Duloxetine and escitalopram for hot flushes: efficacy and compliance in breast cancer survivors.

Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) might be an effective treatment for hot flushes (HFs) in breast cancer survivors (BCSs). This study aims to compare the efficacy and tolerability of duloxetine (SNRI) versus escitalopram (SSRI) in reducing frequency and severity of HFs in BCSs and to assess the effect on depression. Thirty-four symptomatic BCSs with emotional impairment received randomly duloxetine 60 mg daily or escitalopram 20 mg daily for 12 weeks. Patients were asked to record in a diary HF frequency and severity at baseline and after 4 and 12 weeks of treatment. Depression was evaluated through validated questionnaires (Beck Depression Inventory and Montgomery Asberg Depression Rating Scale) at baseline and after 4 and 12 weeks of treatment. Both drugs showed a significant reduction of HF frequency and severity after 12 weeks of treatment with no significant difference between the two groups. A significant improvement in depression symptoms was observed at the end of the study period within both the groups, without difference between the two drugs. In conclusion, escitalopram and duloxetine are both effective treatment for the relief of HFs in BCSs, with similar beneficial effect. A significant improvement of depression was obtained with no major side effects.

Spirituality, quality of life, psychological adjustment in terminal cancer patients in hospice.

The purpose of this study was to show the different components of spirituality in the last few weeks of life for advanced cancer patients admitted to hospice and to evaluate quality of life (QoL), pain, anxiety, depression and psychological adjustment to cancer. One hundred and fifteen patients were interviewed with a series of rating scales: the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being Scale, the Hospital Anxiety and Depression Scale, the Visual Analogue Scale for pain, the Brief Coping Orientation to Problem Experienced and the Functional Assessment of Cancer Therapy Scale - General Measure. Workers and single patients with higher education level showed a worse QoL. Moreover, anxiety and pain were negatively associated with QoL, while spirituality and 'Instrumental Support' coping style were positively associated with QoL. In the Italian sample, it was observed that when patients are close to death, faith is a more important component of spirituality than meaning/peace. This study confirms that QoL could be related to physical and psychological symptoms, and this reiterates the importance of faith in end-of-life care.

The Neurobiological Basis of the Distress Thermometer: A PET Study in Cancer Patients.

The objective of this study was to investigate the possible associations between the Distress Thermometer (DT) scores and the brain metabolism of structures involved in stress response. Twenty-one cancer patients were assessed using the DT, Problem Checklist and Hospital Anxiety and Depression Scale (HADS). The psychological measures were correlated with [18 F]PET-FDG brain glucose metabolism. Multiple and linear regression and binary logistic regression were run to analyse data. The DT and HADS scores illustrated that 48% of patients were distressed, 19% were depressed and 48% were anxious. Results showed that some subcortical areas activity, such as part of midbrain and of hypothalamus, was correlated with the DT scores. The Problem Checklist scores correlated with the activity of the same areas and included more regions in the limbic forebrain and brainstem. Compared with the DT and Problem Checklist, HADS-Depression scores showed a more extensive pattern of correlation with brain activity, including limbic and cortical areas. The results highlighted that the DT scores correlated with the activity of brain areas typically involved in stress response. Indeed, hypothalamus metabolism was found to be the best predictor of distressed patients.

Anxiety and depression in rheumatologic diseases: the relevance of diagnosis and management.

The high prevalence of emotional disorders (anxiety, chronic stress, mood depression) in patients with pain during rheumatologic diseases (particularly fibromyalgia) is closely related to the common pathogenic mechanisms concerning emotions and pain. Therefore a prompt identification of any psychic component of pain, also by means of specific tools, is a must, because it can require an adjustment of the therapeutic approach by combining both an analgesic treatment and antidepressants and/or psychotherapeutic strategies.

The chemotherapy long-term effect on cognitive functions and brain metabolism in lymphoma patients.

