Faculty Bibliography

PURPOSE/OBJECTIVE:We compared the mean basilar artery blood flow velocity (BABFV) between patients with panic disorder and healthy subjects both at rest and immediately following carbon dioxide (CO(2)) challenge, and examined the effects of treatment on BABFV. METHODS:Twenty four patients with panic disorder with or without agoraphobia and 12 healthy comparison subjects were studied. Visual Analog Anxiety Scale was used to evaluate the anxiogenic effect of 35% CO(2) inhalation. Mean BABFV was monitored using transcranial Doppler ultrasonography at rest and 10, 20, 30, 60, 90, 120 s after 35% CO(2) challenge both before and after four weeks treatment with paroxetine. RESULTS:The hemodynamic response pattern of basilar artery to CO(2) inhalation was significantly different between two groups. CO(2) rapidly triggered blood flow velocity in basilar artery amongst panic patients but not in healthy comparisons. The mean time to normalization of BABFV was significantly longer in panic patients. Four weeks of treatment with paroxetine led to a significantly reduced mean BABFV after 35% CO(2) inhalation in comparison with pretreatment. CONCLUSIONS:Patients with panic disorder had impaired cerebral regulatory mechanisms observed as a change in response characteristics in BABFV in response to CO(2) inhalation. Treatment with paroxetine reduced the increase of BABFV seen in patients after the CO(2) challenge.

Panic disorder (PD) is a heterogeneous phenomenon with respect to symptom profile. Most studies agree that a group of patients with prominent respiratory symptoms emerged as a distinct PD subtype. In this study we compared a range of clinical features associated with PD and agoraphobia in patients with respiratory (RS) and nonrespiratory (NRS) subtypes of PD. The participants were 124 patients with PD (79 women and 45 men), with or without agoraphobia, diagnosed by DSM-IV criteria. Following the observer-rated Panic Disorder Severity Scale assessment, subjects completed self-report measures, including the Anxiety Sensitivity Index (ASI), Panic-Agoraphobia Scale; the Beck Anxiety Inventory; and the Panic-Agoraphobic Spectrum Scale (PAS-SR). Multivariate analysis of variance (MANOVA) showed significant group differences [Pillai's trace = 0.95, F (5, 118)(=)2.48, P = .036]. Patients in RS group had higher mean total scores on the ASI (F = 5.00, df = 1, P = .027) and PAS-SR (F = 11.23, df = 1, P = .001) than patients in NRS group. Also, patients with RS attained higher scores than patients with NRS on four domains of PAS-SR (panic-like symptoms, agoraphobia, separation sensitivity, and reassurance seeking). A descriptive discriminant analysis of the data correctly identified 69.4% of the patient group in general and 86.1% of RS group (Wilks's lambda = 0.87, df = 8, P = .048). The significant discriminating factors of the RS and NRS groups were domains of panic-like symptoms, agoraphobia, separation sensitivity, and reassurance seeking. Our findings suggest that anxiety sensitivity and panic-agoraphobic spectrum symptoms might be particularly relevant to understanding subtypes of PD.

PURPOSE/OBJECTIVE:Although antidepressant drugs have been proven as an effective treatment for posttraumatic stress disorder (PTSD), there are few comparative studies of antidepressants that are acting on different neurotransmitters. The main aim of this study is to compare the efficacy of different class of antidepressant drugs on the PTSD. SUBJECTS/MATERIALS AND METHODS: In this open label study, the patients who met DSM-IV criteria for PTSD were randomly assigned to flexible doses of fluoxetine, moclobemide, or tianeptine. After the first assessment, consecutive assessments were performed at the end of weeks 2, 4, 8, and 12 using clinician administered PTSD scale (CAPS) and Clinical Global Impression of Severity (CGI-S). Changes in the total score of CAPS and sub-scale scores of symptom clusters (re-experience, avoidance, and hyperarousal) were the main output of efficacy. All statistics were based on intention-to-treat and last-observation-carried-forward (LOCF) principles. RESULTS:Thirty-eight patients were assigned to fluoxetine, 35 patients were assigned to moclobemide, and 30 patients were assigned to tianeptine group. Gender distributions and mean ages of the treatment groups were not significantly different. Drop-out rates due to an adverse events or unknown reasons were not significantly different among fluoxetine (18.4%), moclobemide (14.3%), and tianeptine (20.0%) groups. All three treatments has led to a significant improvement in PTSD severity assessed with CAPS total score (ANOVA P < 0.001). Similarly, total scores of re-experiencing, avoidance, and hyperarousal clusters that are subscales of CAPS were significantly reduced by all three treatments (with ANOVA all P values < 0.001). There was not significant difference in terms of treatment effect between three groups. DISCUSSION/CONCLUSIONS:Treatment groups showed very similar improvement on all ratings scales. The findings support that fluoxetine, moclobemide, and tianeptine are all effective in the treatment of PTSD. Different mechanisms of action for these antidepressant drugs might result in the same common neurochemical end point. However, further studies using different classes of antidepressant drugs are needed.

