Effects of different doses of intranasal dexmedetomidine on preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia undergoing adenoidectomy with or without tonsillectomy

Dexmedetomidine is a highly selective α2 receptor agonist, this study aimed to investigate the effects of different doses of intranasal dexmedetomidine on the preoperative sedation and postoperative agitation in pediatric with total intravenous anesthesia (TIVA) for adenoidectomy with or without tonsillectomy.This is a double-blind placebo-controlled randomized trial. Pediatric were randomly divided into the D1, D2, and S groups, each group contained 30 patients. Twenty-five to 40 minutes before surgery, the D1 and D2 groups received intranasally dexmedetomidine 1 μg kg or 2 μg kg, respectively, while the S group received saline of the same volume. A unified protocol of TIVA induction and maintenance was used for the three groups. The preoperative sedation, behavior of separation from parents, postoperative agitation, and postoperative pain of the children were evaluated.The proportions of satisfactory sedation in the D1, D2, and S groups were 63.3%, 76.7%, and 0%, respectively. There was a statistically significant difference between D1 and S groups (P = .000) and D2 versus S groups (P = .000), while there was no statistically significant difference between D1 and D2 groups (P = .399). As for scale on the behavior of separation from parents, there was a statistically significant difference between D1 and S groups (P = .009) and D2 versus S groups (P = .009), whereas there was no significant difference between D1 and D2 groups (P = 1). The incidence of postoperative agitation in the D1, D2, and S groups was 43.3%, 30.0%, and 63.3%, respectively, and there was a statistical difference between D2 and S groups (P = .010). There was a significant difference in the Pediatric Anesthesia Emergence Delirium (PAED) scale between D2 and S groups (P = .029). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) in the D2 group was significantly lower than the S group (P = .013).The intranasal dexmedetomidine of 1 or 2 μg kg 25 to 40 minute before induction of anesthesia both could deliver effective preoperative sedation, reducing the children's distress of separation from parents. Moreover, intranasal dexmedetomidine of 2 μg kg could deliver more effective postoperative analgesia and reduce postoperative agitation, without prolonging postoperative recovery or causing severe adverse events.

Extended Release Guanfacine in Pediatric Anxiety Disorders: A Pilot, Randomized, Placebo-Controlled Trial

OBJECTIVE

This is a feasibility study evaluating the safety, tolerability, and potential anxiolytic efficacy of the α2 agonist guanfacine extended-release (GXR) in children and adolescents with generalized anxiety disorder (GAD), separation anxiety disorder (SAD), or social phobia/social anxiety disorder.

METHODS

Youth aged 6-17 years with a primary diagnosis of GAD, SAD, and/or social anxiety disorder were treated with flexibly dosed GXR (1-6 mg daily, n = 62) or placebo (n = 21) for 12 weeks. The primary aim of this study was to determine the safety and tolerability of GXR in youth with anxiety disorders, which involved the analysis of treatment-emergent adverse events (TEAEs), the emergence of suicidal ideation and behaviors, vital signs, and electrocardiographic/laboratory parameters. Exploratory efficacy measures included dimensional anxiety scales (Pediatric Anxiety Rating Scale [PARS] and Screen for Child Anxiety Related Emotional Disorders [SCARED]), as well as the Clinical Global Impression-Improvement (CGI-I) scale. As this was an exploratory study, no inferential statistical analyses were performed.

RESULTS

GXR was safe and well tolerated. Treatment-related mean ± standard deviation changes in heart rate (GXR: 1.8 ± 12 beats per minute [bpm] decrease; placebo: 0.5 ± 11 bpm decrease), systolic blood pressure (GXR: 2.3 ± 11 mm Hg decrease; placebo: 1.7 ± 11 mm Hg decrease), or diastolic blood pressure (GXR: 1.3 ± 9 mm Hg decrease; placebo: 0.9 ± 7 mm Hg increase) were similar between treatment groups. TEAEs, including headache, somnolence/fatigue, abdominal pain, and dizziness, were consistent with the known safety profile of GXR. No differences were observed between treatment groups for PARS and SCARED scores, although at endpoint, a higher proportion of subjects receiving GXR versus placebo demonstrated CGI-I scores ≤2 (54.2% vs. 31.6%), as rated by the clinician investigator.

CONCLUSIONS

GXR was well tolerated in pediatric subjects with GAD, SAD, and/or social anxiety disorder. ClinicalTrials.gov Identifier: NCT01470469.

The therapeutic relationship in cognitive-behavioral therapy and pharmacotherapy for anxious youth

OBJECTIVE

We examined the therapeutic relationship with cognitive-behavioral therapists and with pharmacotherapists for youth from the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008). The therapeutic relationship was examined in relation to treatment outcomes.

METHOD

Participants were 488 youth (ages 7-17 years; 50% male) randomized to cognitive-behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), their combination, or placebo pill. Participants met criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). The therapeutic relationship was assessed by youth report at Weeks 6 and 12 of treatment using the Child's Perception of Therapeutic Relationship scale (Kendall et al., 1997). Outcome measures (Pediatric Anxiety Rating Scale; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002; and Clinical Global Impressions Scales; Guy, 1976) were completed by independent evaluators blind to condition.

RESULTS

For youth who received CBT only, a stronger therapeutic relationship predicted positive treatment outcome. In contrast, the therapeutic relationship did not predict outcome for youth receiving sertraline, combined treatment, or placebo.

CONCLUSION

A therapeutic relationship may be important for anxious youth who receive CBT alone.

