A randomized controlled clinical trial comparing "guideline exposed" and "guideline naive" physicians in respect to dosage selection and treatment outcome with doxepin in depressive disorders.

INTRODUCTION: Can prescribing of insufficient dosages and outcome of treatment with antidepressants in routine care be improved by guidelines? METHODS: 161 general practitioners and 162 psychiatrists in private practice documented 1319 patients, receiving doxepin for individual clinical reasons. Physicians were randomly divided into a guideline exposed and a control group. All physicians treated their patients according to individual clinical considerations. RESULTS: Average maximum daily dosage was 83 mg/d in the control and 95 mg/d in the intervention group (F=19.15; p<0). Only 3% of patients in both groups got the recommended dosage of 150 mg/d. Guideline exposure resulted in increased dosages preferably for milder forms of depression and in comparatively lower rates of improvement. CONCLUSION: Guideline exposure did not reach its goal in respect to the recommended dosage. It missed its goal in respect to improvement of outcome and even showed negative effects. Guidelines should be evidence-based not only by referring to literature reviews but by testing their clinical effects in controlled clinical trials.

[Loperamide abuse in anxiety disorder]. / Loperamid-Abusus bei Angststörung.

Anxiety disorders often accompany somatic correlates of anxiety such as abdominal trouble and diarrhoea. Nevertheless, misuse of antidiarrhoeals has been described only once. We report on a 34-year-old woman who abused loperamide for over 10 years, taking up to 16 mg per day. Loperamide is an opioid that stimulates opioid receptors in the gastrointestinal tract, thereby inhibiting intestinal secretion and propulsive peristalsis, probably without affecting the central nervous system. As our patient's digestive trouble was a consequence of her states of anxiety, diazepam application helped against her diarrhoea as well. This second strategy of self-medication gained particular importance for her, when even high doses of loperamide stopped having an effect. So she developed a benzodiazepine dependence. As soon as she began treatment as an inpatient, her feelings of anxiety became less and the diarrhoea disappeared.

Subthreshold affective disorders: a useful concept in psychiatric epidemiology?

OBJECTIVE: In recent years an extensive literature has grown up around the concepts of subthreshold, subsyndromal, minor and brief recurrent affective disorder and their applications in population-based research. The aim of this short review is to examine the definitions and current status of these proposed categories with special reference to depression, and to assess their potential contribution to psychiatric epidemiology. METHOD: A Medline search was carried out for the period 1965-1999, based on the above four terms. Relevant references found in all identified publications were also followed up. RESULTS: In great measure these constructs have been developed as a response to deficiencies in the DSM classification system and to a lesser extent in the ICD. The groups are all defined by having fewer criterial symptoms, or a shorter duration of symptoms, than the 'official' diagnostic categories. Use of these definitions has resulted in widely varying prevalence estimates. CONCLUSION: Improved methods are badly needed for classifying all those persons in the wider community who are in need of medical treatment and help for psychological disorder, but do not satisfy operational criteria laid down in the official guidelines. This cannot, however, be achieved simply by lowering operational thresholds in these systems. Further research on clinical and psycho-social characteristics of the common mental disorders is called for, and in many societies a favourable setting is that of primary health care, where a move towards pragmatic, comprehensive classification of community health problems is already under way.