Residual Depressive Symptoms Research Articles

Personality predicts recurrence of late-life depression

ObjectiveTo examine the association of personality with recurrence of depression in later life. MethodA subsample of 91 subjects from the Longitudinal Aging Study Amsterdam (LASA; baseline sample size n=3107; aged ≥55 years) depressed at baseline, who had recovered in the course of three years (first follow-up cycle) was identified. 41 (45%) respondents experienced a recurrence during the subsequent six years. The influences of personality and late life stress (demographic factors, health and social factors) on recurrence were investigated prospectively. ResultsRecurrence of depression was associated with a high level of neuroticism and low level of mastery, residual depressive symptoms at time of recovery, female gender, pain complaints and feelings of loneliness. In multivariable analysis entering all predictors significant in single variable analysis, residual depressive symptoms and lack of mastery remained significantly associated with recurrence. ConclusionIn predicting the recurrence of depression in later life, the direct effects of personality remain important and comparable in strength with other late life stressors related to recurrence.

Treating Partial Responders to Antidepressant Treatment

Many patients with major depressive disorder only partially respond to initial antidepressant treatment. Residual depressive symptoms need to be addressed so that patients can achieve full remission and return to presymptomatic levels of functioning. This case vignette presents Ms M, a 26-year-old woman who continues to experience depression, fatigue, and sleepiness after adequate antidepressant therapy, and discusses pharmacologic strategies to relieve residual symptoms.

Which depressive symptoms remain after response to cognitive therapy of depression and predict relapse and recurrence?

BackgroundMajor Depressive Disorder (MDD) is highly prevalent, severely debilitating, and often recurrent. Greater residual depressive symptoms after acute phase treatment predict greater relapse and recurrence. It is unknown, however, which specific depressive symptoms remain and are most predictive. MethodThe current study examined (a) which specific residual symptoms remained after effective treatment with acute phase cognitive therapy (A-CT) for recurrent depression and (b) if any of those specific residual symptoms were risk factors for relapse and recurrence over a 2-year follow-up. ResultsAfter completing 20 sessions of A-CT, a substantial proportion of adult responders continued to endorse somatic anxiety (42%), psychological anxiety (37%), middle insomnia (36%), depressed mood (29%), loss of libido (29%), late insomnia (24%), anergia (21%), guilt feelings (18%), early insomnia (17%), and anhedonia (14%), as defined by the 17-item Hamilton Rating Scale for Depression (HRSD). Decreased agitation, increased psychological anxiety, increased loss of appetite, increased loss of libido, and increased hypochondriasis were all risk factors for relapse and recurrence over a 2-year follow-up (all p<.05), after stratifying on number of previous episodes and controlling for age at onset and whether A-CT responders received continuation phase CT instead of assessment only control. LimitationsThese findings are based on a limited sample size (n=84), which was modestly restricted in terms of gender, ethnicity, region, and mean education level. ConclusionsThese results confirm that residual symptoms are common after A-CT. We hypothesize that treatments, intervention modules, or durations that effect and/or target specific residual symptoms may further reduce depression relapse and recurrence.

Adult attachment in bipolar 1 disorder

To determine how security of adult attachment style is related to the mania, major depression and euthymic mood states in bipolar 1 (BP1) disorder. An observational cross-sectional study. One hundred and seven BP1 patients (34 in a manic type episode, 30 in major depressive episode, and 43 in remission) and 41 healthy controls similar in age, gender, reading age, and education were recruited. The groups were compared on self-reported mean and preferred attachment style controlling for psychiatric comorbidity. Preferred attachment style was insecure in 84 (78%) BP1 patients but only 13 (32%) healthy controls (chi(2)=34.3, df=3, and p<.001). Healthy controls reported higher secure attachment, lower anxious, and lower preoccupied attachment scores than all groups of patients with bipolar disorder, although the scores for secure attachment in mania and preoccupied attachment in euthymic patients were not significantly different from healthy controls. Overall, within the bipolar groups, anxious attachment style varied little with mood but mania was associated with higher secure and preoccupied attachment style, and depression with higher preoccupied and lower dismissing attachment style scores. Insecure attachment is found in most patients with BP1 disorder. Attachment style is affected by mood episodes so it should be assessed when a patient with bipolar disorder is in remission with minimal residual depressive or manic symptoms.

