Cristian Damsa

Effect of Nicotine Replacement Therapy on Agitation in Smokers With Schizophrenia: A Double-Blind, Randomized, Placebo-Controlled Study

OBJECTIVE The authors conducted a randomized, placebo-controlled study of nicotine replacement therapy for the reduction of agitation and aggression in smokers with schizophrenia. METHOD Participants were 40 smokers 18-65 years of age admitted to a psychiatric emergency service with a diagnosis of schizophrenia confirmed by the Mini International Neuropsychiatric Interview. Patients were screened for agitation with the excited component subscale of the Positive and Negative Syndrome Scale (PANSS) and for nicotine dependence with the Fagerström Test for Nicotine Dependence. A score of at least 14 on the PANSS excited component subscale and at least 6 on the Fagerström test were required for study eligibility. Participants in the nicotine replacement group received a 21-mg nicotine transdermal patch, and those in the placebo group were treated with a placebo patch. Participants received usual care with antipsychotics. The Agitated Behavior Scale and other agitation measures were administered at baseline and again at 4 and 24 hours. RESULTS At baseline, participants were at least moderately agitated, and 28% reported aggressive behavior in the previous week. The mean Agitated Behavior Scale score for the nicotine replacement group was 33% lower at 4 hours and 23% lower at 24 hours than for the placebo group. Participants with lower levels of nicotine dependence responded better than those with higher levels of dependence. CONCLUSIONS The drug-placebo difference in this study was similar to that obtained in trials of parenteral antipsychotics in similar populations. This finding suggests that in patients with schizophrenia, smoking status should be included in the assessment of agitation and nicotine replacement included in the treatment of those who are smokers.

Pharmacotherapy of panic disorder.

Panic disorder (PD) is a common, persistent and disabling mental disorder. It is often associated with agoraphobia. The present article reviews the current status of pharmacotherapy for PD with or without agoraphobia as well as the current status of treatments combing pharmacotherapy with cognitive behavior therapy (CBT). The review has been written with a focus on randomized controlled trials, meta-analyses, and reviews that have been published over the past few years. Effective pharmacological treatments include tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and various benzodiazepines. Treatment results obtained with CBT compare well with pharmacotherapy, with evidence that CBT is at least as effective as pharmacotherapy. Combining pharmacotherapy with CBT has been found to be superior to antidepressant pharmacotherapy or CBT alone, but only in the acute-phase treatment. Long term studies on treatments combining pharmacotherapy and CBT for PD with or without agoraphobia have found little benefit, however, for combination therapies versus monotherapies. New investigations explore the potential additional value of sequential versus concomitant treatments, of cognitive enhancers and virtual reality exposure therapy, and of education, self management and Internet-based interventions.

Therapeutic alliance in short-term supportive and psychodynamic psychotherapies: A necessary but not sufficient condition for outcome?

The therapeutic alliance is considered as one of the active relational factors to improve the outcome of patients engaged in a psychotherapeutic process. Our objective was to examine the role played by the therapeutic alliance in psychodynamic versus supportive psychotherapy. We examined data from a previously published randomized controlled study. Outpatients suffering from depression (n=74) received the same antidepressant (clomipramine) and were randomized into two groups, receiving either psychodynamic or supportive psychotherapy. Subjects were assessed at inclusion (Structured Clinical Interview for DSM-IV Disorders, SCID), during treatment and at discharge (Global Assessment Scale, Hamilton Depression Rating Scale, Helping Alliance questionnaire). Over time, the therapeutic alliance improved regardless of condition, and the relationship between alliance and outcome strengthened. This relationship was significant only among patients assigned to the supportive therapy condition. These data suggest that although the therapeutic alliance is an important factor in psychodynamic treatment, additional ingredients may be involved in its superiority compared to supportive therapy.

Are psychiatric residents still interested in psychoanalysis? A brief report.

In spite of the efficacy of the psychodynamic psychotherapies, the number of young psychiatric residents interested in psychodynamic therapies is decreasing. Our psychoanalytical group, Genden (Genève—Denver), explored the possible reasons for psychiatric residents’ hesitation to get psychoanalytic training. Five psychoanalytical psychotherapists met weekly for a year in order to debate that question, focusing on personal feedbacks from all of our 100 residents in psychiatry working with us for at least 4 years. Following the residents’ responses, our focus group proposed ten commonsense feedbacks for psychoanalysts regarding stimulating young psychiatric residents’ interest in psychoanalytic approaches.

A Naturalistic Study of Consecutive Agitated Emergency Department Patients Treated With Intramuscular Olanzapine Prior to Consent

1. Zayfert C, Deviva JC, Becker CB, Pike JL, Gillock KL, Hayes SA: Exposure utilization and completion of cognitive behavioral therapy for PTSD in a “real world” clinical practice. J Trauma Stress 2005; 18:637–645 2. Bryant RA, Sackville T, Dang ST, Moulds M, Guthrie R: Treating acute stress disorder: an evaluation of cognitive behavior therapy and counseling techniques. Am J Psychiatry 1999; 156: 1780–1786 3. Bradley R, Greene J, Russ E, Dutra L, Westen D: A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry 2005; 162:214–227