Efficacy of dog-appeasing pheromone (DAP) for ameliorating separation-related behavioral signs in hospitalized dogs

Dogs hospitalized in veterinary clinics are likely to show signs of separation-induced anxiety from hospitalization. The study assessed the effect of dog-appeasing pheromone (DAP) on 10 typical separation-related behavioral signs in hospitalized dogs. A DAP treated group (n = 24) was compared with a placebo control group (n = 19). There was overall amelioration of the signs without 'vigilance' and 'anorexia' in the DAP-treated dogs; marked decreases were noted in elimination (P = 0.038), excessive licking (P = 0.005), and pacing (P = 0.017). The results suggest that the use of DAP could decrease separation-induced anxiety, distress, and fear in inpatients, and possibly facilitate recovery in hospitalized dogs.

[Psychodynamic psychopharmacology in clinical practice--interpretations of adverse events of pharmacotherapy. Case report]

INTRODUCTION

Psychodynamic psychopharmacology offers possibility of implementation of psychodynamic thinking and interpretations in the process of pharmacotherapy of mental disorders. It can be helpful in improving results of treatment and solving difficulties in it's course.

METHOD

The case report of a female patient after psychotic episode is presented. During the treatment with quetiapine the patient presented complains about adverse effects like weight gain and somnolence. These symptoms (at least partially) resulted from her emotional problems and changed after psychodynamic interpretation. After stopping the medication the patient's reactions to stress and process of separation from her mother changed dramatically. It was probably due to the discontinuation of medication.

RESULTS

In some cases adverse events of medication have not only biological but also emotional roots. If properly recognized they can be interpreted and changed by psychological tools.

CONCLUSIONS

Psychodynamic psychopharmacology can be useful in deeper understanding and solving problems in the process of pharmacotherapy of mental disorders.

[Pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children and adolescents: an overview]

BACKGROUND

Anxiety disorders are among the most prevalent psychiatric disorders during childhood. They are often persistent and are associated with a number of negative outcomes. Therefore, effective treatment is required.

AIM

To present an overview of placebo-controlled studies of pharmacotherapy for social phobia, generalised anxiety disorder and separation anxiety disorder in children an adolescents and to determine which medication is the most effective.

METHOD

The literature was reviewed using Pubmed.

RESULTS

Nine randomised double-blind studies on the efficacy of pharmacotherapy for generalised anxiety disorder, separation anxiety disorder and social phobia were found. Tricyclic antidepressants were not more effective than placebo. Studies on benzodiazepines showed that the effect of these drugs was not superior to that of placebo either. Studies of the efficacy of ssris, however, proved that they were superior to placebo.

CONCLUSION

SSRIS are the drugs of first choice for the treatment of social phobias, separation anxiety disorder and generalised anxiety disorder in children and adolescents. There is strong evidence that ssris are effective for the treatment of these anxiety disorders; the standardised effect size varies between medium and large.

Penile self-mutilation as an unusual sign of a separation-related problem in a crossbreed dog

A two-year-old, male, crossbreed dog was presented for evaluation of licking, biting and severe self-mutilation of its penis, which resulted in ulcers and haemorrhagic preputial discharge. History revealed signs of separation anxiety such as active greeting behaviour, excessive vocalisation and intermittent episodes of licking of the penis when the dog was left alone. The owner reported that he had been hospitalised after a car accident, and he had no chance of seeing the dog. During that time, the behaviour progressed to frequent episodes of licking and biting of the penis. Three weeks of treatment with clomipramine in addition to the presence of the dog's brother, who was brought into the dog's living environment, appeared to produce a considerable degree of improvement. The purpose of this report is to contribute to an increased awareness within veterinary practice of unusual signs of separation anxiety such as penile self-mutilation.

Sleep-related problems among children and adolescents with anxiety disorders

OBJECTIVE

The present study examined sleep-related problems (SRPs) among a large sample (n = 128) of youth with anxiety disorders (i.e., generalized, separation, and social). The frequency of eight specific SRPs was examined in relation to age, gender, type of anxiety disorder, anxiety severity, and functional impairment. The impact of pharmacological treatment (fluvoxamine versus pill placebo) in reducing SRPs also was examined.

METHOD

As part of a large, double-blind, randomized, controlled trial (Research Units on Pediatric Psychopharmacology Anxiety Study Group), clinician and parent reports of SRPs were examined among children and adolescents, ages 6 to 17 years, before and after treatment.

RESULTS

Eighty-eight percent of youth experienced at least one SRP, and a majority (55%) experienced three or more. Total SRPs were positively associated with anxiety severity and interference in family functioning. Significantly greater reductions in SRPs were found among children treated with fluvoxamine compared with placebo.

CONCLUSIONS

These findings indicate that SRPs are commonly associated with childhood anxiety disorders and suggest a need for the assessment of and attention to these problems in research and clinical settings.

Effects of reconcile (fluoxetine) chewable tablets plus behavior management for canine separation anxiety

Canine separation anxiety is a common behavioral problem presented to veterinarians. Associated behaviors are distressing to both dog and owner, have the potential to disrupt the human-companion animal bond, and may lead to euthanasia. The results of this study demonstrate the clinical efficacy and safety of Reconcile (fluoxetine, 1 to 2 mg/kg/day [0.45 to 0.91 mg/lb/day]), in conjunction with behavior management, for the treatment of canine separation anxiety. The beef flavored chewable formulation was palatable to treated dogs and easy to administer. This study provides to veterinarians and owners valuable information about an effective separation anxiety treatment plan that combines use of Reconcile with behavior modification.