Self-rated residual symptoms do not predict 1-year recurrence of depression

Background Residual depressive symptoms are generally documented as a risk factor for recurrence. In the absence of a specific instrument for the assessment of residual symptoms, a new 25-item Depression Residual Symptom Scale (DRSS) was elaborated and tested for recurrence prediction over a 1-year follow-up. Sampling and methods Fifty-nine patients in remission after a major depressive episode (MDE) were recruited in two centres. They were assessed with the DRSS and the Montgomery-Asberg Depression Rating Scale (MADRS) at inclusion and followed for 1 year according to a seminaturalistic design. The DRSS included specific depressive symptoms and subjective symptoms of vulnerability, lack of return to usual self and premorbid level of functioning. Results Severity of residual symptoms was not significantly associated with increased risk of recurrence. However, DRSS score was significantly higher among patients with three or more episodes than one to two episodes. Number of previous episodes and treatment interruption were not identified as significant predictors of recurrence. Conclusion The proposed instrument is not predictive of depressive recurrence, but is sensitive to increased perception of vulnerability associated with consecutive episodes. Limitations include small sample size, seminaturalistic design (no standardisation of treatment) and content of the instrument.

An Association between Residual Renal Function and Depression Symptoms in Haemodialysis Patients

Background: The loss of residual renal function (RRF) and subsequent urine volume among haemodialysis (HD) patients may influence affect. Although RRF has been associated with improved patient outcome, its relationship with depression symptomatology is unknown. Methods: 106 HD patients completed the Beck Depression Inventory (BDI). The BDI is a depression symptom screening tool, with a score of ≥16 indicating possible clinical depression. Clinical parameters, including RRF (urea clearance, KRU [ml/min]) and interdialytic urine volume, were averaged over the 3-month pre-assessment including the month of the BDI assessment. Results: BDI scores correlated negatively with KRU and interdialytic urine volume. Patients with a KRU <1 had significantly higher BDI scores compared to those with a KRU ≥1. In logistic regression, KRU significantly predicted a BDI score ≥16, after controlling for a range of clinical parameters including urea, dialysis vintage and treatment time. A history of depressive illness was the only other predictive factor. Conclusion: We have demonstrated an association between RRF and depression symptoms in HD patients. The perception of loss associated with low RRF and urine volume may increase depressive vulnerability. Longitudinal assessment is required in order to validate this finding and to determine causality.

Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report

Many patients with major depressive disorder (MDD) who experience full symptomatic remission after antidepressant treatment still have residual depressive symptoms. We describe the types and frequency of residual depressive symptoms and their relationship to subsequent depressive relapse after treatment with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. Participants in primary (n=18) and psychiatric (n=23) practice settings were openly treated with citalopram using measurement-based care for up to 14 weeks and follow-up for up to 1 year. We assessed 943 (32.8% of 2876) participants who met criteria for remission to determine the proportions with individual residual symptoms and any of the nine DSM-IV criterion symptom domains to define a major depressive episode. At each visit, the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) and the self-report Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale were used to assessed depressive symptoms and side-effects respectively. More than 90% of remitters had at least one residual depressive symptom (median=3). The most common were weight increase (71.3%) and mid-nocturnal insomnia (54.9%). The most common residual symptom domains were sleep disturbance (71.7%) and appetite/weight disturbance (35.9%). Those who remitted before 6 weeks had fewer residual symptoms at study exit than did later remitters. Residual sleep disturbance did not predict relapse during follow-up. Having a greater number of residual symptom domains was associated with a higher probability of relapse. Patients with remission of MDD after treatment with citalopram continue to experience selected residual depressive symptoms, which increase the risk of relapse.

Targeting Glutamatergic Signaling for the Development of Novel Therapeutics for Mood Disorders

