Michelle N. Levitan

A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine.

Abstract This long-term extension of an 8-week randomized, naturalistic study in patients with panic disorder with or without agoraphobia compared the efficacy and safety of clonazepam (n = 47) and paroxetine (n = 37) over a 3-year total treatment duration. Target doses for all patients were 2 mg/d clonazepam and 40 mg/d paroxetine (both taken at bedtime). This study reports data from the long-term period (34 months), following the initial 8-week treatment phase. Thus, total treatment duration was 36 months. Patients with a good primary outcome during acute treatment continued monotherapy with clonazepam or paroxetine, but patients with partial primary treatment success were switched to the combination therapy. At initiation of the long-term study, the mean doses of clonazepam and paroxetine were 1.9 (SD, 0.30) and 38.4 (SD, 3.74) mg/d, respectively. These doses were maintained until month 36 (clonazepam 1.9 [SD, 0.29] mg/d and paroxetine 38.2 [SD, 3.87] mg/d). Long-term treatment with clonazepam led to a small but significantly better Clinical Global Impression (CGI)–Improvement rating than treatment with paroxetine (mean difference: CGI-Severity scale −3.48 vs −3.24, respectively, P = 0.02; CGI-Improvement scale 1.06 vs 1.11, respectively, P = 0.04). Both treatments similarly reduced the number of panic attacks and severity of anxiety. Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001). The efficacy of clonazepam and paroxetine for the treatment of panic disorder was maintained over the long-term course. There was a significant advantage with clonazepam over paroxetine with respect to the frequency and nature of adverse events.

Tapering clonazepam in patients with panic disorder after at least 3 years of treatment.

High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic disorder (PD) because of their rapid onset of action and good tolerability. However, there is concern about their potential to cause withdrawal symptoms. We aimed to develop a protocol for safely tapering off clonazepam in patients with PD who had been receiving treatment for at least 3 years. A specific scale for judging withdrawal was also developed, the Composite Benzodiazepine Discontinuation Symptom Scale. We selected 73 patients with PD who had been asymptomatic for at least 1 year and who wished to discontinue the medication. The trial consisted of a 4-month period of tapering and an 8-month follow-up period. The dosage of clonazepam was decreased by 0.5 mg per 2-week period until 1 mg per day was reached, followed by a decrease of 0.25 mg per week. The mean dosage at the start of tapering was 2.7 ± 1.2 mg/d. In total, 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol, and 19 (26.0%) of the patients needed another 3 months to be free of medication. Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches. The improvement in PD and general well-being was maintained during both the taper and follow-up phases. Clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. We recommend reducing the dosage of clonazepam after intermediate-term use by 0.25 mg/wk.

Tradução e adaptação transcultural do Questionário de Atividade Física Habitual

CONTEXTO: Atualmente ha na literatura um crescente interesse na interface entre exercicio fisico e transtornos psiquiatricos. Apesar disso, ainda ha uma deficiencia de instrumentos de autorrelato para medir os niveis de atividade fisica dos pacientes. OBJETIVO: A traducao, a afericao da equivalencia semântica e uma aplicacao piloto (n = 30), sem pretensao psicometrica, do Questionario de Atividade Fisica Habitual, visando sua utilizacao na populacao brasileira de diferentes niveis de escolaridade. METODOS: O processo envolveu duas traducoes e retrotraducoes realizadas por avaliadores independentes, avaliacao das versoes seguida da elaboracao de uma versao sintese e pre-teste comentado. RESULTADOS: A maioria dos participantes (91%) nao apresentou dificuldades de compreensao com o questionario. Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Mais estudos sao necessarios para determinar a adequacao para populacoes de baixa escolaridade. Os autores recomendam que sujeitos menos instruidos sejam supervisionados ao preencher o questionario. CONCLUSOES: A utilizacao de duas versoes de traducao e retrotraducao, a discussao sobre a versao sintese e a interlocucao com a populacao-alvo proporcionam maior seguranca ao processo de equivalencia semântica.

A Review of Preliminary Observations on Agomelatine in the Treatment of Anxiety Disorders

Agomelatine is an antidepressant with a novel mechanism of being a selective melatonergic MT₁/MT₂ receptor agonist with serotonin 5-HT(2c) receptor antagonist activities. Although the vast majority of the clinical data concerning the effectiveness of agomelatine concern its antidepressant properties, there is also preliminary evidence of anxiolytic effects. The purpose of the study was to perform a review of studies that investigated the efficacy of agomelatine in the treatment of anxiety disorders (ADs) and a discussion of the clinical utility of agomelatine in this clinical population. Previous clinical data indicated that agomelatine was more efficacious than both placebo and comparator drugs in reducing anxiety symptoms in depressed patients. Moreover, agomelatine effectiveness in the treatment of AD patients was observed in 2 double-blind, randomized trials, in a case series and in 3 case reports. Greater clinical evidence was observed with generalized AD patients. Agomelatine was efficacious both in reducing anxiety symptoms and in preventing relapses after a 6-month follow-up. However, concerning other ADs, evidence of agomelatines effects on anxiety was found only in isolated case descriptions. Nevertheless, those case reports emphasized the drugs favorable side effect profile (in comparison to serotonin reuptake inhibitors) and its effectiveness in treatment-refractory patients. Considering the high incidence of poor efficacy and tolerability of the first-line agents in the treatment of ADs, agomelatine seems to be a promising option in cases of treatment failure, and it could be used as a second or third option, as monotherapy or as augmentation treatment.

