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L M Koran

Publications and source records attributed to L M Koran.

At least 37 records · Page 2Linked to original sources
PubMed1997

A 2-year study of sertraline in the treatment of obsessive-compulsive disorder.

The present study investigated the tolerability, safety profile, and anti-obsessional efficacy of sertraline, a selective serotonin reuptake inhibitor, during long-term treatment of patients with obsessive-compulsive disorder (OCD). Fifty-nine OCD patients who had completed a 1 year double-blind, fixed dose study comparing sertraline and placebo subsequently entered a 1-year open extension. Among the 51 patients who had been treated with sertraline during the double-blind phase, the mean total duration of sertraline treatment was 690 days. Only treatment responders who completed the 52-week double-blind treatment phase were permitted to enter the open extension. The higher rate (p < 0.02) of sertraline patients (51 out of 241) than of placebo patients (eight out of 84), who responded to treatment and entered the open-label phase is therefore consistent with the greater mean improvement observed in the sertraline group during double-blind treatment. Placebo responders differed from sertraline responders in that they were less impaired at baseline of the double-blind study [Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) of 18.5 versus 23.4] and they exhibited less improvement during double-blind treatment (-6.1 versus -11.4). In the open-label phase all patients received sertraline at a starting dose of 50 mg once a day, titrated in 50 mg increments to a maximum dose of 200 mg according to clinical response. At end-point the mean Y-BOCS score for all patients decreased by a further 3.6 points. Patients previously treated with placebo showed greater improvement after being switched to sertraline than those who received continued sertraline treatment. Patients who completed the study and received 2 full years of sertraline treatment (n = 38) exhibited a mean improvement of 15.6 points using the Y-BOCS. Sertraline was well tolerated during both the double-blind phase and the open extension, and the incidence of adverse experiences was generally reduced during the second year of treatment. Three patients discontinued open treatment because of adverse experiences. Long-term sertraline treatment did not appear to be associated with the emergence, increased incidence, or increased severity of adverse experiences or clinically significant abnormalities in laboratory tests, vital signs, or the electrocardiogram. The study supports the long-term safety and tolerability of sertraline over a 2-year treatment course and the sustained efficacy of sertraline in patients with OCD.

1-Naphthylamine↗
PubMed1997

Rapid benefit of intravenous pulse loading of clomipramine in obsessive-compulsive disorder.

OBJECTIVE: The authors conducted a randomized, double-blind, placebo-controlled trial of intravenous versus oral pulse loading of clomipramine in patients with obsessive-compulsive disorder to test two hypotheses: 1) intravenous pulse loading will cause greater immediate improvement than oral pulse loading and 2) patients who respond to pulse loading will continue to improve during 8 weeks of oral clomipramine treatment. METHOD: Fifteen patients with DSM-III-R obsessive-compulsive disorder of at least 1 year's duration and baseline Yale-Brown Obsessive Compulsive Scale scores of 17 or higher were enrolled in the study. Yale-Brown scale ratings were made 4.5 days after double-blind oral or intravenous pulse loading of clomipramine, and patients were then given 150 mg/day of oral clomipramine with increases of 25 mg every 4 days to 250 mg/day as tolerated or, in two cases, other selective serotonin reuptake inhibitors (SSRIs). RESULTS: The first hypothesis was confirmed: 4.5 days after the second pulse-loaded dose, six of seven patients given intravenous clomipramine but only one of eight given oral medication responded to the drug. After 8 weeks of oral clomipramine, the results partially supported the second hypothesis: four of six patients who had responded to intravenous clomipramine continued their improvement, but those who had responded to pulse loading did not improve statistically significantly more than those who had not. CONCLUSIONS: Intravenous pulse loading of clomipramine may be a valuable new treatment for obsessive-compulsive disorder, particularly for patients who have failed oral treatment trials.

Administration, Oral↗
PubMed1997

Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum.