There have been no recent advances in drug development for mood disorders in terms of identifying drug targets that are mechanistically distinct from existing ones. As a result, existing antidepressants are based on decades-old notions of which targets are relevant to the mechanisms of antidepressant action. Low rates of remission, a delay of onset of therapeutic effects, continual residual depressive symptoms, relapses, and poor quality of life are unfortunately common in patients with mood disorders. Offering alternative options is requisite in order to reduce the individual and societal burden of these diseases. The glutamatergic system is a promising area of research in mood disorders, and likely to offer new possibilities in therapeutics. There is increasing evidence that mood disorders are associated with impairments in neuroplasticity and cellular resilience, and alterations of the glutamatergic system are known to play a major role in cellular plasticity and resilience. Existing antidepressants and mood stabilizers have prominent effects on the glutamate system, and modulating glutamatergic ionotropic or metabotropic receptors results in antidepressant-like properties in animal models. Several glutamatergic modulators targeting various glutamate components are currently being studied in the treatment of mood disorders, including release inhibitors of glutamate, N-methyl-D-aspartate (NMDA) antagonists, alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) throughput enhancers, and glutamate transporter enhancers. This paper reviews the currently available knowledge regarding the role of the glutamatergic system in the etiopathogenesis of mood disorders and putative glutamate modulators.

Influence of Clinical and Neuropsychological Variables on the Psychosocial and Occupational Outcome of Remitted Bipolar Patients

Objective: To measure the impact of the clinical course, the residual mood symptoms and the cognitive variables on the psychosocial and occupational functioning in bipolar disorder patients in remission. Method: Forty-four euthymic DSM-IV-TR bipolar lithium-treated outpatients were assessed with a clinical interview and neuropsychological testing. To assess psychosocial function, some psychometric scales were administered (Global Assessment of Functioning Scale and World Health Organization Disability Assessment Schedule), and to evaluate occupational function, the sample was divided according to the current work status (active vs. inactive). Cognitive assessment was performed by means of a neuropsychological test battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory). Results: Measures of psychosocial functioning were significantly correlated with cognition (processing speed, p = 0.004), clinical severity (p = 0.03) and residual depressive symptoms (p = 0.05). Occupational functioning showed a significant effect with a cognitive domain (visual memory, p = 0.006) and a clinical variable (chronicity, p = 0.04) but not with residual mood symptoms (p > 0.2). Conclusions: Remission in bipolar disorder is not synonymous with recovering in psychosocial and occupational functioning. Cognitive deficits, clinical course and persistent subsyndromal symptoms may compromise psychosocial functioning, and neurocognitive symptoms and chronicity may particularly affect occupational functioning.

Maintenance treatment of adolescent bipolar disorder: open study of the effectiveness and tolerability of quetiapine

BackgroundThe purpose of the study was to determine the effectiveness and tolerability of quetiapine as a maintenance treatment preventing against relapse or recurrence of acute mood episodes in adolescent patients diagnosed with bipolar disorder.MethodsConsenting patients meeting DSM-IV lifetime criteria for a bipolar disorder and clinically appropriate for maintenance treatment were enrolled in a 48-week open prospective study. After being acutely stabilized (CGI-S ≤ 3 for 4 consecutive weeks), patients were started or continued on quetiapine and other medications were weaned off over an 8-week period. Quetiapine monotherapy was continued for 40-weeks and other mood stabilizers or antidepressants were added if clinically indicated. A neurocognitive test battery assessing the most reliable findings in adult patients was administered at fixed time points throughout the study to patients and matched controls.ResultsOf the 21 enrolled patients, 18 completed the 48-week study. Thirteen patients were able to be maintained without relapse or recurrence in good quality remission on quetiapine monotherapy, while 5 patients required additional medication to treat impairing residual depressive and/or anxiety symptoms. According to symptom ratings and global functioning scores, the quality of remission for all patients was very good.Neurocognitive test performance over treatment was equivalent to that of a matched control group of never ill adolescents. Quetiapine was generally well tolerated with no serious adverse effects.ConclusionThis study suggests that a proportion of adolescent patients diagnosed with bipolar disorder can be successfully maintained on quetiapine monotherapy. The good quality of clinical remission and preserved neurocognitive functioning underscores the importance of early diagnosis and effective stabilization.Clinical Trials RegistryD1441L00024

P01-215 Clinical factors as predictors on functional impairment in bipolar disorder

