significantly greater with CBGT. Both interventions were comparable in improving mood, functionality and quality of life. The results confirm that CBGT is the treatment of choice of generalized SAD and suggest that MBSR may have some benefit in the treatment of generalized SAD.

Association of the Val158Met catechol O-methyltransferase genetic polymorphism with panic disorder

Genetic as well as clinical data suggest that catechol O-methyltransferase (COMT) is involved in multiple complex psychiatric conditions. Recent studies have described an association between the Val158Met COMT polymorphism and panic disorder. Other recent investigations provide evidence that there are other loci within or nearby the COMT gene that may contribute to the susceptibility to panic disorder. To further evaluate the influence of the Val158Met COMT polymorphism in panic disorder we genotyped this marker in the coding region of the COMT gene and two additional variants (rs737865 and rs165599) in the 5' and the 3' region, respectively, in two independent Canadian samples: 121 nuclear families, and 89 cases with matched controls. In the nuclear families, significant transmission disequilibrium for the valine allele was observed between the alleles of the Val158Met COMT polymorphism and panic disorder (p<0.01). A significant excess of the valine allele was found in analysis of the case-control sample (p<0.01). This effect was mainly derived from the subgroup of females. This finding, including the female effect, replicates earlier results in studies of the Val158Met polymorphism in panic disorder. No significant results were found for the other two markers. These results support the hypothesis that the valine allele of the Val158Met COMT polymorphism or a nearby locus is involved in the etiopathogenesis of panic disorder.

Lack of association between the corticotrophin-releasing hormone receptor 2 gene and panic disorder

Panic disorder is classified as an anxiety disorder and affects 1-3% of the population. An individual suffering from such a disorder may experience unexpected recurrent panic attacks and fear of future attacks. Twin and family studies have pointed towards a strong heritability of the disorder. Stress response and anxiety are thought to be mediated, at least in part, by the corticotrophin-releasing hormone (CRH), which is known to be a regulator of the hypothalamic-pituitary-adrenal pathway. To search for markers conferring genetic susceptibility to panic disorder, we typed three polymorphisms of the CRHR2 gene - CRHR2(CA), CRHR2(GT), and CRHR2(GAT) - in 466 individuals, 183 of whom had DSM-IV panic disorder. Seventy-five case-controls and 101 triad families plus 13 siblings were examined. Case-control association analyses using chi(2) tests yielded no difference in the distribution of the alleles. Linkage analysis using the Transmission Disequilibrium Test showed no preferential transmission of alleles for any of the three markers. Haplotype analysis indicated that allele 7 of CRHR2 (GAT) and 8 of CRHR2 (GT) are in almost complete linkage disequilibrium (P = 0.000 000 1). Although both neurobiology and chromosomal location point to the CHRH2 receptor gene as a candidate for panic disorder, our study indicates that the CRHR2 polymorphisms examined do not confer susceptibility to panic disorder. Further studies investigating additional polymorphisms in this gene and other components of the CRH signalling system may prove useful.

Venlafaxine extended-release capsules in panic disorder: flexible-dose, double-blind, placebo-controlled study

BACKGROUND

Venlafaxine extended-release (ER) has proven efficacy in the treatment of anxiety symptoms in major depression, generalised anxiety disorder and social anxiety disorder.

AIMS

To evaluate the efficacy, safety and tolerability of venlafaxine ER in treating panic disorder.

METHOD

Adult out-patients (n=361) with panic disorder were randomly assigned to receive venlafaxine ER (75-225 mg/day) or placebo for up to 10 weeks in a double-blind study.

RESULTS

Venlafaxine ER was not associated with a greater proportion of patients free from full-symptom panic attacks at the final on-therapy evaluation, but was associated with lower mean panic attack frequency and a higher proportion free from limited-symptom panic attacks, higher response and remission rates, and improvements in anticipatory anxiety, fear and avoidance. Adverse events were comparable with those of the drug in depression and anxiety disorders.

CONCLUSIONS

Venlafaxine ER seems to be effective and well tolerated in the short-term treatment of panic disorder.