Anxiolytic-like properties of the anandamide transport inhibitor AM404

The endocannabinoids anandamide and 2-arachidonoyglycerol (2-AG) may contribute to the regulation of mood and emotion. In this study, we investigated the impact of the endocannabinoid transport inhibitor AM404 on three rat models of anxiety: elevated plus maze, defensive withdrawal and separation-induced ultrasonic vocalizations. AM404 (1-5 mg kg(-1), intraperitoneal (i.p.)) exerted dose-dependent anxiolytic-like effects in the three models. These behavioral effects were associated with increased levels of anandamide, but not 2-AG, in the prefrontal cortex and were prevented by the CB(1) cannabinoid antagonist rimonabant (SR141716A), suggesting that they were dependent on anandamide-mediated activation of CB(1) cannabinoid receptors. We also evaluated whether AM404 might influence motivation (in the conditioned place preference (CPP) test), sensory reactivity (acoustic startle reflex) and sensorimotor gating (prepulse inhibition (PPI) of the startle reflex). In the CPP test, AM404 (1.25-10 mg kg(-1), i.p.) elicited rewarding effects in rats housed under enriched conditions, but not in rats kept in standard cages. Moreover, AM404 did not alter reactivity to sensory stimuli or cause overt perceptual distortion, as suggested by its lack of effect on startle or PPI of startle. These results support a role of anandamide in the regulation of emotion and point to the anandamide transport system as a potential target for anxiolytic drugs.

Modeling anxiety-like states: pharmacological characterization of the chick separation stress paradigm

While previous research has sought to validate the chick separation stress paradigm as an anxiolytic screening assay, it is unknown whether the paradigm better models a nonspecific anxiety-like state or something similar to panic disorder or generalized anxiety disorder. To characterize the anxiety model pharmacologically, cockerels were administered drug probes that were either: (1) only effective for treating panic disorder (phenelzine 3.125-25.0 mg/kg), (2) effective for treating both panic disorder and generalized anxiety disorder (alprazolam 0.065-0.5 mg/kg; clonidine 0.1-0.25 mg/kg; imipramine 1.0-15.0 mg/kg), (3) only effective for treating generalized anxiety disorder (buspirone 2.5-10.0 mg/kg; trazodone 0.1-3.0 mg/kg) or (4) capable of exacerbating symptoms of panic disorder in humans (yohimbine 0.1-3.0 mg/kg). At 7 days after hatch, chicks received either vehicle or drug probe intramuscularly 15 min prior to social separation under a mirror (low-stress) or no-mirror (high-stress) condition for a 180-s observation period. Dependent measures were distress vocalizations to index separation stress and sleep-onset latency to index sedation. Phenelzine, alprazolam, imipramine and clonidine were able to attenuate distress vocalizations (at doses without significant sedation) whereas buspirone and trazodone did not. Paradoxically, yohimbine modestly attenuated distress vocalizations. These results suggest that the chick separation stress paradigm better models panic disorder than generalized anxiety disorder as an anxiolytic screen.

Psychopharmacology of maternal separation anxiety in vervet monkeys

Maternal separation in non-human primates has been proposed as a model of early adversity. The symptoms of separation anxiety were studied in vervet monkeys, during the weaning period, when psychotropic medications were administered. The control group received a normal diet and treatment groups received citalopram, reboxetine or lamotrigine in their food daily. Treatment was given for 7 weeks starting 1 month prior to weaning. Behavior was recorded twice weekly for 8 weeks, and was rated for anxiety and depression. Cerebrospinal fluid was collected at the beginning and end of the trial and analyzed for monoamines and metabolites using High Performance Liquid Chromatography. Citalopram pretreatment prevented the reduction of affiliation behavior and reduced stereotypies after weaning, and both citalopram and reboxetine abolished the increase in activity seen in control monkeys after weaning, but no statistically significant differences were found between groups. Citalopram pretreatment also significantly increased noradrenaline and 5-hydroxyindolacetic acid (5-HIAA) levels and reboxetine significantly decreased dopamine levels over time. The 5-HIAA levels of reboxetine and lamotrigine treated monkeys were significantly lower than that of the control group at the end of the trial. Although limited by a small sample size, this study demonstrates the possibility of investigating the psychopharmacology of early adversity in a non-human primate model.

Bipolar disorder and comorbid anxiety disorders in children and adolescents

Recent attention has focused on the association between bipolar disorder and comorbid anxiety disorders in children and adolescents. There is a high rate of comorbidity between bipolar disorder and anxiety disorders in children and youths. Often, a child or adolescent with bipolar disorder has multiple comorbid anxiety disorders. In general, anxiety disorders precede the development of bipolar disorder in children. Comorbid disorders may worsen the course of each individual disorder. Pharmacologic management of the comorbid anxiety disorder is complicated by potential mood destabilization in a child or adolescent with bipolar disorder.

Clomipramine and selegiline: do they influence impulse control?

Anxiety disorders in dogs are often accompanied by loss of impulse control and can result in inappropriate behaviour such as destructiveness, excessive barking and aggression. The reduction of these undesirable actions is the focus of behaviour therapy. Clomipramine and selegiline have been approved for the treatment of separation anxiety in dogs, but there are anecdotal reports that they produce inconsistent therapeutic effect. Hence, the aim of this study was to verify the efficacy of clomipramine and selegiline for regulating impulse control by using a rat model based on the delay of reward procedure. The principle is that the animal has to decide between an immediate small food reward, normally preferred by impulsive animals, and a delayed large food reward. In this study, acute effects of clomipramine (0.3-10.0 mg/kg), selegiline (0.3-3.0 mg/kg), and diazepam (1.0-3.0 mg/kg) on the impulsive behaviour of two breeding lines of rats with different anxiety-related behaviour were investigated. Neither clomipramine nor selegiline had an effect on impulse control in either breeding line. However, motor activity was decreased by clomipramine and increased by selegiline. Diazepam led to an increase in impulsive behaviour of one rat line concomitant with an increase in motor activity. The results of this rat model for studying impulsive behaviour suggest that a single administration of selegiline and clomipramine has no influence on impulsive behaviour.

Fluoxetine for the treatment of childhood anxiety disorders: open-label, long-term extension to a controlled trial

OBJECTIVE

To assess the efficacy of fluoxetine for the long-term treatment of children and adolescents with anxiety disorders, including generalized anxiety disorder, separation anxiety disorder, and/or social phobia.