Introduction:Recent studies have suggested that functional impairment in bipolar disorder may be strongly associated with residual depressive symptoms. However, there is a notable disparity between functional recovery and symptomatic recovery. This study was carried out to investigate clinical factors as potential predictors on functional impairment in a well defined euthymic bipolar sample.Methods:Seventy-one patients were recruited from the Bipolar Disorder Program at the Clinic Hospital of Barcelona. A Structured Clinical Interview for DSM-IV-TR, HAM-D and YMRS were used to diagnostic assessment and euthymia criteria. The Functioning Assessment Short Test (FAST) was employed to assess functional impairment. The FAST is a reliable and valid, interview-administered scale, rapid and easy to apply (3-6 min). It consists of 24 items which allow to assess six specific areas of functioning such as autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time.Results:The sample comprised 36 (51%) men, aged 48±13.56 years. Several clinical variables were associated with poor functioning on a linear regression model, such as age, depressive symptoms, number of previous mixed episodes and number of previous hospitalizations. This model explained 44% of the variance (F=12.54, df=58, p&lt; 0.001).Discussion:In this study, specific clinical and socio-demographic characteristics were identified as predictors of functional impairment in remitted bipolar patients. Poor functioning was identified in patients with older age and more severe illness course.

CS11-02 Interepisode functioning of bipolar disorder

Even though bipolar disorder is suggested to have a benign course with episodes and remissions, it has been shown that interepisode functioning of bipolar disorder is not so good. Subclinical residual mood symptoms are found to be in 24% of bipolar patients during remission. Furthermore, it appears that 30-60% of individuals with bipolar disorder fail to regain full functioning in occupational and social domains. In cognitive domain, euthymic bipolar patients demonstrate relatively marked impairment in aspects of executive function such as processing speed and verbal fluency, sustained attention, and verbal memory.It is estimated that 30-50% of largely remitted patients fail to attain premorbid levels of psychosocial functioning due to their cognitive impairment. It is also suggested that the subsyndromal residual depressive symptoms have substantial effect on the persistence of cognitive and psychosocial impairment after remission. Thus, residual symptoms play an important role in the inter-episode functioning of the bipolar patients.In the assessment of interepisode functioning, subjective QOL in bipolar patients may not accurately reflect objective functional outcome status. Especially, in the subjective assessment of cognitive functions, bipolar patients tend to over-estimate themselves. There is only weak to moderate correlation between subjective cognitive complains and objective cognitive tests. Therefore, it would be more accurate to assess the inter-episode functioning of the bipolar patients via objective tests and ratings.

Toward achieving optimal response: understanding and managing antidepressant side effects

The safety and tolerability of antidepressants have improved considerably over the past two decades. Nevertheless, antidepressant side effects are still common and problematic. The majority of patients treated with contemporaty agents experience one or more bothersome side effects. These side effects often create barriers to achieving depressive remission, as well as to preventing relapse and recurrence. Clinicians tend to underestimate the prevalence of side effects, and as many as one quarter of patients discontinue their antidepressants because of difficult-to-tolerate side effects; others may continue on antidepressant therapy but experience diminished quality of life related to troublesome side effects. This article reviews the prevalence of side effects, the impact of side effects on treatment adherence, and methodological issues including the challenge of distinguishing side effects from residual depressive symptoms, discontinuation effects, and general medical problems. In addition, we address the most common side effects such as sexual dysfunction, gastrointestinal problems, sleep disturbance, apathy and fatigue, and offer strategies for management that may help patients achieve optimal response to pharmacotherapy

Towards achieving remission in the treatment of depression

The burden of depressive illness constitutes a major public health issue. Despite real progress and better tolerance of new antidepressant medications, a significant number of depressed patients still suffer from rather severe residual depressive symptoms.This relative lack of efficacy clearly interferes with their psychosocial functioning and their quality of life. In addition, it is now well-recognized that the failure to reach full clinical remission after antidepressant treatment involves a high risk of relapse or recurrence in patients suffering from major depression, This paper reviews the concept of remission across different definitions, and the potential risk factors associated with the failure to reach clinical remission. The identification of specific residual symptoms in nonremitted patients is also of great importance, in order to assess the predictive value of those symptoms in relation to relapse and recurrence. Some methodological issues are also discussed, as well as various therapeutic strategies aimed at relieving residual depressive symptoms. Clinical remission remains a gold standard and a primary objective of modern antidepressant therapy.

