Veeraindar Goli

Venlafaxine extended release in the treatment of painful diabetic neuropathy: a double-blind, placebo-controlled study.

&NA; To evaluate the efficacy and safety of 6 weeks of venlafaxine extended‐release (ER) (75 mg and 150–225 mg) treatment in patients with painful diabetic neuropathy. This multicenter, double‐blind, randomized, placebo‐controlled study included 244 adult outpatients with metabolically stable type 1 or 2 diabetes with painful diabetic neuropathy. Primary efficacy measures were scores on the daily 100 mm Visual Analog Pain Intensity (VAS‐PI) and Pain Relief (VAS‐PR) scales. Secondary efficacy measures included the Clinical Global Impressions–Severity of Illness and the Clinical Global Impressions–Improvement, Patient Global Rating of Pain Relief, and percentage of patients achieving 50% reduction in pain intensity. Baseline pain intensity was 68.7 mm (moderately severe). At week 6, the percentage reduction from baseline in VAS‐PI was 27% (placebo), 32% (75 mg), and 50% (150–225 mg; P<0.001 vs placebo). Mean VAS‐PR scores in the 150–225 mg group were significantly greater than placebo at week 6 (44 vs 60 mm; P<0.001). The number needed to treat (NNT) for 50% pain intensity reduction with venlafaxine ER 150–225 mg was 4.5 at week 6. Nausea and somnolence were the most common treatment‐emergent adverse events. Seven patients on venlafaxine had clinically important ECG changes during treatment. Venlafaxine ER appears effective and safe in relieving pain associated with diabetic neuropathy. NNT values for higher dose venlafaxine ER are comparable to those of tricyclic antidepressants and the anticonvulsant gabapentin.

Leukoencephalopathy in patients diagnosed as major depressive

Bradley et al. (1984) reported that 30% of patients over the age of 60 demonstrate leukoencephalopathy or patchy, deep white matter lesions (PWML) of abnormal signal intensity on T2 weighted images on magnetic resonance imaging (MRI). These foci, which are not seen in normal individuals below the age of 45 (George et al. 1986b), are believed to be a function of the late stage of the aging process. With MRI, areas of deep white matter foci resemble those seen in known cerebral infarction (Erkinjuntti et al. 1984) and are reported to correspond to areas of moderate to severe arteriolar hyalinization and rarefaction on pathological examination (George et al. 1986a). The overall perspective on the clinical significance of PWML has yet to be determined. In patients with Alzheimer’s disease, the prevalence and severity of PWML is increased (Bent-~wad~i et al. 1985; George et al. 1986b). Prevalence of PWML of 36.67% was found in patients with Alzheimer’s disease at our medical center (mean age 64.3 years) (Heyman et al. 1986). Post (1962) and Roth (1986) suggested that the increased prevalence and severity of depressive illness and suicide in middle and late life is due to subtle cerebral (primarily vascular) changes correlated with aging. As PWML may reflect early and subtle alterations in cerebral function, we decided to assess the relationship, if any, between the occurrence of PWML (leuk~nceph~opa~y) and depression, especially depression in middle and late life. We also examined the relationship between PWML and early-onset affective disorder (i.e., onset of first episode before the age of 45) and affective disorder that first occurs after the age of 45. We used 45 years as the cutoff for the study because of the report that PWML are not seen in normal individuals below the age of 45 (George et al. 1986b). We also examined the hypothesis that the incidence of PWML would be higher in patients with the first episode of affective disorder above age 45 than in those patients above 45 with affective disorder that started before the age of 45. Such a finding would suggest that PWML may be causally related to depression in some of these individuals.

Loving-kindness meditation for chronic low back pain: Results from a pilot trial

Purpose: Loving-kindness meditation has been used for centuries in the Buddhist tradition to develop love and transform anger into compassion. This pilot study tested an 8-week loving-kindness program for chronic low back pain patients. Method: Patients (N = 43) were randomly assigned to the intervention or standard care. Standardized measures assessed patients’ pain, anger, and psychological distress. Findings: Post and follow-up analyses showed significant improvements in pain and psychological distress in the loving-kindness group, but no changes in the usual care group. Multilevel analyses of daily data showed that more loving-kindness practice on a given day was related to lower pain that day and lower anger the next day. Conclusions: Preliminary results suggest that the loving-kindness program can be beneficial in reducing pain, anger, and psychological distress in patients with persistent low back pain. Implications: Clinicians may find loving-kindness meditation helpful in the treatment of patients with persistent pain.

Survival and Health Care Utilization in Elderly Medical Inpatients With Major Depression

Forty‐one elderly medical inpatients with active major depression were matched with nondepressed controls from the same population. Survival and health care utilization were examined during a mean follow‐up period of five months. Cases and controls were matched by age, functional status, severity and type of medical illness, and extent of disease. In‐hospital mortality was significantly higher among depressed compared with nondepressed controls (6 vs 0 deaths, P=.03). For patients discharged from the hospital alive, however, depression did not have a substantial impact on mortality (31.4% cases, 31.7% controls). Health care utilization—in terms of days of inpatient care—was significantly higher both during the index admission (25 vs 14 days, P < .005) and during the follow‐up period (16 vs 7 days, P < .05) for depressed patients compared with controls. Hence, older medically ill patients with major depression consume more healthcare resources and experience greater mortality during their initial hospital stay. After discharge, while survival is little affected, excess resource utilization persists among those with depression.