Central cholecystokinin activity in irritable bowel syndrome, panic disorder, and healthy controls

OBJECTIVE

Irritable bowel syndrome (IBS) and panic disorder (PD) coexist with a high frequency. However, the nature of this relationship remains obscure. We have proposed that PD and IBS may share a common dysfunction of the central cholecystokinin (CCK) system. To test this hypothesis, we assessed whether the enhanced panicogenic response to CCK-tetrapeptide (CCK-4) observed in PD is also present in IBS.

METHODS

Eight psychiatrically healthy IBS patients, 8 PD patients with no history of IBS, and 12 normal controls received a bolus injection of CCK-4 and placebo on two separate days in a double-blind, randomized fashion.

RESULTS

Consistent with previous findings, panicogenic sensitivity to CCK-4 was enhanced in PD patients relative to controls. In contrast, IBS patients exhibited a response that was comparable to controls. Interestingly, CCK-4-induced nausea and abdominal distress were decreased in IBS patients relative to the other groups. No diagnostic difference was noted for cardiovascular response to CCK-4.

CONCLUSION

These data indicate that IBS patients with no lifetime psychiatric history do not share the CCK-2 receptor dysfunction implicated in the pathophysiology of PD and that this dysfunction may not be a common mechanism for both CNS and enteric nervous system disorders. Nevertheless, the results suggest that a dysfunction of the CCK system may be involved in the pathophysiology of some enteric symptoms associated with IBS.

Assessing patient beliefs in a clinical trial of Hypericum perforatum in major depression

Little is known about the beliefs of patients suffering from major depression as to the causes of their illness and effective treatments. This study introduces a new instrument for capturing these beliefs, the Explanatory Model for Depression (EMD) Questionnaire, and explores the beliefs of patients participating in a clinical trial of an alternative medicine, Hypericum perforatum. Although the EMD was originally conceptualized as having five factors pertaining to models of the illness and treatment approaches, the data suggest that patient beliefs are aligned on two factors pertaining to internal and external locus of control. Strong beliefs on either of the EMD locus of control subscales are associated with more severe depression. More importantly, strong beliefs on the external locus of control subscale are associated with less improvement over the 8-week period of observation. These results support the role of patients' beliefs in their recovery from depression and suggest that patients who believe the causes of their depression are outside of their control are less likely to improve over time. It is important to note that beliefs did not mediate the effect of treatment on depression in this study, perhaps because patients were blinded to their treatment condition. Future studies should explore whether patient beliefs have an even greater impact when patients are aware of the treatment they are receiving and can determine whether that treatment is consistent with their beliefs.

Effects of CCK-tetrapeptide in patients with social phobia and obsessive-compulsive disorder

Panicogenic sensitivity to CCK-tetrapeptide (CCK-4) is enhanced in panic disorder patients relative to normal controls (NC). We sought to determine whether CCK-4 sensitivity is augmented in patients with social phobia (SP) (n = 12) and obsessive-compulsive disorder (OCD) (n = 8) versus NC (n = 12). We also determined whether CCK-4 could elicit syndrome-specific symptoms in SP and OCD patients. The study employed a single-blind, placebo-controlled, within-subject design. Behavioral, cardiovascular and hormonal responses to a submaximal dose (20 microg) of CCK-4 were evaluated. Panic frequency after the placebo and CCK-4 challenge varied as a function of diagnosis. Differences in panic frequency between groups and between challenge agents within each group did not, however, reach statistical significance. Further, the number and intensity of panic symptoms, intensity of subjective anxiety, autonomic reactivity and hormonal release after CCK-4 administration did not distinguish the groups. Core symptoms of SP and OCD were unaffected by CCK-4. These data failed to detect significant differences between groups on behavioral, cardiovascular and hormonal response to CCK-4. The lack of effect of CCK-4 on SP and OCD symptoms suggests that this peptide does not play a salient role in the pathophysiology of these disorders.

A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder

BACKGROUND

Generalized social anxiety disorder is a debilitating psychiatric illness characterized by maladaptive thoughts about social situations. This double-blind study evaluated the anxiolytic efficacy, safety, and tolerability of venlafaxine extended release (ER) in adult out-patients with generalized social anxiety disorder.

METHOD

Patients were randomly assigned to receive 12 weeks of treatment with a flexible dose of venlafaxine ER (75 to 225 mg/day) or placebo. The Liebowitz Social Anxiety Scale (LSAS) total score was the primary efficacy variable. Secondary efficacy variables included scores on the Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales, Social Phobia Inventory (SPIN), and LSAS subscales. Response was defined as a CGI-I score of 1 or 2. Two definitions of remission were used: LSAS total score < or = 30 and CGI-I score of 1.

