Handbook of psychopharmacology

Over the past 5 yr, we have examined some of the sharpest edges of the pathology of aging. We have studied the capacity of aged organisms to respond appropriately to stress and the capacity of stre...

The Neuroendocrinology of Stress and Aging: The Glucocorticoid Cascade Hypothesis

Physical activity may play an important role in the management of mild-to-moderate mental health diseases, especially depression and anxiety. Although people with depression tend to be less physically active than non-depressed individuals, increased aerobic exercise or strength training has been shown to reduce depressive symptoms significantly. However, habitual physical activity has not been shown to prevent the onset of depression. Anxiety symptoms and panic disorder also improve with regular exercise, and beneficial effects appear to equal meditation or relaxation. In general, acute anxiety responds better to exercise than chronic anxiety. Studies of older adults and adolescents with depression or anxiety have been limited, but physical activity appears beneficial to these populations as well. Excessive physical activity may lead to overtraining and generate psychological symptoms that mimic depression. Several differing psychological and physiological mechanisms have been proposed to explain the effect of physical activity on mental health disorders. Well controlled studies are needed to clarify the mental health benefits of exercise among various populations and to address directly processes underlying the benefits of exercise on mental health.

Physical activity and mental health: current concepts.

Past suicidal behaviors including ideation and attempts have been identified as significant risk factors for subsequent suicidal behavior. However, inadequate attention has been given to the development or validation of measures of past suicidal behavior. The present study examined the reliability and validity of a brief self-report measure of past suicidal behavior, the Suicidal Behaviors Questionnaire-Revised (SBQ-R). Participants included psychiatric inpatient adolescents, high school students, psychiatric inpatient adults, and undergraduates. Logistic regression analyses provided empirical support for the usefulness of the SBQ-R as a risk measure of suicide to differentiate between suicide-risk and nonsuicidal study participants. Receiver operating characteristic (ROC) analyses indicated that the most useful cutoff scores on the SBQ-R were 7 for nonsuicidal samples, and 8 for clinical samples. Both the single SBQ-R Item 1 and SBQ-R total scores are recommended for use in clinical and nonclinical settings.

The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and nonclinical samples

Advanced Statistical Methods in Biometric Research.

ContextDespite the high prevalence, chronicity, and associated comorbidity
of posttraumatic stress disorder (PTSD) in the community, few placebo-controlled
studies have evaluated the efficacy of pharmacotherapy for this disorder.ObjectiveTo determine if treatment with sertraline hydrochloride effectively
diminishes symptoms of PTSD of moderate to marked severity.DesignTwelve-week, double-blind, placebo-controlled trial preceded by a 2-week,
single-blind placebo lead-in period, conducted between May 1996 and June 1997.SettingOutpatient psychiatric clinics in 8 academic medical centers and 6 clinical
research centers.PatientsA total of 187 outpatients with a Diagnostic and Statistical
Manual of Mental Disorders, Revised Third Edition diagnosis of PTSD
and a Clinician Administered PTSD Scale Part 2 (CAPS-2) minimum total severity
score of at least 50 at baseline (mean age, 40 years; mean duration of illness,
12 years; 73% were women; and 61.5% experienced physical or sexual assault).InterventionPatients were randomized to acute treatment with sertraline hydrochloride
in flexible daily dosages of 50 to 200 mg/d, following 1 week at 25 mg/d (n=94);
or placebo (n=93).Main Outcome MeasuresBaseline-to-end-point changes in CAPS-2 total severity score, Impact
of Event Scale total score (IES), and Clinical Global Impression–Severity
(CGI-S), and CGI-Improvement (CGI-I) ratings, compared by treatment vs placebo
groups.ResultsSertraline treatment yielded significantly greater improvement than
placebo on 3 of the 4 primary outcome measures (mean change from baseline
to end point for CAPS-2 total score, −33.0 vs −23.2 [P=.02], and for CGI-S, −1.2 vs −0.8 [P=.01]; mean CGI-I score at end point, 2.5 vs 3.0 [P=.02]), with the fourth measure, the IES total score, showing a trend
toward significance (mean change from baseline to end point, −16.2 vs −12.1; P=.07). Using a conservative last-observation-carried-forward
analysis, treatment with sertraline resulted in a responder rate of 53% at
study end point compared with 32% for placebo (P=.008,
with responder defined as >30% reduction from baseline in CAPS-2 total severity
score and a CGI-I score of 1 [very much improved], or 2 [much improved]).
Significant (P<.05) efficacy was evident for sertraline
from week 2 on the CAPS-2 total severity score. Sertraline had significant
efficacy vs placebo on the CAPS-2 PTSD symptom clusters of avoidance/numbing
(P=.02) and increased arousal (P=.03) but not on reexperiencing/intrusion (P=.14).
Sertraline was well tolerated, with insomnia the only adverse effect reported
significantly more often than placebo (16.0% vs 4.3%; P=.01).ConclusionsOur data suggest that sertraline is a safe, well-tolerated, and effective
treatment for PTSD.

