Sriram Ramaswamy

Risperidone monotherapy for post-traumatic stress disorder related to sexual assault and domestic abuse in women

Post-traumatic stress disorder is a common, chronic, and often disabling mental illness. Selective serotonin reuptake inhibitors are the usual first-line treatment for post-traumatic stress disorder, but many patients fail to respond adequately. Thus, other treatment options, including the atypical antipsychotics such as risperidone, need to be tested. Women between the ages of 19 and 64 years with post-traumatic stress disorder were enrolled. Symptom severity was rated at baseline using the Treatment Outcomes Post-traumatic Stress Disorder Scale-8, Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, and Clinician Administered Post-traumatic Stress Disorder Scale. After washout from other psychotropic medications, 20 participants were randomized to either risperidone or placebo. Total score on the Treatment Outcomes Post-traumatic Stress Disorder Scale-8 served as the primary outcome measure. Repeated-measures analysis of variance was followed by Newman–Keuls tests. A significant main effect exists for visits using the Treatment Outcomes Post-traumatic Stress Disorder Scale-8 raw score. For the treatment group, the difference between baseline Treatment Outcomes Post-traumatic Stress Disorder Scale-8 scores and treatment visit scores was significant beginning at visit 6 and continued through visit 11. No significant difference observed between baseline and any treatment visit for the placebo group. The Clinician Administered Post-traumatic Stress Disorder Scale, Hamilton Rating Scale for Anxiety, and Hamilton Rating Scale for Depression data revealed a similar pattern. In this small pilot study, risperidone monotherapy was more effective than placebo in the treatment of post-traumatic stress disorder.

Aripiprazole possibly worsens psychosis.

Aripirazole is a novel antipsychotic that functions as a partial agonist at the dopamine D2 receptor and, thus, might theoretically worsen psychosis. We report a series of four clinical cases of exacerbation of psychosis related to initiation of aripiprazole therapy. Cases 1 and 2 demonstrated the worsening of psychosis following initiation of aripiprazole (15-30 mg daily) while tapering off the previous atypical antipsychotic. Cases 3 and 4 demonstrated worsening of psychosis following the addition of aripiprazole (15-30 mg daily) to an atypical antipsychotic. In two out of the four cases, discontinuation of arpiprazole resulted in improvement of psychotic symptoms. Although the cases presented are suggestive of a relationship between initiation of aripiprazole therapy and worsening of psychosis, further research is needed to clarify any potential association.

An Open-Label Trial of Memantine for Cognitive Impairment in Patients with Posttraumatic Stress Disorder

Background. Studies using standard neuropsychological instruments have demonstrated memory deficits in patients with PTSD. We evaluated the efficacy and safety of the N-methyl-D-aspartate antagonist memantine in veterans with PTSD and cognitive impairment. Methods. Twenty-six veterans with PTSD and cognitive impairment received 16 weeks of memantine in an open-label fashion. Cognition was assessed using the Spatial Span, Logical Memory I, and Letter-Number Sequencing subtests of the Wechsler Memory Scale III and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). RBANS measures attention, language, visuospatial skills, and immediate and delayed memories. The Clinician Administered PTSD Scale (CAPS), Hamilton Depression Scale (HAM-D), Hamilton Anxiety Scale (HAM-A), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), and Sheehan Disability Scale (SDS) were secondary outcome measures. Results. There was a significant improvement in RBANS, both total and subscale scores (P < 0.05), over time. There was a reduction in total CAPS scores, avoidance/numbing symptoms (CAPS-C) and hyperarousal symptoms (CAPS-D), HAM-D, Q-LES-Q, and SDS scores. However, there was no reduction in reexperiencing (CAPS-B) and HAM-A scores. Memantine was well tolerated. Conclusions. Memantine improved cognitive symptoms, PTSD symptoms, and mood in veterans with PTSD. Randomized double-blind studies are needed to validate these preliminary observations.

Artificial sweeteners as a sugar substitute: Are they really safe?

Nonnutritive sweeteners (NNS) have become an important part of everyday life and are increasingly used nowadays in a variety of dietary and medicinal products. They provide fewer calories and far more intense sweetness than sugar-containing products and are used by a plethora of population subsets for varying objectives. Six of these agents (aspartame, saccharine, sucralose, neotame, acesulfame-K, and stevia) have previously received a generally recognized as safe status from the United States Food and Drug Administration, and two more (Swingle fruit extract and advantame) have been added in the recent years to this ever growing list. They are claimed to promote weight loss and deemed safe for consumption by diabetics; however, there is inconclusive evidence to support most of their uses and some recent studies even hint that these earlier established benefits regarding NNS use might not be true. There is a lack of properly designed randomized controlled studies to assess their efficacy in different populations, whereas observational studies often remain confounded due to reverse causality and often yield opposite findings. Pregnant and lactating women, children, diabetics, migraine, and epilepsy patients represent the susceptible population to the adverse effects of NNS-containing products and should use these products with utmost caution. The overall use of NNS remains controversial, and consumers should be amply informed about the potential risks of using them, based on current evidence-based dietary guidelines.

A Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska: A Methodological Caveat

Abstract This study explored differences between homeless male veterans in metropolitan and micropolitan cities in Nebraska on sociodemographic, housing, clinical, and psychosocial characteristics as well as health service use. A convenience sample of 151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. Research staff conducted structured interviews with homeless veterans. Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.

