Biomedical subjects

D L Dunner

Publications and source records attributed to D L Dunner.

At least 37 records · Page 2Linked to original sources

PubMed1998

A prospective safety surveillance study for bupropion sustained-release in the treatment of depression.

BACKGROUND: This prospective 105-site study was conducted to determine the rate of seizures and other serious adverse experiences associated with the therapeutic use of the sustained-release formulation of bupropion (bupropion SR). METHOD: 3100 patients with a DSM-III-R diagnosis of depression without a current or past diagnosis of an eating disorder and with no personal or family history of seizure disorders were treated for up to 8 weeks with bupropion SR in an open-label study. Dosing was initiated at 50 mg b.i.d. and increased to a maximum of 150 mg b.i.d. unless not tolerated. Patients had the option to continue treatment with bupropion SR (50 mg b.i.d. to 150 mg b.i.d.) in a continuation phase lasting up to 1 year. During the acute and continuation phases, patients were evaluated for the occurrence of seizures and other serious adverse experiences. Clinical response to and tolerability of bupropion SR were also evaluated. RESULTS: Three patients each experienced a seizure associated with the therapeutic use of bupropion SR during the acute and continuation phases combined. The observed seizure rate during the 8-week acute phase was 2 seizures in 3094 evaluable patients, or 0.06%. The observed seizure rate for the acute and continuation phases combined was 3 seizures in 3094 patients, or 0.10%. Survival analysis yielded a cumulative seizure rate of 0.08% for the acute phase and 0.15% for both phases combined. Two patients who intentionally overdosed with bupropion SR also experienced seizures; however, these events were not included in calculations of the overall seizure rate. Therapeutic doses of bupropion SR were well tolerated and clinically efficacious. CONCLUSION: The therapeutic use of bupropion SR at total daily doses up to 300 mg/day in depressed patients without predisposition to seizures is associated with a seizure rate that is well within the range observed with other marketed antidepressants.

Adolescent↗

PubMed1998

Lithium carbonate: maintenance studies and consequences of withdrawal.

The treatment of mood disorders with lithium carbonate has made a significant impact on the health of patients who have these disorders and on the nature of psychiatry itself. Perhaps the single, most important finding about the efficacy of lithium that has influenced American psychiatry is the fact that lithium, given over long periods of time, reduces the frequency and severity of subsequent affective episodes in manic depressive patients. This paper discusses the selection of patients for maintenance treatment, the dose of lithium, the maintenance treatment of patients who have breakthrough episodes, those with hypomanic breakthrough episodes, and rapid cycling. The use of lithium in unipolar depression and the elderly and the consequences of lithium discontinuation are also reviewed.

Bipolar Disorder↗

PubMed1998

Treatment of dysthymic disorder.

Recent studies support the use of pharmacotherapy in the treatment of dysthymic disorder. This article reviews the relationship of the definition of dysthymic disorder to clinical treatment studies and discusses the treatment of dysthymic disorder with pharmacotherapy (with special emphasis on the use of fluoxetine) and psychotherapy.

Dysthymic Disorder↗

PubMed1997

Venlafaxine in dysthymic disorder.

BACKGROUND: Dysthymic disorder is a chronic depression that is usually characterized by depression rating scale scores that are lower than those for major depressive disorder. Recent studies suggest that pharmacotherapy is quite effective in the treatment of patients with this condition and, in particular, that the newer antidepressants may be better tolerated than older tricyclic antidepressants. The purpose of this study was to investigate the use of a structurally novel antidepressant, venlafaxine, in the treatment of dysthymic disorder. METHOD: Seventeen patients with dysthymic disorder were entered into the study, and 14 completed it. A psychiatric interview was used to establish diagnosis, and behavior was assessed by using the Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI). Patients were seen over a 9-week period, and venlafaxine treatment proceeded on an open-label basis, from a starting dose of 18.75 mg b.i.d. to a maximum dose of 225 mg/day. RESULTS: Two patients discontinued early because of side effects, and 1 patient took a single dose, felt better, and did not complete the trial. Analyses of all 17 patients showed significant improvement in HAM-D and BDI scores at the end of the study. Among the completers, there were two response patterns: one group of 7 patients responded quickly to low-dose (75 mg) venlafaxine, and a second group of 7 required the maximum dose. Three of the 7 high-dose patients showed considerable improvement. Side effects in this study were generally in keeping with what has been reported using venlafaxine in treatment of major depressive disorder. No patients evidenced increased blood pressure. CONCLUSION: Our study supports the treatment of dysthymic patients with venlafaxine, which has equal efficacy and greater tolerability than tricyclic antidepressants.

