Clinical effectiveness of non-TMS neurostimulation in depression: Clinical trials from 2010 to 2020.

OBJECTIVE: Treatment for major depressive disorder (MDD) have evolved, although there is still a strong unmet need for more effective and tolerable options. The present study summarizes and discusses recent evidence regarding the non-transcranial magnetic stimulation (non-TMS) neurostimulation treatment for MDD. METHODS: The authors reviewed non-TMS neurostimulation clinical trials for MDD between 2010 and 2020. Electroconvulsive therapy was not included in this review. A systematic review was performed in MEDLINE database through PubMed, the Cochrane Collaboration's Clinical Trials Register (CENTRAL), PsycINFO and Thomson Reuters's Web of Science. RESULTS: Only 20 articles met the inclusion criteria. Randomized controlled trials demonstrated efficacy of transcranial direct current stimulation (tDCS) in five of seven trials. tDCS augmented with sertraline, fluoxetine, citalopram and escitalopram was superior to placebo and to tDCS only. A comparative trial demonstrated that the duration of tDCS sessions can modulate the effectiveness of this treatment. Open trials indicated that deep brain stimulation, epidural cortical stimulation, trigeminal nerve stimulation, magnetic seizure therapy and vagus nerve stimulation may be effective in treatment-resistant depression. CONCLUSION: This review confirmed the efficacy of tDCS in MDD. Despite new evidence showing effectiveness for other non-TMS neurostimulation, their effectiveness is still unclear. Non-TMS neurostimulation RCTs with large samples and head-to-head studies comparing non-TMS neurostimulation and gold standard pharmacological treatments are still lacking.

Quality of life in panic disorder: the influence of clinical features and personality traits / Qualidade de vida no transtorno de pânico: a influência de características clínicas e traços de personalidade

Abstract Objective To identify which clinical features and personality traits are associated with quality of life (QoL) in panic disorder (PD) patients. Methods This was a cross-sectional study with PD patients. The brief version of the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) and the Big Five Inventory (BFI) were used to assess QoL and personality traits respectively. The strength of correlations was measured with Pearson's, Spearman's, and point-biserial correlation coefficients. We also performed multiple linear regressions, considering sociodemographic data and scores from clinical scales as independent variables and QoL scores as dependent variables. Results A total of 98 patients were evaluated. Depressive symptoms had a strong negative correlation with QoL and, to a lesser extent, panic and anxiety symptoms were also negatively correlated with QoL. While consciousness, extraversion, and agreeableness had mild positive correlations with QoL, neuroticism had a strong negative correlation. Conclusion Symptoms of depression, anxiety, and panic seem to have a negative impact on the QoL of PD patients. Personality traits, especially neuroticism, may also influence QoL in these patients.

Resumo Objetivo Identificar quais características clínicas e traços de personalidade são mais associados à qualidade de vida (QdV) em pacientes com transtorno de pânico (TP). Métodos Este foi um estudo transversal, realizado em pacientes com TP. A versão breve do Questionário de Qualidade de Vida da Associação Mundial de Saúde (World Health Organization Quality of Life Questionnaire - WHOQOL-BREF) e o Inventário dos Cinco Grande Fatores (Big Five Inventory - BFI) foram utilizados para avaliar QdV e traços de personalidade, respectivamente. A força de associação foi medida através da correlação de Pearson, de Spearman ou ponto bisserial. Foram também realizadas regressões lineares múltiplas, considerando os dados sociodemográficos e escores obtidos nas escalas clínicas como variáveis independentes, e os escores de QdV como variáveis dependentes. Resultados Um total de 98 pacientes foram avaliados. Sintomas depressivos apresentaram uma forte relação negativa com QdV; em menor intensidade, sintomas de TP e ansiosos também se correlacionaram com QdV. Nos domínios de personalidade, enquanto conscienciosidade, extroversão e amabilidade apresentaram uma leve correlação positiva com QdV, neuroticismo apresentou forte correlação negativa. Conclusão Sintomas depressivos, ansiosos e de TP parecem ter forte impacto negativo na QdV dos pacientes com TP. Traços de personalidade, principalmente neuroticismo, podem influenciar QdV nesses pacientes.

