An effect-size analysis of the relative efficacy and tolerability of serotonin selective reuptake inhibitors for panic disorder.

OBJECTIVE: Serotonin selective reuptake inhibitors (SSRIs) are now considered the first-line pharmacotherapy for panic disorder. The preferential use and the presumption of greater tolerability of SSRIs relative to older agents, such as tricyclic antidepressants, occurred without direct comparisons between the two classes of medication. In this study the authors used an effect-size analysis to provide an initial comparison. METHOD: The authors conducted an effect-size analysis of 12 placebo-controlled, efficacy trials of SSRIs for panic disorder and compared these results to findings obtained in a recent meta-analysis of non-SSRI treatments for panic disorder. RESULTS: The mean effect size for acute treatment outcome for SSRIs relative to placebo was 0.55, not significantly different from that for antidepressants in general (0.55) and for imipramine in particular (0.48). More recent studies of SSRIs, and studies using larger samples, were associated with lower effect sizes. No significant differences were found in dropout rates between those taking SSRIs and those taking older agents during acute treatment. CONCLUSIONS: An effect-size analysis of controlled studies of treatments for panic disorder revealed no significant differences between SSRIs and older antidepressants in terms of efficacy or tolerability in short-term trials. An inverse relationship was evident between sample size and effect size for SSRIs. Early studies of small samples may have led to initial overestimations of the efficacy of SSRIs for panic disorder.

Childhood history of anxiety disorders among adults with social phobia: rates, correlates, and comparisons with patients with panic disorder.

We examined the rates and correlates of a childhood history of anxiety disorders in 100 adults with a primary diagnosis of social phobia (social anxiety disorder). Adulthood and childhood disorders were assessed by experienced clinicians with structured clinical interviews. Rates of childhood anxiety disorders were evaluated to diagnostic comorbidity and a comparison group of patients with panic disorder. Onset of social phobia occurred before age 18 in 80% of the sample. Over half of the sample (54%) met criteria for one or more childhood anxiety disorders other than social phobia: 47% for overanxious disorder, 25% for avoidant disorder, 13% for separation anxiety disorder, and 1% for childhood agoraphobia. A history of childhood anxiety was associated with an early age of onset of social phobia, greater severity of fear and avoidance of social situations, greater fears of negative evaluation, and greater anxiety and depression morbidity. Rates of childhood social phobia, overanxious disorder, and avoidant disorder were significantly higher in patients with social phobia relative to our panic-disordered comparison group. We found approximately equal rates of a childhood history of separation anxiety disorder in patients with social phobia and panic disorder, providing further evidence against a unique relationship between separation anxiety disorder and panic disorder.

Cognitive therapy for psychosis in schizophrenia: an effect size analysis.

We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive therapy (CT) for psychotic symptoms in schizophrenia. Effect sizes were calculated for seven studies involving 340 subjects. The mean effect size for reduction of psychotic symptoms was 0.65. The findings suggest that cognitive therapy is an effective treatment for patients with schizophrenia who have persistent psychotic symptoms. Follow-up analyses in four studies indicated that patients receiving CT continued to make gains over time (ES=0.93). Further research is needed to determine the replicability of standardized cognitive interventions, to evaluate the clinical significance of cognitive therapy for schizophrenia, and to determine which patients are most likely to benefit from this intervention.

A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia.

There is a growing body of evidence that social phobia may be treated effectively by either pharmacologic or cognitive-behavioral interventions. but few studies have examined the relative benefits of these treatments. In this study, we examined the relative efficacy of pharmacotherapy with clonazepam and cognitive-behavioral group therapy (CBGT) for treating social phobia. In addition, we examined potential predictors of differential treatment response. Outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised) criteria for social phobia were randomly assigned to treatment. Clinician-rated and patient-rated symptom severity was examined at baseline and after 4, 8, and 12 weeks of treatment. All clinician-rated assessments were completed by individuals blind to treatment condition. Patients in both conditions improved significantly, and differences between treatment conditions were absent, except for greater improvement on clonazepam on several measures at the 12-week assessment. Symptom severity was negatively associated with treatment success for both methods of treatment, and additional predictors-sex, comorbidity with other anxiety or mood disorders, fear of anxiety symptoms, and dysfunctional attitudes-failed to predict treatment outcome above and beyond severity measures. In summary, we found that patients randomized to clinical care with clonazepam or CBGT were equally likely to respond to acute treatment, and pretreatment measures of symptom severity provided no guidance for the selection of one treatment over another.

The development of a scale to assess war-time atrocities: the War Events Scale.

