RESUMO
BACKGROUND: Prominent and persistent anxiety, depression, and/or negative features characterize a substantial minority of recovered or residually psychotic schizophrenic outpatients and contribute to poor outcome. Because extrapyramidal side effects of typical neuroleptic medications often resemble such features, we first systematically studied the contribution of extrapyramidal side effects to these problems and their treatment. For patients who remained distressed, controlled trials of supplemental thymoleptics were undertaken. METHODS: In trial 1, 92 distressed (depressed and/or anxious) patients and 36 patients in a defect state (patients with negative symptoms) participated in a double-blind, intramuscular challenge that compared centrally acting benztropine mesylate with peripherally acting glycopyrrolate. In trial 2, 57 distressed patients and 22 patients in a defect state were randomly assigned to a double-blind, neuroleptic medication dose-reduction group. In trial 3, 57 chronically distressed patients who were maintained on a low dose of fluphenazine decanoate were randomly assigned to a supplemental desipramine hydrochloride, lithium carbonate, or placebo group under double-blind conditions for 12 weeks. RESULTS: For patients who were already maintained on antiparkinsonian medication, impaired affect was not resolved by additional benztropine. Only distressed patients with a family history of severe mental disorder (often affective) showed improvement with neuroleptic medication dose reduction. Patients in the defect-state group reported less dysphoria on a reduced neuroleptic medication dose, but negative symptoms persisted. Desipramine improved diverse aspects of mood and residual psychoticism, possibly as a prophylaxis against minor affective exacerbations. Depression improved in women only. Lithium positively affected multiple indexes of anxiety and anxious depression. CONCLUSION: Most often, persistent affective impairments are neither resistant extrapyramidal side effects nor characterological traits. Thymoleptics improve the nonphasic, chronic types of anxiety and depression in contrast to the acute, episodic forms, for which little support can be found in the literature.
Assuntos
Transtornos de Ansiedade/tratamento farmacológico , Transtorno Depressivo/tratamento farmacológico , Flufenazina/análogos & derivados , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Adolescente , Adulto , Assistência Ambulatorial , Antipsicóticos/efeitos adversos , Transtornos de Ansiedade/induzido quimicamente , Transtornos de Ansiedade/diagnóstico , Doenças dos Gânglios da Base/diagnóstico , Doenças dos Gânglios da Base/etiologia , Doenças dos Gânglios da Base/prevenção & controle , Benzotropina/análogos & derivados , Benzotropina/uso terapêutico , Transtorno Depressivo/induzido quimicamente , Transtorno Depressivo/diagnóstico , Desipramina/uso terapêutico , Diagnóstico Diferencial , Relação Dose-Resposta a Droga , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Flufenazina/uso terapêutico , Glicopirrolato/uso terapêutico , Humanos , Carbonato de Lítio/uso terapêutico , Masculino , Pessoa de Meia-Idade , Placebos , Escalas de Graduação Psiquiátrica , Fatores SexuaisRESUMO
OBJECTIVE: To compare the efficacy of a neuroleptic (haloperidol) to a monoamine oxidase inhibitor antidepressant (phenelzine sulfate) against the affective, cognitive, and impulsive-aggressive symptoms of criteria-defined borderline inpatients in an effort to dissect apart affective and schizotypal symptom patterns or subtypes using medication response. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Inpatient unit of a tertiary care university psychiatric hospital serving a large public catchment area. PATIENTS: One hundred eight consecutively admitted borderline inpatients defined by Gunderson's Diagnostic Interview for Borderline Patients and DSM-III-R criteria, randomly assigned to 38 phenelzine, 36 haloperidol, and 34 placebo trials. INTERVENTIONS: Following 1 week free of medication, haloperidol (average dose, 4 mg/d), phenelzine sulfate (average dose, 60 mg/d), or placebo were given for 5 weeks with weekly symptom ratings and plasma drug level determinations. MAIN OUTCOME MEASURES: Efficacy was measured on depression (Hamilton Rating Scale, Beck Depression Inventory), global severity (Global Assessment Scale, Symptom Checklist-90 items [SCL-90]), anxiety, anger-hostility (SCL-90, Inpatient Multidimensional Psychiatric Scale [IMPS], Buss-Durkee Hostility Inventory), psychoticism (Schizotypal Symptom Inventory, SCL-90, IMPS), impulsivity (Ward Scale, Barratt Impulsiveness Scale, Self-Report Test of Impulse Control), and borderline psychotherapy (Borderline Syndrome Index). RESULTS: Three-way comparisons between groups indicated superior efficacy for phenelzine, followed by placebo and haloperidol on measures of depression, borderline psychopathologic symptoms, and anxiety. Pairwise comparisons between medication and placebo revealed significant efficacy for phenelzine against anger and hostility but no efficacy against atypical depression or hysteroid dysphoria. We were unable to replicate prior reports of efficacy for the neuroleptic. CONCLUSIONS: Pharmacologic dissection of borderline personality disorder patients into affective and schizotypal subtypes could not be demonstrated.
Assuntos
Transtorno da Personalidade Borderline/tratamento farmacológico , Haloperidol/uso terapêutico , Fenelzina/uso terapêutico , Adulto , Transtorno da Personalidade Borderline/epidemiologia , Transtorno da Personalidade Borderline/psicologia , Comorbidade , Transtorno Depressivo/tratamento farmacológico , Transtorno Depressivo/epidemiologia , Transtorno Depressivo/psicologia , Método Duplo-Cego , Feminino , Hospitalização , Humanos , Masculino , Inventário de Personalidade , Placebos , Escalas de Graduação Psiquiátrica , Reprodutibilidade dos TestesRESUMO
Depressive illness with initial onset after age 60 has different clinical and prognostic features compared to depression beginning at a younger age. We evaluated waking electroencephalograms (EEGs) in 61 elderly depressed patients (32 early onset, 29 late onset) without cognitive impairment and not receiving psychotropic medications. The groups were comparable for age, severity of Hamilton depression score, education, and Folstein Mini-Mental State scores. Conventional visual EEG analysis revealed no significant differences in the mean alpha rhythm, incidence of abnormal records, or types of EEG abnormalities. Computerized spectral EEG analysis was also performed in 48 patients (23 early onset, 25 late onset). There were no significant differences in the pooled parasagittal mean frequency, theta--beta difference, combined delta and theta percentage, or relative power of the frequency bands. Thus, waking EEGs do not differentiate between elderly patients with the initial onset of the depression before or after age 60.