A randomized, double-blind, placebo-controlled study of ziprasidone monotherapy in bipolar disorder with co-occurring lifetime panic or generalized anxiety disorder. Randomised controlled trials of conventional antipsychotic versus new atypical drugs, and new atypical drugs versus clozapine, in people with schizophrenia responding poorly to, or intolerant of, current drug treatment. Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders. Atypical (second generation) antipsychotic treatment response in very late-onset schizophrenia-like psychosis. Randomized controlled trial of the effect on Quality of Life of second- vs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1). Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia. A clinical trial of cranial electrotherapy stimulation for anxiety and comorbid depression. A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder. Prospective outcome of early intervention for individuals at ultra-high-risk for psychosis. The expert consensus guideline series. Optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary. Effectiveness of second-generation antipsychotics: a naturalistic, randomized comparison of olanzapine, quetiapine, risperidone, and ziprasidone Prescribing second-generation antipsychotics and the evolving standard of care in Italy. The feasibility and acceptability of a novel anxiety in bipolar disorder intervention compared to treatment as usual: A randomized controlled trial World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-Traumatic Stress Disorders – First Revision Therapy for youths with anxiety disorders: a second randomized clinical trial. The feasibility of improving CBT for childhood anxiety disorders through a dismantling study. Long‐term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2‐year naturalistic follow‐up
OBJECTIVE Bipolar disorder often co-occurs with anxiety disorders . Evidence suggests that second-generation antipsychotics ( SGAs ) may be useful in treating both conditions . This study examined the efficacy of ziprasidone in the treatment of these disorders . METHOD This 3-site , r and omized , double-blind , placebo-controlled , parallel group , 8-week trial of ziprasidone monotherapy examined 49 subjects with bipolar disorder and lifetime panic disorder ( with or without agoraphobia ) or generalized anxiety disorder ( GAD ) experiencing moderately severe anxiety symptoms at entrance into the study . Both bipolar disorder and anxiety diagnoses were based on DSM-IV-TR criteria . Patients were screened and r and omized from June 25 , 2010 , through August 23 , 2011 . Primary outcome measures were the Clinical Global Impressions-21 Anxiety Scale ( CGI-21 Anxiety ) and the Sheehan Disability Scale ( SDS ) , with secondary measures monitoring anxiety and mood symptoms . RESULTS Last-observation-carried-forward analyses demonstrated that patients in the ziprasidone group did not improve significantly more than those in the placebo group on the CGI-21 Anxiety ( F1 = 0.34 ; P = .564 ) or SDS ( F1 = 0.26 ; P = .611 ) . Secondary analysis using hierarchical linear modeling found similar results ( CGI-21 Anxiety : F1 = 1.82 ; P = .178 ; and SDS : F1 = 0.70 ; P = .408 ) . Regardless of group , time in the study was associated with significant decrease in anxiety ( F1 = 11.08 ; P = .001 ) and total disability ( F1 = 26.16 ; P < .001 ) . Patients in the ziprasidone group showed a greater increase in abnormal involuntary movement , and 81.8 % ( n = 9 ) of the subjects who withdrew from the study due to adverse events , serious adverse events , or side effects were in the ziprasidone group . CONCLUSIONS Results suggest that ziprasidone monotherapy was not associated with a clinical ly significant improvement in anxiety symptoms or improved function for patients with bipolar disorder , lifetime panic disorder or GAD , and concurrent moderately severe anxiety symptoms , and it was associated with a more negative side-effect profile relative to placebo . TRIAL REGISTRATION Clinical Trials.gov identifier : NCT01172652 OBJECTIVES To determine the clinical and cost-effectiveness of different classes of antipsychotic drug treatment in people with schizophrenia responding inadequately to , or having unacceptable side-effects from , their current medication . DESIGN Two pragmatic , r and omised controlled trials ( RCTs ) were undertaken . The first RCT ( b and 1 ) compared the class of older , inexpensive conventional drugs with the class of new atypical drugs in people with schizophrenic disorders , whose current antipsychotic drug treatment was being changed either because of inadequate clinical response or owing to side-effects . The second RCT ( b and 2 ) compared the new ( non-clozapine ) atypical drugs with clozapine in people whose medication was being changed because of poor clinical response to two or more antipsychotic drugs . Both RCTs were four-centre trials with concealed r and omisation and three follow-up assessment s over 1 year , blind to treatment . SETTING Adult mental health setting s in Engl and . PARTICIPANTS In total , 227 participants aged 18 - 65 years ( 40 % of the planned sample ) were r and omised to b and 1 and 136 ( 98 % of the planned sample ) to b and 2 . INTERVENTIONS Participants