The War Events Scale (WES) was developed to assist clinicians with the assessment of war zone veterans' exposure to, and participation in war-time atrocities distinct from combat, and their current distress from these events. Data concerning content validity, test-retest reliability, internal consistency, as well as correlational data with the Combat Exposure Scale and the Mississippi Scale are presented. Results indicate that the WES does have adequate internal consistency and test-retest reliability, and correlates moderately with the Combat Exposure and Mississippi Scales. Initial results suggest that the WES may be helpful in collecting extremely sensitive information concerning the exposure of war zone veterans to atrocities.

Prevalence and correlates of anger attacks: a two site study.

Although anger attacks have been described in depressed outpatients, they have not been well studied in other disorders. In Study 1, we examined the prevalence of anger attacks in 50 outpatients with panic disorder. In Study 2, we replicated the initial findings at an independent site and examined the specificity of anger attacks by comparing their occurrence in patients with panic disorder, patients with other non-panic anxiety disorders and patients with a depressive disorder. At both sites, we also explored the relationship between anger attacks and demographic and clinical characteristics, such as gender, presence and severity of depression, and social anxiety measures. In both sites, the prevalence of anger attacks in patients with panic disorder was approximately one-third. However, anger attacks were not unique to panic disorder, with similar rates emerging for patients with other anxiety disorders. Furthermore, patients with depressive diagnoses had twice the prevalence of anger attacks than did anxiety patients. At both sites, those with anger attacks were significantly more depressed and were likely to have either current or past history of major depression. Anger attacks were not associated with social anxiety measures, but were related to cluster B, cluster C and self-defeating personality disorder traits. Our findings support the notion that anger attacks are best conceptualized as an associated feature of depression.

The pharmacotherapy of social phobia.

Social phobia has been recognized as a discrete diagnostic condition only relatively recently. Epidemiological studies have shown that social phobia is associated with significant impairment and an increasing body of evidence has now indicated that pharmacological treatment is effective. Placebo-controlled studies have demonstrated the efficacy of the monoamine oxidase inhibitor phenelzine. A reversible inhibitor of monoamine oxidase A, moclobemide, is better tolerated and safer than the irreversible monoamine oxidase inhibitors and placebo-controlled studies have also demonstrated efficacy for this compound; moreover, positive results from a small study of brofaromine also support the efficacy of this class of compounds. It has been reported that a high-potency benzodiazepine, clonazepam, is effective but there is little placebo-controlled evidence to support the use of other benzodiazepines. Selective serotonin reuptake inhibitors are also being tested in social phobia with encouraging results. More studies are now needed on the long-term treatment of social phobia.

A comparison of bibliotherapy and group therapy in the treatment of panic disorder.

This study investigated 2 methods of disseminating a cognitive-behavioral intervention for panic disorder (PD). Thirty-six Ss who met diagnostic criteria for PD according to the Anxiety Disorders Interview Schedule-Revised were randomly assigned to 1 of 3 conditions: bibliotherapy (BT), group therapy (GT), or a waiting-list control (WL) condition. Interventions lasted 8 weeks and were followed by a posttest, along with 3- and 6-month follow-up assessments. Results indicated that both the BT and GT treatments were more effective than the WL condition in reducing frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression and that the BT and GT treatments were more effective in increasing self-efficacy. Both interventions maintained their effects throughout the follow-up periods and produced clinically significant levels of change among the majority of treated Ss.

Less food, less hunger: reports of appetite and symptoms in a controlled study of a protein-sparing modified fast.

This study compared reports of appetite and symptoms in 28 obese subjects randomly assigned to either a 500 calorie protein-sparing modified fast (PSMF) or a 1200-kcal balanced diet. During the first comparison month, subjects consuming the PSMF lost significantly more weight and reported significantly less hunger than did subjects consuming the 1200 kcal diet. Similar results were obtained for the second month, but differences in hunger were not statistically significant. There were no significant differences between conditions in subjects' ratings of their preoccupation with eating or in their ratings of the acceptability or disruptiveness of their diets. PSMF subjects reported significantly greater problems with cold intolerance, constipation, dizziness, dry skin, and fatigue. These symptoms remitted completely, however, when PSMF subjects consumed a 1200-kcal balanced diet. There were no significant differences between conditions in subjects' reports of psychological functioning. Results are discussed in terms of the need for further research to identify the characteristics of PSMF which confer anorexia.

Unilateral multicystic renal disease in adults.

Patients with multicystic kidneys that remained undetected for many years are currently our best source of information on the long-term fate of this type of renal dysplasia. We review 24 cases with adequate data reported in the literature and add 3 personal cases. Significant problems that were encountered and were related to these retained multicystic kidneys include abdominal pain, erroneous diagnosis of renal agenesis leading to repeated unrewarding medical studies for abdominal pain, abdominal mass and renal neoplasm arising in the dysplastic kidney.