Evolution of sexual functioning of men through treated and untreated depression.

OBJECTIVES: Depression as well as a treatment by antidepressant are factors that may interfere with sexuality. Due to this complex relationship between depression, antidepressant and sexuality, it is difficult to incontestably establish the exclusive accountability of a treatment or of a psychiatric disorder on sexual dysfunctions. The main purpose of the SADD (for Sexuality, Anti-Depressant and Depression) study is to evaluate sexual dysfunctions in depressed men treated with antidepressant or not. METHODS: Participants of this transversal, observational study were men aged over 18 years old, suffering from unipolar major depressive disorder and treated by a psychiatrist, with or without antidepressant. Assessment of sexual functioning through three times: euthymia (before depression), untreated depression and treated depression if applicable was performed based on the ASEX scale. RESULTS: Seventy patients were included. Eight percent of euthymic patients presented a sexual dysfunction (average score on the ASEX=12.4) whereas 56% of untreated patients presented a sexual dysfunction (average total score on the ASEX=17.7) and 62% (34/55) of patients treated with antidepressant (average total score on ASEX=18.5) (P<0.001). Sexual functioning of men receiving treatment is not significantly different to that among men not receiving any antidepressant, even if patients treated with antidepressant reported that they had a better mood than those untreated. CONCLUSIONS: Our results reveal a high prevalence of sexual dysfunction within the framework of major depressive disorder and its treatment and underlines the complex relationship between major depressive disorder, antidepressant and sexuality.

[Oral glucocorticoid-induced psychiatric side-effects: focus on clinical specificities, incidence, risk factors and treatment]. / Troubles psychiatriques induits par la corticothérapie orale : mise au point sur la nature, l'incidence, les facteurs de risque et le traitement.

Oral glucocorticoids have been used for several decades and psychiatric side-effects may occur. This review will discuss relevant data of the clinical specificities, the incidence, the risk factors for the occurrence of these episodes and the preventive and curative medications of these episodes. We performed a literature review by using PubMed database. We selected and discussed articles and studies with high standard of evidence. The occurrence of psychiatric symptoms is quite frequent. The varying intensity of clinical features ranges from minor signs (impregnation) to acute psychotic episodes which may occur from 5 to 30% of patients. Affective symptoms or disorders are the most prominent clinical features. Delirium may occur and suicidal risk could be increased. The significant predictive factors are prednisone dosage more than 40 mg/day, particularly weight-based dosage, and a history of psychiatric disorders. When a reduced dosage of glucocorticoids is not sufficient to control the symptomatology, curative medication is mainly based on atypical antipsychotics such as olanzapine. Studies about neuropsychiatric complications of glucocorticoids present various and heterogeneous results. Further prospective clinical studies should be based on a close cooperation between physicians and consultation liaison psychiatrists. This collaboration is required for an optimized management of the patient who receive glucocorticoids.

[Schizophrenia and circadian rhythms]. / Schizophrénie et rythmes circadiens.

Circadian rhythms have not been widely studied in schizophrenic patients, probably for methodological feasibility reasons. The available findings relate to the awake/asleep cycle and are not particularly up to date. Clinically' the reduction in overall sleep time and sleep fragmentation are usual but relatively non-specific findings in decompensated psychotic episodes. Although H Ey's hypothesis of intermediate sleep by has not been followed up, EEG recordings support moderate abnormalities linked to certain times of progression such as a possible increase in MOR density or reduction in REM latency in delusional phases. The reduction in SLP is thought to be more a marker of the schizophrenic state as an illness. A possible action of some antipsychotics on sleep fragmentation would give them resynchronising activity, which remains to be confirmed.

[The therapeutic alliance in the initial stages of the management of depression by the general practitioner]. / L'alliance thérapeutique au début d'une prise en charge pour dépression par le généraliste.

In the field of depression, good initial management is crucial for the subsequent treatment. A relationship based on trust is essential. This can be of various types: there is no consensus on what is the "best" type of relationship. General practitioners diagnose more than two-thirds of depression and write out more than one third of prescriptions for antidepressors. Physicians are faced with various problems in the management of depressed patients: lack of time during the consultation, insufficient training in depression and its treatment, absence of somatic markers, fear of suicide risks... To specify the problems and elaborate responses, this survey assessed, mirror-wise, the point of view of the patient and that of the physician, the feelings regarding the pathology and its treatment, during consultations when the physician is confronted with a depression syndrome. Patient anonymousness was guaranteed by the use of a ballot box and sealed envelopes. In both parties, the survey explored the perception and experience of the pathology, the patient-physician relationship, and the history and perception of the initial consultations. Eligible patients were those who had been diagnosed with depression by the general practitioner and who had been informed of this during the past three months. Based on this information, and other than the data regarding the pathology, the procedure for establishing the diagnosis, the conditions in which the diagnosis was announced and the treatment measures, a characterisation of the alliance between the patient and the physician was established based on the combination of the patients' and physicians' data. Homogenous patient-physician groups were thus identified using multiple component factorial analysis followed by mixed classification. This methodology identified types of patient-physician binomials according to the nature of their alliance (independent of any "doctor effect"): a clinical alliance, a united alliance, an alliance based on sense, and a difficult alliance.

