- Email: [email protected]
The burden of post-traumatic stress disorder
S35I
P3 Anxiety disorders and anxiolytics mean of 8.0 disability days experienced in the previous month. General population studies in Europe and the US have reported similar data and also revealed that impairment of pure GAD is equivalent in magnitude to impairment of pure major depression, even when controlled for other DSM-III-R disorders (Kessler et, 1999, Wittchen e&& in press). Although there are substantial differenoes between countries concerning health care utilisation rates, patients with GAD seem to be significantly higher users of primary care physicians compared with other anxiety disorders and up to 50% may have visited a medical specialist in the previous year. One study suggested that the specialists seen most often by GAD patients are gastroenterologists; hospitalisations are more prevalent in GAD patients with comorbid conditions, with internal medicine and emergency admission being the most frequently used service. Comprehensive and sound estimation of the burden of GAD on the individual and society is at this point difficult given the high prevalence of comorbid disorders. However, the burden in pure GAD is likely to ,be of at least the same magnitude as major depression, and the presence of GAD in other somatic and mental disorders seems to magnify the disability found for the other condition per se. This necessitates further inquiries into the associated burden as well as a step-change in the current approach to recognition and treatment of GAD. References [l] Kessler, R.C. et (1999) Am. .I. Psychiatry 156, 1915-1923. [2] Weiller, E. et (1998) Br. J. Psychiatry 173, 18-23. [3] Wittchen, H.-U. u (1994) Am. J. Psychiatry 51, 355-364.
of 861 patients (We&&erg, 1999). Two studies were flexibledose comparisons of paroxetine (20-50 mg daily) and placebo, and the third was a dose-finding study of paroxetine at a fixed dose (20, 40 or 60 mg daily) versus placebo. Using the SDS, positive improvements with paroxetine were observed in social functioning in all three studies, and in work functioning in the two flexibledose studies (all p < 0.05). A long-term maintenance of efficacy study conducted in 323 responders to short-term treatment showed a significantly improved overall SDS score (p < 0.001) in patients who continued on paroxetine for a farther 24 weeks, compared with those switched to placebo. Large, short-term, multicentre, placebo-controlled studies of paroxetine in the treatment of posttraumatic stress disorder and generalised anxiety disorder have been completed recently, and also assess the effect of paroxetine treatment on disability. In conclusion, paroxetine can improve daily functioning in a range of anxiety disorders, with reduced disability in both personal and work situations. Treatment with paroxetine can therefore be an effective means of not only alleviating anxiety symptoms, but also reducing the burden imposed by anxiety disorders on patients and wider society. References [l] Lecrubier, Y. et al. (1997) Acta. Psychiatr. Stand. 95, 145-152. [2] Lecrubier, Y. and Judge, R. (1997) Acta. Psychiatr. Stand. 95: 153-160. [3] Westenberg, H.G.M. (1999) In: Focus on Psychiatry: Social Anxiety Disorder. Westenberg, H.G.M. and Den Boer, J.A. (eds). Syn-thesis, Amsterdam, The Netherlands. pp. 175-190.