METHOD

Children and adolescents (7-17 years old) with anxiety disorders were studied in open treatment for 1 year after they completed a randomized, controlled trial (RCT) comparing fluoxetine and placebo. The follow-up phase assessments included clinician, parent, and child ratings with measures of global severity, global improvement, and anxiety symptoms.

RESULTS

Subjects taking fluoxetine (n = 42) were compared with those taking no medication (n = 10) during follow-up on anxiety changes from the end of the RCT through the follow-up period. Statistical models included RCT assignment and follow-up psychological treatment. Excluded subjects took other medications (n = 4) or did not complete follow-up (n = 18). Compared with subjects taking no medication, subjects taking fluoxetine showed significantly superior follow-up outcomes on most measures, including clinician, parent, and child ratings.

CONCLUSIONS

The results suggest that fluoxetine is clinically effective for the maintenance treatment of anxiety disorders in children and adolescents. A major limitation, however, was the lack of RCT methodology in the follow-up phase. RCTs are needed to determine the long-term risks and benefits of fluoxetine for this group.

Screening antidepressants in the chick separation-stress paradigm

RATIONALE

Clinical research has indicated that antidepressants are efficacious in the treatment of anxiety disorders, especially when repeatedly administered. However, few animal models of anxiety are sensitive to antidepressants, a finding that may be due to procedures limited to acute administrations.

OBJECTIVES

The purpose of the present research was to further validate the chick separation-stress paradigm as an animal model of anxiety by examining its sensitivity to the monoamine oxidase inhibitor (MAOI) phenelzine (6.25, 12.5, 25.0 mg/kg), the tricyclic antidepressant (TCA) imipramine (5.0, 10.0, 20.0 mg/kg), the selective serotonin reuptake inhibitor (SSRI) citalopram (1.0, 2.5, 5.0 mg/kg), and the norepinephrine reuptake inhibitor (NRI) maprotiline (5.0, 10.0, 20.0 mg/kg) under acute (no pretreatment) or repeated (3 or 6 days pretreatment) administration procedures.

METHODS

Following any pretreatment, 8-day-old chicks received their respective vehicle or drug probe injection 15 min before tests in either a "mirror" (low stress) or "no mirror" (high stress) condition for a 180-s isolation period. The dependent measures were distress vocalizations to index separation stress and sleep onset latency to index sedation.

RESULTS

The model was sensitive to acutely administered phenelzine (MAOI), imipramine (TCA), and maprotiline (NRI), but not citalopram (SSRI) and retained its sensitivity to these drug probes across both repeated administration procedures. None of the drug probes possessed any sedative properties.

CONCLUSIONS

These results help extend the validity and utility of the chick separation-stress paradigm as an animal model of anxiety by demonstrating its sensitivity to antidepressants under both acute and repeated administration procedures.

Comparison of the efficacy of a synthetic dog-appeasing pheromone with clomipramine for the treatment of separation-related disorders in dogs

Sixty-seven dogs that showed signs of distress when separated from their owners (destructiveness, excessive vocalisation and house soiling) and hyperattachment were used in a randomised, blind trial to assess the potential value of a dog-appeasing pheromone in reducing the unacceptable behaviours. For ethical reasons, there was no placebo group and the effects of the pheromone were compared with the effects of clomipramine which is regularly used to treat this type of problem. The undesirable behaviours decreased in both groups, but the overall assessment by the owners indicated that there was no significant difference between the two treatments, although there were fewer undesirable events in the dogs treated with the pheromone, and the administration of the pheromone appeared to be more convenient.

The chick separation stress paradigm: a validation study

To expand the generalizability of the chick separation stress paradigm as a high-throughput anxiolytic screen, six positive drug probes (doses in mg/kg: meprobamate 15-120, pentobarbital 2.5-20.0, chlordiazepoxide 2.5-15.0, buspirone 2.5-10.0, imipramine 1-15, and clonidine 0.10-0.25) and five negative drug probes (amphetamine 0.5-4.0, scopolamine 0.2-1.6, caffeine 5-20, chlorpromazine 1-30, and haloperidol 0.03-1.00) were evaluated in the test. Seven-day-old chicks received intramuscular injections of either vehicle or drug probe 15 min prior to tests in either a mirror (low-stress) or a no-mirror (high-stress) condition for a 3-min observation period. The dependent measures were distress vocalizations to index separation stress and sleep onset latency to index sedation. All positive drug probes attenuated distress vocalizations in a dose-dependent manner, except buspirone. All positive drug probes affected sleep onset latency in a dose-dependent manner, except buspirone and imipramine. In all cases, the anxiolytic-like effect of positive drug probes was greater than its sedative effect. None of the negative drug probes affected either distress vocalizations or sleep onset latency, except for the highest dose of amphetamine, which caused pronounced stereotypy. These findings demonstrate that this anxiolytic screen is sensitive to a wide range of positive pharmacological probes and insensitive to a wide range of negative pharmacological probes.