OBJECTIVE:Patients with psychiatric disorders have a higher incidence of smoking than the general population. In particular, the rate of smoking among patients with schizophrenia has been found to be between two and three times in the general population in western countries. This paper reviews the biological factors that might be contributing to the high rate of smoking among patients with schizophrenia and examines the interaction between nicotine and neurobiological disturbances observed in schizophrenia. METHOD/METHODS:Papers assessing the possible biological causes of smoking in patients with schizophrenia and the physiological effects of nicotine were reviewed by using the key words "nicotine, schizophrenia, smoking and cigarette" in Pubmed, Turk Medline, and the Turkish Psychiatric Index. RESULTS:Studies conducted in humans and animals show that nicotine can directly increase dopaminergic transmission in the central nervous system, enhance cognitive performance and improve sensory gating deficits observed in patients with schizophrenia. Moreover, smoking diminishes the efficacy of most antipsychotic drugs via an increased hepatic metabolism. CONCLUSION/CONCLUSIONS:Studies suggest a link between the physiological effects of nicotine and the neurobiological disturbances in schizophrenia. Disturbances in the cholinergic transmission may be responsible for some symptoms of schizophrenia. The harmful effects of smoking vastly outweigh any possible benefits, but, nevertheless, further investigation may lead to important insights regarding the etiology of schizophrenia at a molecular level.

BACKGROUND:The objective of the study is to describe the community prevalence of psychiatric disorder, mainly posttraumatic stress disorder (PTSD) and Major Depressive Disorder (MDD) 3 years after a devastating earthquake. METHODS:Three years after the Marmara Earthquake, 683 individuals from the epicentre were randomly selected to form a representative sample and were assessed with Composite International Diagnostic Interview (CIDI), General Health Questionnaire (GHQ), Traumatic Stress Symptom Checklist (TSSC) and Beck Depression Inventory (BDI). RESULTS:The 36 months prevalence of PTSD and MDD after the Marmara Earthquake were 19.2% and 18.7% respectively. The current prevalence of PTSD and MDD in the affected community was found to be 11.7% and 10.5%, respectively. PTSD and MDD were the most prevalent disorders after the disaster and showed a decrease over time. However, only 38.9% of the PTSD cases identified at any time over the 3 years were in remission at the 3rd-year. The co-occurrence of MDD with PTSD resulted in a decrease in the rate of recovery from PTSD. MDD was also the most prevalent disorder accompanying PTSD. Of all the subjects 37.5% with PTSD still met the MDD criteria at the 3rd year postearthquake. CONCLUSIONS:In comparison with the data from pre-earthquake national mental health profile, the present study showed that the prevalence of MDD, panic disorder, OCD, GAD, social phobia and special phobias were still higher in the affected region 3 years after the earthquake.

Objective. Reboxetine is a selective noradrenaline reuptake inhibitor (NaRI), a study on the effects of reboxetine on amenorrhea has not been reported in the literature up to now. This report describes a patient with symptoms of amenorrhea which is thought to be caused by reboxetine. Case. A female patient with major depressive disorder was given reboxetine 8 mg/day. She had experienced secondary amenorrhea for 3 months. The patient had no periodic irregularity before reboxetine use, and after reboxetine was discontinued menstruation resumed. After another trial with reboxetine at the optimal dose (8 mg/day, increased gradually), the patient reported amenorrhea again for 2 months. On discontinuing reboxetine, her menstrual cycle became regular again. Discussion. FSH, LH, E2 and prolactin levels were normal in our patient. Because amenorrhea was temporally related with reboxetine trials, we posit that this phenomenon may be due to side effects of reboxetine. This may be due to noraderenergic effects on hormonal function.

We explored the prevalence of posttraumatic stress disorder (PTSD) and its relation to demographic characteristics and other risk factors for developing PTSD in a large sample (N = 910) of earthquake survivors living in tent city. Twenty-five percent of the sample met DSM-IV criteria for PTSD assessed with the Posttraumatic Stress Disorder Self Test (PTSD-S). Peritraumatic factors explained the most variance when the risk factors were grouped as demographics, pretraumatic, peritraumatic, and posttraumatic. The study emphasized that PTSD among the earthquake victims was as prevalent in Turkey as after disasters in other developing countries but higher than usually found after disasters in developed countries, and there was a relation between some factors-mostly peritraumatic-and PTSD.