BACKGROUND: Recent reports suggest that pregnancy and the puerperium may precipitate or exacerbate obsessive-compulsive disorder (OCD). The influence of this illness on other reproductive events, such as the premenstruum, is unknown. We examined retrospectively the relationships of pregnancy, the puerperium, and premenstruum to the course of OCD in 57 women. METHOD: Women outpatients with OCD meeting DSM-III-R criteria completed a standardized telephone interview administered by a psychiatric resident. They were asked retrospectively about the clinical course of their illness premenstrually and during and after pregnancy. RESULTS: Of 72 women eligible for the study, 79% (N = 57) completed the interview. Premenstrual worsening of OCD was described by 24 (42%) of the 57 women, and 12 (21%) described premenstrual dysphoria. Of the 57 women, 38 (67%) had been pregnant at least once; 31 (54%) had delivered at least one child. Pregnancy was associated with the onset of OCD in only 5 (13%) of the 38 women. Of the 29 women with preexisting OCD who became pregnant, 20 (69%) described no change in symptoms during pregnancy, 5 (17%) described worsening, and 4 (14%) described improvement. Postpartum exacerbation of OCD symptoms was reported by 7 (29%) of the 24 women with preexisting OCD who completed full-term pregnancies. Nine (37%) of the 24 women with both preexisting OCD and completed pregnancies also reported postpartum depression. CONCLUSION: The premenstrual and postpartum exacerbation of OCD symptoms in some women suggests that the course of this disorder may, in some cases, be influenced by changes in gonadal hormones. Our finding that women with OCD may be at increased risk for postpartum depression underscores the importance of careful postpartum evaluation of women with OCD to prevent maternal and infant morbidity.

Adult↗
PubMed1996

Fluvoxamine versus clomipramine for obsessive-compulsive disorder: a double-blind comparison.

The efficacy and tolerability of fluvoxamine (100-300 mg/day) and clomipramine (100-250 mg/day) were compared in a randomized, double-blind, parallel-group study of 79 patients with obsessive-compulsive disorder (OCD) without coexisting major depression. After a 2-week placebo lead-in period, patients were randomized to fluvoxamine (37 patients) or clomipramine (42 patients) for 10 weeks. Efficacy was evaluated with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the National Institute of Mental Health Obsessive-Compulsive scale, and Patient and Clinical Global Improvement scales. Hamilton Rating Scale for Depression scores and somatic symptoms were also assessed. Seventy-eight percent of fluvoxamine patients and 64% of clomipramine patients completed the study. At the end of treatment, 56% of fluvoxamine patients were classified as responders (> or = 25% decrease in Y-BOCS score), compared with 54% of clomipramine patients. Both groups showed steady improvement throughout the study; no statistically significant differences were observed between the groups for any efficacy variable at any time. A similar percentage of patients in both groups withdrew because of adverse events. No serious adverse events related to drug occurred with either drug. Insomnia, nervousness, and dyspepsia were more statistically frequent with fluvoxamine; dry mouth and postural hypotension were more frequent with clomipramine. In this study, fluvoxamine and clomipramine were equally effective in reducing OCD symptoms over a 10-week treatment period but displayed different side effect profiles.

Adolescent↗
PubMed1996

Impact of physical illness on quality of life and antidepressant response in geriatric major depression. Fluoxetine Collaborative Study Group.

OBJECTIVE: Because physical illness may influence quality of life, we assessed its impact on functional status and treatment outcome in older depressed patients who participated in a clinical trial, which showed a significantly higher remission rate for fluoxetine over placebo (31.6% vs 18.6%, P < .001). DESIGN: Six-week, randomized, double-blind, placebo-controlled trial of fluoxetine, 20 mg daily. SETTING: Multiple clinical sites, both university and private. PARTICIPANTS: Outpatients (N = 671) were > or = 60 years (mean +/- SD = 67.7 +/- 5.7), met DSM-III-R criteria for unipolar major depression and had baseline scores > or = 16 on the Hamilton Depression Rating Scale. MEASUREMENTS: The 36-item short-form health survey (SF-36) was used to measure baseline and posttreatment functional health and well-being. Physical illness was rated by number of current chronic or historical illnesses. Change from baseline to endpoint in the Hamilton Depression Rating Scale total score was used to measure depression outcome. MAIN RESULTS: Most patients reported physical illness: 83% had one or more chronic illness, and 89% had one or more historical illness. Greater numbers of baseline chronic illness indicated worse physical functioning, general health perceptions, and vitality and greater bodily pain and role limitation from physical problems. Historical physical illness was associated with worse physical functioning, vitality, general health perceptions, social functioning, and mental health. Although the number of chronic illnesses did not influence treatment response, historical physical illness was associated with greater fluoxetine response and lower placebo response. CONCLUSIONS: These findings suggest that both current and previous physical illness are associated with lower quality of life in geriatric depression and that depressed older patients with chronic physical illness respond to antidepressants as well as those without such illness. Recovery from previous physical illness should be explored as a potential predictor of antidepressant treatment outcome.