were r and omised to a class of drug . The managing clinician selected the individual drug within that class , except for the clozapine arm in b and 2 . The new atypical drugs included risperidone , olanzapine , quetiapine and amisulpride . The conventional drugs included older drugs , including depot preparations . As in routine practice , clinicians and participants were aware of the identity of the prescribed drug , but clinicians were asked to keep their participating patient on the r and omised medication for at least the first 12 weeks . If the medication needed to be changed , the clinician was asked to prescribe another drug within the same class , if possible . MAIN OUTCOME MEASURES The primary outcome was the Quality of Life Scale ( QLS ) . Secondary clinical outcomes included symptoms [ Positive and Negative Syndrome Scale ( PANSS ) ] , side-effects and participant satisfaction . Economic outcomes were costs of health and social care and a utility measure . RESULTS Recruitment to b and 1 was less than anticipated ( 40 % ) and diminished over the trial . This appeared largely due to loss of perceived clinical equipoise ( clinicians progressively becoming more convinced of the superiority of new atypicals ) . Good follow-up rates and a higher than expected correlation between QLS score at baseline and at follow-up meant that the sample as recruited had 75 % power to detect a difference in QLS score of 5 points between the two treatment arms at 52 weeks . The recruitment to b and 2 was approximately as planned . Follow-up assessment s were completed at week 52 in 81 % of b and 1 and 87 % of b and 2 participants . B and 1 data showed that , on the QLS and symptom measures , those participants in the conventional arm tended towards greater improvements . This suggests that the failure to find the predicted advantage for new atypicals was not due to inadequate recruitment and statistical power in this sample . Participants reported no clear preference for either class of drug . There were no statistically significant differential outcomes for participants entering b and 1 for reasons of treatment intolerance to those entering because of broadly defined treatment resistance . Net costs over the year varied widely , with a mean of 18,850 pounds sterling in the conventional drug group and 20,123 pounds sterling in the new atypical group , not a statistically significant difference . Of these costs , 2.1 % and 3.8 % were due to antipsychotic drug costs in the conventional and atypical group , respectively . There was a trend towards participants in the conventional drug group scoring more highly on the utility measure at 1 year . The results for b and 2 showed an advantage for commencing clozapine in quality of life ( QLS ) at trend level ( p = 0.08 ) and in symptoms ( PANSS ) , which was statistically significant ( p = 0.01 ) , at 1 year . Clozapine showed approximately a 5-point advantage on PANSS total score and a trend towards having fewer total extrapyramidal side-effects . Participants reported at 12 weeks that their mental health was significantly better with clozapine than with new atypicals ( p < 0.05 ) . Net costs of care varied widely , but were higher than in b and 1 , with a mean of 33,800 pounds sterling in the clozapine group and 28,400 pounds sterling in the new atypical group . Of these costs , 4.0 % and 3.3 % , respectively , were due to antipsychotic drug costs . The increased costs in the clozapine group appeared to reflect the licensing requirement for inpatient admission for commencing the drug . There was a trend towards higher mean participant utility scores in the clozapine group . CONCLUSIONS For b and 1 , there is no disadvantage in terms of quality of life and symptoms , or associated costs of care , over 1 year in commencing conventional antipsychotic drugs rather than new atypical drugs . Conventional drugs were associated with non-significantly better outcomes and lower costs . Drug costs represented a small proportion of the overall costs of care ( < 5 % ) . For b and 2 , there is a statistically significant advantage in terms of symptoms but not quality of life over 1 year in commencing clozapine rather than new atypical drugs , but with increased associated costs of care . The results suggest that conventional antipsychotic drugs , which are substantially cheaper , still have a place in the treatment of patients unresponsive to , or intolerant of , current medication . Further analyses of this data set are planned and further research is recommended into areas such as current antipsychotic treatment guidance , valid measures of utility in serious mental illness , low-dose ' conventional ' treatment in first episode schizophrenia , QLS validity and determinants of QLS score in schizophrenia , and into the possible financial and other mechanisms of rewarding clinician participation in trials OBJECTIVE Major depression occurs with generalized anxiety disorder and panic disorder in up to 60 % of psychiatric and primary care patients . This comorbidity has been associated with greater severity of depression , poorer psychosocial functioning , and poorer treatment outcomes in psychiatric sample s. This study examined the clinical outcomes for depressed primary