RESULTS

Data from 271 patients (intent-to-treat population) were analyzed for efficacy; 279 patients were analyzed for safety. Overall, 173 patients completed the study. Improvement on the LSAS was significantly greater with venlafaxine ER treatment than with placebo at weeks 6 through 12 (p < .05, weeks 6 and 8; p < .01, week 10; and p < .001, week 12) and at weeks 8 through 12 based on CGI-S and SPIN scores. Week 12 response and remission (LSAS score < or = 30) rates were significantly greater in the venlafaxine ER group than in the placebo group (response: 44% vs. 30%, respectively, p = .018; remission: 20% vs. 7%, respectively, p < .01). Patients experienced no unexpected or serious adverse events.

CONCLUSION

Venlafaxine ER is safe, well tolerated, and efficacious in the short-term treatment of generalized social anxiety disorder.

Association study of serotonin-2A receptor gene polymorphism and panic disorder in patients from Canada and Germany

The T102C serotonin-2A (5-HT2A) receptor gene polymorphism has been studied extensively in a number of complex psychiatric conditions with mixed results. Recently a genetic association has been described between this polymorphism and panic disorder in a Japanese sample. To evaluate the impact of the T102C polymorphism in panic disorder we genotyped triad families (panic disorder patient and parents), and cases with controls in Canadian and German samples. No significant transmission disequilibrium was observed between the alleles of the T102C 5-HT2A receptor gene polymorphism and panic disorder, nor was a significant excess of either allele found in the case control analysis. Our data suggest thus that this polymorphism is unlikely to play a major role in the pathogenesis of panic disorder.

Sensitivity to cholecystokinin-tetrapeptide in major depression

BACKGROUND

Sensitivity to the panicogenic effects of cholecystokinin-tetrapeptide (CCK-4) is enhanced in panic disorder patients relative to normal controls (NC). In the present study, we determined whether sensitivity to CCK-4 is enhanced in patients with major depressive disorder (MDD) with no history of panic attacks. We also determined whether CCK-4 would exacerbate depressive symptoms.

METHODS

The study used a double-blind, randomized, placebo-controlled design. Behavioral and cardiovascular response to a submaximal dose (20 microg) of CCK-4 was studied in seven patients with MDD and 12 NC subjects.

RESULTS

None of the subjects panicked with placebo, whereas 29% of MDD and 17% of NC subjects panicked with CCK-4. There was no significant difference between groups on the frequency of CCK-4-induced panic or the number and intensity of panic symptoms. No significant difference was detected for cardiovascular response to the CCK-4 challenge. CCK-4 did not worsen depressive symptoms in MDD patients.

LIMITATIONS

Small number of study subjects.

CONCLUSIONS

These data indicate that MDD patients show a response to CCK-4 that is comparable to NC. The lack of effect of CCK-4 on depressive symptoms suggest that central CCK receptors may not play an important role in the pathophysiology of MDD.

Acute Effects of Cholecystokinin Tetrapeptide on Brain Stem Auditory Evoked Potentials in Healthy Volunteers

This study investigated the effects of continuous slow intravenous infusion of cholecystokinin tetrapeptide (CCK-4) on brain stem auditory evoked potentials (BSAEP) in healthy subjects. Twenty-four subjects, 15 females and 9 males, were assigned to infusion with either placebo or CCK-4 in a randomized, double-blind, parallel group design. BSAEPs, mood, physical symptoms, and vital signs were assessed once before infusion and at 10 min and 40 min after the onset of infusion. In the 16 subjects (N = 8, CCK-4; N = 8, placebo) CCK-4, compared to placebo, delayed peak I latency during early infusion, slowed the latencies of peaks III and V, and decreased the amplitude of peak III throughout the infusion. No significant treatment differences were observed with respect to symptoms, mood, or cardiovascular measures. These preliminary findings suggest that CCK-4 may interfere with information processing in the brain stem auditory pathways and that prolonged intravenous CCK-4 administration may be a useful challenge paradigm for investigating CCK's modulatory role on brain stem mechanisms mediating anxiety and panic in humans.