A double-blind randomised comparative trial of amisulpride versus olanzapine for 2 months in the treatment of subjects with schizophrenia and comorbid depression.

PURPOSE: To compare the efficacy and safety of amisulpride and olanzapine in subjects with schizophrenia and comorbid depression in a randomised double-blind trial. PATIENTS: Eighty-five adult patients fulfilling DSM-IV criteria for schizophrenia and presenting a depressive episode were randomised to amisulpride (200-600 mg/day) or olanzapine (5-15 mg/day) for 8 weeks. Primary efficacy variables were change in Calgary Depression Scale (CDS) score and Clinical Global Impression (CGI) of Change. Safety was monitored by adverse event reporting and determination of extrapyramidal function and metabolic variables. RESULTS: The mean change from baseline of CDS score was -6.84 in the amisulpride group and -7.36 in the olanzapine group. 65.9% and 61.5% of subjects, respectively, were considered "much" or "very much" improved. No significant inter-group difference in effect size was observed. The frequency of adverse events was low and emergence of extrapyramidal symptoms was not seen. Four patients in the olanzapine group developed abnormal triglyceride levels. Mean weight gain was 1.45 and 0.5 kg, respectively, in the olanzapine and amisulpride groups. CONCLUSION: Amisulpride and olanzapine are effective in patients with schizophrenia and comorbid depression. Tolerance of both drugs was acceptable, although use of olanzapine was associated with a trend toward greater metabolic side-effects .

A double-blind comparative study of clozapine and risperidone in the management of severe chronic schizophrenia.

OBJECTIVE: This prospective, double-blind, multicenter, parallel-group study compared the efficacy and safety of therapeutic doses of clozapine and risperidone in patients with severe chronic schizophrenia and poor previous treatment response. METHOD: Male or female patients aged 18-65 years who met DSM-IV criteria for schizophrenia and study requirements for poor previous treatment response (N=273) were randomly assigned to double-blind treatment with either clozapine or risperidone administered over 12 weeks in increasing increments. The primary efficacy measures were the magnitude of improvement in Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores. Adverse events were recorded throughout the study. RESULTS: The magnitude of improvement in mean BPRS and CGI scores from baseline to end of the study was significantly greater in the clozapine group than in the risperidone group. Statistically significant differences in favor of clozapine were also seen for most of the secondary efficacy measures (Positive and Negative Syndrome Scale, Calgary Depression Scale, Psychotic Depression Scale, and Psychotic Anxiety Scale). The adverse event profile was similar for both treatment groups, with a lower risk of extrapyramidal symptoms in the clozapine group. CONCLUSIONS: Clozapine showed superior efficacy over risperidone in this patient population. Both treatments were equally well tolerated as demonstrated through their adverse event profiles, although as expected clozapine was associated with a lower risk of extrapyramidal symptoms than risperidone.

Consensus on the Practical Use of Amisulpride, an Atypical Antipsychotic, in the Treatment of Schizophrenia.

Clinical expectations in schizophrenia treatment have greatly increased since the introduction of new atypical antipsychotics, but the choice of therapeutic strategy has become more complex and reference guidelines are scarce. This paper summarizes the consensus of a broad range of professionals after long-term commercialization in France of an atypical antipsychotic, amisulpride. Participants were from psychiatric hospitals, private clinics, out-patients settings and research; all were experienced with the drug. Discussions focused on the practical use of amisulpride, as, in addition to the double-blind trials information, it may be useful for psychiatrists of other countries to intuitively understand the therapeutic properties of amisulpride. The topics selected include acute psychotic episodes, short- and long-term follow-up, feasibility of treating the initial phase, the elderly and switching treatments. The French experience emphasizes the central role of amisulpride as a first-line treatment of schizophrenia.

[Risperidone-induced tardive dystonia: a case of torticollis]. / Dystonie tardive sous rispéridone: à propos d'un cas de torticolis.

Tardive dystonia is one of the most serious adverse events of typical neuroleptic treatments. They differ from tardive dyskinesia by their clinical and evolutive features. The occurrence of tardive dystonia due to new antipsychotics remained unknown. For the first time in the literature, we report a case of typical tardive dystonia occurring in a young male schizophrenic patient treated for 8 months with risperidone. No remission was observed despite several therapeutics including botulinic toxin.