care patients with and without a lifetime anxiety disorder . METHOD A total of 157 primary care patients who met criteria for major depression were r and omly assigned to st and ardized interpersonal psychotherapy or pharmacotherapy with nortriptyline and were assessed at baseline and at 4 and 8 months on severity of depression , psychosocial functioning , and health-related functioning . RESULTS Depressed patients with a comorbid anxiety disorder presented with significantly more psychopathology and tended to prematurely terminate treatment more frequently than patients with major depression alone . Both st and ardized depression-specific treatments were effective for depressed patients with and without a comorbid generalized anxiety disorder , although time to recovery was longer for the former . Patients with lifetime panic disorder showed poor recovery in response to psychotherapy or pharmacotherapy . CONCLUSIONS St and ardized psychotherapy and pharmacotherapy are effective for patients with major depression with and without a generalized anxiety disorder . However , the longer time to recovery for the former group and lack of response to these treatments by patients with lifetime panic disorder suggest that primary care physicians should carefully assess history of anxiety disorder among depressed patients so as to select a proper intervention INTRODUCTION Symptom amelioration in older patients with very late onset schizophrenia-like psychosis ( VLOSLP ) is often difficult , with limited psychotropic response reports yielding variable findings . Information about atypical ( second generation ) antipsychotic use in this population is scant . METHODS A consecutive sample of geriatric psychiatry out patients and in patients with psychotic disorders were retrospectively identified over a 31-month period based on systematic information abstract ion from an electronic medical record ( e-record ) . After exclusion criteria were applied , 8/138 out patients and 13/362 in patients met inclusion criteria for VLOSLP and had been naturalistically treated with an atypical antipsychotic during hospitalization or nine months of outpatient care . M and atorily completed e-record st and ardized symptom severity response ratings were converted into positive treatment response thresholds . RESULTS 38 % of out patients and 77 % of in patients ( mean age = 76 years for both groups ; mean age of onset of psychosis = 70 years for out patients and 74 years for in patients ) met criteria for positive treatment response to an atypical antipsychotic ( either aripiprazole , olanzapine , quetiapine , or risperidone ) with sign/symptom amelioration , rather than eradication . CONCLUSIONS Various atypical antipsychotics at geriatric doses yielded a positive treatment response in nearly two-thirds of VLOSLP patients . Patients with less chronic , more severe symptoms responded at a higher rate . Prospect i ve , double-blind , placebo-controlled trials with representative subject sample s are needed to vali date these preliminary findings CONTEXT Second-generation ( atypical ) antipsychotics ( SGAs ) are more expensive than first-generation ( typical ) antipsychotics ( FGAs ) but are perceived to be more effective , with fewer adverse effects , and preferable to patients . Most evidence comes from short-term efficacy trials of symptoms . OBJECTIVE To test the hypothesis that in people with schizophrenia requiring a change in treatment , SGAs other than clozapine are associated with improved quality of life across 1 year compared with FGAs . DESIGN A noncommercially funded , pragmatic , multisite , r and omized controlled trial of antipsychotic drug classes , with blind assessment s at 12 , 26 , and 56 weeks using intention-to-treat analysis . SETTING Fourteen community psychiatric services in the English National Health Service . PARTICIPANTS Two hundred twenty-seven people aged 18 to 65 years with DSM-IV schizophrenia and related disorders assessed for medication review because of inadequate response or adverse effects . INTERVENTIONS R and omized prescription of either FGAs or SGAs ( other than clozapine ) , with the choice of individual drug made by the managing psychiatrist . MAIN OUTCOME MEASURES Quality of Life Scale scores , symptoms , adverse effects , participant satisfaction , and costs of care . RESULTS The primary hypothesis of significant improvement in Quality of Life Scale scores during the year after commencement of SGAs vs FGAs was excluded . Participants in the FGA arm showed a trend toward greater improvements in Quality of Life Scale and symptom scores . Participants reported no clear preference for either drug group ; costs were similar . CONCLUSIONS In people with schizophrenia whose medication is changed for clinical reasons , there is no disadvantage across 1 year in terms of quality of life , symptoms , or associated costs of care in using FGAs rather than nonclozapine SGAs . Neither inadequate power nor patterns of drug discontinuation accounted for the result OBJECTIVE Investigators compared patient characteristics and antipsychotic use patterns between individuals with schizophrenia treated in usual care with first-generation depot antipsychotics and those treated with oral antipsychotics ( first- or second-generation or both ) .  