Effects of acute cholecystokinin infusion on hemispheric EEG asymmetry and coherence in healthy volunteers

This study investigated the effects of continuous slow infusion of cholecystokinin tetrapeptide (CCK-4), a neuropeptide with panicogenic properties, on functional hemispheric differences, as indexed by quantitative electroencephalographic (EEG) asymmetry and coherence measures. Twenty-four adult volunteers (15 females and 9 males) were assigned to infusion with either placebo or CCK-4 in a randomized, double-blind, parallel-group design, with EEG being recorded before and during (10 and 40 min) a 60-min infusion period. No significant treatment differences were observed for absolute EEG power but, compared to placebo, CCK-4 infusion increased asymmetry and reduced coherence of slow-wave activity at midtemporal recording sites. These findings support the contention that functional imbalance of the temporal cortex, perhaps mediated by CCK-4, is involved in panic disorder (PD).

Aging and panicogenic response to cholecystokinin tetrapeptide: an examination of the cholecystokinin system

Older age is associated with diminished symptomatic and cardiovascular response to the panicogenic agent cholecystokinin tetrapeptide (CCK-4). We hypothesized that circulating concentrations of endogenous CCK-4 and/or CCK-8 are increased in later life, possibly due to decreased enzymatic degradation, and that this is associated with desensitization of CCK-B receptors. The study group consisted of 20 healthy subjects aged 18-30 years and 20 healthy subjects aged 65-85 years. The two groups were compared on fasting basal plasma concentrations of CCK-4, sulfated CCK-8 (CCK-8s) and nonsulfated CCK-8 (CCK-8 ns), and on binding capacity of lymphocyte CCK-B receptors. Under single-blind (to subject) conditions, subjects were then administered an intravenous bolus of placebo, followed 50 min later by an intravenous bolus of 50 micro g of CCK-4. Plasma concentrations of total CCK (CCK(T)) were measured 2 min before and 2, 5, 10, and 15 min after each injection. Compared with younger subjects, older subjects had a significantly higher basal plasma concentration of CCK-8s and significantly diminished binding capacity of CCK-B receptors. Following injection of placebo, plasma CCK(T) concentrations did not significantly change from baseline in either age group, but the elderly had significantly higher concentrations than the young at 2, 5, and 10 min. Following injection of CCK-4, the plasma concentration of CCK(T) was highest at 2 min and declined after that. The elderly had significantly higher CCK(T) concentrations (ie. a slower decline in CCK(T)) than the young at 5, 10, and 15 min. These findings are consistent with our hypothesis and suggest that age-related changes in the CCK system could contribute to the diminished panicogenic response to exogenous CCK-4 in older persons.

Mental health reform and evolution of general psychiatry in Ontario

OBJECTIVES

To discuss developments in Ontario mental health reform, describe general psychiatric services in contrast to tertiary services, describe guidelines for the training of general psychiatrists, and suggest what changes may be required to develop an integrated mental health system (IMHS).

METHOD

We review the Ontario government's recent blueprint for mental health reform and the Canadian federal government's document on best practices in psychiatry, in the context of defining general psychiatric services and their relation to tertiary services. From this, we consider the education of general psychiatrists and make suggestions for their training.

RESULTS

General psychiatric services correspond to first-line and intensive psychiatric services delivered by community mental health agencies, community psychiatrists, and general hospitals for patients with moderate or serious mental illness. Many suggest that psychiatrists are not being trained to meet the needs of a reformed mental health system. An education program for general psychiatrists should include training in a wide range of community and general hospital settings, work within a multidisciplinary mental health team, and experience working in a shared care model with family physicians.

CONCLUSIONS

Along with training general psychiatrists better, we must also develop recruitment and payment incentives, which would allow general psychiatrists who are based in the community and general hospitals to work within an IMHS.