Adult↗

PubMed1996

The effect of alcohol and substance abuse on the course of bipolar affective disorder.

It has been found that > 60% of bipolar I and almost 50% of bipolar II patients have a history of substance abuse (Regier et al., 1990). While previous studies have examined comorbidity of bipolar disorder and substance abuse, little has been done to examine the effect of substance abuse on the course of bipolar disorder. There has also been little distinction made between bipolar disorder occurring prior to substance abuse and that occurring after the onset of substance abuse. Given the high prevalence of substance abuse in bipolar patients, it would be useful to determine more about the effect of substance abuse on demographic and clinical features and on the course of illness. We attempted to do this with a retrospective chart review of 188 bipolar patients seen by D.L. Dunner between January 1992 and December 1993. Demographic and clinical information as well as information about course of illness were systematically extracted from the charts. We compared the means and percentages of these variables and analysed them for significance. Preliminary results show differences in demographics, clinical features and course of illness between patient groups. These differences may illustrate the clinical effects of substance abuse on the course of bipolar disorder. Our results also indicate that there are differences between patients whose bipolar disorder began prior to and those whose disorder began after the onset of substance abuse.

Adult↗

PubMed1996

Cognitive therapy versus fluoxetine in the treatment of dysthymic disorder.

We studied the effects of a fixed dose of fluoxetine (20 mg) or cognitive psychotherapy in a 16 week trial of patients with dysthymic disorder. More patients assigned to fluoxetine dropped out of the 16 week treatment (33%) than those assigned to cognitive therapy (9%), but this difference did not attain statistical significance. Both treatments showed improvement over baseline conditions at 8 weeks and further improvement at 16 weeks. There were no statistically significant group differences in treatment response. No follow-up data were collected so the enduring effects of the treatments are unknown. An optimal treatment for dysthymic disorder may be combined psychotherapy and pharmacotherapy for a longer period of time.

Adolescent↗

PubMed1995

Reduction of suicidal thoughts with paroxetine in comparison with reference antidepressants and placebo.

In order to determine whether paroxetine was associated with any increase in suicidal thoughts or acts all controlled studies of paroxetine were examined in a series of metanalyses. Paroxetine showed an advantage in reducing suicidal thoughts in all analyses compared with placebo. On the MADRS there was a significant advantage compared with active controls at weeks 1, 3, 4 and 6 (P < 0.01). There were significantly fewer emergent suicidal thoughts on paroxetine compared with placebo in all analyses, and a significant advantage for paroxetine compared with active controls on the MADRS. A significant advantage for active controls compared with placebo was seen only on the HAMD. In the analysis of the data from controlled studies and open extension studies of paroxetine calculated by patient year of exposure there were 2.8 times fewer suicides in the paroxetine-treated group compared with active control and 5.6 times fewer compared with placebo.

Antidepressive Agents↗

PubMed1995

The effects of substance use disorder on the clinical presentation of anxiety and depression in an outpatient psychiatric clinic.

BACKGROUND: The comorbidity of substance abuse or dependence and psychiatric illness can complicate the diagnosis, clinical course, and treatment of dually diagnosed patients. In this study, we examined the relationship between substance use disorder (SUD) and psychopathology in an outpatient psychiatric setting. METHOD: Among 391 patients evaluated at an anxiety and effective disorders clinic, 54 patients met DSM-III-R criteria for lifetime substance use disorder and current unipolar depression or anxiety disorder. We selected 54 sex- and age-matched controls with psychiatric illness without SUD as a comparison group. All patients were given a structured diagnostic interview and symptom rating scales. In addition to comparing dual and single diagnosis groups, we compared those within the dual diagnosis group and those with primary psychiatric disorder with those with primary SUD; we also compared those with current versus past SUD. RESULTS: In contrast to findings in other settings, there were no significant differences in the severity of psychopathology between patients with and without substance abuse/dependence. Within dually diagnosed patients, those with primary mental disorder were more anxious and depressed than those with primary SUD. Patients with primary mental disorder had a significantly higher number of psychiatric diagnoses, an earlier onset of any psychiatric disorder, and were more likely to have received treatment. Conversely, patients with primary SUD had a higher number of substance use disorder diagnoses and an earlier onset of SUD. CONCLUSION: Dually diagnosed patients had the same degree of psychopathology as patients with only psychiatric disorders in this outpatient psychiatric population. The primary/secondary classification may be useful to distinguish between subgroups of dual diagnosis patients. Future studies are necessary to determine if this distinction can be useful to predict course and outcome in dually diagnosed patients.