AIM: A growing number of neuropsychological studies reported that chemotherapy may impair brain functions, inducing persistent cognitive changes in a subset of cancer survivors. The aim of this paper was to investigate the neural basis of the chemotherapy induced neurobehavioral changes by means of metabolic imaging and neuropsychological testing. METHODS: We studied the resting brain [¹8F]FDG-PET/CT images of 50 adult cancer patients with diagnosis of lymphoma: 18 patients were studied prior and 32 after to chemotherapy. All patients underwent to a neuropsychological examination assessing cognitive impairment (tests for shifting attention, verbal memory, phonemic fluency), depression, anxiety and distress. RESULTS: Compared to no chemotherapy patients, the treated group showed significant bilateral lower rate of glucose metabolism in prefrontal cortices, cerebellum, medial cortices and limbic brain areas. The metabolism of these regions negatively correlated with number of cycles and positively with post-chemotherapy time. The treated group showed a poorer performance in many frontal functions, but similar level of depression, anxiety and distress. CONCLUSIONS: Chemotherapy induced significant long-term changes in metabolism of multiple regions with a prevailing involvement of the prefrontal cortex. The observed cognitive dysfunctions could be explained by these changes. The recovery from chemotherapy is probably affected by treatment duration and by the time elapsed after its end. We speculated that the mechanism could be an accelerating ageing / oxidative stress that, in some patients at risk, could result in an early and persistent cognitive impairment.

Migraine and depression comorbidity: antidepressant options.

Migraine and mood depression demonstrate a high clinical relation and share, also with pain, neurobiological mechanisms, particularly neuro-transmettitorial and phlogistic ones. The choice of an antidepressant to treat both depression and migraine is determined by its efficacy, safety, and tolerability. Antidepressants share comparable effectiveness for the treatment of depressive disorders, but their efficacy on headache varies widely: Tricyclic antidepressants are more effective than SNRIs and SSRIs, but demonstrate dose-limiting side effects.

Objective and self-reported cognitive dysfunction in breast cancer women treated with chemotherapy: a prospective study.

The objective of this study is to investigate if changes in cognitive functions can be recognised in patients undergoing chemotherapy for breast cancer. Forty women with breast cancer and without depression underwent cognitive evaluation before and after 6 months of chemotherapy; emotional evaluation was performed before and after 1, 3 and 6 months of chemotherapy. Self-reported cognitive deficit evaluation was included. Global cognitive functioning before starting chemotherapy was good. After 6 months of treatment there was a significant decline in some cognitive functions, particularly involving the attention subdomain. Objective cognitive deficit resulted independent from the emotional status. On the contrary, self-perceived mental dysfunction was unrelated to the objective cognitive decline, but it was associated with depression and anxiety. Breast cancer chemotherapy can induce domain-specific cognitive dysfunction. Patients' self-perception of mental decline is unrelated to objective cognitive deficit. Breast cancer patients negatively judge their cognitive performances if they have a negative emotional functioning.

Fast screening of depression in cancer patients: the effectiveness of the HADS.

In oncology clinics, there is an increasing need for fast and accurate screening scales and procedures in order to evaluate cancer patients for depression. The present study investigated the comparative effectiveness in recognising depressed patients of the Hospital Anxiety and Depression Scale (HADS), a self-report screening scale, and the Montgomery-Asberg Depression Rating Scale (MADRS), a semi-structured clinician-rated scale, in 151 patients affected by mixed cancer pathologies. With the MADRS, 73.5% of the patients were identified as depressed, whereas the HADS identified 36.4% and 58.3% as depressed, using the cut-offs of 11 and 8 respectively. The results suggest moderate agreement between the MADRS and the HADS when a cut-off of 8 is used (K-test: 0.44), while using a HADS cut-off of 11 gave a significantly higher underestimation of depressed patients (K-test: 0.29). In conclusion, the results suggest that the HADS can be useful as a sufficiently accurate first-step screening tool for depression in mixed oncology settings.

Discussion about switch strategy in the adjuvant hormonal therapy of breast cancer: psychological aspects of physician-patient communication.