Discontinuation of Maintenance Selective Serotonin Reuptake Inhibitor Monotherapy After 5 Years of Stable Response

Selective serotonin reuptake inhibitors (SSRIs) are effective treatments of major depressive disorder (MDD), but data to guide the duration of maintenance therapy in community settings are limited. We assessed whether extending maintenance beyond 5 years provided additional benefit and identified other predictors of outcome. All patients treated at an urban community outpatient clinic between June 1993 and September 2005 were considered for inclusion in this study. Based upon patient preference and clinician judgment, 60 patients with DSM-IV MDD elected to continue, and 27 patients to discontinue, SSRI treatment after 5 years of clinical stability on maintenance monotherapy in a community clinic. Differences in relapse risk were assessed using the Kaplan-Meier product limit method, and risk factors were evaluated in Cox proportional hazards regression, based on up to 8 years of illness course. Subjects who continued on SSRI treatment experienced a survival probability of maintaining remission during the first year, which was twice that of discontinued subjects (0.79 vs. 0.40), and survival differences persisted for over 30 months. Median survival time until relapse for patients who continued SSRIs was 38 months, exceeding the 10-month survival time of patients who discontinued. After controlling for significant covariates, the hazard ratio for SSRI discontinuation was 4.9. Residual depressive symptoms conferred increased relapse risk, while age, gender, SSRI type and dose, and prior depressive episodes did not predict relapse. After 5 years of maintenance monotherapy for MDD, SSRI discontinuation in a community setting is associated with a far poorer illness course than continued maintenance. Discontinuation of long-term maintenance is most likely to be successful in patients with minimal residual symptoms, and discontinued patients should be carefully monitored.

Withdrawal Symptoms of Trifluoperazine

Back to table of contents Previous article Next article LETTERFull AccessWithdrawal Symptoms of TrifluoperazineRudraprosad Chakraborty M.B.B.S., D.P.M., M.D.Arunima Chatterjee M.B.B.S., D.P.M., M.D.Suprakash Chaudhury M.D., Ph.D.,Rudraprosad Chakraborty M.B.B.S., D.P.M., M.D.Search for more papers by this authorArunima Chatterjee M.B.B.S., D.P.M., M.D.Search for more papers by this authorSuprakash Chaudhury M.D., Ph.D.Search for more papers by this author,Published Online:1 Oct 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor : Trifluoperazine, a typical antipsychotic, has been frequently used in major psychotic disorders for many years. Sudden discontinuation of trifluoperazine is known to cause relapse of psychotic symptoms in patients suffering from major psychosis. 1 , 2 Trifluoperazine is not known to cause any distinct withdrawal symptoms like craving, dysphoria, irritability, restlessness, or insomnia. An extensive literature search revealed a prior report of trifluoperazine withdrawal symptoms like craving, irritability, dysphoria, and inability to work. 3 Below, we describe the development of nonpsychotic withdrawal symptoms in a patient after use of trifluoperazine for several years. Case ReportA 78-year-old Indian man presented to us with a moderate depressive episode for 1 month. He had two previous episodes of depression which occurred 45 and 20 years ago, respectively. Both the episodes fully resolved with treatment, and the patient had no residual depressive symptoms in between the episodes. He also had severe nicotine dependence (smokeless tobacco) for about 56 years, from which he was abstinent for the previous year.The patient was treated with antidepressants for his second episode of depression along with trifluoperazine, 2 mg/day. After 1 month, his depressive symptoms resolved completely, and he stopped taking the antidepressants. However, he continued taking trifluoperazine in the same dose for the next 20 years. He said that if he ever tried to stop this medicine he felt very weak, restless, dysphoric, and had difficulty getting to sleep. But there was never any depressive cognition, guilty feeling, or other characteristic depressive symptoms. On days when he could not take this medicine, he experienced a craving for it. He and his family members felt that this was not normal and he tried to reduce the dose to 1 mg/day. Such attempts failed when he developed the above-mentioned symptoms the next day, which forced him to restart trifluoperazine, 2 mg/day. Symptoms resolved immediately every time thereafter. At times he started taking 3 mg/day, but generally he maintained a dosage of 2 mg/day.We treated the patient with escitalopram, 20 mg/day, for his depression and clonazepam, 1 mg/day, for associated sleep problems which developed during this depressive episode. With this he showed marked improvement in depressive symptoms. He was, however, still continuing trifluoperazine and was not motivated to stop it. When we asked him to try abstinence from trifluoperazine, he said he was unable to do away with it.DiscussionOur patient fulfilled ICD-10 criteria of a possible trifluoperazine withdrawal syndrome. This is interesting because unlike all other dependence-producing substances, trifluoperazine is a dopamine blocking agent and is not expected to stimulate the mesolimbic/mesocortical dopaminergic reward circuit. So it might be due to a sensitive reward circuit in our patient, as evidenced by his severe nicotine dependence. Further research is needed to examine the possibility of a unique trifluoperazine withdrawal syndrome. As trifluoperazine is very commonly used in developing countries like India because of its low cost, such a finding may have important therapeutic implications.Ranchi Institute of Neuropsychiatry and Allied Sciences, Ranchi, Jharkhand, IndiaReferences1 . Morton MR: A study of the withdrawal of chlorpromazine or trifluoperazine in chronic schizophrenia. Am J Psychiatry 1968; 124:1585–1588Google Scholar2 . Polizos P, Engelhardt DM, Hoffman SP, et al: Neurological consequences of psychotropic drug withdrawal in schizophrenic children. J Autism Dev Disord 1973; 3:247–253Google Scholar3 . Basu D, Marudkar M, Khurana H: Abuse of neuroleptic drug by psychiatric patients. Indian J Med Sci 2000; 54:59–62Google Scholar FiguresReferencesCited byDetailsCited ByCurrent awareness: Pharmacoepidemiology and drug safety26 June 2009 | Pharmacoepidemiology and Drug Safety, Vol. 18, No. 7 Volume 20Issue 4 Fall, 2008Pages 495-496 Metrics PDF download History Published online 1 October 2008 Published in print 1 October 2008