Aged↗
PubMed1996

Are fluoxetine plasma levels related to outcome in obsessive-compulsive disorder?

OBJECTIVE: In obsessive-compulsive disorder, the relationship between blood levels of serotonin reuptake inhibitors and clinical outcome is unclear. In a multicenter trial, the authors examined the relationship between steady state plasma levels of fluoxetine and norfluoxetine (determined after 7 weeks of treatment), and their sum, and clinical outcome. METHOD: Ratings of symptom severity of obsessive-compulsive disorder (Yale-Brown Obsessive Compulsive Scale scores) were obtained at baseline and after 13 weeks for 200 adult outpatients with moderately severe obsessive-compulsive disorder treated with fluoxetine doses of 20 mg/day (N = 68), 40 mg/day (N = 64), and 60 mg/day (N = 68). RESULTS: Mean plasma levels of fluoxetine and norfluoxetine were statistically significantly higher with higher dose. Statistical analyses revealed no significant relationship for plasma level of either molecule or their sum in predicting endpoint percent change in obsessive-compulsive scores. Plasma levels of patients with a marked response (decrease of 50% or more in obsessive-compulsive score) did not differ significantly from those of nonresponders (less than a 25% decrease in obsessive-compulsive score). No hint was seen of a therapeutic window or of a relationship limited to one gender or within the lowest dose group (20 mg/day). However, since S-norfluoxetine is a much more potent serotonin reuptake inhibitor than R-norfluoxetine, the absence of chiral (stereospecific) assays in this study limits the results. CONCLUSIONS: Steady state plasma levels of fluoxetine and norfluoxetine are not related to clinical outcome in patients with obsessive-compulsive disorder. Individual patients can be told only that the optimum dose of fluoxetine for them will be the dose that produces the largest therapeutic effect with the smallest side effect burden. Future studies should examine the predictive utility of measures of serotonergic neuronal function and, if plasma levels of norfluoxetine are examined, the use of chiral assays.

Adolescent↗
PubMed1996

Quality of life for patients with obsessive-compulsive disorder.

OBJECTIVE: The health-related quality of life of patients with obsessive-compulsive disorder was compared to published norms for the general U.S. population and for patients with either depressive disorders or diabetes. METHOD: Sixty medication-free outpatients with moderate to severe obsessive-compulsive disorder were evaluated by using the Structured Clinical Interview for DSM-III-R and the Yale-Brown Obsessive Compulsive Scale. Health-related quality of life was measured with the self-rated Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: The instrumental role performance and social functioning of the patients with obsessive-compulsive disorder were worse than those of the general population and of diabetes patients. The more severe the obsessive-compulsive disorder, the lower were the patients' social functioning scores, even after depression ratings were controlled for; scores on instrumental role performance did not correlate with severity of obsessive-compulsive disorder. The ratings of the obsessive-compulsive disorder patients on physical health domains resembled those of the general population and exceeded those of the diabetes patients. The general health and physical health ratings of the obsessive-compulsive disorder patients exceeded those of the depressed patients. In mental health domains, after adjustment for differences in gender distribution, quality of life ratings were similar for the patients with obsessive-compulsive disorder and those with depressive disorders. CONCLUSIONS: Moderate to severe obsessive-compulsive disorder is associated with impaired social functioning and impaired instrumental role performance, but only impairment in social functioning is linearly related to severity of obsessive-compulsive disorder.

Adult↗
PubMed1995

Comparing the cost effectiveness of psychiatric treatments: bulimia nervosa.

We conducted an exploratory post hoc study that compared the cost effectiveness of five treatments for bulimia nervosa: 15 weeks of cognitive behavioral therapy (CB) followed by three monthly sessions, 16 weeks (Med16) and 24 weeks (Med24) of desipramine (< or = 300 mg/day), and CB combined with desipramine for those durations (Combo16 and Combo24). We illustrate how a treatment's cost effectiveness varies according to when evaluation is done and how effectiveness and cost are defined. At 32 weeks, Med16 appears the most cost-effective treatment, and Combo16 appears the least. At 1 year, Med24 appears the most cost-effective treatment, and Combo16 appears the least. Using this post hoc analysis as an example, we discuss the pitfalls and limitations of cost-effectiveness analysis of psychiatric treatments.