Ip.3.041]
)G3Z)
Improving impairment and disability in anxiety disorders with paroxetine treatnient
D.S. Baldwin, J. Birtwistle. University Department of Psychiatry, Royal South Hants Hospital,’ Southampton, UK Typically, anxiety disorders are chronic conditions that severely impair a patient’s ability to undertake normal daily activities at home and at work. A WHO Collaborative Study showed that patients attending primary care with a current anxiety disorder experienced a similar number of disability days per month as patients with current depression, and a considerably greater number of disability days per month than patients with no mental disorder. Improvement in disability is therefore an important outcome measure in treatment studies. Here we report disability data from controlled studies selected from the world-wide database for paroxetine in the treatment of various anxiety disorders. The main disability measure in these studies was the Sheehan Disability Scale (SDS), which covers impairment in social, work and family life. In a 12-week, multicentre, placebo-controlled study in 367 patients with panic disorder, significant improvements in SDS scores for social, work and family life were noted for both paroxetine (10-60 rng’ daily, flexible dose) and clomipramme in comparison with placebo (all p 5 0.002; Lecrubier & al, 1997). In addition, patients who satisfactorily completed the 12 weeks of treatment could choose to continue their randomised treatment for a further 36 weeks (Lecrubier and Judge, 1997). With paroxetine and clomipramine, the SDS social, work and family life scores continued to improve throughout this further period. In social anxiety disorder, paroxetine has been evaluated in three 12-week4 multicentre, placebo-controlled studies involving a total
The burden of post-traumatic
stress disorder
D.J. Nutt. University of Bristol, Psychopharmacology Bristol, UK
Unit,
Post-traumatic stress disorder (PTSD) differs from other anxiety disorders in that the onset is initiated by exposure to a traumatic experience such as occurs during war, natural disasters, severe accidents or personal attacks. The recognition and diagnosis of PTSD is frequently complicated by the presence of secondary depression and in many cases the underlying PTSD is overlooked. General population surveys and m-depth studies carried out in trauma samples have supplied data that’ provide an insight into the extent of the disorder. In a US community survey, nearly 90% of respondents reported exposure to at least one lifetime traumatic event (Breslau aal, 1998) and as many as one-third of people who experience an acute tramna may develop either PTSD alone (S10%) or PTSD in combination with depression Q-30%). In recent years PTSD has been classified according to DSM-III-R or DSMIV criteria and it is considered one of the most common anxiety disorders ,in the general population, with a lifetime prevalence of 5 to 10%. PTSD markedly affects life-course opportunities, increasing the likelihood of poor school performance, marital instability or unemployment. Suicidal behaviour has been associated more strongly with PTSD than with any other anxiety disorder and the rate of suicide attempts has been reported at 19% in sufferers from PTSD. The impact of PTSD on the ability of sufferers to function normally in their daily lives has been assessed in the National Comorbidity Survey. The data indicate that twice as many work days were lost to PTSD than to major depression (0.8 Jo 0.6 versus 0.4 f 0.3) and the number of work cutback days per month was the same for both disorders (2.8 Z+Z 1.0 and 2.8 f 0.7). Therefore,
S352
P3 Anxiety disorders and anxiolytics
the overall 3.6 days of work impairment due to PTSD is equivalent to an annual productivity loss of over $3 billion (lost work day equal to the average wage in the US labour force). Healthcare costs have not been quantified but some 38% of people with PTSD receive treatment each year compared with 36% with major depression (Kessler et, 1999). Clearly PTSD is a disabling condition with substantial life consequences for the individual and costs to society that have not been fully quantified to date. In view of the huge cost implications of PTSD, there is clearly a need to properly evaluate the potential of treatment (both drug and psychological) with a view to minimising disability. Moreover, a detailed investigation of the biological basis of PTSD is required to understand the reasons why it is such a debilitating condition and to underpin research into new therapies (Nutt, 2000). References [l] Breslau, N. aal. (1998) Arch. Gen. Psychiatry 55, 626-632. [2] Kessler, R.C. et. (1999) Am. J. Psychiatry 156, 115-123. [3] Nutt, D.J. (2000) J. Clin. Psychiatry 61 (Suppl 5), 24-29.
