Digest

Phone line for drug‐ related sexual dysfunction Patients may be more willing to reveal drug‐induced sexual dys‐ function via an impersonal computerised system than face to face. An automated system would be quicker than conventional written assessments too but, asked US psychiatrists, is it accurate? They randomised 99 healthy men to placebo or paroxetine 20mg daily for three weeks ( Clin Psychiatry 2007;68:525‐32). Sexual dysfunction was assessed using the validated Changes in Sexual Function Questionnaire in writing or by interactive voice response (IVR) technology at baseline and on days 8, 15 and 21. IVR is a computer‐automated touch‐tone telephone system accessed by a free number and protected by a PIN: the questions are delivered by a recording and the response selected by a number on the keypad. Paroxetine was associated with significantly more adverse effects on sexual function, affecting 73 to 94 per cent of individuals compared with 39 to 67 per cent for placebo. Symptoms scores worsened after the first week with maximal effects by the end of the second week. There were no significant differences in symptom scores between the automated and written assessments for either the drug or placebo. The average IVR call lasted 3.27 minutes and the compliance rate was 94 per cent; half of the non‐compliance was attributed to non‐availability of the computer. The authors conclude that IVR, due to its inherent anonymity and potential for increased frequency, could be a useful tool for assessing sensitive problems. Antidepressants help recognise happy faces Patients with depression have impaired affective processing of facial expressions. UK scientists have now shown, using MRI scans, that the dynamic range of responses in brain regions encompassing the core visual system and emotional processing of face perception is attenuated in patients confronted with images of happy faces compared with controls ( Am J Psychiatry 2007;164:599‐607). After eight weeks' treatment with fluoxetine 20mg daily, neural responses among (previously untreated) patients increased significantly in the lingual gyrus and cuneus, though not the amygdala. These findings complement previous research showing an exaggerated response to sad faces in patients with depression. Atypicals for acute mania Recent trials have shown that atypical antipsychotics are effective in the treatment of acute mania but treatment guidelines have not adopted a uniform approach to their use. Specialists from Germany have now conducted a meta‐analysis of 24 randomised controlled trials lasting three to six weeks, involving a total of 6187 patients and the atypicals aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone ( Arch Gen Psychiatry 2007;64:442‐55). Compared with placebo, atypicals significantly reduced symptoms and increased response rates; only olanzapine and risperidone reduced overall discontinuation rates. All were associated with increased somnolence but only olanzapine and quetiapine caused weight gain. Aripiprazole, ziprasidone and risperi‐ done were associated with increased rates of extrapyramidal symptoms. The atypicals were similar in efficacy to mood stabilisers; again, olanzapine and quetiapine caused more weight gain. Fewer studies compared atypical and typical antipsychotics as adjuncts to a mood stabiliser. Overall, there were no differences in symptom scores though the results were heterogeneous. There were also no consistent differences in discontinuation rates. Donepezil for postoperative delirium? Delirium following elective hip replacement is common; it delays recovery and prolongs hospital stay, say researchers from London, who therefore carried out a pilot study of prophylaxis with donepezil ( Int J Geriatr Psychiatry 2007;22:343‐9). They randomised 50 patients without pre‐existing dementia (mean age 68 years) to placebo or donepezil 5mg within three hours of returning to the ward after hip‐ replacement surgery and every 24 hours thereafter for three days. Thirty‐three patients completed the trial; withdrawals were unrelated to treatment. The incidence of delirium was 36 per cent with placebo and 10 per cent with donepezil, though the difference was not statistically significant. Duration was mild in both groups but slightly shorter‐lasting with donepezil (1.5 vs 1.8 days). Mean hospital stay was 12 days with placebo and 10 days with donepezil. There were no significant differences in adverse effects. Botulinum toxin works… Facial synkinesis can be effectively treated with low doses of botulinum toxin type A (BTX), say Japanese neurologists ( Acta Neurol Scand 2007;115:271‐4). Noting that previous studies had reported facial weakness following administration of BTX at the doses used to treat hemifacial spasms (12.5.‐50 units of Botox) , they treated 11 patients with 0.5‐1.25 units per point of Botox at a mean of 5.6 points (range 2‐10 points) per treatment (mean total dose 5.76 units Botox), on average every 14 weeks. Synkinesis disappeared within two to three days of the injection and resolved in three patients after three sessions. One case of hyper‐ lacrimation remitted for one year after a single injection. The only adverse events were two cases of mild and transient subcutaneous haemorrhage. … but not all the time BTX does not relieve chronic neck pain due to whiplash injury, according to a study from The Netherlands ( J Neurol 2007;254:290‐5). Forty patients with post‐whiplash neck pain lasting at least six months were randomised to placebo or a single treatment with Botox 100 units injected into muscles with increased tone or tenderness. After 12 weeks, visual analogue pain scores improved in both groups –slightly, but not significantly, more with BTX. Cervical range of movement improved with BTX but again, not significantly so. There were no differences in patients' assessments