Adult↗

PubMed1994

An overview of paroxetine in the elderly.

Depression in the elderly is an increasingly prevalent problem affecting some 15% of the elderly population and can be difficult to diagnose and treat. Complicating factors include poor compliance, the high frequency of concomitant disease, and the alterations in drug absorption and metabolism with age. This paper reviews controlled studies of the treatment of depression in elderly patients using paroxetine, a selective serotonin reuptake inhibitor. The studies demonstrate that paroxetine has efficacy in these patients which is similar to that of comparative compounds. The side effect profile of paroxetine is favourable, as compared with tricyclics, in terms of cardiovascular effects. The side effects of paroxetine in the elderly are similar to those reported in younger individuals. The improved tolerability profile of paroxetine is particularly welcome for the treatment of the elderly who have an increased sensitivity to adverse effects of drug therapy.

Aged↗

PubMed1994

Multisite data reanalysis of the validity of rapid cycling as a course modifier for bipolar disorder in DSM-IV.

OBJECTIVE: The validity of rapid cycling as a distinct course modifier for bipolar disorder was assessed by comparing patients with and without a history of rapid cycling (4 or more affective episodes in 12 months) on demographic, clinical, family history, and outcome variables. These data were also used to formulate operational criteria for the modifier. METHOD: Data on subjects with rapid-cycling (N = 120) and nonrapid-cycling (N = 119) bipolar disorder from four sites were pooled and analyzed by using case-control and historical cohort methods. RESULTS: The rapid-cycling group contained more women and more subjects from higher social classes than the nonrapid-cycling group. Family history did not differ between the groups. The diagnosis had predictive validity in that the rapid-cycling patients had more episodes than the nonrapid-cycling patients during prospective follow-up. The relationship between gender and episode frequency supported the validity of the cutoff point of 4-8 episodes per year. The data regarding whether patients with rapid cycling based on truncated episodes more closely resembled rapid-cycling or nonrapid-cycling patients were equivocal. Patients whose only rapid cycling was associated with antidepressants resembled spontaneously rapid-cycling patients, while the majority of spontaneously rapid-cycling patients also had periods of antidepressant-associated rapid cycling. CONCLUSIONS: The validity of rapid cycling as a distinct course modifier for bipolar disorder is supported by differences in gender, prospectively assessed outcome, and perhaps social class between rapid-cycling and nonrapid-cycling patients. The relationship of gender to episode frequency supports the cutoff of 4 or more episodes per year.

Adult↗

PubMed1994

Therapeutic considerations in treating depression in the elderly.

The elderly depressed patient has a clinical picture unlike that of the younger individual. The pharmacokinetic profile, for example, changes in the normal aging process, which must be considered in choosing the proper antidepressant--and dosage--for an older person. Depressive illnesses are described in this review, with the focus on symptoms, prevalence, diagnosis, and treatment modalities. Cited are results of studies comparing tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Equivalent efficacy of the two classes of drugs was not unexpected. The higher degree of tolerability with SSRIs, however, should be of special interest to the clinician treating the elderly.

Age Factors↗

PubMed1993

DSM-III-R personality disorders in a mood and anxiety disorders clinic: prevalence, comorbidity, and clinical correlates.

This study examined the prevalence, comorbidity, and clinical correlates of personality disorders in an outpatient sample (N = 352) with anxiety and depression. Subjects were diagnosed using the Structured Clinical Interview for DSM-III-R (SCID) on Axes I and II, and they also completed interview and self-report measures of symptoms. Subjects with a personality disorder were less likely to be married, more likely to be single or divorced, had lower family incomes, had more severe symptoms of both anxiety and depression, and had a greater number of lifetime Axis I diagnoses. Subjects with dysthymic and bipolar disorders were more likely, and subjects with panic disorder uncomplicated by agoraphobia were less likely to have a personality disorder compared to the rest of the sample. The most prevalent personality disorders were Avoidant, Obsessive-Compulsive, Paranoid, and Borderline. Paranoid co-occurred with Narcissistic, and Borderline co-occurred with Histrionic personality disorder significantly more often than chance and base rates would predict.

Adolescent↗

PubMed1993

Suicide attempts in rapid cycling bipolar disorder patients.

We studied 100 rapid cycling patients (33% of whom had truncated episodes), and 120 non-rapid cycling bipolar patients for history of suicide attempts. In contrast to our hypothesis, no significant differences were found when comparing suicide attempt histories for these two groups.