Pharmacological and Neuromodulatory Treatments for Panic Disorder: Clinical Trials from 2010 to 2018.

OBJECTIVE: Treatment for panic disorder (PD) have evolved, although there is still a strong unmet need for more effective and tolerable options. The present study summarizes and discusses recent evidence regarding the pharmacological and neuromodulatory treatment of PD. METHODS: MEDLINE, Cochrane Library, PsycINFO and Thomson Reuters's Web of Science were searched for clinical trials published between 2010 and 2018. We included all prospective experimental studies including randomized controlled trials (RCT) and other clinical trials with more than 10 patients. RESULTS: Only 11 articles met the inclusion criteria, including 4 RCT, 3 open clinical trials and 5 comparative clinical trials. RCT demonstrated efficacy of transcranial magnetic stimulation (TMS) in only one of two trials. Neither pindolol nor d-fenfluramine were effective in blocking flumazenil-induced panic attacks. Augmentation with quetiapine was not superior to placebo. Open trials indicated that escitalopram, vortioxetine and TMS may be effective. Comparative trials did not demonstrate superiority from any drug, but confirmed tranylcypromine, paroxetine, clonazepam and alprazolam as effective options. CONCLUSION: The current study confirmed the efficacy of tranylcypromine, paroxetine, clonazepam, alprazolam and escitalopram. Vortioxetine and TMS, with duration of 4 or more weeks, also seems to be effective. Quetiapine, pindolol and d-fenfluramine were not considered effective compounds.

Quality of life in panic disorder: the influence of clinical features and personality traits.

OBJECTIVE: To identify which clinical features and personality traits are associated with quality of life (QoL) in panic disorder (PD) patients. METHODS: This was a cross-sectional study with PD patients. The brief version of the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF) and the Big Five Inventory (BFI) were used to assess QoL and personality traits respectively. The strength of correlations was measured with Pearson's, Spearman's, and point-biserial correlation coefficients. We also performed multiple linear regressions, considering sociodemographic data and scores from clinical scales as independent variables and QoL scores as dependent variables. RESULTS: A total of 98 patients were evaluated. Depressive symptoms had a strong negative correlation with QoL and, to a lesser extent, panic and anxiety symptoms were also negatively correlated with QoL. While consciousness, extraversion, and agreeableness had mild positive correlations with QoL, neuroticism had a strong negative correlation. CONCLUSION: Symptoms of depression, anxiety, and panic seem to have a negative impact on the QoL of PD patients. Personality traits, especially neuroticism, may also influence QoL in these patients.

Personality Traits in Panic Disorder Patients With and Without Comorbidities.

Panic disorder (PD) is often correlated with high neuroticism and low extraversion. This study aims to ascertain whether PD patients differ from healthy controls in regard to personality traits and determine if these traits are correlated with comorbid disorders, anxiety, and depression symptoms. Personality traits of 69 PD patients and 42 controls were compared using the Maudsley Personality Inventory. In PD patients, comorbidities, anxiety, and depression symptoms were also evaluated. PD patients showed higher neuroticism and lower extraversion compared with healthy controls. Patients without comorbidities presented similar results to controls, whereas those with comorbidities presented higher neuroticism and lower extraversion scores. PD per se may be unrelated to deviant personality traits, although comorbidities with major depressive disorder and agoraphobia are probably associated with high neuroticism and low extraversion. These traits show a strong correlation with the accumulation and severity of these disorders.

