CSF cholecystokinin, gamma-aminobutyric acid and neuropeptide Y in pathological gamblers and healthy controls.

The sulphated cholecystokinin (CCK) octapeptide (CCK-8S), the CCK tetrapeptide (CCK-4), neuropeptide Y (NPY) and gamma-aminobutyric acid (GABA) were determined in cerebrospinal fluid (CSF) obtained from 11 pathological male gamblers and 11 healthy male controls. Compared with healthy controls, pathological male gamblers displayed higher concentrations of CCK-8S, CCK-4 and GABA (but not NPY). A gradient with decreasing concentrations from the first to the third 6-ml CSF fraction was found for CCK-8S, CCK-4 and NPY, but only in pathological gamblers. Disrupted gradients were found for GABA and for NPY in healthy controls. Given that CCK is a modulator of dopamine in the reward process, the increase in CCK-8S and CCK-4 is not unexpected. The high level of GABA in pathological gamblers is in conformity with a compensatory inhibitory action on noradrenergic neurons. The CSF gradient of CCK-8S and CCK-4 in pathological male gamblers (but not healthy controls) might indicate a difference in diurnal variation. The results obtained are in line with an altered CCK and GABA function in pathological gambling.

A controlled, prospective, 1-year trial of citalopram in the treatment of panic disorder.

BACKGROUND: The objective of this study was to evaluate the efficacy and tolerability of citalopram in the long-term treatment of adult outpatients with panic disorder with or without agoraphobia. METHOD: Patients in this double-blind, parallel-group trial were assigned to 1 of 3 fixed dosage ranges of citalopram (10 or 15 mg/day, 20 or 30 mg/day, or 40 or 60 mg/day), 1 dosage range of clomipramine (60 or 90 mg/day), or placebo. After the completed 8-week acute treatment period, the eligible patients could continue the treatment for up to 1 year. Of the 475 patients who were randomly assigned for the short-term trial, 279 agreed to continue double-blind treatment at their assigned doses. The primary efficacy measure used was the Clinical Anxiety Scale panic attack item, and the response was defined as no panic attacks (score of 0 or 1). The other key measures used were the Physician's Global Improvement Scale, the Patient's Global Improvement Scale, and the Hamilton Rating Scale for Anxiety (HAM-A). RESULTS: In all drug-treated groups, except the group receiving the lowest citalopram dose, the treatment outcome was generally better than with placebo. As determined by a life table analysis of response, the probability of response during the 12 months was significantly greater with all treatment regimens than with placebo (p < .05), with citalopram 20 or 30 mg/day demonstrating the best response. Panic attacks tended to disappear in all patients remaining in the study until the end of follow-up. Analysis of the difference in the number of patients in different treatment groups remaining in the study (perhaps the best measure of long-term efficacy) also demonstrated that the patients treated with citalopram in dosage ranges of 20 or 30 mg/day and 40 or 60 mg/day had better response than placebo-treated patients (p < .0002 and p < .004, respectively). HAM-A and Global Improvement Scale scores also showed that patients treated with active drug showed greater improvement than placebo-treated patients. All treatment groups showed no new or exceptional adverse event clusters. CONCLUSION: Citalopram in the dosage range of 20 to 60 mg/day is effective, well tolerated, and safe in the long-term treatment of patients who have panic disorder.

Are dysfunctional attitudes in depressive disorder trait or state dependent?

The aim of this study was to investigate whether euthymic patients in remission on lithium prophylaxis score higher on the Dysfunctional Attitude Scale (DAS) than healthy subjects, thus indicating a trait quality of dysfunctional attitudes in unipolar depression. A total of 79 patients with recurrent unipolar depressive episodes and 79 individually matched healthy controls were compared using a Swedish version of the DAS. The results indicate that DAS score is a state-dependent variable in depressive disorder.

Quality of life after gastrectomy for gastric carcinoma: controlled study of reconstructive procedures.

The choice of reconstruction after gastrectomy and the significance of remaining reservoir function is a matter of controversy. To broaden the criteria for choice of treatment, we conducted a prospective randomized clinical trial to determine the impact of various gastrectomy procedures on quality of life. Consecutive patients (n = 64) eligible for curative gastric cancer surgery were randomized to have either a total (n = 31) or subtotal (n = 13) gastrectomy or a jejunal S-shaped pouch (n = 20) implanted as a gastric substitute. The quality-of-life evaluation was based on a battery of questionnaires covering both general and specific aspects of life. The patients were rated by one of two psychiatrists who were blinded to the patients' group affiliation. Assessments were made on three occasions: during the week prior to surgery and 3 and 12 months after the surgical intervention. The postoperative complication and mortality rates were similar in all treatment groups, with few serious complications recorded. Irrespective of type of treatment, the patients suffered from alimentary symptoms and functional limitations in everyday life, whereas their mental well-being improved after surgery. Patients who underwent subtotal gastrectomy had the best outcome, especially with respect to complaints of diarrhea. Patients given a gastric substitute after gastrectomy showed no difference from those who had only a total gastrectomy. We conclude that despite significant unfavorable consequences that follow gastrectomy, patients recover with an improved mental status. A pouch reconstruction after total gastrectomy does not improve quality of life, but a subtotal gastrectomy has advantages that must be considered when the procedure is clinically feasible.

