Xavier Torres

Hyperexcitable C nociceptors in fibromyalgia

To test the hypothesis that peripheral C nociceptor function may be abnormal in fibromyalgia and that C nociceptor dysfunction may contribute to the symptoms reported by these patients.

Relapse of major depression after complete and partial remission during a 2-year follow-up

BACKGROUND Rates of remission and relapse were studied over more than 2 years in a sample of Spanish outpatients with DSM-III-R criteria of unipolar major depressive episodes. METHODS Patients were treated following standardised pharmacological protocols at our centre. In the first visit, the structured clinical interview for DSM-III-R (SCID) was used. The following visits were held monthly. Phases of evolution were recorded using the Hamilton Depression Rating Scale (HDRS), applying the Frank criteria. RESULTS A significantly greater proportion of relapse was observed in the partial remission group compared to the complete remission one. The rate of relapses for patients in complete remission was 15.18%, while for patients in partial remission was 67.61%. Partial remission was significantly associated with relapses. LIMITATIONS The short duration of the study and the decreasing sample size during the follow-up. CONCLUSIONS Partial remission after a depressive episode seems to be strongly associated with relapses. Moreover, this clinical factor could by itself fully predict short-term relapses. CLINICAL RELEVANCE The study shows the importance of reaching complete remission to decrease the rate of short-term relapses.

Continuation/Maintenance Treatment with Nortriptyline Versus Combined Nortriptyline and ECT in Late-Life Psychotic Depression : A Two-Year Randomized Study

OBJECTIVE The identification of effective continuation and maintenance strategies for elderly patients with psychotic depression is a critical issue that has not been fully explored. The aim of this study was to assess the tolerability and efficacy of continuation/maintenance electroconvulsive therapy (ECT) in elderly patients with psychotic depression after acute ECT remission. METHODS The authors used a longitudinal, randomized, single-blind design to compare by survival analysis the 2-year outcome of two subgroups of elderly patients with psychotic unipolar depression who were ECT (plus nortriptyline) remitters. One group was treated with a continuation/maintenance nortriptyline regimen (N = 17) and the other with combined continuation/maintenance ECT plus nortriptyline (N = 16). RESULTS Over 2 years of treatment in elderly, psychotic, unipolar depressed ECT (plus nortriptyline) remitters, the mean survival time was significantly longer in the combined ECT plus nortriptyline subgroup than in the nortriptyline subgroup. No differences were observed between treatments with regard to tolerability. CONCLUSIONS This study supports the judicious use of combined continuation/maintenance ECT and antidepressant treatment in elderly patients with psychotic unipolar depression who are ECT remitters.

Reduced Levels of Creatine in the Right Medial Temporal Lobe Region of Panic Disorder Patients Detected with 1H Magnetic Resonance Spectroscopy

In vivo proton magnetic resonance spectroscopy ((1)H MRS) was used to study possible neurochemical abnormalities in drug-free, symptomatic panic disorder patients at rest. (1)H MRS was performed in 11 panic disorder patients and 11 healthy age- and sex-matched comparison subjects. Levels of brain metabolites were determined in the right medial temporal lobe region (encompassing the whole amygdala and part of the hippocampus) and in the medial prefrontal cortex on the basis of previous work with both structural and functional neuroimaging techniques. The concentration of creatine and phosphocreatine, metabolites involved in energy-dependent systems in brain, was significantly lower in the right medial temporal lobe region of panic disorder patients compared to healthy subjects. No significant differences between the two groups were observed in the medial prefrontal cortex. These results provide neurochemical evidence suggesting the involvement of the amygdalohippocampal region in the pathogenesis of panic disorder.

Structure of personality pathology in normal and clinical samples: Spanish validation of the DAPP-BQ.