Adolescent↗
PubMed1995

Predicting response to fluoxetine in geriatric patients with major depression.

No consensus exists regarding whether early response to an antidepressant strongly predicts a good outcome, what is the criterion for early response, or when to measure it. We hypothesized that early response (> or = 20% decrease in HAM-d21) after any of weeks 1, 2, or 3 of fluoxetine treatment of major depression in geriatric outpatients would predict a favorable outcome by week 6 or an earlier endpoint accurately enough for clinical use. We also hypothesized that the week 1, 2, and 3 percent changes in 21-item Hamilton Rating Scale for Depression (HAM-D21) would predict the percent change at week 6 (or endpoint) accurately enough for clinical use. We enrolled 671 elderly outpatients with unipolar DSM-III-R major depression in a double-blind, placebo-controlled trial of fluoxetine, 20 mg/day. For analysis, fluoxetine-treated patients were randomly divided into a development set (N = 154) for a preliminary test of our criteria and a validation set (N = 181) to validate the development data set's results. Early responders at weeks 1, 2, and 3 were statistically significantly more likely to experience marked improvement or remission than those lacking early response. However, at week 3, this criterion correctly classified only about three-fourths of patients with regard to marked improvement and only about two-thirds with regard to remission. Moreover, about one-third of patients predicted to experience marked improvement and about three-fifths of those predicted to remit did not. The continuous variable, percent change in HAM-D21, did not produce predictive results of any greater clinical utility. We believe that the sensitivity, specificity, false-positive rate, false-negative rate, and kappa of outcome predictions all should be reported in future studies. Without a full set of descriptive statistics, clinicians can be misled by statistically significant results.

Aged↗
PubMed1995

Do soft signs predict treatment outcome in obsessive-compulsive disorder?

The authors examined 21 outpatients with obsessive-compulsive disorder for five neurological soft signs and abnormalities on two neuropsychological tests before and after 10 to 12 weeks of treatment with serotonin reuptake inhibitors. Patients showed a mean of 1.8 soft signs. Prevalences were finger-to-finger, 10%; adventitious movements, 29%; mirror movements, 33%; impaired cube drawing, 33%; and agraphesthesia, 76%. The Stroop Color and Word Test was abnormal in 10% and the Controlled Oral Word Association Test was abnormal in 14% of patients. Neither the presence of specific soft signs, the number of signs present, nor a combination of signs and test abnormalities predicted a poorer response to pharmacological treatment. Some baseline soft signs and abnormalities disappeared at endpoint in medication responders and nonresponders; no clear pattern of change emerged.

1-Naphthylamine↗
PubMed1994

A multicenter investigation of fixed-dose fluoxetine in the treatment of obsessive-compulsive disorder.

OBJECTIVES: To determine the effectiveness of fluoxetine hydrochloride at fixed doses of 20 mg/d, 40 mg/d, and 60 mg/d in patients with obsessive-compulsive disorder (OCD) and to evaluate its safety. METHODS: Fixed-dose fluoxetine hydrochloride (20 mg/d, 40 mg/d, 60 mg/d) was compared with placebo in two randomized, double-blind, parallel, 13-week trials of identical design in 355 outpatients with OCD aged 15 to 70 years (DSM-III-R criteria; 1 year's duration or longer; depression secondary if present). RESULTS: Fluoxetine (all doses) was significantly (P < or = .001) superior to placebo on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) total score (mean baseline-to-end-point decrease, 4.6, 5.5, and 6.5 vs 0.9, respectively, studies pooled) and other efficacy measures (P < or = .01). A trend suggesting greater efficacy at 60 mg/d was observed. Most patients (79.2%) completed the study. Eight adverse events were statistically significantly more frequent with fluoxetine and one, with placebo. For some events, incidence tended to increase with increasing dosage; however, few patients discontinued treatment for any single event. CONCLUSION: Fluoxetine was associated with a statistically significant reduction in OCD severity, including time engaged in obsessional and/or compulsive behaviors. Adverse events infrequently led to study discontinuation.