Anxiolytic-like effects of escitalopram, citalopram, and R-citalopram in maternally separated mouse pups

The S-enantiomer of citalopram, escitalopram, is a selective serotonin reuptake inhibitor (SSRI) that appears to be responsible for citalopram's antidepressant and anxiolytic effects. Clinically, escitalopram is reported to have fewer adverse side effects than do other SSRIs. This study compared escitalopram to other antidepressants in a preclinical procedure predicting anxiolytic-like effects of drugs. Carworth Farms Webster (CFW) mouse pups (7 days old) were separated from the dam and maintained at a temperature of 34 degrees C. Forty-five minutes after administering citalopram (0.56-10 mg/kg), escitalopram (0.0056-3 mg/kg), R-citalopram (1-10 mg/kg), paroxetine (0.3-3 mg/kg), fluoxetine (1-30 mg/kg), or venlafaxine (3-56 mg/kg) subcutaneously, the pups were placed individually on a 19.5 degrees C surface for 4 min. Ultrasonic vocalizations (USVs) (30-80 kHz), grid crossing, rolling (i.e., the pup turned on one side or its back), and colonic temperature were recorded. All the drugs reduced USV emission; escitalopram was the most potent (ED(50) 0.05 mg/kg), followed by paroxetine (0.17 mg/kg), citalopram (1.2 mg/kg), fluoxetine (4.3 mg/kg), R-citalopram (6 mg/kg), and venlafaxine (7 mg/kg). The doses that decreased USVs differed from those that increased motor activity. Increased grid crossing occurred after low doses of paroxetine (0.03 or 0.1 mg/kg) and fluoxetine (1 mg/kg), but only after the highest doses of the citalopram enantiomers and venlafaxine (0.3, 10, and 56 mg/kg, respectively). Except for escitalopram and venlafaxine, high doses of the treatments increased rolling. R-Citalopram caused a 10-fold rightward shift in escitalopram's dose-effect curve, suggesting that R-citalopram inhibits escitalopram's anxiolytic-like effects. These data support clinical findings that escitalopram is a potent, well tolerated SSRI with anxiolytic-like effects.

Behavioral, hormonal and histological stress markers of anxiety-separation in postnatal rats are reduced by prepro-thyrotropin-releasing hormone 178-199

We investigated in the present study whether systemic injections of prepro-thyrotropin-releasing-hormone 178-199 (PPTRH 178-199) in postnatal 3-days old rat pups can provide ameliorative effects in a model of anxiety-separation disorder. The pups were individually separated from their mother and placed in a novel environment. PPTRH 178-199-treated animals started exploring the novel environment in a significantly shorter time and elicited significantly less distress vocalizations than control animals. PPTRH 178-199-treated animals also had markedly lower serum adrenocorticotropic hormone and corticosterone compared to control animals. Furthermore, we observed a significant increase in PPTRH 178-199 immunoreactive cell bodies in the hypothalamus of PPTRH 178-199-treated animals compared to controls, suggesting that the peptide crossed the blood-brain barrier. PPTRH 178-199 treatment can help to reduce behavioral and hormonal disturbances associated with anxiety-separation situations.

Fluvoxamine: a review of its therapeutic potential in the management of anxiety disorders in children and adolescents

Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) which may be used for the management of anxiety disorders in children and adolescents. Absorption of fluvoxamine was similar in adolescents to that in adults, which suggests that the maximum dosage of the drug for patients aged between 12 and 17 years can be as high as 300 mg/day. However, steady-state plasma fluvoxamine [corrected] concentrations were 2 to 3 times higher in children (aged between 6 and 11 years) than in adolescents; thus, the maximum fluvoxamine dosage recommended for children is 200 mg/day. Fluvoxamine (50 to 300 mg/day) for 8 to 16 weeks significantly reduced symptoms of obsessive-compulsive disorder (OCD) [measured across multiple assessment scales] compared with placebo in a well controlled trial in paediatric patients (n = 120) or from baseline in noncomparative trials in adolescent (n = 20) or paediatric (n = 16) patients. Improvements with fluvoxamine (up to 200 mg/day) were observed for up to 1 year in 98 patients with OCD in a noncomparative trial. The drug (up to 250 or 300 mg/day) also improved symptoms of anxiety compared with placebo in an 8-week well controlled trial in 128 paediatric patients with social phobia, separation anxiety disorder or generalised anxiety disorder (GAD). Fluvoxamine (50 to 300 mg/day) appears to be well tolerated in paediatric patients, with most adverse events with the drug (except abdominal discomfort, which occurred more often in patients receiving fluvoxamine) occurring with a similar incidence to those with placebo. The most common adverse events involved the central nervous system or gastrointestinal system. Most adverse events reported by paediatric patients with OCD were similar to those reported by adults. In conclusion, fluvoxamine is generally well tolerated and has demonstrated short-term efficacy compared with placebo in the treatment of OCD, and social phobia, separation anxiety disorder or GAD in well controlled trials in paediatric patients. Reductions in symptoms of anxiety with fluvoxamine have been observed for up to 1 year in children and adolescents with OCD. However, there are currently no comparative trials of fluvoxamine with other pharmacological agents. In the absence of such trials, current consensus opinion recommends that when pharmacotherapy is indicated, fluvoxamine, like other SSRIs, can be used as first-line treatment for anxiety disorders, particularly OCD, in paediatric patients. However, direct comparisons are required to assess the relative efficacy and tolerability of pharmacological agents in order to make firm recommendations for the treatment of anxiety disorders in this patient group.

Behavior modification and pharmacotherapy for separation anxiety in a 2-year-old pointer cross

Separation anxiety is a common behavioral problem in dogs. Treatment is based on developing a behavior modification protocol that gradually desensitizes and counter-conditions the dog to being left alone, by rewarding calm, relaxed behavior. Judicious use of pharmacotherapy can be a useful adjunct to a behavior modification program.

Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management

This paper provides an overview of the phenomenology, longitudinal outcome data, assessment and management of separation anxiety disorder (SAD) in children and adolescents. SAD is qualitatively different from early worries, and is characterised by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Longitudinal studies have suggested that childhood SAD may be a risk factor for other anxiety disorders, but whether this link is specific to, for example, panic disorder and agoraphobia, or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated. Most relevant data are reported on nonpharmacological treatments (psychoeducational, behavioural, cognitive-behavioural, family and psychodynamic), and these are the first choice approach in SAD. Controlled studies show efficacy of cognitive-behavioural therapy in children with anxiety disorders and specifically in SAD-school phobia, supporting this approach as the best proven treatment. Pharmacotherapy should be used in addition to behavioural or psychotherapeutic intervention when the child's symptoms have failed to respond to those treatments, and he/she is significantly impaired by the symptoms. Selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRI) have a good adverse effect profile and may be considered as first choice drugs in SAD. When different SSRIs fail to improve symptomatology, a trial with a tricyclic antidepressant (TCA) is indicated, with careful monitoring of cardiac functioning. Because of the adverse effect profile and the potential for abuse and dependence, benzodiazepines should be used only when a rapid reduction of symptomatology is needed, until the SSRI or the TCA have begun to be effective (few weeks). Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer antidepressants (venlafaxine, mirtazapine, nefazodone) in childhood anxiety disorders.