Given that the DSM taxonomy of personality disorders is flawed by severe classificatory problems, the development of alternative classificatory systems, such as the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ), has now become a priority. This study examined the internal consistency, second-order factor structure, and criterion validity of a Spanish translation of the DAPP-BQ in two samples: subjects with personality disorder (n = 155) and subjects from the general population (n = 300). Alpha coefficients ranged satisfactorily from .75 to .93. Four second-order factors of Emotional Dysregulation, Dissocial Behavior, Inhibitedness, and Compulsivity were obtained, which were replicable between samples and identical to those reported in the literature. Finally, disordered subjects scored significantly higher than normal subjects on 17 of the 18 DAPP-BQ traits. Some pending issues in the construction of an alternative taxonomy of personality disorders are discussed.

Personality does not distinguish people with fibromyalgia but identifies subgroups of patients

OBJECTIVES The objectives were to compare the personality of fibromyalgia (FM) patients with other chronic painful and nonpainful disorders considering the confusion due to psychopathology and to assess the clustering of FM patients according to their personality profile. METHODS Differences in the NEO Five-Factor Inventory between FM, non-FM chronic pain and drug-resistant epileptic patients were assessed including the confounding effect of demographics and psychopathological status by multivariate regression analysis. Clustering of FM patients was assessed by two-step cluster analysis. Differences in clinical severity and psychosocial problems between subgroups and their outcome 6 months after multidisciplinary treatment were assessed. RESULTS The final sample comprised 874 patients. Once the effect of confounding variables was considered, clinically nonsignificant differences in personality were observed between groups. FM patients could, however, be grouped into two clusters. Cluster 1 was characterized by higher neuroticism and lower extraversion and showed a worse pretreatment clinical state including more psychosocial problems. In spite of having reached a wider general improvement at 6-month follow-up, Cluster 1 patients remained more anxious and depressed. CONCLUSIONS Identifying personality-based subgroups of FM might allow implementing specific preventive strategies. FM treatment might be optimized by increasing medication compliance, improving therapeutic alliance and testing different therapeutic options and treatment sequencing for each personality subgroup.

Pain locus of control predicts return to work among Spanish fibromyalgia patients after completion of a multidisciplinary pain program.

OBJECTIVE To assess the influence of the pain locus of control on return to work in fibromyalgia patients. METHODS Ninety-eight fibromyalgia patients on sick leave were enrolled in a multidisciplinary treatment program and were followed up for 12 months post-discharge. Treatment was considered successful at discharge in the case of patients who returned to work and unsuccessful in patients who remained sick listed. Treatment was considered successful during follow-up in patients who remained at work for at least the last 6 months of follow-up. Patients who took sick leave again and those lost to follow-up were considered failures. Logistic regression methods were used to define the best predictive models of treatment failure. RESULTS Fifty-eight patients were considered treatment successes at discharge and 50 at 12-month follow-up. The subscale Fate from the Multidimensional Health Locus of Control-Pain Scale and the Health Assessment Questionnaire predicted treatment failure at discharge (-2lnR=57.79; chi-square=74.74; df=2; P<.001). The predictive model of treatment failure at 12-month follow-up was unspecific. CONCLUSION Fibromyalgia patients undergoing a multidisciplinary treatment who were least likely to return to work at discharge were those with a pain locus of control characterized by more negative expectations about pain progression and a high perceived functional disability.

Prediction of relapse in melancholic depressive patients in a 2-year follow-up study with corticotropin releasing factor test