Equivalência semântica da versão brasileira da Social Avoidance and Distress Scale (SADS)

INTRODUCTION: There has been a growing scientific production on the adaptation of international instruments for social phobia. The cross-cultural adaptation is the first stage on the comparisons between different populations and presents the advantage of a low financial cost. This paper consisted in the process of semantic equivalence of the Social Avoidance and Distress Scale for the Brazilian population of different sociocultural levels. METHODS: The semantic equivalence involved two translations and back-translations performed by two independent evaluators, an evaluation of the versions and the development of a synthetic version, and a commented pretest. RESULTS: The results of the four stages were showed for each item of the instrument. Most participants had no difficulties in understanding the instrument. CONCLUSION: Use of two versions of translations, critical appraisal of the versions, and assessment of the target population provides more safety to the process of semantic equivalence.

Nocturnal panic attacks: clinical features and respiratory connections.

The clinical and therapeutic aspects of nocturnal panic attacks (NPAs) remain poorly understood. Some authors present NPAs as a more severe and less cognitive form of panic disorder (PD), whereas others treat it as a different manifestation of conventional panic attack. Overall, few articles address NPA relative to the large amount of literature regarding PD. Important aspects regarding the management of NPAs, such as the appropriate pharmacological and psychological treatment, rely on relatively few studies. This review provides an update and review of the most relevant articles regarding conceptualization of NPA, differential diagnosis, comorbidities, treatments, etiological theories and new investigations developed by various research centers. We also discuss the etiological hypotheses of NPAs, focusing on the suffocation false alarm theory and conditioned fear. NPA patients may represent a subtype of PD with specific agoraphobic features, respiratory connections and unique therapeutic aspects.

Habilidades Sociais na Agorafobia e Fobia Social

Anxiety disorders are commonly associated to social skills deficits. Social phobia is often related to this deficit, while agoraphobia is not considered. The purpose of this review is to investigate the literature on this association. An electronic search was conducted in the following databases: PsycINFO, MEDLINE and SCIELO, besides the references of some selected articles. Social skills deficit were more frequent in the studies that evaluated the performance of anxious individuals on unstructured tasks. Agoraphobia appears to be associated to an assertiveness deficit, although few studies were conducted.

Profile of agomelatine and its potential in the treatment of generalized anxiety disorder

Background Although many generalized anxiety disorder (GAD) patients respond to the available pharmacological treatments, nearly half of them do not present the expected results. Besides, the side effects associated to some drugs have a negative impact on treatment adherence. Therefore, the aim of this review was to report the clinical profile of agomelatine, a selective melatonergic MT1/MT2 receptor agonist with serotonin 5-HT2c receptor antagonist activities, as a potential pharmacological option in the treatment of GAD. Methods We performed a literature review regarding studies that evaluated the use of agomelatine in GAD treatment. Results Two short-term, double-blinded studies and one prevention-treatment trial evaluated the efficacy of agomelatine in the treatment of GAD. Agomelatine was associated with higher rates of clinical response and remission, when compared to placebo. In addition, the long-term use of agomelatine decreased the risk of relapse of anxiety symptoms, even for the severely ill patients. Besides, the tolerability was satisfactory with the absence of discontinuation symptoms, as observed in previous studies. Conclusion The efficacy and tolerability profiles of agomelatine in the treatment of GAD were good. However, the scarce number of trials, the small sample sizes, and the use of patients without any comorbid conditions were some limitations that impaired the generalization of the results in the general population. Nevertheless, agomelatine is an attractive off-label option in the treatment of GAD that needs more conclusive evidences to establish its role in future guidelines.

Public Speaking in Social Phobia: A Pilot Study of Self-Ratings and Observers' Ratings of Social Skills

OBJECTIVES The aim of this pilot study was to investigate whether patients with social anxiety disorder (SAD) differ from controls in the quality of skill-related behaviors displayed during a speech and in overall behavioral adequacy as perceived by observers and by the patients themselves. DESIGN A total of 18 SAD patients and 18 controls were screened by a diagnostic interview and took part in a 3-minute speech of their own choosing. For each videotaped speech, observers rated the adequacy of the skill-related behaviors and overall performance adequacy. After the experiment, participants were asked to rate their own overall performance adequacy. RESULTS The results showed that SAD patients exhibited significantly worse voice intonation and fluency of the speech, however no differences were found in global self-ratings. Moreover, the performance evaluations of the SAD group were consistent with the observers, while the controls evaluated their performance lower than the observers. CONCLUSIONS The results are inconsistent with the cognitive model, because patients with SAD did not underestimate their performance. Compared with spontaneous interactions, the clear rules established for such social situations as speeches may result in less cognitive distortion for SAD patients.

Social skill deficits in socially anxious subjects.

Research into the aetiology of social phobia can contribute to the prevention and treatment of socially anxious people. Based on the theory of social skills deficits, we reviewed several studies that examined the adequacy of social behaviour through behavioural experiments with the purpose of evaluating the existence of lack of social skills in socially anxious people compared with the general population. In addition to electronic searches for papers published since 1970, using Medline, Scielo and Lilacs, references from articles were identified. In general, the results indicate that socially anxious people perform poorly in spontaneous social interactions than control participants, are classified by observers as less assertive, friendly and shy but present only discrete differences in structured situations. Social skills deficit seems to be more easily identified when children and adolescents are observed, since they probably still have not developed coping strategies. Differences between social phobics appear to be found on the more global measures of performance rather than specific skills measures.