https://jamanetwork.com/journals/jama/articlepdf/192575/JOC91246.pdf

Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial.

Subjective reports of sleep disturbance indicate that 70–91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep. Nightmares are reported by 19–71% of patients, depending on the severity of their PTSD and their exposure to physical aggression. Objective measures of sleep disturbance are inconsistent, with some studies that used these measures indicating poor sleep and others finding no differences compared with non-PTSD controls. Future research in this area may benefit from examining measures of instability in the microstructure of sleep. Additionally, recent findings suggest that sleep disordered breathing (SDB) and sleep movement disorders are more common in patients with PTSD than in the general population and that these disorders may contribute to the brief awakenings, insomnia and daytime fatigue in patients with PTSD. Overall, sleep problems have an impact on the development and symptom severity of PTSD and on the quality of life and functioning of patients. In terms of treatments, SSRIs are commonly used to treat PTSD, and evidence suggests that they have a small but significant positive effect on sleep disruption. Studies of serotonin-potentiating non-SSRIs suggest that nefazodone and trazodone lead to significant reductions in insomnia and nightmares, whereas cyproheptadine may exacerbate sleep problems in patients with PTSD. Prazosin, a centrally acting α1-adrenoceptor antagonist, has led to large reductions in nightmares and insomnia in small studies of patients with PTSD. Augmentation of SSRIs with olanzapine, an atypical antipsychotic, may be effective for treatment-resistant nightmares and insomnia, although adverse effects can be significant. Additional medications, including zolpidem, buspirone, gabapentin and mirtazapine, have been found to improve sleep in patients with PTSD. Large randomised, placebo-controlled trials are needed to confirm the above findings. In contrast, evidence suggests that benzodiazepines, TCAs and MAOIs are not useful for the treatment of PTSD-related sleep disorders, and their adverse effect profiles make further studies unlikely. Cognitive behavioural interventions for sleep disruption in patients with PTSD include strategies targeting insomnia and imagery rehearsal therapy (IRT) for nightmares. One large randomised controlled trial of group IRT demonstrated significant reductions in nightmares and insomnia. Similarly, uncontrolled studies combining IRT and insomnia strategies have demonstrated good outcomes. Uncontrolled studies of continuous positive airway pressure for SDB in patients with PTSD show that this treatment led to significant decreases in nightmares, insomnia and PTSD symptoms. Controlled studies are needed to confirm these promising findings.

Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management

• Plasma levels of cortisol were sampled for 24 hours in 32 endogenously depressed (ED) patients and 72 normal controls who also underwent the dexamethasone suppression test. The ED patients had significantly higher mean 24-hour plasma levels of cortisol (X 24h PC). However, X 24h PC values of subjects in both groups were normally distributed, with a marked overlap between the two. Only seven ED patients had X 24h PC values higher than 2 SDs from the normal mean (>10 μg/dL). An abnormal dexamethasone suppression test result was only partially related to basal cortisol levels. The mean plasma level of cortisol between 1 and 4pmwas found to be highly correlated with the X 24h PC value in ED patients, as has been previously reported in normal subjects and patients with various other diseases (in which it also powerfully discriminated between hypersecretors and normosecretors). This finding supports the use of mean cortisol levels between 1 and 4pmas a reliable and convenient indication of cortisol secretion.

Gregory M. Asnis

Papers

Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial.

Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management

Cortisol Secretion in Endogenous Depression: I. Basal Plasma Levels

Denosologization of biological psychiatry or the specificity of 5-HT disturbances in psychiatric disorders.

Serotonin and anxiety revisited.