Hyperparathyroidism and long-term lithium therapy--a cross-sectional study and the effect of lithium withdrawal.

OBJECTIVES: To assess in patients with long-term lithium treatment the incidence and prevalence of hypercalcaemia and hyperparathyroidism, and to evaluate the relationship between parathyroid function and renal function: also, to examine the effect of treatment discontinuation. DESIGN: Part 1. An epidemiological cross-sectional study covering defined catchment areas. Part 2. A lithium withdrawal study in a subgroup of the patients who were examined after a mean of 8.5 (4-16) weeks off lithium. Comparisons were made with a group of psychiatric non-lithium patients matched for sex and age. SETTING: Outpatient treatment at nine psychiatric departments in southern Sweden. SUBJECTS: Inclusion criterion was 15 years or more on lithium. Excluded from Part 2 were patients with a high risk of relapse. Out of 215 identified patients. 142 (66%) entered and completed Part 1, while 13 of the latter entered and completed Part 2. RESULTS: The point prevalence of persistent hypercalcaemia was 3.6% and of surgically verified hyperparathyroidism 2.7%. The observed incidence of hyperparathyroidism over 19 years was 6.3%. It was significantly higher than expected in females. In the withdrawal group serum calcium was significantly increased compared to controls, and did not change during 8.5 weeks without lithium. Isostenuria was significantly more common among patients with than without hyperparathyroidism. CONCLUSIONS: The point prevalence, and the 19-year incidence of hyperparathyroidism, were increased. The point prevalence of hypercalcaemia was also increased, and not reversible during 8.5 weeks off lithium. The findings support the hypothesis of a causal relationship between lithium treatment and hyperparathyroidism. Hypercalcaemia and hyperparathyroidism are sometimes aetiologically related to reduced renal function in long-term lithium patients.

Quality of life in gastric cancer prior to gastrectomy.

A growing number of surgical trials include quality of life variables in the overall assessment of outcomes. This is believed to broaden the criteria for choice of treatment and the evaluation of treatment regimens. The present study is a baseline evaluation of the health-related quality of life in patients with gastric cancer facing surgery. The quality of life in these patients was related to that of other patient groups referred for surgical interventions and general population groups. Our study included 103 consecutive patients with carcinoma of the stomach considered amenable to a curative major surgical procedure. The quality of life evaluation was based on a battery of questionnaires, covering general body symptoms, mood level and functional limitations. Patients with gastric cancer reported more neurasthenic complaints such as reduced sexual interest, insomnia and poor appetite as well as a lower mood level than the general population. The gastric cancer group also showed a markedly lower mood level in comparison with a group of cancer survivors 2-3 years after diagnosis and patients with intermittent claudication. The mental well-being of gastric cancer patients matched that of cancer survivors with one or more recurrences. Overall, 25% of the gastric cancer patients reported functional limitations regarded as clinically significant. Patients with intermittent claudication reported more and patients with small cell lung cancer markedly more limitations. We conclude that although patients with gastric cancer showed a low level of limitations on average, problems in the areas of sleep/rest, home management and, especially, eating were frequently reported.

Renal function on and off lithium in patients treated with lithium for 15 years or more. A controlled, prospective lithium-withdrawal study.

BACKGROUND: Controversy remains over the magnitude and reversibility of reduced renal function in long-term lithium patients. METHODS: Thirteen patients with 18 years (range 15-24) on lithium discontinued the treatment, and were re-examined twice after 5 and 9 weeks (4-16) off lithium. They were compared to a non-lithium psychiatric control group, matched for age and sex. RESULTS: Glomerular filtration rate (GFR) tended to improve from 69 (39-96) to 74 (39-94) ml/min/1.73 m2 BSA, P = 0.057, which was not significantly different from 78 (61-106 ml/min per 1.73 m2 BSA in the controls. Reduced GFR was found in only two of the lithium patients off lithium, and in none of the controls. Maximal urinary concentrating capacity did not improve at all. It was 637 (130-875) mOsm/kg H2O in the lithium patients, which was lower than 856 (705-1.035) mOsm/kg H2O (P < 0.01) in the controls. Two of the lithium patients had isosthenuria. CONCLUSIONS: Lithium patients often have an irreversible, clinically important reduction of Umax, sometimes progressing to nephrogenic diabetes insipidus, while GFR is well preserved in most patients.

Kidney damage in long-term lithium patients: a cross-sectional study of patients with 15 years or more on lithium.