Adult↗

PubMed1993

Dawn simulation treatment of winter depression: a controlled study.

OBJECTIVE: This study sought to determine whether dawn simulation was superior to a shorter dimmer "placebo" dawn signal in treating winter depression. METHOD: In a randomized, parallel design, 22 patients with winter depression were treated with either 1 week of a 2-hour dawn simulation peaking at 250 lux or 1 week of a 30-minute dawn simulation peaking at 0.2 lux. The subjects were told that they would receive either a "gradual" dawn or a "rapid" dawn reaching an intensity that would be dimmer than standard bright light treatment. At the end of both the baseline week and the treatment week, subjects were assessed in a blind manner with the Hamilton Rating Scale for Depression. Analysis of covariance was used to compare the two dawn treatments. RESULTS: The 2-hour, 250-lux dawn simulation resulted in Hamilton depression scale scores that were significantly lower than scores after the 30-minute, 0.2-lux dawn simulation. CONCLUSIONS: This study indicates that dawn simulation is an effective treatment for winter depression.

Adult↗

PubMed1993

Diagnostic assessment.

Precision in diagnosis is the basis for treatment. The use of structured assessments of diagnosis, severity of illness, and side effects through various rating instruments likely will become of greater importance to clinicians in the next decade.

Humans↗

PubMed1993

Treatment resistance in unipolar depression and other disorders. Diagnostic concerns and treatment possibilities.

The disorders discussed in this article share common problems with treatment-resistant depression both in research and clinical treatment. Lack of clear treatment-resistant definitions leads to difficulties in comparing the results of research studies. The absence of double-blind, placebo-controlled studies that match alternative treatments against each other creates confusion for the clinician who has to decide on a treatment paradigm. The future will, no doubt, see an increase in interest in treatment-resistant research and the answer to some of these questions. Although this review emphasizes the work that remains to be done before treatment resistance becomes a curiosity of the past, it also highlights the wealth of treatment options available to clinicians and their patients. As long as treatment-resistant patients are amendable to trying new therapies, hope that their depressions will lift remains.

Antidepressive Agents↗

PubMed1992

Differential diagnosis of bipolar disorder.

The historical antecedents of the current diagnostic criteria for mania involve the German phenomenologic descriptions of the late 1800s, the introduction of lithium for treatment and prevention of mania (which broadened the definition of mania in this country), the attempts to subclassify bipolar disorder into at least two subtypes, and the differentiation of patients with mania and hypomania from those with depression alone. Current diagnostic criteria for bipolar disorder are delineated in DSM-III-R. The differential diagnosis of bipolar disorder includes other conditions that may have manic-like symptoms, including organic mood disorders such as endocrine or metabolic conditions, drug intoxications, and tumors. Mania occurring in the context of substance abuse would be called a secondary mania. In addition, schizoaffective disorder can be diagnosed if there is a manic syndrome superimposed in the context of schizophrenia. Because of the absence of duration criteria for mania in DSM-III-R, the differential diagnosis within the bipolar disorders is largely based on severity and duration of depression. A problem in studying mania at present is that the prototypic cases have largely disappeared from treatment centers because of the success of lithium maintenance treatment. Patients available for study at psychiatric treatment facilities are largely treatment resistant, atypical, and likely to have experienced considerable amounts of substance abuse in their histories. Among the changes being considered for DSM-IV are to include duration criteria for mania, to separate bipolar II patients (depression and hypomania) from bipolar not otherwise specified, to refine the criteria for hypomania, and to add rapid cycling to the list of parenthetical modifiers for bipolar disorder with mania and bipolar disorder with hypomania.

Bipolar Disorder↗

PubMed1992

Coping in panic and major depressive disorder. Relative effects of symptom severity and diagnostic comorbidity.

This study used the Ways of Coping Checklist to examine coping style in patients with panic and major depressive disorders. The relative contribution of distress (symptom severity) and diagnostic comorbidity was determined in three sets of diagnostic subgroups: patients suffering from both panic and major depressive disorders (compared with either disorder alone); panic patients with and without agoraphobia (regardless of concurrent depression); and patients with versus without a concurrent axis II personality disorder. Use of less problem-focused and more emotion-focused coping was strongly correlated with level of distress and was associated with all three examples of diagnostic comorbidity when level of distress was used as a covariate. Regression analyses showed that, except for the presence of a personality disorder, distress was a much stronger predictor of coping than diagnostic subtype.

Adaptation, Psychological↗