Treatment outcomes in patients with Internet Addiction and anxiety / Resultado de tratamento de pacientes com dependência de internet e ansiedade

OBJECTIVE: To investigate the effectiveness of a treatment for Internet addiction and anxiety disorders, using cognitive behavioral therapy combined with medication, and to analyze the relationship between anxiety and Internet addiction. METHOD: An open clinical trial included 84 patients (42 in the "comorbidities" group; 42 in the "no comorbidities" group) seeking treatment for anxiety symptoms and/or Internet Addiction. The subjects responded to The Mini International Neuropsychiatric Interview 5.0; the Hamilton Anxiety Scale (HAM-A), the Hamilton Depression Scale (HDRS), Clinical Global Impressions Severity and Improvement (CGI-S and CGI-I) and the Young Internet Addiction Scale (IAT). Patients who had only Internet addiction received psychoeducation on conscious internet use and bibliotherapy; they were defined as the group without comorbidities; patients diagnosed with Internet addiction and anxiety disorder (the group with comorbidities) were forwarded for pharmacotherapy and psychotherapy. RESULTS: Both Internet Addiction and anxiety decreased after treatment; the average of Hamilton Anxiety Scale of the "comorbidities" group at the beginning was 33.9 ± 7.6, suggesting severe anxiety, and at the end of treatment it was 15.0 ± 5.1, suggesting mild anxiety and a significant improvement. The average Internet Addiction score at the beginning was 67.8 ± 9.0; at the end of the psychotherapy an average score of 37.7 ± 11.4 was registered, indicating a notable and highly significant improvement. CONCLUSIONS: The relationship between anxiety and Internet Addiction existed and was strong. Treatment significantly improved both.

OBJETIVO: Investigar a eficácia de tratamento para dependência de internet e transtornos de ansiedade, utilizando terapia cognitivo comportamental combinada com medicação, e analisar a relação entre ansiedade e dependência de internet. MÉTODO: Ensaio clínico aberto realizado no Laboratório de Pânico e Respiração no Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB/UFRJ) com 84 pacientes (42 do grupo com comorbidades e 42 do grupo sem comorbidades) que procuravam tratamento para transtornos de ansiedade e/ou dependência de internet. Os sujeitos responderam ao MINI Entrevista Neuropsiquiátrica Internacional 5.0; a Escala Hamilton de Ansiedade (HAM-A), a Escala Hamilton de Depressão (HDRS), a Escala Clínica de Impressão Global de Severidade e de Melhora (CGI-S e CGI-I) e a Escala de Dependência de Internet de Young (IAT). Os pacientes com apenas dependência de internet receberam psicoeducação sobre o uso consciente da internet e biblioterapia, e foram considerados o grupo sem comorbidades, enquanto que, os pacientes com transtornos de ansiedade e dependência de internet foram encaminhados para o tratamento medicamentoso e psicoterapia. RESULTADOS: Tanto a dependência de internet quanto a ansiedade diminuíram após o tratamento, a média da HAM-A no grupo com comorbidades no início foi de 33,9 ± 7,6, sugerindo ansiedade grave e ao final do tratamento foi de 15 ± 5,1, sugerindo uma significativa melhora. A media de dependência de internet obtida na IAT no início do tratamento foi de 67.8 ± 9.0 e ao final da psicoterapia a maioria dos participantes apresentou média de 37.7 ± 11.4 indicando uma melhora notável. CONCLUSÃO: A relação entre ansiedade e dependência de internet existe e é forte.

Treatment of Internet Addiction with Anxiety Disorders: Treatment Protocol and Preliminary Before-After Results Involving Pharmacotherapy and Modified Cognitive Behavioral Therapy.