Use of clomipramine in treatment of obsessive-compulsive disorder, separation anxiety and noise phobia in dogs: a preliminary, clinical study

OBJECTIVE

To evaluate the efficacy and tolerance of a treatment protocol for obsessive-compulsive disorder, separation anxiety and noise phobia in dogs.

DESIGN

A study was undertaken to assess clinical responses in 24 dogs diagnosed with one or more of three behavioural disorders stated above to a treatment regimen that included clomipramine and behaviour modification.

PROCEDURE

A detailed behavioural and clinical history was obtained for each dog. Obsessive-compulsive disorder was diagnosed in nine cases: primary presenting complaints were tail-chasing, shadow-chasing, circling and chewing; one case was diagnosed with concurrent separation anxiety. Separation anxiety was diagnosed in 14 cases: presenting complaints included destruction, vocalisation and escaping in the absence of the owner; four cases also exhibited noise phobia. The study also included one dog diagnosed with noise phobia only and another with inappropriate fear responses. Clomipramine was administered orally twice daily. The starting dose was 1 to 2 mg/kg bodyweight. The dose was increased incrementally to a maximum of 4 mg/kg if needed. A behaviour modification program was designed and the owner instructed on its implementation. Dogs continued medication for at least 1 month after clinical signs disappeared or were acceptably reduced, then withdrawal of medication was attempted by decreasing drug dosage at weekly intervals while behaviour modification continued.

RESULTS

The presenting clinical sign was largely improved or disappeared in 16 dogs, 5 demonstrated slight to moderate improvement and the behaviour was unchanged in 3. Clomipramine withdrawal was attempted in nine cases: this was successful in five.

CONCLUSION

Clomipramine was effective and well-tolerated in controlling signs of obsessive-compulsive disorder and/or separation anxiety and/or noise phobia in 16 of 24 assessable cases, when used in combination with behaviour modification, and improvement in clinical signs was noted in 5 others.

Fluoxetine enhances cell proliferation and prevents apoptosis in dentate gyrus of maternally separated rats

The mother-infant relationship is an instinctive phenomenon, and loss of maternal care in early life influences neonatal development, behavior and physiologic responses.(1,2) Furthermore, the early loss may affect the vulnerability of the infant to neuropsychiatric disorders, such as childhood anxiety disorders, personality disorders and depression, over its lifespan.(3,4) Fluoxetine is prescribed worldwide for depression and is often used in the treatment of childhood mental problems related to maternal separation or loss of maternal care.(5,6) In the present study, fluoxetine was administrated to rats with maternal separation to determine its effects on neuronal development, in particular with respect to cell proliferation and apoptosis in the dentate gyrus of the hippocampus. Rat pups were separated from their mothers and socially isolated on postnatal day 14 and were treated with fluoxetine (5 mg kg(-1)) and 5-bromo-2'-deoxyuridine (BrdU) (50 mg kg(-1)) for 7 days, after which immunohistochemistry and a terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) staining were carried out. In the pups with maternal separation treated with fluoxetine, the number of BrdU-positive cells was significantly increased and that of TUNEL-positive cells was significantly decreased in the dentate gyrus compared to pups with maternal separation that did not receive fluoxetine treatment. These findings indicate that fluoxetine affects new cell proliferation and apoptosis, and we propose that fluoxetine may be useful in the treatment of maternal separation-related diseases.

Fluvoxamine for the treatment of anxiety disorders in children and adolescents. The Research Unit on Pediatric Psychopharmacology Anxiety Study Group

BACKGROUND

Drugs that selectively inhibit serotonin reuptake are effective treatments for adults with mood and anxiety disorders, but limited data are available on the safety and efficacy of serotonin-reuptake inhibitors in children with anxiety disorders.

METHODS

We studied 128 children who were 6 to 17 years of age; who met the criteria for social phobia, separation anxiety disorder, or generalized anxiety disorder; and who had received psychological treatment for three weeks without improvement. The children were randomly assigned to receive fluvoxamine (at a maximum of 300 mg per day) or placebo for eight weeks and were evaluated with rating scales designed to assess the degree of anxiety and impairment.

RESULTS

Children in the fluvoxamine group had a mean (+/-SD) decrease of 9.7+/-6.9 points in symptoms of anxiety on the Pediatric Anxiety Rating Scale (range of possible scores, 0 to 25, with higher scores indicating greater anxiety), as compared with a decrease of 3.1+/-4.8 points among children in the placebo group (P<0.001). On the Clinical Global Impressions-Improvement scale, 48 of 63 children in the fluvoxamine group (76 percent) responded to the treatment, as indicated by a score of less than 4, as compared with 19 of 65 children in the placebo group (29 percent, P<0.001). Five children in the fluvoxamine group (8 percent) discontinued treatment because of adverse events, as compared with one child in the placebo group (2 percent).

CONCLUSIONS

Fluvoxamine is an effective treatment for children and adolescents with social phobia, separation anxiety disorder, or generalized anxiety disorder.