BACKGROUND: A survey of oncologists was conducted in Italy to evaluate the potential problems of physician-patient discussion about hormonal switch in the adjuvant therapy of breast cancer. MATERIALS AND METHODS: A questionnaire, including both closed and open-ended questions, was administered to 70 oncologists. Fifty-one of them returned completely filled questionnaires. RESULTS: Forty-seven percent of the physicians reported difficulties in proposing the hormonal switch, and 60% stated that they found it difficult to make the therapeutic change acceptable to patients. The oncologist's barriers to propose the switch were related mostly to scientific and economic issues, such as the lack of certain advantages of aromatase inhibitors over tamoxifen (28%), their costs (14%) and their side-effects (34%). On the other hand, according to physicians, the patient's barriers to accept the therapeutic change were mainly due to psychological-relational factors, in particular the anxiety produced by the change (40%) and the bad patient-physician communication experienced in the past (26%). CONCLUSIONS: Patient-physician communication difficulties about switch strategy in the adjuvant hormonal treatment of breast cancer are, at least in part, related to psychological and relational factors. It is likely that training programs, improving doctor's communication skills, can overcome these problems.

Fibromyalgia syndrome: preventive, social and economic aspects.

There many open questions concerning the concept of primary prevention in FM. Diagnostic or classification criteria are not universally accepted, and this leads to difficulties in establishing the onset and duration of the disease. In the case of FM, primary prevention may consist of the immediate care of acute pain or treatment for affective disturbances as we do not have any specific laboratory or instrumental tests to determine risk factors of the disease. The goal of secondary prevention is early detection of the disease when patients are largely asymptomatic and intervention improves outcome. Screening allows for identification of an unrecognized disease or risk factor, which, for potential FM patients, includes analysis of tender points, Fibromyalgia Impact Questionnaire (FIQ), pain location and intensity, and fatigue and sleep complaints. Tertiary prevention inhibits further deterioration or reduces complications after the disease has developed. In FM the aim of treatment is to decrease pain and increase function via multimodal therapeutic strategies, which, in most cases, includes pharmacological and non-pharmacological interventions. Patients with FM are high consumers of health care services, and FM is associated with significant productivity-related costs. The degree of disability and the number of comorbidities are strongly associated with costs. An earlier diagnosis of FM can reduce referral costs and investigations, thus, leading to a net savings for the health care sector. However, every social assessment is closely related to the socio-economic level of the general population and to the legislation of the country in which the FM patient resides.

Fibromyalgia syndrome: definition and diagnostic aspects.

Ever since it was first defined, fibromyalgia (FM) has been considered one of the most controversial diagnoses in the field of rheumatology, to the point that not everybody accepts its existence as an independent entity. The sensitivity and specificity of the proposed diagnostic criteria are still debated by various specialists (not only rheumatologists), whose main criticism of the 1990 American College of Rheumatology criteria is that they identify subsets of particular patients that do not reflect everyday clinical reality. Furthermore, the symptoms characterising FM overlap with those of many other conditions classified in a different manner. Over the last few years, this has led to FM being considered less as a clinical entity and more as a possible manifestation of alterations in the psychoneuroendocrine system (the spectrum of affective disorders) or the stress reaction system (dysfunctional symptoms). More recently, doubts have been raised about even these classifications; and it now seems more appropriate to include FM among the central sensitisation syndromes, which identify the main pathogenetic mechanism as the cause of skeletal and extra-skeletal symptoms of FM and other previously defined "dysfunctional" syndromes.

Etiopathogenetic mechanisms of fibromyalgia syndrome.

Fibromyalgia syndrome (FMS) is a common chronic condition of widespread pain with causal mechanisms that are largely unknown. It is characterized by moderate to severe musculoskeletal pain and allodynia, but its pathogenesis appears confined to the nociceptive structures of the central nervous system. FMS is often triggered by negative environmental influences, especially if they occur in childhood. In a fetus, these environmental triggers may influence the development of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal axis (HPA). Increasing evidence supports the comorbidity of psychological conditions including depression, panic disorders, anxiety, and post-traumatic stress disorder (PTSD). Recent evidence suggests that genetic factors may play a role in the pathogenesis of FMS. Central sensitization has long been associated with FMS pain. It describes enhanced excitability of dorsal horn neurons, which leads to transmission of altered nociceptive information to the brain. Understanding of pathogenetic pathways in FMS has advanced beyond observing patient responses to neurophysiologically targeted therapies and basic research.