Major depressive disorder in hospitalized medically ill patients : an examination of young and elderly male veterans

Objective: To study the epidemiology of depressive disorder in younger and older medical inpatients.

Predictors of response to pain management treatment. The role of family environment and changes in cognitive processes

Objective:The purpose of the present study was to examine factors that influence individual differences in treatment response after multidisciplinary pain management. Design:Pre-post assessment design. Patients:119 chronic pain inpatients. Main Outcome Measures:Outcome measures included pain report from the McGill Pain Questionnaire, emotional distress from the Symptom Checklist-90 Revised, and activity discomfort from the Activity Discomfort Scale. Process measures included the Family Environment Scale, the Coping Strategies Questionnaire, and the Inventory of Negative Thoughts in Response to Pain. Results:Results indicated that pretreatment family environment, cognitive coping strategies, and negative thinking accounted for small yet significant proportions of the variance in outcome. The proportion of variance accounted for by the changes in cognitive coping and negative thinking was somewhat higher. An increase in pain control and rational thinking was related to decreases in depression and anxiety, pain report, and activity discomfort. Decreases in negative social cognition were related to decreased depression at posttreatment. Conclusion:Changes in coping strategies and negative thinking may be important mechanisms related to improvement, or lack of improvement, in a range of outcome measures. Patients from families who are controlling and disorganized, and patients high on negative thinking at pretreatment may represent high-risk groups in need of further individually tailored interventions.

Antidepressant use in elderly medical inpatients

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was halted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was cnducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antide-pressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy.

Self-rated depressive symptoms in medical inpatients: Age and racial differences.

One thousand and eleven men under age forty (n = 161) or over age sixty-four (n = 850) admitted to medical and neurological services of an acute care hospital were screened for depressive symptoms as part of the Durham VA Mental Health Survey. Thirty-three percent of younger and 22 percent of older men scored 11 or higher on the Geriatric Depression Scale. Self-rated symptoms were most prevalent among younger whites (40%) and least common in older blacks (19%). Other exogenous factors such as being retired or unemployment and prior psychiatric history were also related to depressive symptoms, as were poor functional status, impaired cognitive status, and respiratory illness. Coping resources associated with fewer symptoms were social support and moderate alcohol use. In a subgroup of 443 patients, self-rated symptoms were compared with observer-rated symptoms. Agreement was highest among young Whites and lowest in older Blacks. Other correlates also varied depending on whether self-rated or observer-rated symptoms were considered. We conclude that self-rated symptoms are common among medical inpatients, are linked with and confounded by certain health and sociodemographic factors, and may be relatively insensitive as a measure of depression in elderly blacks.

Neuroanatomical changes and hypothalamo-pituitary-adrenal axis abnormalities ☆

Hypothalamo-pituitary-adrenal (HPA) axis abnormalities are frequently observed in patients with major depression (Carroll 1982). The most extensively assessed abnormality is the early escape of cortisol from suppression after dexamethasone. Although this abnormality is state dependent (Carroll et al. 1976. 1981). its relationship to the initiation and development of depressive symptomatology remains an enigma. Ventricular enlargement and cerebral atrophy are also observed frequently in patients with major depression (Pearlson and Veroff 1981). The ventricular brain ratio (VBR) has been reported to be correlated with 24-hr urine-free cortisol (Kellner et al. 1983). Although Targum et al. (1983) did not find a relationship between VBR and the Dexamethasone Suppression Test (DST), Rothschild et al. (1988) recently reported a statistically significant positive correlation between VBR and highest postdexamethasone plasma cortisol concentrations. In an earlier study of patients with major

Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations

Abstract Although certain risk factors can identify individuals who are most likely to develop chronic pain, few interventions to prevent chronic pain have been identified. To facilitate the identification of preventive interventions, an IMMPACT meeting was convened to discuss research design considerations for clinical trials investigating the prevention of chronic pain. We present general design considerations for prevention trials in populations that are at relatively high risk for developing chronic pain. Specific design considerations included subject identification, timing and duration of treatment, outcomes, timing of assessment, and adjusting for risk factors in the analyses. We provide a detailed examination of 4 models of chronic pain prevention (ie, chronic postsurgical pain, postherpetic neuralgia, chronic low back pain, and painful chemotherapy-induced peripheral neuropathy). The issues discussed can, in many instances, be extrapolated to other chronic pain conditions. These examples were selected because they are representative models of primary and secondary prevention, reflect persistent pain resulting from multiple insults (ie, surgery, viral infection, injury, and toxic or noxious element exposure), and are chronically painful conditions that are treated with a range of interventions. Improvements in the design of chronic pain prevention trials could improve assay sensitivity and thus accelerate the identification of efficacious interventions. Such interventions would have the potential to reduce the prevalence of chronic pain in the population. Additionally, standardization of outcomes in prevention clinical trials will facilitate meta-analyses and systematic reviews and improve detection of preventive strategies emerging from clinical trials.