Open fluoxetine treatment of mixed anxiety disorders in children and adolescents

An open-label pilot study examined fluoxetine treatment in 16 outpatients (9-18 years old) with mixed anxiety disorders. Following nonresponse to psychotherapy, fluoxetine monotherapy was started at 5 mg daily and was increased weekly by 5 or 10 mg daily for 6-9 weeks until improvement occurred or to a maximum of 40 mg (children under 12) or 80 mg (adolescents). Among patients on fluoxetine, severity of illness ratings were "much improved" (mean final Clinical Global Impression scale score 2.8 +/- 0.7). Clinical improvement occurred in 10 of 10 patients with current separation anxiety disorder, 8 of 10 with social phobia, 4 of 6 with specific phobia, 3 of 5 with panic disorder, and 1 of 7 with generalized anxiety disorder. Mean time to improvement was 5 weeks. Mean doses were 24 mg (0.7 mg/kg) for children and 40 mg (0.71 mg/kg) for adolescents. Side effects were transient and included drowsiness (31% of patients), sleep problems (19%), decreased appetite (13%), nausea (13%), abdominal pain (13%), and excitement (13%). No patient developed disinhibition, akathisia, or suicidality. These preliminary findings suggest fluoxetine effectiveness in separation anxiety disorder and social phobia. Youths with only one anxiety disorder appeared to respond to lower doses of fluoxetine than patients with multiple anxiety disorders (0.49 +/- 0.14 versus 0.80 +/- 0.28 mg/kg, p < 0.05).

Anxiolytic properties of botanical extracts in the chick social separation-stress procedure

RATIONALE

The recent growth in sales of natural products labeled as dietary supplements in the United States has renewed scientific interest in the study of the therapeutic effects of multi-component botanical products.

OBJECTIVES

This study sought to determine whether botanical extracts derived from the Rutaceae family, Acori graminei, the Magnoliaceae family, Alchemilla vulgaris and Primula veris, which had previously been identified in bioassays as having potential anxiolytic activity, were active in the chick social separation-stress procedure.

METHODS

Eight-day-old chicks received IP injections of test articles 30 min before being tested in the presence of two social companions or in isolation for a 3-min observation period. Dependent measures were: a) latency to adopt a ventral recumbent posture to index sedation, b) number of vocalizations to index separation-distress and c) a composite pain score (comprised of footlift frequency and footlift duration in response to 50 microl of 0.10% formalin injected into the plantar surface of the foot) to index stress-induced analgesia.

RESULTS

Proprietal extracts NPS00033 from the Rutaceae plant family and NPS00039 (Relora) from the Magnoliaceae plant family screened positive in this chick model without causing sedation.

CONCLUSIONS

These results suggest that botanical extracts Relora and NPS00033 may be useful in modulating anxiety states.

Evaluation of clomipramine as an adjunct to behavioural therapy in the treatment of separation-related problems in dogs

Forty-nine dogs showing signs of separation-related problems were randomly assigned to one of three groups: group A (15 dogs) received a placebo twice daily; group B (17 dogs) received clomipramine at 0.5 to 1.0 mg/kg twice daily; and group C (17 dogs) received clomipramine at 1.0 to 2.0 mg/kg twice daily. All the dogs also received behavioural therapy. Their owners were required to complete questionnaires about their dog's behaviour initially, and one, four and eight weeks after the treatment with clomipramine began. Bipolar ratings scales were used to monitor the frequencies of 'general', 'attachment-related' and 'separation-related' behaviours. Kruskal-Wallis tests and Kendall Rank correlations were used to determine any initial differences between the treatment groups, and the association between the initial scores and behavioural changes after one week of treatment with clomipramine. Extended Mantel-Haenszel statistics were used to evaluate the effects of clomipramine treatment versus the placebo, and Page's test was used to assess the effectiveness of behavioural therapy on its own. There were no significant differences in the demographic characteristics of the owners of the dogs assigned to the three groups. The dogs differed slightly in age between groups, and the dogs in the two clomipramine-treated groups were reported as showing problems at a significantly earlier age than those in the placebo group. Clomipramine treatment had a sustained suppressive effect on the dogs' general activity levels, and a more modest suppressive effect on their attachment-related tendency to want much physical contact with their owners. The typical signs of separation-related behaviour problems were not significantly affected by treatment with clomipramine, but behavioural therapy on its own was highly effective in reducing behavioural problems.

Effects of rearing condition on HPA axis response to fluoxetine and desipramine treatment over repeated social separations in young rhesus monkeys

Normal hypothalamic-pituitary-adrenal (HPA) axis activity is disrupted in several types of human psychiatric disorders, and has been widely reported to be altered as a result of early experience in rodents. In this study the effects of early social experience on later response of the HPA axis to separations from cagemates and pharmacologic treatments were examined in rhesus monkeys. HPA axis activity was measured in mother-reared and peer-reared monkey infants in conjunction with six repeated separations from and reunions with their cagemates. Within each rearing group, infants were assigned to one of three treatment groups that received continuous treatment with either fluoxetine (2 mg/kg), desipramine (DMI, 5 mg/kg) or placebo (saline) beginning 2 weeks prior to separations. At 2 weeks after drug treatment, fluoxetine increased ACTH and cortisol in the treated groups, while DMI decreased ACTH and cortisol in both treated groups; however, these effects were not persistent over the separations. While these treatment effects tended to be more pronounced in the mother-reared group, the rearing groups did not show a clearly differential response to either of the treatments. The most prominent finding was that mother-reared monkeys showed significantly higher ACTH and cortisol levels than peer-reared monkeys over all samples, an effect that may have mitigated a potential rearing group difference in treatment response. The results add to growing evidence for the influence of primate mothers on the functional development of psychobiological systems in their infants, and suggest that the HPA axis is among the more sensitive of these systems to postnatal experience.