Non pharmacological treatments in fibromyalgia.

Fibromyalgia is a complex syndrome associated with significant impairment in quality of life and function and with substantial financial costs. Once the diagnosis is made, providers should aim to increase patients' function and minimize pain. Fibromyalgia patients frequently use alternative therapies, strongly indicating both their dissatisfaction with and the substantial ineffectiveness of traditional medical therapy, especially pharmacological treatments. At present, pharmacological treatments for fibromyalgia have a rather discouraging cost/benefit ratio in terms of poor symptom control and high incidence of side effects. The interdisciplinary treatment programs have been shown to improve subjective pain with greater success than monotherapy. Physical therapies, rehabilitation and alternative therapies are generally perceived to be more "natural," to have fewer adverse effects, and in some way, to be more effective. In this review, physical exercise and multimodal cognitive behavioural therapy are presented as the more accepted and beneficial forms of nonpharmacological therapy.

Symptoms and signs in fibromyalgia syndrome.

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population. Chronic widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headaches, and mood disorders. The etiology of FM is not completely understood and the syndrome is influenced by factors such as stress, medical illness, and a variety of pain conditions. Establishing diagnosis may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. A unifying hypothesis is that FM results from sensitization of the central nervous system; this new concept could justify the variety of characteristics of the syndrome. FM symptoms can be musculoskeletal, non-musculoskeletal, or a combination of both; and many patients will also experience a host of associated symptoms or conditions. The ACR classification criteria focus only on pain and disregard other important symptoms; but three key features, pain, fatigue and sleep disturbance, are present in virtually every patient with FM. Several other associated syndromes, including circulatory, nervous, digestive, urinary and reproductive systems are probably a part of the so called central sensitivity or sensitization syndrome. A minority subgroup of patients (30-40%) has a significant psychological disturbance. Psychological factors are an important determinant of any type of pain, and psychological comorbidity is frequent in FM. Psychiatric disorders most commonly described are mood disorders, but psychiatric illness is not a necessary factor in the etiopathogenesis of FM.

Fibromyalgia syndrome: the pharmacological treatment options.

Pharmacological treatment has been gradually enriched by a variety of compounds; however, no single drug is capable of fully managing the constellation of fibromyalgia (FM) symptoms. Currently, it is not possible to draw definite conclusions concerning the best pharmacological approach to managing FM because results of randomized clinical trials present methodological limitations and therapeutic programs are too heterogeneous for adequate comparison. However, a variety of pharmacological treatments including antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDS), opioids, sedatives, muscle relaxants and antiepileptics have been used to treat FM with varying results. In this review, we will evaluate those pharmacological therapies that have produced the most significant clinical results in treating FM patients. The nature of FM suggests that an individualized, multimodal approach that includes both pharmacologic and nonpharmacologic therapies seems to be the most appropriate treatment strategy to date.

The evaluation of the fibromyalgia patients.

Fibromyalgia (FM) is a rheumatic disease characterized by musculoskeletal pain, chronic diffuse tension and/or stiffness in joints and muscles, easy fatigue, sleep and emotional disturbances, and pressure pain sensitivity in at least 11 of 18 tender points. At present, there are no instrumental tests or specific diagnostic markers for FM; in fact, many of the existing indicators are significant for research purposes only. Many differential diagnoses may be excluded by an extensive clinical examination and patient history. Considering overlap of FM with other medical conditions, the treating physicians should be vigilant: chest-X-rays and abdominal ultrasonography are the first steps of general evaluation for all the patients with suspected FM. Functional neuroimaging methods have revealed a large number of supraspinal effects in FM, a disorder mediated by mechanisms that are essentially unknown. Many treatments are used in FM patients, but evaluating their therapeutic effects in FM is difficult because the syndrome is so multifaceted. To address the identification of core outcome domains, the Initiative on IMMPACT and OMERACT workshop convened a meeting to develop consensus recommendations for chronic pain clinical trials.