(p.3.042(
Rehabilitation of refugees and forced migrants with social-stress disorders in Russia
E.N. Prokudina’, VN. Prokudin’~*, Al? Muzychenko3. ‘Civic Assistance Commmittee for Refuges and Forced Migrants; 2Dep. Psychiatry, Rus. St. Medical University; 3Dep. Psychiatry, Rus. St. Med. Univer.. Moscow, Russia Since 1990 in Moscow the first Russian public charity organization which assist to refugees and forced migrants - Civic Assistance Committee - have started to work. Socio-psychological situation which gradually was developing in Russia for last 10 years had brought the fundamental breakage in public consciousness and vital orientation of hundred million people. Mass manifestation of psychoemotional tension and psychical disadaptation in the ethnic Rus-Sian in former republics of Soviet Union became natural “experimental model” of Social-Stress Disorders (SSD) - variant of posttraumatic stress disorders when enormous mass of civil population are involved). Likewise the typical posttraumatic stress disorders the SSD appear in majority of people as result of the revolutional changes in entrenched massive consciousness and way of life. The following vain reasons of SSD appearance in Russia and in former republics of Soviet Union may be marked: consequences of a long time dominance of totalitarium regime; restructuring (“peresnoyka”) has brought the increase of economical and political chaos; interethnical conflicts and local civil wars; appearance of hundred thousand regugees and forced migrants, split of the society, civil contumacy and criminality, re-thinking of life aims, collapse of persistent perspectiva and authorities, pauperation, which touched enormous group population, dis-belief towards many promises of leaderships, absence of real hopes on improvement of situation. In 1994 the group of medicopsychological help began to act in Civic Assistance Committee (therapeutist and psychiatrist) with the aim to improve the refugees’ and forced migrants’ psycho-social rehabilitation. We present here the psychopathological analysis of 1245 migrants from Cbechnya, Tadzhikistan, Abchazia, Azerbaidjan. It was shown that: 12% of refugees and forced migrants suffered from pre-disease reactions with emotional tension, obssesive reminiscences about tragic events during civil war or pogrom, emotional tension and insomnia. These reactions have transitory character and in majority of
cases they did not appear as sick conditions. 18% of refugees suffered from affective-shock reactions (in anamnesis) with disturbances of consciousness, hsychomotor exitation or delayedstates, different acute and subchronic pamnoidal, conversional or pseudo-dementional pictures. 31% of refugees suffered from psycho-adaptive states with neurasthenical, hysterical, anxiotical and phobical reactions and states. These states developed when stabilization and complication of the above mentioned pre-desease reactions took place. 39% of refugees suffered from pathological personality development or psychosomatic disorders or reactions of social protest. In the aspect of syndromogenezis it is pos-sible to consider that in SSD and also in posttraumatic stress disorders the pathological development of personality and formation of acquired social-specific psychopathy take place. Nozologically all above mentioned groups of patients were determined as SSD. In treatment of these patients the combination of different kind of psychotherapy (rational, suggestive, behavioral) and varied psycho-pharmacotherapy (va-hum, phenazepam, clonazepam, alprazolam, coax& zoloft, neuleptil, melleril, nootropil) was the most effective.
-1
The use of citalopram in resistant OCD
D. Marazziti. University of Pisa, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, Section of Psychiatry, Piss, Italy The prognosis of obsessive compulsive disorder (OCD) has improved dramatically, following the introduction of selective serotonin (5-HT) reuptake inhibitors (SSRIs) into clinical practice, since these, drugs have demonstrated a specific antiobsessive effect (Zohar and Insel, 1987; Goodman et al., 1989a; Montgomery, 1994; Tollefson et al., 1994; Greist et al., 1995; Piccinelli et al., 1995; Fineberg, 1996). Nevertheless, 30-40% of OCD patients fail to respond to SSRIs. Therapeutic strategies in these resistant cases may consist in the addition of clomipramine (a non selective SRI) (MC Dougle and Goodman, 1999) or of drugs which enhance the serotonergic system but do not belong to the class of SSRIs, or of low doses of typical neuroleptics, such as haloperidol and pimozide (MC Dougle et al., 1994a). With the present research, we report our experience