Acute cholecystokinin effects on event-related potentials in healthy volunteers

This study investigated the effects of a continuous slow infusion of cholecystokinin tetrapeptide (CCK-4), a neuropeptide with panicogenic properties, on brain event-related potentials (ERPs) in healthy adults. Twenty-four volunteers, 15 females and 9 males, were assigned to infusion with either placebo or CCK-4 in a randomized, double-blind, parallel group design. ERPs, elicited within a standard auditory odd-ball paradigm requiring the counting of rare (20%) occurring 'deviant' tones interspersed among more frequent (80%) occurring 'standard' tones, were assessed once before infusion, and at 10 min and 40 min after the onset of infusion. Compared with the placebo, CCK-4 delayed the latencies of N100 and P200 components elicited by 'deviant' stimuli. No significant treatment differences were observed with respect to N200, P300b, mood or adverse symptoms. These preliminary findings suggest that CCK-4 may interfere with information processing relating to the selection of significant stimuli and as such, may be of relevance to mechanisms underlying panic disorder.

The ventilatory response to cholecystokinin tetrapeptide in healthy volunteers

The cholecystokinin (CCK) system, which has been shown to interact with both the panicogenic and respiratory systems, provides an interesting mechanism to further evaluate the central chemoreceptor and its effect on panic attack sensitivity. Intravenous CCK, a naturally occurring neuropeptide in the brain, has been found to induce the emotional and somatic symptoms of panic in both Panic Disorder (PD) and Normal Control (NC) subjects in a dose-dependent and reproducible fashion. To induce these effects, lower doses of intravenous CCK are required in the PD patients, relative to the NC subjects potentially suggesting that endogenous alterations in the CCK system may be contributing to the development of PD. Intravenous administration of CCK-4 in association with panic also results in subjective dyspnea, that is, diminution in vital capacity without an effect on the respiratory resistance. CCK-4 also causes a significant increase in tidal volume and minute ventilation but has no effect on breathing frequency. These observations suggest that a CCK-B receptor agonist may be acting as a respiratory stimulant, exerting its effect on anxiety through a direct effect on respiration. This study represents an examination of the specific effects of CCK-4 on the central chemoreceptor response. The study used a modified rebreathing technique, which accurately measures the ventilatory response to carbon dioxide in terms of both threshold and sensitivity. This technique requires the subject to rebreathe from a bag containing a hyperoxic and hypercapnic gas mixture resulting in rapid equilibration between alveolar gas and arterial blood. Use of a hyperoxic gas allows for the preferential examination of the central chemoreflexes (sensitive to CO(2)) with little if any effect of the peripheral (oxygen sensitive) chemoreflexes. After significant training, 15 healthy control subjects were assigned via a double blind procedure to receive an intravenous injection of placebo or CCK-4, using a between-subjects design. A between-subjects comparison was undertaken for the injection run (run #3) between subjects receiving the CCK-4 injection and those receiving the placebo injection. As well, a within-subject comparison was undertaken to compare the results of the run following the injection (run #3) vs. the previous run when no injection took place (run #2). No significant differences were noted between subjects who received CCK-4 as compared with placebo for: basal or sub-threshold ventilation, threshold CO(2) resulting in a change in ventilation, or sensitivity of the central chemoreflex, regardless of whether a panic attack did or did not take place. In addition, within the group receiving the CCK-4 challenge, no significant differences were noted during run #3 (received the CCK-4 injection) and a prior run where no injection took place (run #2). We conclude that CCK-4 does not act to induce panic by altering the central (CO(2) sensitive) chemoreceptor.

Cholecystokinin and panic disorder: past and future clinical research strategies

The involvement of cholecystokinin (CCK) in human anxiety is well documented. Exogenous administration of CCK-2 receptor agonists, such as cholecystokinin-tetrapeptide and pentagastrin, provoke panic attacks in man. Patients with panic disorder (PD) are hypersensitive to CCK-2 receptor stimulation compared to healthy volunteers and patients with other anxiety disorders, and they differ from healthy subjects in CCK metabolism and genetic characteristics of the CCK-2 receptor system. This article reviews the corpus of work supporting the role of CCK in anxiety and suggests three research approaches which can further enhance our understanding of the CCK-2 system in PD. These approaches include: i) searching for a specific anomaly of the CCK-2 receptor system, ii) establishing a relationship between CCK-2 receptor polymorphism and vulnerability to pharmacologically-induced or spontaneous panic attacks, and iii) evaluating the therapeutic efficacy of CCK-2 receptor antagonists which possess adequate pharmacokinetic properties.