Withdrawal Symptoms of Trifluoperazine

Back to table of contents Previous article Next article LETTERFull AccessWithdrawal Symptoms of TrifluoperazineRudraprosad Chakraborty M.B.B.S., D.P.M., M.D.Arunima Chatterjee M.B.B.S., D.P.M., M.D.Suprakash Chaudhury M.D., Ph.D.,Rudraprosad Chakraborty M.B.B.S., D.P.M., M.D.Search for more papers by this authorArunima Chatterjee M.B.B.S., D.P.M., M.D.Search for more papers by this authorSuprakash Chaudhury M.D., Ph.D.Search for more papers by this author,Published Online:1 Oct 2008AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor : Trifluoperazine, a typical antipsychotic, has been frequently used in major psychotic disorders for many years. Sudden discontinuation of trifluoperazine is known to cause relapse of psychotic symptoms in patients suffering from major psychosis. 1 , 2 Trifluoperazine is not known to cause any distinct withdrawal symptoms like craving, dysphoria, irritability, restlessness, or insomnia. An extensive literature search revealed a prior report of trifluoperazine withdrawal symptoms like craving, irritability, dysphoria, and inability to work. 3 Below, we describe the development of nonpsychotic withdrawal symptoms in a patient after use of trifluoperazine for several years. Case ReportA 78-year-old Indian man presented to us with a moderate depressive episode for 1 month. He had two previous episodes of depression which occurred 45 and 20 years ago, respectively. Both the episodes fully resolved with treatment, and the patient had no residual depressive symptoms in between the episodes. He also had severe nicotine dependence (smokeless tobacco) for about 56 years, from which he was abstinent for the previous year.The patient was treated with antidepressants for his second episode of depression along with trifluoperazine, 2 mg/day. After 1 month, his depressive symptoms resolved completely, and he stopped taking the antidepressants. However, he continued taking trifluoperazine in the same dose for the next 20 years. He said that if he ever tried to stop this medicine he felt very weak, restless, dysphoric, and had difficulty getting to sleep. But there was never any depressive cognition, guilty feeling, or other characteristic depressive symptoms. On days when he could not take this medicine, he experienced a craving for it. He and his family members felt that this was not normal and he tried to reduce the dose to 1 mg/day. Such attempts failed when he developed the above-mentioned symptoms the next day, which forced him to restart trifluoperazine, 2 mg/day. Symptoms resolved immediately every time thereafter. At times he started taking 3 mg/day, but generally he maintained a dosage of 2 mg/day.We treated the patient with escitalopram, 20 mg/day, for his depression and clonazepam, 1 mg/day, for associated sleep problems which developed during this depressive episode. With this he showed marked improvement in depressive symptoms. He was, however, still continuing trifluoperazine and was not motivated to stop it. When we asked him to try abstinence from trifluoperazine, he said he was unable to do away with it.DiscussionOur patient fulfilled ICD-10 criteria of a possible trifluoperazine withdrawal syndrome. This is interesting because unlike all other dependence-producing substances, trifluoperazine is a dopamine blocking agent and is not expected to stimulate the mesolimbic/mesocortical dopaminergic reward circuit. So it might be due to a sensitive reward circuit in our patient, as evidenced by his severe nicotine dependence. Further research is needed to examine the possibility of a unique trifluoperazine withdrawal syndrome. As trifluoperazine is very commonly used in developing countries like India because of its low cost, such a finding may have important therapeutic implications.Ranchi Institute of Neuropsychiatry and Allied Sciences, Ranchi, Jharkhand, IndiaReferences1 . Morton MR: A study of the withdrawal of chlorpromazine or trifluoperazine in chronic schizophrenia. Am J Psychiatry 1968; 124:1585–1588Google Scholar2 . Polizos P, Engelhardt DM, Hoffman SP, et al: Neurological consequences of psychotropic drug withdrawal in schizophrenic children. J Autism Dev Disord 1973; 3:247–253Google Scholar3 . Basu D, Marudkar M, Khurana H: Abuse of neuroleptic drug by psychiatric patients. Indian J Med Sci 2000; 54:59–62Google Scholar FiguresReferencesCited byDetailsCited byCurrent awareness: Pharmacoepidemiology and drug safety26 June 2009 | Pharmacoepidemiology and Drug Safety, Vol. 18, No. 7 Volume 20Issue 4 Fall, 2008Pages 495-496 Metrics PDF download History Published online 1 October 2008 Published in print 1 October 2008