on the use of citalogram, the most selective SSRI, in a group of refractory OCD patients. Eighteen patients with a DSM-IV (APA, 1994) diagnosis of OCD were selected from a larger sample of outpatients who had been included in a 5-year long follow-up and recruited consecutively at the out-patient unit of the Dipartimento di Psi&atria, Neurobiologia, Farmacologia e Biotecnologie, Section of Psychiatry, of the University of Pisa. Selection criteria were the diagnosis of OCD, a duration of illness of at least two years and a baseline Yale-Brown Obsessive Compulsive Scale total score of at least 30 within the first 10 items. Resistance to the treatment was defined as being a reduction in the Y-BOCS total score of less than 25% after six-months’ treatment with a SRI (clomipramine, sertraline, fluoxetine or fluvoxamine) given at adequate dosages. Citalopram given at an initial dosage of 20 mg daily, with a progressive titration up to 40-60 mg daily within 4 weeks and it was continued for 6 months. Responders were defined as being those showing a reduction of between 25% and 35% in the Y-BOCS total score. Fourteen, out of the total of 18 patients, responded significantly to citalogram after 2 months of treatment. The Y-BOCS total score (mean f SD) was 37 f 4 at to and 16 & 5 at the end of the study. No relevant side effect was registered except a mild nausea in 4
P3 Anxiety disorders and anxiolytics mean of 8.0 disability days experienced in the previous month. General population studies in Europe and the US have reported similar data and also revealed that impairment of pure GAD is equivalent in magnitude to impairment of pure major depression, even when controlled for other DSM-III-R disorders (Kessler et, 1999, Wittchen e&& in press). Although there are substantial differenoes between countries concerning health care utilisation rates, patients with GAD seem to be significantly higher users of primary care physicians compared with other anxiety disorders and up to 50% may have visited a medical specialist in the previous year. One study suggested that the specialists seen most often by GAD patients are gastroenterologists; hospitalisations are more prevalent in GAD patients with comorbid conditions, with internal medicine and emergency admission being the most frequently used service. Comprehensive and sound estimation of the burden of GAD on the individual and society is at this point difficult given the high prevalence of comorbid disorders. However, the burden in pure GAD is likely to ,be of at least the same magnitude as major depression, and the presence of GAD in other somatic and mental disorders seems to magnify the disability found for the other condition per se. This necessitates further inquiries into the associated burden as well as a step-change in the current approach to recognition and treatment of GAD. References [l] Kessler, R.C. et (1999) Am. .I. Psychiatry 156, 1915-1923. [2] Weiller, E. et (1998) Br. J. Psychiatry 173, 18-23. [3] Wittchen, H.-U. u (1994) Am. J. Psychiatry 51, 355-364.
of 861 patients (We&&erg, 1999). Two studies were flexibledose comparisons of paroxetine (20-50 mg daily) and placebo, and the third was a dose-finding study of paroxetine at a fixed dose (20, 40 or 60 mg daily) versus placebo. Using the SDS, positive improvements with paroxetine were observed in social functioning in all three studies, and in work functioning in the two flexibledose studies (all p < 0.05). A long-term maintenance of efficacy study conducted in 323 responders to short-term treatment showed a significantly improved overall SDS score (p < 0.001) in patients who continued on paroxetine for a farther 24 weeks, compared with those switched to placebo. Large, short-term, multicentre, placebo-controlled studies of paroxetine in the treatment of posttraumatic stress disorder and generalised anxiety disorder have been completed recently, and also assess the effect of paroxetine treatment on disability. In conclusion, paroxetine can improve daily functioning in a range of anxiety disorders, with reduced disability in both personal and work situations. Treatment with paroxetine can therefore be an effective means of not only alleviating anxiety symptoms, but also reducing the burden imposed by anxiety disorders on patients and wider society. References [l] Lecrubier, Y. et al. (1997) Acta. Psychiatr. Stand. 95, 145-152. [2] Lecrubier, Y. and Judge, R. (1997) Acta. Psychiatr. Stand. 95: 153-160. [3] Westenberg, H.G.M. (1999) In: Focus on Psychiatry: Social Anxiety Disorder. Westenberg, H.G.M. and Den Boer, J.A. (eds). Syn-thesis, Amsterdam, The Netherlands. pp. 175-190.