Controlled efficacy study of fluoxetine in dysthymia.

BACKGROUND: There have been very few controlled studies of antidepressants in dysthymia, particularly in samples diagnosed reliably and with an adequate length of follow-up. In this investigation, we measured the long-term outcome in a large group of patients meeting DSM-III-R criteria for dysthymia. This study was designed to investigate whether fluoxetine is effective in the treatment of dysthymia. METHOD: This randomised study including 140 patients, compared fluoxetine (91 patients) and placebo (49 patients) on a double-blind basis in two distinct phases: a short-term end-point (3 months with 20 mg/day fluoxetine) and a medium-term end-point (6 months) where the initial responders continued double-blind treatment unchanged and non-responders received an additional treatment of 20 mg/day fluoxetine. RESULTS: After three months of treatment, response was seen more frequently in the fluoxetine group (42/72) than in the placebo group (14/39, P < 0.0001). Improved patients at 3 months were still improved at 6 months. Furthermore, 50% of the nonresponders at 3 months improved and rated as responders at 6 months, after fluoxetine was increased to 40 mg daily. CONCLUSIONS: This study showed the significant and persistent action of fluoxetine on dysthymia. The finding that 50% of the non-responders at 3 months were improved at 6 months, after fluoxetine dosage was increased to 40 mg daily, argues in favour of treating dysthymic patients for at least 6 months, and with a higher dosage if the initial doses are ineffective.

[Cytolytic hepatitis during treatment with phenothiazines: apropos of a case]. / Hépatites cytolytiques au cours du traitement par les phénothiazines: à propos d'un cas.

In contrast to the well known chlorpromazine-induced cholestatic hepatitis, we report the case of a schizophrenic patient who presents a cytolytic hepatitis, without any prior hepatic disease. Mr G. was first hospitalized for depressive symptomatology. A pseudo-nevrotic schizophrenia was diagnosed. Pretherapeutic clinical and biological data were normal. A treatment with chlorpromazine 400 mg/day was given. At day 8, the patient was still anxious and began to be agitated. An increase to 500 mg/day of chlorpromazine posology and an addition of haloperidol 200 mg/day was implemented. At day 10, the following clinical symptoms appeared: 38.6 degrees C fever; headache; myalgia; epigastralgia and hypocondrium pain. Biological hepatitis disturbances (ALAT, 984 U/L; ASAT, 414 U/L) and hypereosinophilia with normal white cell count were found. Clinical and biological investigations were normal. Blood-culture, A, B, C hepatitis, HIV and CMV serologies were negative. Neuroleptic treatment was discontinued. Evolution to normality of the disturbances and biological data suggested a cytolytic hepatitis. Mr G... remained treated with flupentixol without side-effects. Phenothiazine-induced cholestatis is frequent, mild, and recovers spontaneously. The biological mechanism is supposed to be immunologic. Prevalence of biological hepatic disturbances is 10 to 20% with chlorpromazine in long-term treatment. More often, symptomatology is the same; jaundice, pruritus, abdominal pain, fever. Although pharmacological data suggest for a cytotoxic activity of phenothiazines, cytolytic hepatitis is poorly described. Maximum range of transaminase blood level reported in previous studies is about 400 U/l. This level is not clearly correlated with hepatic cell lysis. Few cases of hepatic necrosis have been reported. In all cases, preexistent hepatic injuries were observed. Chlorpromazine-induced cytolytic hepatitis is uncommon and cholestatic hepatitis mild. Biological hepatic parameters investigations remain necessary during neuroleptic treatment.

[Profile of the action of neuroleptics in deficit schizophrenia]. / Profil d'action des neuroleptiques dans les schizophrénies déficitaires.

Schizophrenic patients have a deficit syndrom which now is better known with new scales like the SANS of N. Andreasen and the PANSS of Kay. The dichotomy of schizophrenia in two kinds of disease--positive and negative schizophrenia--needs a critical review; but treatment of negative symptoms remains a real and difficult problem. Effects of antipsychotic medication (neuroleptics) on negative symptoms of schizophrenia have been hypothesized since 1958 by french psychiatrists: Broussole and Dubor. The main classifications of neuroleptics by Delay-Deniker, Bobon, Colonna-Petit have acknowleged the action that is called: antiautistic effect, antideficit effect or desinhibiting effect. This conception is a quasi specific position of french psychiatrists in opposition to most of the american psychiatrists who have thought during a long time that negative symptom did not respond, or poorly, to neuroleptics. The improvement of the methodology of clinical studies has made possible to confirm the clinical impression of an effect of some typical neuroleptics on negative symptoms: flupentixol, fluphenazine or pimozide. Moreover, a bipolar action of some NLP: desinhibition at low doses and sedative at higher doses has been individualised for some compounds: sulpiride, pipotiazine or amisulpride. Atypical neuroleptic like clozapine or risperidone also can reduce negative symptoms. Today we are not able to determine "the good desinhibiting NLP for the good schizophrenic patient"; so new studies are needed.

