Rafael Thomaz da Costa

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.

The effectiveness of cognitive behavioral group therapy in treating bipolar disorder: a randomized controlled study

OBJETIVO: Estudos recentes sugerem que uma psicoterapia estruturada aplicada junto com a farmacoterapia pode alterar o curso do transtorno afetivo bipolar. Entretanto, poucos estudos investigam os resultados da terapia cognitivo-comportamental em grupo sobre este transtorno psiquiatrico. O objetivo desta pesquisa foi avaliar a eficacia de 14 sessoes de terapia cognitivo-comportamental em grupo concomitante a farmacoterapia para bipolares e comparar com a farmacoterapia sozinha. METODO: Quarenta e um pacientes com transtorno bipolar I e II participaram do estudo e foram alocados aleatoriamente para um dos dois grupos; trinta e sete preencheram todas as escalas. Os sintomas de humor e ansiedade de todos os participantes foram acessados. A analise estatistica foi utilizada para investigar se os grupos diferiam com relacao aos dados demograficos e entre os escores pre-, durante e pos-tratamento (intra/intergrupos). RESULTADOS: Os participantes dos dois grupos mostraram-se similares nas caracteristicas demograficas. A adicao da terapia cognitivo-comportamental em grupo ao tratamento farmacologico foi efetiva. O grupo da terapia cognitivo-comportamental em grupo apresentou menos sintomas de mania, depressao e ansiedade, bem como uma reducao na frequencia e duracao dos episodios de humor. CONCLUSAO: As sessoes de terapia cognitivo-comportamental em grupo foram especialmente importantes na melhora dos sintomas depressivos.OBJECTIVE Recent studies suggest that, when combined with pharmacotherapy, structured psychotherapy may modify the course of bipolar disorder. However, there are few studies that have examined the effects of cognitive behavioral group therapy on the course of this disorder. The aim of the present study was to evaluate the effectiveness of 14 sessions of cognitive behavioral group therapy, combined with pharmacotherapy, on the treatment of patients with bipolar disorder, and to compare our results against those from the use of pharmacotherapy alone. METHOD Forty-one patients with bipolar I and II disorder participated in the study and were randomly allocated to one of two treatment groups; thirty-seven patients remained in the study until its completion. Mood and anxiety symptoms were measured in all subjects. Statistical analysis was used to investigate if the groups differed with respect to demographic characteristics and the scores recorded in the pre- and post-treatment stages, as well as during treatment (intra/inter groups). RESULTS Patients showed statistically similar population characteristics. The association of cognitive behavioral group therapy and pharmacological treatment proved to be effective. Patients who had undergone cognitive behavioral group therapy presented fewer symptoms of mania, depression and anxiety, as well as fewer and shorter mood change episodes. CONCLUSION Cognitive behavioral group therapy sessions substantially contributed to the improvement of depression symptoms.

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.

Group cognitive behavior therapy for bipolar disorder can improve the quality of life

Bipolar disorder (BD) can have an impact on psychosocial functioning and quality of life (QoL). Several studies have shown that structured psychotherapy in conjunction with pharmacotherapy may modify the course of some disorders; however, few studies have investigated the results of group cognitive behavior therapy (G-CBT) for BD. Our objective was to evaluate the effectiveness of 14 sessions of G-CBT for BD patients, comparing this intervention plus pharmacotherapy to treatment as usual (TAU; only pharmacotherapy). Forty-one patients with BD I and II participated in this study and were randomly allocated to each group (G-CBT: N = 27; TAU: N = 14). Thirty-seven participants completed the treatment (women: N = 66.67%; mean age = 41.5 years). QoL and mood symptoms were assessed in all participants. Scores changed significantly by the end of treatment in favor of the G-CBT group. The G-CBT group presented significantly better QoL in seven of the eight sub-items assessed with the Medical Outcomes Survey SF-36 scale. At the end of treatment, the G-CBT group exhibited lower scores for mania (not statistically significant) and depression (statistically significant) as well as a reduction in the frequency and duration of mood episodes (P < 0.01). The group variable was significant for the reduction of depression scores over time. This clinical change may explain the improvement in six of the eight subscales of QoL (P < 0.05). The G-CBT group showed better QoL in absolute values in all aspects and significant improvements in nearly all subscales. These results were not observed in the TAU control group.