Self-Reported Psychopathological Symptoms and Quality of Life in Outpatients With Bipolar Disorder

Patients with bipolar disorder in a euthymic mood state can suffer from subsyndromal or residual symptoms of depression or hypomania. This study was undertaken to gain insight into the broader spectrum of psychopathological symptoms and quality of life. Participants (n = 157) completed the Symptoms Checklist-90, the World Health Organization Quality of Life Assessment Instrument-Bref, and a questionnaire addressing demographic and clinical characteristics. Outpatients with bipolar disorder reported fewer symptoms of psychopathology than psychiatric outpatients in general, but relative to the general population, a significantly lower quality of life was reported. The number of symptoms showed consistently negative correlations with the quality of life. The results of this study urge nurses to not settle for treatment response in terms of reduced manic or depressive episodes, but instead to strive for full remission of all symptoms.

Eighteen months of drug treatment for depression: Predicting relapse and recovery

Background The clinically relevant outcomes in treating depression are persistent recovery, relapse, and treatment resistance. Method 175 outpatients treated with antidepressants for 6 months were assessed for major depression. Those who had recovered were prospectively monitored for one year to study rates of relapse (at least two weeks of major depression). Those who were depressed at 6 months were monitored for rates of recovery (at least 8 weeks of no major depression). Results 94% of the sample was monitored for one year. Of the 123 patients who were not depressed at 6 months 57 (46%) relapsed. Patients who relapsed were more likely to have a history of recurrent depression, to have residual depressive symptoms, to have a less sustained response to initial treatment, to have avoidant personality disorder symptoms, schizotypal personality disorder symptoms, higher harm avoidance (HA) scores and lower self directedness (SD) scores. Of the 38 patients who were depressed at 6 months 13 (34%) recovered. There were no patient characteristics associated with recovery. Limitations The findings apply to moderately depressed outpatients. There was no placebo control. Conclusion Most patients with depression will recover but many become unwell again within a year. Clinically long term monitoring and sustained efforts to treat patients with major depression seem warranted.

Mindfulness Predicts Relapse/Recurrence in Major Depressive Disorder After Mindfulness-Based Cognitive Therapy

Empirical evidence for the effectiveness of mindfulness-based cognitive therapy (MBCT) is encouraging. However, data concerning the role of mindfulness in its relapse preventive effect are lacking. In our study, 25 formerly depressed patients received MBCT. Mindfulness was assessed before and immediately after MBCT using the Mindful Attention and Awareness Scale. Mindfulness significantly increased during MBCT, and posttreatment levels of mindfulness predicted the risk of relapse/recurrence to major depressive disorder in the 12-month follow-up period. Mindfulness predicted the risk of relapse/recurrence after controlling for numbers of previous episodes and residual depressive symptoms. The results provide preliminary evidence for the notion that mindfulness is an important factor in relapse prevention in major depression.