The influence of Type A behavior pattern on the response to the panicogenic agent CCK-4

OBJECTIVES

Review of the literature equivocally suggests that subjects with Type A behavioral pattern (TABP) compared to subjects with Type B behavioral pattern display an increased sympathetic activity, a condition associated with sudden cardiac death. The objective of this study was to determine whether healthy subjects classified as Type A or Type B differed in their reactivity to the beta 1 and beta 2 receptor agonist isoproterenol and to the panicogenic agent cholecystokinin-tetrapeptide (CCK-4). By comparing reactivity to CCK-4 after pretreatment with placebo or propranolol, a beta 1 and beta 2 receptor antagonist, the role of the beta adrenergic system in the hypothesized increased response of Type A subjects to CCK-4 was also assessed.

METHODS

The study used a randomized, double-blind, placebo-controlled design. Twenty-seven Type A or B subjects were included in the study. The reactivity to isoproterenol was assessed with the CD25 of isoproterenol (i.e., the intravenous dose of isoproterenol necessary to increase the heart rate of 25 bpm). The panic symptom response and the cardiovascular response to bolus injection of 50 microg of CCK-4 was assessed in subjects pretreated with either propranolol or placebo infusions prior to the CCK-4 challenge. An additional group of subjects was recruited and these subjects received a placebo infusion pretreatment before an injection of placebo.

RESULTS

The CD25 was significantly greater in Type A subjects than in Type B subjects. No difference was found among the groups on behavioral sensitivity to the CCK-4 challenge. However, CCK-4-induced maximum increase in heart rate was greater in Type A subjects.

CONCLUSION

Our finding that Type A subjects exhibited greater CD25 of isoproterenol and greater increases in heart rate following CCK-4 administration compared to Type B subjects suggests that peripheral beta-receptor sensitivity may be increased in individuals with TABP.

Arginine-vasopressin and oxytocin response to cholecystokinin-tetrapeptide

This study examined the effects of i.v. administration of cholecystokinin-tetrapeptide (CCK-4) on plasma release of arginine vasopressin (AVP) and oxytocin (OT) in women with premenstrual dysphoric disorder (PMDD) and control women, during both the follicular phase and the luteal phase of their menstrual cycle. Plasma AVP and OT concentrations increased following CCK-4 administration. AVP and OT response to CCK-4 was similar for PMDD and control women and unaffected by menstrual cycle phase. AVP and OT may play a role in the hypothalamo-pituitary adrenal (HPA) axis activity associated with the panic response induced by CCK-4.

Anxiety sensitivity does not predict fearful responding to 35% carbon dioxide in patients with panic disorder

The aim of the present study was to examine the relationship between anxiety sensitivity, as measured by the Anxiety Sensitivity Index (ASI), and four dimensions of behavioural reactivity to a single inhalation of 35% carbon dioxide (CO(2)) in 31 patients with panic disorder. ASI scores correlated positively with baseline State-Trait Anxiety Inventory scores but did not correlate with post-CO(2) scores. Correlational analyses revealed a significant, albeit modest, correlation between anxiety sensitivity and cognitive symptoms induced with CO(2). However, no significant association was found between anxiety sensitivity and other dimensions of CO(2)-induced anxiety, including severity of somatic symptoms, subjective levels of anxiety, fear or apprehension, and fear of the somatic symptoms induced by CO(2). Overall, these data do not support the view that anxiety sensitivity plays a key role in mediating behavioural sensitivity to CO(2) inhalation in panic disorder.

A double-blind, placebo-controlled study on the effects of Gotu Kola (Centella asiatica) on acoustic startle response in healthy subjects

Investigations of the pharmacologic profile of medicinal plants have revealed that a number of plants with purported anxiolytic activity bind to cholecystokinin (CCK) receptors. This finding is intriguing in view of the proposed involvement of CCK in the pathophysiology of fear and anxiety. This double-blind, placebo-controlled study was undertaken to evaluate the anxiolytic activity of Gotu Kola (Centella asiatica) in healthy subjects. Gotu Kola has been used for centuries in Ayurvedic and traditional Chinese medicine to alleviate symptoms of depression and anxiety. Recent studies in the rat have shown that long-term pretreatment with Gotu Kola decreases locomotor activity, enhances elevated-plus maze performance, and attenuates the acoustic startle response (ASR). In this study, the authors evaluated the effects of Gotu Kola on the ASR in humans. Subjects were randomly assigned to receive either a single 12-g orally administered dose of Gotu Kola (N = 20) or placebo (N = 20). The results revealed that compared with placebo, Gotu Kola significantly attenuated the peak ASR amplitude 30 and 60 minutes after treatment. Gotu Kola had no significant effect on self-rated mood, heart rate, or blood pressure. These preliminary findings suggest that Gotu Kola has anxiolytic activity in humans as revealed by the ASR. It remains to be seen whether this herb has therapeutic efficacy in the treatment of anxiety syndromes.