PURPOSE To study the power of CRF stimulation test to predict relapse in a sample of melancholic depressive patients in depressed phase, followed-up over a two-year period from the moment they achieved complete remission of depressive symptoms. METHODS Fifty-one outpatients diagnosed with unipolar depressive disorder with melancholic features according to DSM-IV were assessed with the CRF test. The Structured Clinical Interview for DSM-IV (SCID-IV) was used for diagnosis. Monthly follow-up visits were held over a two-year period after remission; relapse was established using HDRS according to Franks criteria [Frank E, Prien RF, Jarret RB, Keller MB, Kupfer DJ, Lavori PW, et al. Conceptualization and rationale for consensus definitions of terms in major depressive disorder: remission, recovery, relapse, and recurrence. Arch Gen Psychiatry 1991;48:851-5]. Forty-three patients completed the study. Non-controlled antidepressant treatment protocols were used. Predictive statistical analysis was performed through logistic regression. FINDINGS The final predictive model included three variables: net area under cortisol curve (NAUCC), previous suicide attempt, and stress during follow-up. Sensitivity was of 89%, and specificity was of 92%. NAUCC has shown a predictive power of 80%, with an optimal cut-off point of 251.24 microg/ml/min. CONCLUSIONS Cortisol is the hormone of the HPA axis which shows the highest power to predict relapse. NAUCC is the most relevant variable. The complete predictive model is a complex combination of biological, clinical and psychoenvironmental variables (NAUCC, previous suicide attempts, and stress during follow-up). Further studies with better control of the psychoenvironmental variables are required to obtain more precise neuroendocrine findings.

The Symptom Checklist-Revised (SCL-90-R) is able to discriminate between simulation and fibromyalgia.

This study assessed the ability of the Symptom Checklist-Revised (SCL-90-R) to discriminate between two groups of fibromyalgia patients (those who were about to begin a treatment including the explicit aim of returning to work and those who were initiating a legal procedure to obtain permanent disability compensation) and two groups of healthy volunteers (medical students and psychology graduates), who were asked to produce a symptomatic resemblance to a chronic pain disorder. Logistic regression analyses were applied to the SCL-90-R subscales and individual probabilistic indices of simulation were calculated. Results showed that the SCL-90-R was able to discriminate between healthy subjects and both groups of patients with a high sensitivity and specificity. The individual indices of simulation, which might be more useful in clinical practice than the comparison of the SCL-90-R profiles, also showed an appropriate level of accuracy.

Tratamiento electroconvulsivo de mantenimiento en la depresión unipolar psicótica del anciano

Fundamento y objetivo Este estudio se ha disenado para evaluar la seguridad y la eficacia del tratamiento electroconvulsivo (TEC) de continuacion/ mantenimiento en los pacientes ancianos que han experimentado una depression mayor psicotica y que respondieron durante el episodio indice al TEC. Pacientes y metodo Estudio longitudinal comparative aleatorizado de 2 anos de duracion. Se comparan dos subgrupos de pacientes ancianos afectados de una depresion mayor unipolar psicotica y con respuesta al TEC agudo: uno de los subgrupos realizo tratamiento de mantenimiento con nortriptilina (n = 13) y el otro, tratamiento de mantenimiento combinado con TEC y nortriptilina (n = 6). Resultados Tras un periodo de seguimiento y tratamiento de 2 anos, la tasa de recaida/recurrencia fue significativamente superior en el grupo de tratamiento con nortriptilina que en el grupo de tratamiento combinado TEC y nortritptilina. Por el contrario, la tolerabilidad de ambos tratamientos fue similar. Conclusiones Este estudio refuerza el uso del tratamiento de mantenimiento combinado con TEC y antidepresivos en la depresion mayor psicotica del anciano con antecedente personal de buena respuesta al TEC agudo.BACKGROUND AND OBJECTIVE This study was designed to assess the safety and efficacy of continuation/maintenance electroconvulsive therapy (ECT) in elderly psychotic major depressed patients after ECT remission. PATIENTS AND METHOD Using a longitudinal randomized single-blind design, we compared the two-year outcome of two subgroups of psychotic unipolar depressed elderly patients who were ECT remitters: one treated with a maintenance nortriptyline regimen (n = 13) and one treated with combined maintenance ECT plus nortriptyline (n = 6). RESULTS During 2 years of maintenance treatment in elderly psychotic unipolar depressed ECT remitters, relapse/recurrence rates were significantly higher in the nortriptyline subgroup than in the combined ECT plus nortriptyline subgroup. The tolerability of both treatments was similar. CONCLUSIONS This study supports the use of combined maintenance ECT and antidepressant treatment in elderly psychotic unipolar depressed patients who are ECT remitters.