Ip.3.041]
)G3Z)
Improving impairment and disability in anxiety disorders with paroxetine treatnient
D.S. Baldwin, J. Birtwistle. University Department of Psychiatry, Royal South Hants Hospital,’ Southampton, UK Typically, anxiety disorders are chronic conditions that severely impair a patient’s ability to undertake normal daily activities at home and at work. A WHO Collaborative Study showed that patients attending primary care with a current anxiety disorder experienced a similar number of disability days per month as patients with current depression, and a considerably greater number of disability days per month than patients with no mental disorder. Improvement in disability is therefore an important outcome measure in treatment studies. Here we report disability data from controlled studies selected from the world-wide database for paroxetine in the treatment of various anxiety disorders. The main disability measure in these studies was the Sheehan Disability Scale (SDS), which covers impairment in social, work and family life. In a 12-week, multicentre, placebo-controlled study in 367 patients with panic disorder, significant improvements in SDS scores for social, work and family life were noted for both paroxetine (10-60 rng’ daily, flexible dose) and clomipramme in comparison with placebo (all p 5 0.002; Lecrubier & al, 1997). In addition, patients who satisfactorily completed the 12 weeks of treatment could choose to continue their randomised treatment for a further 36 weeks (Lecrubier and Judge, 1997). With paroxetine and clomipramine, the SDS social, work and family life scores continued to improve throughout this further period. In social anxiety disorder, paroxetine has been evaluated in three 12-week4 multicentre, placebo-controlled studies involving a total
The burden of post-traumatic
stress disorder
D.J. Nutt. University of Bristol, Psychopharmacology Bristol, UK
Unit,
Post-traumatic stress disorder (PTSD) differs from other anxiety disorders in that the onset is initiated by exposure to a traumatic experience such as occurs during war, natural disasters, severe accidents or personal attacks. The recognition and diagnosis of PTSD is frequently complicated by the presence of secondary depression and in many cases the underlying PTSD is overlooked. General population surveys and m-depth studies carried out in trauma samples have supplied data that’ provide an insight into the extent of the disorder. In a US community survey, nearly 90% of respondents reported exposure to at least one lifetime traumatic event (Breslau aal, 1998) and as many as one-third of people who experience an acute tramna may develop either PTSD alone (S10%) or PTSD in combination with depression Q-30%). In recent years PTSD has been classified according to DSM-III-R or DSMIV criteria and it is considered one of the most common anxiety disorders ,in the general population, with a lifetime prevalence of 5 to 10%. PTSD markedly affects life-course opportunities, increasing the likelihood of poor school performance, marital instability or unemployment. Suicidal behaviour has been associated more strongly with PTSD than with any other anxiety disorder and the rate of suicide attempts has been reported at 19% in sufferers from PTSD. The impact of PTSD on the ability of sufferers to function normally in their daily lives has been assessed in the National Comorbidity Survey. The data indicate that twice as many work days were lost to PTSD than to major depression (0.8 Jo 0.6 versus 0.4 f 0.3) and the number of work cutback days per month was the same for both disorders (2.8 Z+Z 1.0 and 2.8 f 0.7). Therefore,
S352
P3 Anxiety disorders and anxiolytics
the overall 3.6 days of work impairment due to PTSD is equivalent to an annual productivity loss of over $3 billion (lost work day equal to the average wage in the US labour force). Healthcare costs have not been quantified but some 38% of people with PTSD receive treatment each year compared with 36% with major depression (Kessler et, 1999). Clearly PTSD is a disabling condition with substantial life consequences for the individual and costs to society that have not been fully quantified to date. In view of the huge cost implications of PTSD, there is clearly a need to properly evaluate the potential of treatment (both drug and psychological) with a view to minimising disability. Moreover, a detailed investigation of the biological basis of PTSD is required to understand the reasons why it is such a debilitating condition and to underpin research into new therapies (Nutt, 2000). References [l] Breslau, N. aal. (1998) Arch. Gen. Psychiatry 55, 626-632. [2] Kessler, R.C. et. (1999) Am. J. Psychiatry 156, 115-123. [3] Nutt, D.J. (2000) J. Clin. Psychiatry 61 (Suppl 5), 24-29.