The Role of Inflammation in Late-Life Post-Traumatic Stress Disorder

INTRODUCTION There is evidence that immune system dysregulation and inflammation may play a role in the development of post-traumatic stress disorder (PTSD). Previous studies have reported elevated levels of inflammatory markers such as C-reactive protein (CRP) in individuals with PTSD. However, it is unclear whether exacerbation of PTSD symptoms late in life is also associated with elevated inflammation. The purpose of this pilot study was to examine the relationship between inflammation and late-life PTSD. METHODS We recruited veterans either diagnosed with PTSD after the age of 55 or with no diagnosis of PTSD. Six veterans did not meet all eligibility criteria, including five who did not meet criteria for PTSD and one with celiac disease. The final sample included a total of 32 male veterans (16 veterans diagnosed with PTSD after 55 and 16 veterans without PTSD). The groups were matched as closely as possible on age, body mass index, and combat exposure. PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and depressive symptoms were assessed using the Hamilton Rating Scale for Depression. Inflammation was measured using serum CRP level. RESULTS The two groups did not differ on sample characteristics including age, body mass index, tobacco use, medication use, and military history. CRP level was found to be significantly higher in the PTSD group than in the comparison group (Z = -3.047, p = 0.002), which was also observed after adjusting for depression scores (F(1, 27) = 8.30, p = 0.0077). CONCLUSION The results from this pilot study suggest that late-life PTSD may be associated with increased inflammation. Further research in larger samples is needed to corroborate these findings and to clarify the relationship between inflammation and PTSD, which may lead to improved methods of diagnosis and treatment.

Clozapine and concomitant chemotherapy in a patient with schizophrenia and new onset esophageal cancer

Clozapine is the antipsychotic of choice in treatmentresistant schizophrenia [1]. Clozapine has been shown to substantially reduce the risk of suicide and psychiatric hospitalizations. However, the use of clozapine is limited by its risk of neutropenia and agranulocytosis, with a cumulative risk of approximately 0.8% to 1.5% at 1 year with little further increase over time. As such, the benefit gained in the reduction in all-cause mortality in schizophrenia far outweighs the risk of death from agranulocytosis [2,3]. Although clozapine can be safely prescribed using blood monitoring protocols, clinicians frequently face a dilemma when faced with the prospect of discontinuing clozapine in a psychiatrically stable patient requiring chemotherapy. Almost half of patients who abruptly discontinue clozapine experience rapid psychotic deterioration [4]. In such cases, the potential loss of therapeutic benefits from clozapine and risk of serious and life-threatening psychiatric symptoms must be carefully weighed against the accentuated risk of druginduced neutropenia. Unfortunately, there is limited evidence to guide clinical decision making under these circumstances. There are anecdotal reports in which clozapine was successfully continued during chemotherapy regimens despite neutropenia [5–8]. We present the case of a patient maintained on clozapine treatment despite chemotherapy (paclitaxel and carboplatin) for squamous cell carcinoma of the distal esophagus.

A Survey on the Preference of Text Book of Pharmacology by Undergraduate Medical Students in a Medical College in Puducherry

Good text books contribute significantly in effective learning of medical students. A total number of 93 second year undergraduate medical students from Sri Lakshminarayana Institute of Medical Sciences, Puducherry, participants in the survey on the use and views of text book of pharmacology. Of these 80 students belong to senior batch who have completed more than one year training in pharmacology; the remaining 13 students (junior batch) have completed six months. The survey revealed that 46.25% of students are using ‘Essentials of Medical Pharmacology’ by KD Tripathi. In contrast only 7.69% of junior batch preferred this text book. Forty percent of students of senior batch preferred the ‘Pharmacology prep manual for Undergraduates’ by Tara V Shanbhag, while 92.3% of the junior batch preferred the same. Text book of medical pharmacology by Padmaja Udaykumar was preferred by 12.5% of senior batch students and only by one student of junior batch. Easy understanding was attributed as a main cause for preference of the text book. From the statement of students it can be inferred that they give top priority for books which contain essential information, with less than 500 pages and simple, brief and clear explanation of mechanism of action. About 35% of students wanted pneumonics for easy recall without much stress. It appears from the survey in this study that students prefer text books from Indian authors. Hence, medical teachers from India should come forward to author text books which are reader friendly, illustrative and concise.

Sotalol-induced depression

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A double-blind, placebo-controlled randomized trial of vilazodone in the treatment of posttraumatic stress disorder and comorbid depression

Objective To determine the efficacy, safety, and tolerability of vilazodone in the treatment of posttraumatic stress disorder (PTSD) with comorbid mild-to-moderate depression. Methods A 12-week randomized, double-blind, placebo-controlled trial was conducted in adult outpatients who met DSM-IV criteria for PTSD with comorbid depression between February 2013 and September 2015. Participants were randomly assigned to receive vilazodone 40 mg/d or placebo, and outcome measures were obtained at scheduled visits. Primary outcome measures included change in PTSD symptoms from baseline to end of study as indexed by the Clinician-Administered PTSD Scale (CAPS) and PTSD Symptom Scale-Self-Report (PSS-SR). Secondary outcome measures of anxiety, depression, and impairment were obtained, as well as biomarker assessment at baseline and end of study. Results A total of 59 patients were randomly assigned to receive vilazodone (n = 29) or placebo (n = 30). Of those who were randomized, there were 25 completers in the vilazodone group and 22 completers in the placebo group. No significant differences were observed between the groups on any of the primary or secondary outcome measures. Vilazodone was generally well tolerated with few differences in the rate of adverse events between groups. Conclusions Treatment with vilazodone 40 mg/d did not improve symptoms of PTSD and comorbid depression. Further investigation of the biological mechanisms underlying PTSD may lead to identification of improved therapeutic targets. Trial Registration ClinicalTrials.gov identifier: NCT01715519.