[Calcium antagonists and lithium in preventive treatment of manic-depressive disorder]. / Inhibiteurs calciques et lithium dans le traitement prophylactique de la maladie maniaco-dépressive.

Recent advances in knowledge about calcium's role as an intracellular regulator allow to broaden understanding of possible pathophysiologic mechanisms in affective disorders. An hypothesis emerge that bipolar illness arise from disorders in calcium-regulated functions. Given this hypothesis, some authors propose to describe the common profiles of action of the different mood-stabilizers: all the neural mechanisms that are hypothesized to explain various psychopharmacological treatments of bipolar illness involve functions that are critically controlled by calcium. Moreover, in every instance, a known action of lithium on calcium-dependent processes could account for lithium's prophylactic results. Similarities exist between the action of lithium and calcium antagonists like verapamil and nimodipine. From these considerations the hypothesis emerge that calcium antagonists could be an alternative pharmacological agent in the maintenance treatment of bipolar illness. Calcium antagonists have been found useful in this indication by a number of investigators. Given the safety and relative lack of side effects of calcium channel blocking agents, their potential efficacy in mood disorders, it is concluded that calcium antagonists may be an alternative choice in prophylactic treatment for bipolar illness, especially in patients who cannot be treated with lithium or carbamazepine. There is evidence for using verapamil at 240 to 320 mg a day, in 2 to 4 times. Some studies suggest that the association of lithium with calcium antagonist resulted more effective than lithium alone or calcium antagonist alone in the reduction of episodes of affective disorders. However, concomitant administration of a calcium channel antagonist and lithium present adverse interactions (lithium toxicity, cardiovascular accidents), probably because of synergistic toxic effects. Therefore, authors advise care in monitoring patients receiving the combination of these medications.

[Treatment refractory schizophrenia]. / Notion de schizophrénie résistante.

Historically, first case-report of resistant schizophrenia were described under insulin therapy. Later on, the development of classical neuroleptics has permitted a better outcome but the persistence of a lack of improvement in certain patients has induced the individuation of treatment-refractory schizophrenia criteria. The difficulties in defining the refractory schizophrenic patients are described: variability of the schizophrenia diagnostic criteria, variability of outcome, lack of consensus about the good practices in neuroleptic treatment, difficulties in defining response criteria and the confusion between resistance, chronicity and severity. Three kinds of treatment refractory schizophrenia criteria are available: by Kane et al., May et Dencker, Brenner Dencker et al. There are few studies including resistant schizophrenic patients: their results are not homogeneous, perhaps because the prevalence of treatment-refractory schizophrenia is poorly known, with ranges from 5 to 25%. The following factors are hypothesized as being readily associated to a poor outcome and perhaps resistance: male sex, early illness beginning, severity of negative or formal thought disorder, absence of an affective syndrome, morphological CT scans abnormalities, pharmacological factors, late treatment initiation, variability of biodisposibility... Then the therapeutic point of view is considered under three main axes: neuroleptic drugs (NLP) are the basis of chemotherapy, but other therapeutic approaches complete the biological treatment: coherent institutional work and implication of family environment.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitive assay of thyroid stimulating hormone in depressed patients.

A decreased thyroid stimulating hormone (TSH) response to thyrotropin releasing hormone (TRH) has been noted in major depression. Some authors found a positive correlation between baseline TSH levels and TSH response to TRH, especially with sensitive assays of TSH. Serum TSH was assayed by a sensitive method in 55 depressed patients and 38 healthy volunteers. Patients were subclassified according to DSM-III as suffering from major depression (n = 40) and non-major depression (n = 15). The patients' mean score on the Hamilton Rating Scale for Depression (HRSD) was 50 (SD = 10). The TSH value was significantly lower in depressed patients compared with healthy control subjects, and in major compared with non-major depression. No differences in TSH levels distinguished the various subtypes of major depression. There was a significant negative correlation between global HRSD scores and TSH concentrations. The most anxious patients tended to have significantly lower TSH values compared with the least anxious subjects. Total HRSD insomnia scores correlated negatively with TSH concentrations after log transformation. The sensitive determination of TSH may also provide an index of thyroid function in depression that is simpler to implement than measurements of the TSH response to TRH.