Psychopharmacology in child and adolescent psychiatry: a review of the past seven years. Part II

OBJECTIVE

To present a critical overview of the selected literature published in the past 7 years on the efficacy and safety of psychoactive agents in conduct disorder, schizophrenia, separation anxiety disorder, selective mutism, obsessive-compulsive disorder, panic disorder, major depressive disorder, bipolar disorder, and sleep and eating disorders.

METHOD

Reports of double-blind and placebo-controlled trials and open studies were reviewed and selected studies presented.

RESULTS

Employment of larger samples of diagnostically homogeneous patients and a more sophisticated design and methodology led to progress in the treatment of most of these conditions. Data have been accumulated on dose range and safety of lithium in this age group, and there is supportive evidence that lithium is useful in reducing aggression.

CONCLUSIONS

For a rational treatment approach, further studies are needed, particularly in depression and conduct disorder; psychosocial-environment contributions and possible biological markers should be investigated in order to identify children who require psychopharmacological treatments and those who will respond to psychosocial interventions or the combination of both. Symptoms targeted to require pharmacotherapy and symptoms targeted to respond to psychosocial interventions have to be identified.

[Case study of an anxious child]

Separation and individuation process ceases to be physiological when the family does not furnish the child with a feeling of security. Very often it becomes the main reason for the development of fears, including separation fear. The described study of the child suffering from separation fear testifies to a strong interrelation between the attitude of the parents, their volatile feeling of security, an the fear developed by the child. It also demonstrates the influence of the generic families on the current family situation. All these factors prove that there should be a strong relation between the child therapy and the family therapy. All the described forms of therapy account for work with the child in the conditions of the day ward according to the Good-Start Method, V. Sherborne, group therapy and system family therapy. The interesting point is the stage at which the family decides to undergo the therapy and consequently break it up.

Psychopharmacologic treatment of anxiety disorders in adolescents and children

Anxiety disorder is more prevalent than attention deficit disorder in children and adolescents, but its current drug treatment is based on inconclusive findings. Treatment of separation anxiety disorder without comorbidity has barely been studied. School absenteeism is often treated with tricyclic antidepressants and benzodiazepines, but the efficacy data are only suggestive for benzodiazepines and not encouraging for antidepressants. Overanxious disorder appears to be responsive to benzodiazepines in open trials but not in controlled studies, and buspirone may have promise. The evidence is weak for treating avoidant disorder with alprazolam or buspirone and for treating panic disorder with antidepressants or benzodiazepines. There are no adequate trials of monoamine oxidase inhibitors. Obsessive compulsive disorder is well documented to respond to clomipramine, but it leaves considerable residual symptoms; fluoxetine also appears to be effective. The anxiety and aggression of post-traumatic stress disorder responded to propranolol in one open trial, but no other drug studies have been reported. Most available trials are small and uncontrolled, are based on an unsatisfactory nosology, and use doses too low for children (who often need higher-than-adult doses to overcome rapid hepatic biotransformation). Comorbid anxiety and mood disorders, substance use, child abuse, development, genetics, and family situational factors must be considered. In view of the limitations of the benzodiazepines and antihistamines, newer antianxiety agents should be investigated, optimally in conjunction with cognitive and behavioral approaches in multimodal treatments. The creation of anxiety disorder clinics for children and adolescents will facilitate more effective research and treatment of this highly prevalent problem.

[Panic attacks and panic disorders in the child]

Panic disorders in adults have been the object of many studies. They are better known in adolescents but have been noticed insufficiently in children although panic disorder is potentially dangerous at that age. After demographic considerations, the clinical aspects are examined and illustrated using two detailed observations.

Imipramine treatment of children with separation anxiety disorder

The efficacy of imipramine was investigated in 20 children (ages 6 to 15) with separation anxiety disorder. Children were treated for a month with vigorous behavioral treatment. If they did not respond, they entered a double-blind, randomized, 6-week trial of imipramine or placebo. Of 45 children accepted, 21 (47%) entered the trial. About half the children improved with either treatment, and no superiority for imipramine was obtained. There was no instance of clinically significant EKG changes. This small study failed to replicate previous findings of imipramine efficacy in a similar, but larger, clinical population.

NMDA receptor complex antagonists have potential anxiolytic effects as measured with separation-induced ultrasonic vocalizations

Pre-weaning rat pups emit ultrasonic vocalizations when removed from the litter. These 'separation-induced vocalizations' (SIV) are suppressed by classical benzodiazepine anxiolytics and by non-benzodiazepine anxiolytics which lack muscle relaxant and sedative properties. The present study used the SIV model to assess potential anxiolytic properties of compounds which target different sites associated with the NMDA receptor complex. Comparison was made to drugs which affect benzodiazepine or serotonin (5-HT) receptors. Muscle relaxant potential was assessed using 'TIP' (time on an inclined plane), the amount of time a pup was able to retain its position on a steeply inclined surface. Mephenesin, a centrally acting muscle relaxant, significantly suppressed TIP but not SIV. The benzodiazepine agonist diazepam suppressed both SIV and TIP, whereas the 5-HT1A partial agonists, buspirone and MDL 73,005EF, suppressed SIV without affecting TIP. The 5-HT2 antagonist MDL 11,939 suppressed TIP but not SIV, whereas neither measure was affected by the 5-HT3 antagonist MDL 73,147EF. SIV was suppressed by NMDA antagonists including those acting at the glutamate recognition site (D,L-amino-phosphonovaleric acid (AP5) and MDL 100,453) or at the ion channel (MK-801), or by the strychnine-insensitive glycine antagonist 5,7-dichlorokynurenic acid (5,7-DCKA). TIP was suppressed even more potently by AP5, MDL 100,453 and MK-801, whereas 5,7-DCKA was inactive on this measure. Thus, antagonists acting at different sites present on the glutamate recognition site exhibit potential anxiolytic activity, but the glycine antagonist was unusual in its lack of prominent muscle relaxant side effects.