of change, days with neck pain or use of analgesics. Follow‐up makes a big difference in depression Patients in clinical trials of anti‐ depressants improve more the more often they are followed up, a new meta‐analysis shows ( Br J Psychiatry 2007;190:287‐92). The analysis of forty‐one six‐ week randomised trials included 3063 patients randomised to placebo. At baseline, the mean Hamilton Rating Scale for Depression (HRSD) score was approximately 25. The mean reduction in HRSD score between weeks two and four in trials without an assessment at week three was 1.70, but in those including a week three assessment it was 2.56 –accounting for 34 per cent of the reduction in this period. For an assessment at week five the corresponding figures were a 0.85 point decrease from week four to six without an assessment and 1.52 with assessment –equivalent to 44 per cent of the decrease. Furthermore, performing two additional assessments was associated with twice the reduction in HRSD score compared with one additional assessment. There were similar differences among patients who received active treatment. Tranylcypromine and refractory bipolar depression Further studies of the monoamine oxidase inhibitor (MAO‐I) tranylcypromine in treatment‐resistant bipolar depression are needed, say investigators who acknowledged their own trial as a failure ( Acta Psychiatry Scand 2007;115:360‐5). They had planned to compare tranylcypromine with lamotrigine as adjuncts to a mood stabiliser in a 10‐ week crossover trial in 70 patients. Patient recruitment proved difficult and ultimately only 19 patients were randomised. Response rates to the two drugs were not significantly different but more patients completed treatment with the MAOI (75 vs 45 per cent) and there were fewer withdrawals due to lack of efficacy than with lamotrigine. Infliximab for myasthenia gravis? A case study from Sweden suggests that infliximab, an anti‐TNFαmonoclonal antibody, may be useful in the treatment of myasthenia gravis ( Acta Neurol Scand 2007; 115:279‐83). A 61‐year‐old man, unable to tolerate immunosuppressant drugs, was treated with four infusions of infliximab at the doses used for rheumatoid arthritis. Muscle function score improved, though he noticed no subjective change. Serum levels of anti‐acetylcholine antibodies were reduced and levels of HLADR on CD4 T cells also decreased. Although the dose of prednisolone was reduced from 30mg to 10mg daily, severe periapical infection meant discontinuation of infliximab was necessary. The patient is now treated with high‐dose IgG. Galantamine may reduce verbal repetition Verbal repetition by patients with Alzheimer's disease (AD) –repeated questioning or storytelling –is more often a concern for patients and care givers than doctors, Canadian specialists say ( Neurology 2007;68:1116‐21). In a post hoc analysis of a non‐blinded trial of galantamine in 130 patients with mild to moderate AD living in the community, they found that verbal repetition was a treatment goal for 57 patients (44 per cent). Repetition goals were set by 32 per cent of patients and carers compared with 18 per cent of doctors. Diminution of verbal repetition was achieved for more patients treated with galantamine (58 per cent) than placebo (24 per cent) after four months, though at eight months there were no differences between the groups. Improvement in verbal repetition correlated with overall clinical change but not with ADAS‐cog score. Prolonged‐release ropinirole for PD A prolonged‐release formulation of ropinirole is an effective adjunct to levodopa in patients with Parkinson's disease (PD), US investigators say ( Neurology 2007; 68:1108‐15). The new once‐daily formulation was compared with placebo in 393 patients whose symptoms were not controlled with levodopa alone (mean dose 776‐824mg daily). After six months, ropinirole was associated with a greater reduction in ‘off’ time (2.1 vs 0.3 hours), increased ‘on’ time, motor scores and response rates compared with placebo. Mean doses of levodopa were 546mg and 613mg daily in ropinirole and placebo groups respectively. Adverse effects typical of a dopamine agonist were more frequent with ropinirole. However, adverse effects led to study withdrawal in 5 per cent of both ropini‐ role and placebo groups. The authors conclude that prolonged‐release ropinirole is effective and well tolerated; studies comparing it with the conventional formulation are now needed. Oxcarbazepine for peripheral neuropathy Oxcarbazepine seems to reduce chronic pain due to peripheral neuropathy but one in five patients stop treatment due to adverse effects –most within six months ( Acta Neurol Scand 2007;115:284‐8). An analysis of two non‐blinded one‐year studies involving a total of 594 patients with diabetic neuropathy has shown that about 20 per cent stopped treatment due to adverse effects. In the larger study (n=497), 88 per cent of withdrawals occurred during the first six months and 60 per cent within the dose titration period. The target dose of 1800mg daily was achieved in 24 per cent of patients in the larger study and 46 per cent in the smaller. Rapid dose titration –over four weeks –was blamed for the high discontinuation rate. Guide to Primary Care Mental Health A new training resource produced by the Centre for Clinical and Academic Workforce Innovation has recently been launched. A Complete Guide to Primary Care Mental Health comprises a reference book and CD Rom set aimed at all those involved in treating mental illness in the primary care setting or working in a non‐medical setting with those affected by mental ill health. Ethical frameworks, cognitive behavioural therapy and mental health law are among the topics covered. The resource costs £75 and is available by calling 01206 255 800 or online at www.amazon.co.uk. Copyright © 2007 Wiley Interface Ltd