The renal risks associated with long-term lithium treatment are a growing concern. We have therefore studied renal function by means of glomerular filtration rate (GFR) and maximum urinary concentrating capacity (Umax) in 142 of 215 patients with more than 15 years of lithium treatment in nine psychiatric clinics. Data on psychiatric and somatic diseases, hospital admissions, cumulative lithium doses, and other psychotropic treatments were extracted from the medical records. The patients were investigated according to a standardized protocol. GFR was measured as 51Cr EDTA clearance and Umax using the DDAVP test. Thirteen patients had had signs of lithium intoxication. GFR was reduced in 21% of the patients and Umax in 44%. Nephrogenic diabetes insipidus was present in 12%. Umax but not GFR was inversely correlated to the cumulative lithium dose. Kidney function was more reduced in patients on lithium combined with psychotropic treatment and/or concomitant treatment for somatic disorders. Thirst was a complaint of 53% of the patients, predominantly those with additional psychotropics. We conclude that kidney damage is common in patients on long-term lithium treatment and that both glomerular and tubular function are affected.

GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease.

An interview-based rating scale consisting of 15 items for assessment of gastrointestinal symptoms in irritable bowel syndrome and peptic ulcer disease has been developed. The interrater reliability was estimated by means of independent and simultaneous duplicate ratings by two raters in 20 cases and ranged from 0.86 to 1.00. The scale was easy to apply and proved to be useful in comparing the effectiveness of different modes of treatment in two clinical trials.

Upper gastrointestinal and mental symptoms in the irritable bowel syndrome.

Gastrointestinal and mental symptoms were assessed in 101 outpatients with the irritable bowel syndrome (IBS). A normal female population was used for comparison of mental symptoms. By definition all patients had abdominal pains and/or change of bowel habits (constipation or diarrhoea, or both) but no demonstrable organic disease. Upper gastrointestinal symptoms without peptic ulcer disease were reported by 87% of the patients. Mental symptoms were reported by almost all patients. Symptoms of anxiety, fatiguability, hostile feelings, sadness, and sleep disturbances were seen significantly more often among IBS women than in the controls. We conclude that patients with IBS frequently have upper gastrointestinal and mental symptoms that should be taken into account in the therapeutic management and evaluation of new modes of treatment.

Symptom profiles in chronic peptic ulcer disease. A detailed study of abdominal and mental symptoms.

Abdominal and mental symptoms were assessed in 103 outpatients with chronic peptic ulcer disease. Patients with present symptoms and a history of duodenal or prepyloric ulcer were included if they had no other disorder requiring treatment. A normal female population was used for comparison of mental symptoms. Besides the cardinal ulcer or acid-related symptoms, there was a high rate of indigestion and bowel dysfunction symptoms, usually associated with the irritable bowel syndrome. Mental symptoms were reported by almost all patients. Symptoms of anxiety, depression, and neurasthenia were seen significantly more often among the female patients than in the normal women. We conclude that a wide range of both abdominal and mental symptoms should be taken into account in the therapeutic management of peptic ulcer disease, in evaluation of clinical trials, and in studies of the natural history.

A psychosomatic approach to treatment in the irritable bowel syndrome and peptic ulcer disease with aspects of the design of clinical trials.

To compare the effects of conventional medical treatment with treatment that combines medical treatment and psychotherapy, 101 out-patients with irritable bowel syndrome (IBS) and 103 with peptic ulcer disease (PUD) were randomly allocated to two treatment groups. All patients with PUD received medical treatment with antacids and anticholinergics or antacids and H2-receptor antagonists, while the patients with IBS received bulk-forming agents and, when appropriate, anticholinergic drugs, antacids and minor tranquillisers. In addition, the patients in one group with IBS and one group with PUD received dynamically oriented individual psychotherapy in ten hour-long sessions spread over three months. There was a greater improvement in the psychotherapy groups for patients with IBS after three months and for both IBS and PUD patients after 15 months. The difference had become more pronounced after 15 months, with the patients given psychotherapy showing further improvement, and the patients who had received medical treatment only showing some deterioration. In the short-term, the results were more in favour of the psychotherapy group in patients with IBS than PUD, but in the long run, the combination of medical treatment with psychotherapy improved the outcome for both IBS and PUD.

Psychological aspects of non-ulcer dyspepsia: a psychosomatic view focusing on a comparison between the irritable bowel syndrome and peptic ulcer disease.

In spite of the fact that both laymen and clinicians have pointed out their relevance, the psychological aspects of gastrointestinal disorders, especially their influence on etiology and pathophysiology, have been a matter of controversy and challenge to researchers. Difficulties in this field arise from several sources, for instance, the sampling methodology in the selection of patients and the heterogeneity of the disorders studied. When the irritable bowel syndrome (IBS) is compared with peptic ulcer disease (PUD), the personality features of IBS have not been described with the same consistency as the dependency traits of PUD. Also, IBS patients have been regarded as more neurotic and depressed than PUD patients. In this study of 101 IBS and 103 PUD patients, our overall impression was that mental symptoms and personality profiles were essentially the same in IBS and PUD, but that both groups differed from a normal population. We conclude that from a psychosomatic point of view IBS and PUD may be looked upon as different facets of the same underlying psychogenic mechanism. Although conclusive evidence of how psychological factors affect physiological processes and contribute to the clinical picture in gastrointestinal disorders is still lacking, it seems reasonable to state that they are often significant and must be considered in treating individual IBS and PUD patients.