BACKGROUND: The growth of the Internet has led to significant change and has become an integral part of modern life. It has made life easier and provided innumerous benefits; however, excessive use has brought about the potential for addiction, leading to severe impairments in social, academic, financial, psychological, and work domains. Individuals addicted to the Internet usually have comorbid psychiatric disorders. Panic disorder (PD) and generalized anxiety disorder (GAD) are prevalent mental disorders, involving a great deal of damage in the patient's life. OBJECTIVE: This open trial study describes a treatment protocol among 39 patients with anxiety disorders and Internet addiction (IA) involving pharmacotherapy and modified cognitive behavioral therapy (CBT). METHODS: Of the 39 patients, 25 were diagnosed with PD and 14 with GAD, in addition to Internet addiction. At screening, patients responded to the MINI 5.0, Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, Clinical Global Impressions Scale, and the Young Internet Addiction Scale. At that time, IA was observed taking into consideration the IAT scale (cutoff score above 50), while anxiety disorders were diagnosed by a psychiatrist. Patients were forwarded for pharmacotherapy and a modified CBT protocol. Psychotherapy was conducted individually, once a week, over a period of 10 weeks, and results suggest that the treatment was effective for anxiety and Internet addiction. RESULTS: Before treatment, anxiety levels suggested severe anxiety, with an average score of 34.26 (SD 6.13); however, after treatment the mean score was 15.03 (SD 3.88) (P<.001). A significant improvement in mean Internet addiction scores was observed, from 67.67 (SD 7.69) before treatment, showing problematic internet use, to 37.56 (SD 9.32) after treatment (P<.001), indicating medium Internet use. With respect to the relationship between IA and anxiety, the correlation between scores was .724. CONCLUSIONS: This study is the first research into IA treatment of a Brazilian population. The improvement was remarkable due to the complete engagement of patients in therapy, which contributed to the success of the treatment from a behavioral perspective, and gave patients the confidence to continue to manage Internet use in their lives.

Treatment-resistant panic disorder: a systematic review.

INTRODUCTION: The prevalence of panic disorder (PD) in the population is high and these patients have work impairment, high unemployment rates, seek medical treatment more frequently and have more hospitalizations than people without panic symptoms. Despite the availability of pharmacological, psychological and combined treatments, approximately one-third of all PD patients have persistent panic attacks and other PD symptoms after treatment. AREAS COVERED: MEDLINE/Pubmed, CENTRAL, PsycINFO and Web of Science databases were searched for clinical trials in treatment-resistant PD. Only studies published between 1980 and 2015, in English, with human subjects, considered "journal articles" and clinical trial were included. We included trials recruiting only adult subjects with treatment-resistant PD, consistent with criteria from DSM-III to DSM5. We included all prospective experimental studies. Case, case series, retrospective studies or studies with <10 PD subjects were not included. EXPERT OPINION: Only 11 articles were included in this review. There were few quality studies, only two were randomized, controlled and double blind. Augmentation of the pharmacological treatment with cognitive-behavioral therapy demonstrated some short-term efficacy in treatment-resistant PD. There were also preliminary evidences of efficacy for monotherapy with reboxetine and olanzapine, and augmentation with pindolol, divalproex sodium, aripiprazole and olanzapine in short-term treatment.

Laboratory, clinical and therapeutic features of respiratory panic disorder subtype.

OBJECTIVE: It is our aim to elaborate on the new developments in regard to the respiratory subtype (RS) of panic disorder (PD) since it was first described. We will present psychopathological features, diagnostic criteria, genetic and physiopathological hypotheses, as well as therapeutic and prognostic characteristics. METHOD: Two searches were performed in the Thomson Reuters Web of Knowledge (http://wokinfo.com/): 1 - search terms: "panic disorder" AND ("respiratory symptom" OR "respiratory symptoms" OR "respiratory subtype" OR "respiratory panic" OR "cardiorespiratory"); 2 - all articles citing Briggs and colleagues' 1993 article "Subtyping of Panic Disorder by Symptom Profile" (Br J Psychiatry 1993;163: 201-9). Only those articles involving human subjects and written English were included. RESULTS: In comparison with patients of the non-respiratory subtype (NRS), RS patients showed greater familial history of PD, and higher comorbidity rates for anxiety disorders and depressive disorders. These patients were also more sensitive to CO2, hyperventilation and caffeine. CONCLUSION: Certain characteristics, such as heightened sensitivity to CO2 and the higher incidence of a family history of PD, clearly distinguished the Respiratory Subtype patients from the Non-Respiratory. Nonetheless, some studies failed to demonstrate differential responses to pharmacological treatment and CBT across the subtypes. RS patients seem to respond faster than NRS to pharmacological treatment with antidepressants and benzodiazepines, but more studies are needed to confirm this finding.