Michelle Magid

Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, double-blind, placebo-controlled study.

OBJECTIVE To determine whether a single treatment of botulinum toxin A in the forehead (glabellar) region can improve symptoms of depression in patients with major depressive disorder (MDD), as defined by DSM-IV criteria. METHOD Thirty participants were randomly assigned to receive either placebo or botulinum toxin A (BTA; onabotulinumtoxinA) injections in the forehead. Female participants received 29 units; male participants received 39 units. At week 12, the groups were crossed over. Participants were evaluated at weeks 0, 3, 6, 12, 15, 18, and 24 for improvement in MDD symptoms using the Patient Health Care Questionnaire-9, Beck Depression Inventory (BDI), and 21-Item Hamilton Depression Rating Scale (HDRS-21) objective measurement scales. The primary outcome was the rate of HDRS-21 response, defined as ≥ 50% score reduction from baseline. The study occurred from July 2011 to November 2012. RESULTS Patients who received BTA at week 0 (BTA-first group) and at week 12 (BTA-second group) had a statistically significant reduction in MDD symptoms as compared to placebo. Improvement in MDD continued over 24 weeks in the group that received BTA first even though the cosmetic effects of BTA wore off at 12 to 16 weeks. HDRS-21 response rates were 55% (6/11) in the BTA-first group, 24% (4/17) in the BTA-second group, and 0% (0/19) in the placebo group (P < .0001). HDRS-21 remission rates (score ≤ 7) were 18% (2/11), 18% (3/17), and 0% (0/19), respectively (P = .057). HDRS-21 scores dropped -46% and -35% in the BTA-first and -second groups versus -2% in the placebo group (P < .0001). The BDI response rate (≥ 50% reduction from baseline) was 45% (5/11) in the BTA-first group, 33% (6/18) in the BTA-second group, and 5% (1/19) in the placebo group (P = .0067). BDI remission rates (score ≤ 9) were 27% (3/11), 33% (6/18), and 5% (1/19), respectively (P = .09). BDI scores dropped -42% and -35% in the BTA-first and -second groups versus -15% in the placebo group (P < .0001). CONCLUSIONS Botulinum toxin A injection in the glabellar region was associated with significant improvement in depressive symptoms and may be a safe and sustainable intervention in the treatment of MDD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01392963.

Agitation Predicts Response of Depression to Botulinum Toxin Treatment in a Randomized Controlled Trial

In a randomized, controlled trial (n = 30), we showed that botulinum toxin injection to the glabellar region produces a marked improvement in the symptoms of major depression. We hypothesized that the mood-lifting effect was mediated by facial feedback mechanisms. Here we assessed if agitation, which may be associated with increased dynamic psychomotor activity of the facial musculature, can predict response to the treatment. To test this hypothesis, we re-analyzed the data of the scales from our previous study on a single item basis and compared the baseline scores in the agitation item (item 9) of the Hamilton Depression Rating Scale (HAM-D) between responders (n = 9) and participants who did not attain response (n = 6) among the recipients of onabotulinumtoxinA (n = 15). Responders had significantly higher item 9 scores at baseline [1.56 + 0.88 vs. 0.33 + 0.52, t(13) = 3.04, d = 1.7, p = 0.01], while no other single item of the HAM-D or the Beck Depression Inventory was associated with treatment response. The agitation score had an overall precision of 78% in predicting response in a receiver operating characteristic (ROC) analysis (area under the curve, AUC = 0.87). These data provide a link between response to botulinum toxin treatment with a psychomotor manifestation of depression and thereby indirect support of the proposed facial feedback mechanism of action. Moreover, it suggests that patients with agitated depression may particularly benefit from botulinum toxin treatment.

Use of electroconvulsive therapy in a patient 10 days after myocardial infarction.

Electroconvulsive therapy (ECT) is a safe and effective treatment of severe depression, even in patients with cardiac risk factors. Although rare, cardiovascular events during ECT remain a principal cause of morbidity and mortality. In particular, a history of recent myocardial infarction (MI) increases the risk of ventricular arrhythmias and cardiac rupture. A widely accepted recommendation is to administer ECT at least 3 months after MI, but sometimes a delay is not possible. Limited literature exists on the use of ECT in severely depressed patients with recent MI. Our literature review revealed 1 previously published case, with less than favorable results. In this case report, we describe a severely depressed, catatonic elderly man who was safely and successfully treated with ECT 10 days after an acute MI. It is essential that appropriate cardiac management be provided before, during, and after ECT by a multidisciplinary team of psychiatrists, internists, cardiologists, and anesthesiologists. Our case report suggests that, with proper management and close monitoring, ECT can be administered safely, even in patients with recent MI.

Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials.

INTRODUCTION Botulinum toxin A (BTA) injection into the glabellar region is currently being studied as a treatment for major depressive disorder (MDD). Here we explore efficacy data of this novel approach in a pooled analysis. METHODS A literature search revealed 3 RCTs on this topic. Individual patient data and clinical end points shared by these 3 trials were pooled and analyzed as one study (n=134) using multiple regression models with random effects. RESULTS In the pooled sample, the BTA (n=59) and the placebo group (n=75) did not differ in the baseline variables. Efficacy outcomes revealed BTA superiority over placebo: Improvement in the Hamilton Depression Rating Scale or Montgomery-Asberg Depression Rating Scale 6 weeks after baseline was 45.7% for BTA vs. 14.6% for placebo (p<0.0001), corresponding to a BTA response rate of 54.2% (vs. 10.7%) and a BTA remission rate of 30.5% (vs. 6.7%). DISCUSSION Equalling the status of a meta-analysis, this study increases evidence that a single treatment of BTA into the glabellar region can reduce symptoms of MDD. Further studies are needed to better understand how BTA exerts its mood-lifting effect.