Therapeutic rationale of antidepressant use in the elderly.

Despite the dramatic increase of the number of elderly patients, and that depression represents one of the most important comorbidity in this age, psychopharmacological treatment always tends to be underused in this age. In this paper we reviewed the problems in the usage of antidepressant drugs in elderly patients, focusing on the pharmacokinetic and pharmacodynamic changes occurring with aging, which have to be carefully take into account to reduce side effects, and to maintain the same effectiveness of young and adult populations.

Quantification of the risk of post stroke depression: the Italian multicenter observational study DESTRO.

OBJECTIVE: The Italian multicenter observational study depression in stroke (DESTRO) aimed to identify risk factors for post stroke depression (PSD) and quantify the likelihood of it arising in various categories of patients. METHOD: Mood evaluation was performed in 1064 consecutive stroke patients by means of Beck Depression Inventory and Visual Analog Mood Scale. Depressive symptoms were classified using the DSM-IV and revised WHO criteria for depression in the course of a neurological disorder. RESULTS: Post stroke depression was seen in 36% of the survivors, with dysthymia by far the predominant form (80.7%). Female sex, disability, previous cerebrovascular or depressive episodes were significantly associated with an increased risk of depression. Combinations of these factors raised the risk of PSD exponentially, from 24.3 to 89.1%. The site of the stroke did not come into the uni- or multivariate analysis. CONCLUSION: At admission, it is possible to predict the likelihood of PSD and quantify the relative risk.

The structured assessment of depression in brain-damaged individuals: translation and validation study of the Italian version.

The aim of this study was to translate the structured assessment of depression in brain-damaged individuals (SADBD) questionnaire into the Italian language, validate, and test reliability and validity of the Italian version. Consecutive patients with stroke were screened in the Department of Neurology, Avogadro University in Novara and the Department of Neurorehabilitation, Maugeri Foundation, Veruno, Italy. Thirty patients were included in the study. The internal consistency ranged between 0.78 and 0.87. The intra-rater test-retest reliability was 0.93 for BDIderived items and 0.82 for HRSD-derived items; while the inter-rater test-retest reliability was 0.94 for BDI-derived items and 0.93 for HRSD-derived items. Correlation between the SADBD diagnosis made by the physician and the nurse was 0.51; correlation between caregiver and physician diagnosis was 0.60. The Italian version of the SADBD was demonstrated to be acceptable, reliable and a valid measure of depression in patients with stroke.

Post-stroke depression: research methodology of a large multicentre observational study (DESTRO).

The heterogeneity of published data regarding post-stroke depression (PSD) prompted an Italian multicenter observational study (DESTRO), which took place in 2000-2003. The investigation involved 53 Italian neurology centers: of these, 50 treat acute patients and 3 provide rehabilitation care; 21 centres are in Northern Italy, 20 are in Central Italy, and 12 are in Southern Italy. The time schedule was articulated into three phases: registration of 6289 stroke patients; selection of 1817 cases and enrollment of 1074 patients; and follow-up for two years (1064 patients). Mood assessment was performed by evaluating depressive symptoms according to DSM IV and the Beck depression inventory (visual analog mood scale for aphasic patients). Depressed patients were also administered the Montgomery-Asberg depression rating scale. Scores were related to function (Barthel index, modified Rankin scale), cognition (MMSE), quality of life (SF-36), and clinical data. Data analysis will provide information on PSD prevalence, onset and evolution, correlation with ischemic clinical syndrome, impact on activities of daily living, cognitive level and quality of life. The few data available at the present time concern PSD prevalence in the first six months after stroke (33.6%). DESTRO is a longitudinal investigation of a large patient sample and is expected to provide insights into the relationship of PDS with the functional and clinical consequences of stroke.