We assessed the reliability and validity of the Turkish version of the seven-item Panic Disorder Severity Scale (PDSS). We recruited 174 subjects, including 104 with current DSM-IV panic disorder with (n=76) or without(n=28)agoraphobia, 14 with a major depressive episode, 24 with a non-panic anxiety disorder, and 32 healthy controls. Assessment instruments were Panic Disorder Severity Scale, Panic and Agoraphobia Scale, both the observer-rated (P&Ao) and self-rating (P& Asr); Clinical Global Impression Scale (CGI); Hamilton Anxiety Scale, and Beck Depression Inventory. We repeated the measures for a group of panic disorder patients (n = 51) after 4 weeks to assess test-retest reliability. The internal consistency (Cronbach's alpha) of the PDSS was .92-94. The inter-rater correlation coefficient was .79. The test-retest correlation coefficient after 4 weeks was .63. In discriminant validity analyses, the highest correlation for PDSS was with P&Ao, P&Asr (r=.87 and.87, respectively) and CGI (r=.76) and the lowest with Beck Depression Inventory (r=.29). The cut-off point was six/seven, associated with high sensitivity (99%) and specificity (98%). This study confirmed the objectivity, reliability and validity of the Turkish version of the PDSS.

OBJECTIVE:To assess general practitioners' attitudes and behavior towards psychotic disorders, antipsychotic drug prescriptions, and patients with psychosis in primary health care settings. METHOD/METHODS:262 general practitioners (GPs) practicing in primary care settings in Kocaeli province were included in the study. The 20-item questionnaire, which was prepared by the researchers, was sent to all GPs via the Kocaeli branch of the Health Ministry. 195 (74.4%) questionnaires were returned. The GPs' responses and the relations between different variables were examined. RESULTS:The participation rate among GPs in any education about psychosis and antipsychotic treatment after graduation was 27.2%. The rate seeking structured and advanced education about psychosis was 41.0%. The mean daily number of patients with psychosis examined by GPs in primary care settings during the previous six months was 1.4. They first prescribed any antipsychotic drug by themselves at a rate of 12.8% in the previous six-month. The most frequent reason for antipsychotic prescription was re-prescription (80.0%). The most frequent problem in the pharmacological treatment of psychotic disorders was the drop-out rate of patients (75.9%). The predictors of starting patients with psychosis on medication were the belief that the patients were treatable in primary care and the suspicion of GPs about psychosis. CONCLUSION/CONCLUSIONS:GPs practicing in primary care settings rarely encounter patients with psychosis. GPs mostly avoid undertaking the responsibility of treating them. However, some are eager to participate in structured education about psychosis in order to have more confidence when diagnosing and treating it.

OBJECTIVE:Fluoxetine and its active metabolite norfluoxetine have long half-lives. We postulate that, owing to the long elimination half-life and the time to reach steady-state level in plasma is nearly four weeks, patients diagnosed with major depressive disorder might be treated with fluoxetine taken once every third day, after being treated initially during 4 weeks with daily doses of fluoxetine. METHODS:In this open label, 12-weeks, randomized, prospective study, patients diagnosed with DSM-IV major depressive disorder were randomly assigned into 1 of 3 treatment groups. Thirty-four patients took 20 mg and 32 patients took 40 mg of fluoxetine daily throughout the study. Twenty-nine patients had been taking 20 mg of fluoxetine daily for 4 weeks of the study initially, and then were switched to 20 mg fluoxetine once every third day regime. The severity of depression was assessed by Hamilton Depression Rating Scale (HDRS) and Clinical Global Impressions- Severity Scale (CGI-S). Response was defined as a 50% or greater reduction of the baseline HDRS total score. After defining a strict criterion of relapse, time to relapse was estimated using survival analyses (Kaplan-Meier method). RESULTS:The repeated measures analysis of variance (ANOVA) of HDRS found a significant time effect (F = 464.04, df = 1.00, p < 0.001), but no significant group effects (F = 0.84, df = 2.00,p = 0.433) from baseline through week 12. The proportion of responders was not significantly different between the treatment groups at the endpoint. Survival analyses showed, however, a significant delayed mean time to relapse in patients treated with 40 mg of fluoxetine daily compared to either patients treated with 20 mg of fluoxetine daily or 20 mg fluoxetine once every third day. The mean times to relapse were 79.8, 70.8, and 70.5 days, respectively. Fluoxetine was associated with some adverse events in 46.3% of patients. The most frequently occurring adverse event was insomnia. CONCLUSION/CONCLUSIONS:It is proposed that either every third day or daily dosing with the same dose of fluoxetine could treat the patients with major depressive disorder during the acute and continuation period of treatment. Nevertheless, higher daily dose of fluoxetine has a reduced relapse rate compared to that of the lower daily dose.