A cure for delusions of parasitosis

© 2007 The Authors 1423 JEADV 2007, 21, 1413–1450 Journal compilation

Psychocutaneous disease: Clinical perspectives

Psychocutaneous disease, defined in this review as primary psychiatric disease with skin manifestations, is commonly encountered in dermatology. Dermatologists can play an important role in the management of psychocutaneous disease because patients visit dermatology for treatment of their skin problems but often refuse psychiatric intervention. This review describes common psychocutaneous syndromes, including delusional, factitious, obsessive-compulsive and related, and eating disorders, as well as psychogenic pruritus, cutaneous sensory (pain) syndromes, posttraumatic stress disorder, and sleep-wake disorders. The updated classification of these disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition is included. Strategies for management are reviewed.

Neurotoxins: Expanding Uses of Neuromodulators in Medicine--Major Depressive Disorder.

Background: Botulinum toxin A (BTA) is one of the most diversely used medications of the 21st century and is now being researched as a treatment for major depressive disorder (MDD). Methods: The authors performed a literature search of PubMed, Web of Science, and the Cochrane Register of Controlled Trials. The primary investigators of the studies were contacted for additional unpublished data. Results: The authors identified 5 studies that met the criteria of using BTA in the treatment of MDD. All studies showed significant reduction in depressive symptoms with BTA injected into the glabellar muscles. In a pooled analysis, botulinum toxin (n = 59) vs placebo (n = 75) had a –47% vs –16% reduction in self-rated depression scores (P < 0.0001) and a –46% vs –15% reduction in expert-rated depression scores (P < 0.0001), respectively. Adverse reactions were mild (temporary headaches and local irritation immediately after injection) and did not differ between active group (13.6%) and placebo group (9.3%) (P = 0.44). Conclusions: Botulinum toxin injections in the glabellar frown muscles have been associated with a significant improvement in depressive symptoms. Given the prevalence of MDD, the promising results of preliminary trials, and the excellent tolerability of this treatment intervention, larger studies are warranted.

The Spectrum of Ideation in Patients with Symptoms of Infestation: From Overvalued Ideas to the Terminal Delusional State

Delusional infestation (DI) is a type of monosymptomatic hypochondriacal psychosis characterized by the steadfast belief that one is infested with living organisms or inanimate material in the absence of objective proof. Although DI is generally regarded as a single psychotic phenotype characterized by either the presence or absence of a delusion, our experience has been that patients with DI present with varying levels of severity represented by various phenotypes along a continuum. Distinguishing where a particular patient presents on this spectrum has allowed us to modify our approach with greater sophistication and thereby optimize management. Our aim is to describe for the first time in dermatology the concept of the DI continuum with support from the psychiatric literature, and to provide practical therapeutic recommendations for each phenotype in the spectrum.

Psychocutaneous disease : Pharmacotherapy and psychotherapy

Building a strong therapeutic alliance with the patient is of utmost importance in the management of psychocutaneous disease. Optimal management of psychocutaneous disease includes both pharmacotherapy and psychotherapy. This article reviews psychotropic medications currently used for psychocutaneous disease, including antidepressants, antipsychotics, mood stabilizers, and anxiolytics, with a discussion of relevant dosing regimens and adverse effects. Pruritus management is addressed. In addition, basic and complex forms of psychotherapy, such as cognitive-behavioral therapy and habit-reversal training, are described.

Efficacy of right unilateral ultrabrief pulse width ECT: A preliminary report

Background and Objectives Ultrabrief (right unilateral) electroconvulsive therapy (UB-RU ECT) is a newer form of ECT, which uses a shorter pulse width than the standard ECT (0.3 vs 1.0 millisecond, respectively). As a result, the use of UB ECT may provide a means of further decreasing ECT-related cognitive adverse effects. In 2011, the University of Texas Southwestern Department of ECT in Austin adopted a UB ECT protocol. The purpose of this study was to perform a preliminary evaluation of the effectiveness and efficiency of UB-RU ECT. This study also examined whether sex, age, or diagnosis affected response rates. Methods This retrospective chart review identified 62 patients treated with the UB ECT protocol. An analysis of ECT response rates and demographic characteristics was conducted based on the data from clinical evaluations and Patient Health Questionnaire 9. Results Sixty-eight percent of patients in the study responded to ECT; 55% responded to UB pulse width RU ECT with another 13% responding when switched to standard pulse width bilateral ECT. The mean number of treatments in an index ECT series was 12.5. There was no statistically significant difference in response rates between bipolar and unipolar depressed patients. Men required progression to bilateral treatment more than women. Conclusions This UB ECT protocol demonstrated a similar response rate when compared to standard ECT protocols; however, an increase in the number of treatments was required. Ultrabrief protocols are a viable option for both bipolar and unipolar depression. In men, UB ECT protocols may be less advantageous due to a need to overcome a potentially higher seizure threshold in men; however, additional research is needed to confirm this finding.