Adolescent↗
PubMed1994

One-year follow-up of psychosocial and pharmacologic treatments for bulimia nervosa.

BACKGROUND: This study examined the outcome 1-year posttreatment of the use of desipramine, cognitive-behavioral therapy (CBT), and their combination in the treatment of bulimia nervosa. METHOD: Sixty-one patients meeting DSM-III-R criteria for bulimia nervosa were randomly assigned to one of five groups--desipramine (withdrawn at 16 or 24 weeks), CBT (18 sessions), or the combined treatment (18 sessions of CBT plus desipramine withdrawn at 16 or 24 weeks)--and were followed to 1-year posttreatment. RESULTS: At 1-year follow-up, both the combined 24-week treatment and CBT alone were significantly superior in reducing binge eating to desipramine given for 16 weeks. The combined treatment was also superior to 16 weeks of desipramine in reducing emotionally driven eating and dietary restraint. Only 18% (2 of 11) of those receiving 16 weeks of desipramine were free of binge eating and purging at follow-up compared with 78% (7 of 9) of those receiving the combined 24-week treatment. The other groups fell between these two extremes. CONCLUSION: With the exception of the group treated for 16 weeks with desipramine alone, maintenance of improvement appeared satisfactory with all the treatments. Since the poorest results were found with 16 weeks of desipramine treatment, this study suggests that desipramine should be continued for at least 24 weeks either alone or combined with CBT. The broadest gain in reducing the psychopathology associated with bulimia nervosa was found with the combined 24-week treatment.

Adolescent↗
PubMed1992

Funding consultation-liaison psychiatry via Medicare screening.

Despite offering many benefits to patients, the hospital, and the hospital staff, an academic psychiatric consultation service is difficult to fund. By screening Medicare patients for psychiatric complications and comorbid conditions, the consultation-liaison (C-L) service can generate incremental revenue for the hospital by moving patients from lower-paying to higher-paying Diagnostic Related Groups (DRGs). The C-L service chief can negotiate with the hospital to obtain a portion of these incremental funds to support the C-L service. Concurrent psychiatric disorders that move patients to more complex DRGs include substance abuse, substance dependence, drug-induced delirium, drug-induced organic affective syndrome, and psychotic depression. This paper presents a method of calculating the incremental hospital revenue generated by such screening along with the results of applying the method to selected DRGs at a west coast teaching hospital. Implementing this program at that hospital in fiscal year 1989 would have resulted in screening 142 Medicare patients (2.2% of Medicare admissions), discovering an estimated 25 patients with comorbid psychiatric conditions, and generating $51,800 in incremental hospital revenue. In creating a screening program, a C-L service chief must be prepared to negotiate issues with the medical records department, referring physicians, and the hospital administration.

Academic Medical Centers↗
PubMed1992

Pharmacologic and cognitive-behavioral treatment for bulimia nervosa: a controlled comparison.

OBJECTIVE: This study examined the relative effectiveness of desipramine, cognitive-behavioral therapy, and their combination in the treatment of bulimia nervosa, together with the effects of withdrawing medication after two different lengths of treatment. METHOD: Seventy-one patients meeting DSM-III-R criteria for bulimia nervosa, recruited from an eating disorders clinic or by advertisements, were assigned at random to one of five groups: desipramine (withdrawn at 16 or 24 weeks), combined treatment (medication withdrawn at 16 or 24 weeks), and cognitive-behavioral therapy (15 sessions). All treatments were conducted individually in an outpatient clinic. The primary outcome measures were binge eating and purging rates assessed at pretreatment, 16, 24, and 32 weeks. The results were analyzed as three groups (medication, cognitive-behavioral therapy, and combined treatment) at 16 weeks and as five groups at subsequent assessments. RESULTS: At 16 weeks, both cognitive-behavioral therapy and the combined treatment were superior to medication given for 16 weeks in reducing binge eating and purging. At 32 weeks, however, only the combined 24-week treatment was superior to medication given for 16 weeks. The combined treatment was also more effective in reducing dietary preoccupation and hunger. Continuing cognitive-behavioral therapy appeared to prevent relapse in patients withdrawn from medication at 16 weeks. CONCLUSIONS: Overall, the results favor the use of a combination of medication and cognitive-behavioral therapy in the treatment of bulimia nervosa, with medication continued for at least 24 weeks.

Adolescent↗