(p.3.042(
Rehabilitation of refugees and forced migrants with social-stress disorders in Russia
E.N. Prokudina’, VN. Prokudin’~*, Al? Muzychenko3. ‘Civic Assistance Commmittee for Refuges and Forced Migrants; 2Dep. Psychiatry, Rus. St. Medical University; 3Dep. Psychiatry, Rus. St. Med. Univer.. Moscow, Russia Since 1990 in Moscow the first Russian public charity organization which assist to refugees and forced migrants - Civic Assistance Committee - have started to work. Socio-psychological situation which gradually was developing in Russia for last 10 years had brought the fundamental breakage in public consciousness and vital orientation of hundred million people. Mass manifestation of psychoemotional tension and psychical disadaptation in the ethnic Rus-Sian in former republics of Soviet Union became natural “experimental model” of Social-Stress Disorders (SSD) - variant of posttraumatic stress disorders when enormous mass of civil population are involved). Likewise the typical posttraumatic stress disorders the SSD appear in majority of people as result of the revolutional changes in entrenched massive consciousness and way of life. The following vain reasons of SSD appearance in Russia and in former republics of Soviet Union may be marked: consequences of a long time dominance of totalitarium regime; restructuring (“peresnoyka”) has brought the increase of economical and political chaos; interethnical conflicts and local civil wars; appearance of hundred thousand regugees and forced migrants, split of the society, civil contumacy and criminality, re-thinking of life aims, collapse of persistent perspectiva and authorities, pauperation, which touched enormous group population, dis-belief towards many promises of leaderships, absence of real hopes on improvement of situation. In 1994 the group of medicopsychological help began to act in Civic Assistance Committee (therapeutist and psychiatrist) with the aim to improve the refugees’ and forced migrants’ psycho-social rehabilitation. We present here the psychopathological analysis of 1245 migrants from Cbechnya, Tadzhikistan, Abchazia, Azerbaidjan. It was shown that: 12% of refugees and forced migrants suffered from pre-disease reactions with emotional tension, obssesive reminiscences about tragic events during civil war or pogrom, emotional tension and insomnia. These reactions have transitory character and in majority of
cases they did not appear as sick conditions. 18% of refugees suffered from affective-shock reactions (in anamnesis) with disturbances of consciousness, hsychomotor exitation or delayedstates, different acute and subchronic pamnoidal, conversional or pseudo-dementional pictures. 31% of refugees suffered from psycho-adaptive states with neurasthenical, hysterical, anxiotical and phobical reactions and states. These states developed when stabilization and complication of the above mentioned pre-desease reactions took place. 39% of refugees suffered from pathological personality development or psychosomatic disorders or reactions of social protest. In the aspect of syndromogenezis it is pos-sible to consider that in SSD and also in posttraumatic stress disorders the pathological development of personality and formation of acquired social-specific psychopathy take place. Nozologically all above mentioned groups of patients were determined as SSD. In treatment of these patients the combination of different kind of psychotherapy (rational, suggestive, behavioral) and varied psycho-pharmacotherapy (va-hum, phenazepam, clonazepam, alprazolam, coax& zoloft, neuleptil, melleril, nootropil) was the most effective.
-1
The use of citalopram in resistant OCD
D. Marazziti. University of Pisa, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, Section of Psychiatry, Piss, Italy The prognosis of obsessive compulsive disorder (OCD) has improved dramatically, following the introduction of selective serotonin (5-HT) reuptake inhibitors (SSRIs) into clinical practice, since these, drugs have demonstrated a specific antiobsessive effect (Zohar and Insel, 1987; Goodman et al., 1989a; Montgomery, 1994; Tollefson et al., 1994; Greist et al., 1995; Piccinelli et al., 1995; Fineberg, 1996). Nevertheless, 30-40% of OCD patients fail to respond to SSRIs. Therapeutic strategies in these resistant cases may consist in the addition of clomipramine (a non selective SRI) (MC Dougle and Goodman, 1999) or of drugs which enhance the serotonergic system but do not belong to the class of SSRIs, or of low doses of typical neuroleptics, such as haloperidol and pimozide (MC Dougle et al., 1994a). With the present research, we report our experience on the use of citalogram, the most selective SSRI, in a group of refractory OCD patients. Eighteen patients with a DSM-IV (APA, 1994) diagnosis of OCD were selected from a larger sample of outpatients who had been included in a 5-year long follow-up and recruited consecutively at the out-patient unit of the Dipartimento di Psi&atria, Neurobiologia, Farmacologia e Biotecnologie, Section of Psychiatry, of the University of Pisa. Selection criteria were the diagnosis of OCD, a duration of illness of at least two years and a baseline Yale-Brown Obsessive Compulsive Scale total score of at least 30 within the first 10 items. Resistance to the treatment was defined as being a reduction in the Y-BOCS total score of less than 25% after six-months’ treatment with a SRI (clomipramine, sertraline, fluoxetine or fluvoxamine) given at adequate dosages. Citalopram given at an initial dosage of 20 mg daily, with a progressive titration up to 40-60 mg daily within 4 weeks and it was continued for 6 months. Responders were defined as being those showing a reduction of between 25% and 35% in the Y-BOCS total score. Fourteen, out of the total of 18 patients, responded significantly to citalogram after 2 months of treatment. The Y-BOCS total score (mean f SD) was 37 f 4 at to and 16 & 5 at the end of the study. No relevant side effect was registered except a mild nausea in 4