Cognitive–behavioral therapy for bipolar disorder

Bipolar disorder is one of the most serious and prevalent psychiatric disorders. The aim of the present article is to review the efficiency of cognitive–behavioral therapy (CBT) for bipolar patients. Some studies show consistent evidence that cognitive therapy, concomitant to psycho-education and pharmacological treatment, offers efficacy in different phases of the disease. In most of the studies, patients undergoing CBT showed improvements in quality of life, with a reduction in both frequency and duration of mood episodes, as well as higher degrees of compliance and fewer hospitalizations. More studies are required to prove the effectiveness of CBT for bipolar disorder in the context of standardizing diagnostic criteria and measuring instruments to evaluate the disorder’s different phases and severity.

Exposição por realidade virtual no tratamento do medo de dirigir

A growing number of researches has appeared on virtual reality exposure therapy (VRET) to treat anxiety disorders. The purpose of this article was to review some evidences that support the VRET efficacy to treat driving phobia. The studies were identified through computerized search (PubMed/Medline, Web of Science, and Scielo databases) from 1984 to 2007. Some findings are promising. Anxiety/avoidance ratings declined from pre to post-treatment. VRET may be used as a first step in the treatment of driving phobia, as long as it may facilitate the in vivo exposure, thus reducing risks and high costs of such exposure. Notwithstanding, more randomized/controlled clinical trials are required to prove its efficacy.

Driving Cognitions Questionnaire: estudo de equivalência semântica

INTRODUCTION: The fear of driving may restrict the life of patients and cause serious personal, social, and occupational problems. It is important to use a suitable tool while assessing patients’ cognitions, once these findings may help formulate the problems observed and may guide the selection of a consistent treatment plan. The objective of this study was to describe the stages of translation and adaptation into Brazilian Portuguese of the Driving Cognitions Questionnaire, designed to measure cognitions that may be present in the fear of driving. METHODS: Three translations and three back translations were conducted by six independent evaluators. Semantic equivalence assessment and evaluation of the different versions were conducted and resulted in a synthesized version of the instrument. Comments made by 10 participants on the preliminary version of the questionnaire were examined. The preliminary Brazilian version of the questionnaire was developed. RESULTS: Most participants understood the cognitions as described in the Brazilian Portuguese version of the questionnaire. CONCLUSION: The use of three different translations and back translations, discussion of a preliminary synthetic version and interaction with the target population contributed to the viability of the process aimed to assess the semantic equivalence of the Brazilian final version.

White Bear Suppression Inventory: translation and cross-cultural adaptation to Brazilian Portuguese

Introduction Intrusive thoughts may cause a significant level of distress, since some individuals evaluate the content of those thoughts as aversive. Suppression of intrusive thoughts is one of the strategies adopted by these individuals, which increases the level of distress. Suppression of thoughts may be present as one of the factors that maintain different psychological disorders. Objective To describe the translation and adaptation into Brazilian Portuguese of the White Bear Suppression Inventory (WBSI), which measures thought suppression. Methods Three translations and back-translations were conducted by independent evaluators. Semantic equivalence was assessed and the three versions were evaluated to produce a synthesized version. Comments from participants on the preliminary version of the questionnaire were examined. Results We developed a preliminary Brazilian Portuguese version of the WBSI. It was found that most participants understood the descriptions of cognitions given in the translated questionnaire. Conclusion The use of three different versions of translations and back-translations, discussion of the synthetic version and interaction with the target population have conferred viability to the process of semantic equivalence of the Brazilian Portuguese final version of the WBSI.

Virtual reality exposure therapy for fear of driving: analysis of clinical characteristics, physiological response, and sense of presence

Objective: To investigate the reactions of women with driving phobia to a therapeutic program of scheduled virtual reality exposure treatment (VRET) sessions. Methods: The study intervention consisted of a computer game with car-driving scenarios that included several traffic situations. We investigated the participants’ sense of presence, subjective distress, and physiological responses during eight virtual-reality exposures. We also evaluated clinical characteristics, driving cognitions, and quality of life in the participants. Results: Thirteen women were selected. Eight were able to complete the protocol. After VRET, there was a decrease in the frequency of distorted thoughts and state anxiety scores, as well as a slight improvement in quality of life. Subjective discomfort scores, heart rate variation, and sense of presence scores confirmed that there was sense of presence in the virtual reality environment. Conclusion: All patients showed some degree of improvement and demonstrated different levels of anxiety in subsequent in vivo driving experiences. Our findings suggest that VRET could be used to facilitate in vivo exposure, because it can induce presence/immersion and reduce anxiety in patients with specific phobia. Furthermore, VRET is not associated with any type of risk.