Marcio Versiani

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care

These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 1: acute and continuation treatment of major depressive disorder

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

The role of noradrenaline and selective noradrenaline reuptake inhibition in depression.

Depression is a common disorder that impacts on all aspects of a persons life. For the past 10 years, clinicians have focused on serotonin in their treatment of depression. This is largely due to the growing acceptance of the efficacy and safety of the selective serotonin reuptake inhibitors (SSRIs) in comparison with older tricyclic antidepressants (TCAs). However, evidence for a role of noradrenaline in depression has been accumulating for some time, beginning with the discovery that drugs which either caused or alleviated depression acted to alter noradrenaline metabolism. Until recently, the role of noradrenaline in depression was predicted from clinical experience with noradrenergic TCAs (desipramine, nortriptyline and protriptyline) and selective serotonin and noradrenaline reuptake inhibitors (venlafaxine, milnacipran). The licensing of reboxetine, a selective noradrenaline reuptake inhibitor now allows the role of noradrenaline in depression to be investigated directly. This review presents key data from the literature that support a role for noradrenaline in depression taking into account neurophysiology, psychopharmacology and clinical trial data.

Tranylcypromine in Social Phobia

Thirty-two patients meeting DSM-III criteria for social phobia entered a 1-year drug treatment with tranylcypromine in dosages between 40 and 60 mg/day. After exclusion of the early dropouts, improvement was rated as marked and moderate in 62% and 17% of the sample (N = 29), respectively. Alcohol abuse was associated with a poor outcome. Side effects were frequent and in some cases delayed the attainment of efficacious dosages until the third month of treatment. No serious adverse reactions occurred. The findings, relative to efficacy, are in accordance with a previous trial with phenelzine but need confirmation in double blind controlled studies.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 2: maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with the biological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Early- and late-onset obsessive-compulsive disorder in adult patients: an exploratory clinical and therapeutic study.

It has been suggested that early- and late-onset forms of obsessive-compulsive disorder (OCD) may stem from different neurobiological substrates manifesting themselves through particular phenotypic profiles. Our study aimed to assess the existence of clinical and therapeutic differences between adult patients with early- and late-onset OCD (EOCD and LOCD, respectively). Sixty-six patients with OCD were consecutively recruited among individuals seeking treatment in a university hospital clinic for anxiety and depressive disorders. Patients with EOCD (n=33) and LOCD (n=33) were compared and contrasted with regard to clinical and therapeutic characteristics using the two tailed t test for continuous variables and the Pearsons goodness of fit Chi-square test for categorical ones; Fishers exact test was employed when indicated. We found that, compared to their LOCD counterparts, adult patients with EOCD were characterized by (1) male gender predominance, (2) greater number of clinically significant obsessions and compulsions, (3) higher frequency of rituals repetition, (4) increased severity of obsessive-compulsive symptoms at baseline, and (5) greater number of required therapeutic trials during the follow-up. However, no significant differences between groups were noted in the final treatment outcome. Our results are consistent with previous studies suggesting that EOCD may represent a more severe subtype of this disorder.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine–fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

Quality of life and symptom dimensions of patients with obsessive-compulsive disorder

The aim of this study was to evaluate the impact of different dimensions of obsessive-compulsive symptoms, of co-morbid anxious depressive symptoms, and of sociodemographic characteristics on the quality of life of patients with obsessive-compulsive disorder (OCD). We evaluated 53 patients with OCD and 53 age- and gender-matched individuals from the community with a sociodemographic questionnaire, the Structured Clinical Interview for the Diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, (DSM-IV), the Short-Form Health Survey-36 (SF-36), the Saving Inventory-Revised, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory. A series of stepwise linear regression analyses were performed, having the SF-36 dimensions as the dependent variables and the sociodemographic and clinical features as the independent ones. Patients with OCD displayed significantly lower levels of quality of life in all dimensions measured by the SF-36, except bodily pain. A model that included depressive symptoms, hoarding and employment status predicted 62% of the variance of the social functioning dimension of the quality of life of patients with OCD. Washing symptoms explained 31% of the variance of limitation due to physical health problems. Further, a series of models that included depressive, but not obsessive-compulsive symptoms, explained the remaining SF-36 dimensions. The severity of depressive and anxiety symptoms seems, therefore, to be powerful determinants of the level of quality of life in patients with OCD.

The long-term treatment of social phobia with moclobemide

Patients meeting the social phobia criteria of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) on the DSM-III-R Structured Clinical Interview (n=101) entered a long-term moclobemide treatment study. These patients were treated for 2 years with moclobemide (phase I) followed by drug withdrawal, in most cases abruptly (phase II). Those who relapsed entered phase III for a further period of 2 years of treatment. During phase I 40 patients (39.6%) withdrew due to inefficacy or relapse. Two patients were removed from the study because of other diagnoses (borderline or schizophreniform). At the end of phase I the remaining patients (58.4%) were rated as not ill (45.5%) or minimally ill (11.9%). Effort was taken to achieve the maximum dose of moclobemide (750 mg/day) and the mean (±SD) dose was 723.3 ± 67.7 mg/day (month 21). A marked decrease in symptoms in the patients who responded was recorded on the Liebowitz Scale for Social Phobia, Clinical Global Impressions, Hamilton Anxiety Scale and Hamilton Depression Scale. Non-response was mainly associated with co-morbidity, especially alcohol abuse, axis II disorders, and a history of major depression or secondary dysthymia. The drug was well tolerated; the more frequent side effects were mild and occurred mainly in the first 2 months of phase I, including nausea, headaches or insomnia. In phase II there was a relapse rate of 88% and 51 patients entered phase III; these patients are still being treated.

Impulse control disorders in patients with obsessive-compulsive disorder.

Abstract  The purpose of the present paper was to identify the rate of prevalence of impulse control disorders (ICD) in patients with obsessive–compulsive disorder (OCD) and to compare patients with OCD with and without ICD with regard to sociodemographic, clinical and prognostic characteristics. Forty‐five patients with OCD were assessed by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn, DSM‐IV) plus additional modules for the assessment of ICD and examined using the Yale–Brown Obsessive–Compulsive Scale, the Clinical Global Impression, the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Global Assessment of Functioning. These patients were treated with serotonin re‐uptake inhibitors (SRI) and followed for a variable period of time. Individuals with ICD (here defined as including not only the impulse control disorders not elsewhere classified of the DSM‐IV, but also other disorders in which impulse control is a prominent feature such as alcohol and drug dependence, paraphilias and bulimia nervosa/binge eating disorder) were compared to those without ICD using the Mann–Whitney U‐test and the Pearsons goodness of fit χ2 test. Sixteen patients with OCD (35.5%) displayed comorbid ICD. Patients with ICD were characterized by a significantly earlier age at OCD onset (P = 0.04), a more insidious appearance of OCD symptoms (P = 0.04), a higher rate of comorbid anxiety disorders (P = 0.03), a greater number (P = 0.02) and severity of compulsive symptoms (P = 0.04), an increased rate of counting compulsions (P = 0.02), and a higher number of required SRI trials (P = 0.01). When OCD is found in association with ICD, the clinical picture is characterized by a greater severity of the obsessive–compulsive symptoms at presentation and by the requirement of a greater number of therapeutic attempts during follow up.