Behavioral, cardiovascular, and neuroendocrine profiles following CCK-4 challenge in healthy volunteers: a comparison of panickers and nonpanickers

Healthy subjects who panic following systemic cholecystokinin-tetrapeptide (CCK-4) challenge typically exhibit a symptom profile reminiscent of that evident among panic patients. However, the biological concomitants of CCK-4-induced panic in healthy subjects remain obscure. Accordingly, we evaluated the behavioral, cardiovascular, and neuroendocrine effects of CCK-4 in panickers and nonpanickers. Predictably, subjects who panicked with CCK-4 experienced more intense symptoms of panic and greater increases in ratings of fearful and anxious mood than did subjects who did not panic. CCK-4-induced increases in diastolic blood pressure, adrenocorticotropic hormone, prolactin, and growth hormone secretion were also significantly enhanced in subjects who panicked. The results of this study demonstrate that the behavioral experience of CCK-4-induced panic in healthy individuals is accompanied by marked biological changes and provide confirmation that CCK-4 is a useful model of panic for research among nonclinical subjects.

Neurohormonal responses to cholecystokinin tetrapeptide: a comparison of younger and older healthy subjects

We recently found that, compared with younger healthy subjects, older healthy subjects had less symptomatic and cardiovascular response to the panicogenic agent cholecystokinin tetrapeptide (CCK-4). As an exploratory part of that study, we also evaluated the effect of aging on neurohormonal responses to CCK-4. These hormonal data are the focus of this article. Forty healthy volunteers aged 20-35 years and 40 healthy volunteers aged 65-81 years, divided equally between men and women, were compared on their hormonal responses (maximum change from baseline in growth hormone [GH], prolactin, adrenocorticotropic hormone [ACTH], and cortisol) to the intravenous administration of 50 microg of CCK-4 or placebo. Blood samples for serum hormone determination were collected at 2 minutes prior to the intravenous challenge (baseline) and at 2, 5, and 10 minutes after the challenge. In both age groups, maximum increase in prolactin, ACTH and cortisol was significantly greater with CCK-4 than with placebo. Following administration of CCK-4, younger and older groups did not significantly differ in maximum increase in prolactin, ACTH, or cortisol. Older subjects had a statistically significant smaller increase in GH compared with younger subjects but the magnitude of the difference was small and of doubtful clinical relevance. Older subjects who had a panic attack had significantly greater elevations of all hormones compared with those who did not panic and younger panickers had a significantly greater elevation of GH compared with young nonpanickers. For the most part, maximum changes in hormonal levels were not correlated with symptom severity, suggesting that other factors may have contributed to the differential effect of panic on the HPA axis.

Effects of CCK-4 infusion on the acoustic eye-blink startle and psychophysiological measures in healthy volunteers

The acoustic startle response (ASR) and a range of psychophysiological parameters were evaluated during a continuous intravenous administration of cholecystokinin-tetrapeptide (CCK-4) in healthy volunteers. Subjects (n=28) were randomly assigned to double-blind infusion of either CCK-4 (0.5 mg/60 min) or placebo. The ASR sessions were performed prior to infusion and at 20 min and 50 min after the onset of infusion by recording eye-blink response to a series of acoustic stimuli (110 dB, 40 ms). An effect of CCK-4 on the eye-blink startle was observed in the first half of infusion. CCK-4 produced an increase of eye-blink startle amplitude from baseline values in contrast to the decrease observed at this time point with placebo. A mild increase in anxiety and heart rate followed by fatigue was reported with CCK-4. Administration of CCK-4 produced increases in plasma concentrations of adrenocorticotropic hormone, cortisol, prolactin and growth hormone. The results of this study show that a prolonged intravenous administration of CCK-4 may be a useful challenge method for further studies on the role of CCK system in the modulation of human anxiety and stress response.