METHODS Analyses used data from the U.S. Schizophrenia Care and Assessment Program , a large , prospect i ve study of treatment for schizophrenia conducted July 1997 through September 2003 . Participants were assessed at enrollment and every six months thereafter with patient self-report , vali date d psychiatric measures , and systematic extraction of medical records . Individuals treated with a first-generation depot antipsychotic at any time during the three-year study ( N=569 ) were compared with those treated with only oral antipsychotics  ( N=1,617 ) on characteristics at enrollment and medication use pattern during the year after enrollment . RESULTS Compared with patients receiving only oral antipsychotics , participants treated with depot medications ( haloperidol or fluphenazine decanoate ) were more likely to be African American ( p<.001 ) ; less likely to be a veteran ( p=.005 ) ; had more psychiatric hospitalizations in the year before enrollment ( p<.001 ) ; and were more likely to have been arrested ( p<.001 ) , to use alcohol and illicit substances ( p<.001 ) , and to show higher psychopathology , particularly psychotic symptoms and disorganized thinking ( p<.01 for both ) . In the year after enrollment , participants treated with depot medications had a high mean medication possession ratio ( 91 % ) , and most of the medication regimens ( 68 % ) were augmented with oral antipsychotics for prolonged duration s ( median of 144 days ) . CONCLUSIONS Patients with schizophrenia treated with first-generation depot antipsychotics differed from those treated with only oral antipsychotics . Findings suggest that first-generation depot antipsychotics might address some unmet needs of a unique subgroup of patients with schizophrenia BACKGROUND Anxiety disorders are among the most prevalent mental disorders and are usually treated with medication and /or psychotherapy . When anxiety disorders are accompanied with comorbid depression , this further complicates the treatment process . Medication compliance is a common problem due to adverse side effects and new and effective treatments that have minimal side effects are needed for the treatment of anxiety and depression . This study used a r and omized , double-blind , sham controlled design to examine the effectiveness of CES  as a treatment for anxiety disorders and comorbid depression in a primary care setting . The study was registered at clinical trials.gov , NCT01533415 . METHODS One hundred and fifteen participants , age 18 years and over , with a primary diagnosis of an anxiety disorder were enrolled from February 2012 to December 2012 The Hamilton Rating Scale for Anxiety ( HAM-A ) and the Hamilton Depression Rating Scale17 ( HAM-D17 ) were used for baseline and outcome measures at weeks one , three , and five . Response to treatment was defined as a reduction of ≥50 % or more on these measures . RESULTS Analysis of covariance revealed a significant difference between the active CES group and the sham CES group on anxiety ( p=0.001 , d=0.94 ) and on depression ( p=0.001 , d=0.78 ) from baseline to endpoint of study in favor of the active CES group . CONCLUSIONS CES significantly decreases anxiety and comorbid depression . Subjects reported no adverse events during the study BACKGROUND Panic disorder is a prevalent , often disabling condition among patients in the primary care setting . Although numerous studies have assessed the effectiveness of treatments for depression in primary care , few such studies have been conducted for panic disorder . OBJECTIVE To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting . DESIGN R and omized , controlled study comparing intervention to treatment as usual . SETTING Six primary care clinics associated with 3 university medical schools , serving an ethnically and socioeconomically diverse patient population . PARTICIPANTS Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder . Comorbid mental and physical disorders were permitted , provided these did not contraindicate the treatment to be provided and were not acutely life threatening . INTERVENTION Patients were r and omized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions ( across 12 weeks ) of cognitive-behavioral therapy ( CBT ) modified for the primary care setting , with up to 6 follow-up telephone contacts during the next 9 months , and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist . Behavioral health specialists , the majority inexperienced in CBT for panic disorder , were trained to deliver the CBT and coordinated overall care , including pharmacotherapy . MAIN OUTCOMES MEASURES Proportion of subjects remitted ( no panic attacks in the past month , minimal anticipatory anxiety , and agoraphobia subscale score < 10 on Fear Question naire ) and responding ( Anxiety Sensitivity Index score < 20 ) and change over time in World Health Organization Disability Scale and short form 12 scores . RESULTS The combined cognitive-behavioral and pharmacotherapeutic intervention result ed in sustained and gradually increasing improvement relative to treatment as usual , with significantly higher rates at all points of both the proportion of subjects remitted ( 3 months , 20 % vs 12 % ; 12 months , 29 % vs 16 % ) and responding ( 3 months , 46 % vs 27 % ; 12 months , 63 % vs 38 % ) and significantly greater improvements in World Health Organization Disability Scale ( all points ) and short form 12 mental health functioning ( 3 and 6 months ) scores . These effects were obtained in spite of similar rates of delivery of guideline -concordant pharmacotherapy to the 2 groups . CONCLUSION Delivery of evidence -based CBT and medication using the collaborative care model and a CBT-naive , midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder AIM Based on previous reports of second-generation antipsychotic agents having a beneficial effect on prodromal symptoms , we investigated the effectiveness and tolerability of atypical antipsychotic therapies in individuals at high risk for developing psychosis . METHODS We examined prodromal symptoms and functioning in individuals at ultra-high-risk for psychosis using an uncontrolled prospect i ve design with pre- and post-treatment measures . RESULTS Of the 27 subjects taking antipsychotics during the study period , 15 took part in at least one follow-up assessment . Overall Comprehensive Assessment of At-Risk Mental States scores significantly improved at the last evaluation point , with a medium-size effect of Cohen 's d = 0.54 ( 95 % confidence interval , -0.02 to 1.08 ) ( mean follow-up period = 8.8 ; SD = 8.3 months ) . Depression and anxiety symptoms were markedly reduced , and global and social functioning also significantly improved . Of the 27 subjects , two ( 7.4 % ) converted to psychosis and 16 ( 59.3 % ) experienced at least one treatment-emergent adverse event , but no subjects exhibited serious adverse events . CONCLUSIONS The results of this study support treating high-risk individuals with antipsychotics to reduce prodromal symptoms with adequate safety OBJECTIVES A growing number of atypical antipsychotics are available for clinicians to choose from in the treatment of psychotic disorders . However , a number of important questions concerning medication selection , dosing and dose equivalence , and the management of inadequate response , compliance problems , and relapse have not been adequately addressed by clinical trials . To aid clinical decision-making , a consensus survey of expert opinion on the pharmacologic treatment of psychotic disorders was undertaken to address questions not definitively answered in the research literature . METHOD Based on a literature review , a written survey was developed with 60 questions and 994 options . Approximately half of the options were scored using a modified version of the R AND 9-point scale for rating the appropriateness of medical decisions . For the other options , the experts were asked to write in answers ( e.g. , average doses ) or check a box to indicate their preferred answer . The survey was sent to 50 national experts on the pharmacologic treatment of psychotic disorders , 47 ( 94 % ) of whom completed it . In analyzing the responses to items rated on the 9-point scale , consensus on each option was defined as a non r and om distribution of scores by chi-square " goodness-of-fit"test . We assigned a categorical rank ( first line/preferred choice , second line/alternate choice , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean rating . Guideline tables indicating preferred treatment strategies were then developed for key clinical situations . RESULTS The expert panel reached consensus on 88 % of the options rated on the 9-point scale . The experts overwhelmingly endorsed the atypical antipsychotics for the treatment of psychotic disorders . Risperidone was the top choice for first-episode and multi-episode patients , with the other newer atypicals rated first line or high second line depending on the clinical situation . Clozapine and a long-acting injectable atypical ( when available)were other high second line options for multi-episode patients . The expert 's dosing recommendations agreed closely with the package inserts for the drugs , and their estimates of dose equivalence among the antipsychotics followed a linear pattern . The experts considered 3 - 6 weeks an adequate antipsychotic trial , but would wait a little longer ( 4 - 10 weeks ) before making a major change in treatment regimen if there is a partial response . The experts recommended trying to improve response by increasing the dose of atypical and depot antipsychotics before switching to a different agent ; there was less agreement about increasing the dose of conventional antipsychotics before switching , probably because of concern about side effects at higher doses . If it is decided to switch because of inadequate response , risperidone was the expert 's first choice to switch to , no matter what drug was initially tried . Although there was some disparity in the expert 's recommendations concerning how many agents to try before switching to clozapine , the expert 's responses suggest that switching to clozapine should be Clozapine was also the antipsychotic of choice for patients with suicidal behavior . When switching oral antipsychotics , the experts considered cross-titration the preferred strategy . When switching to an injectable antipsychotic , the experts stressed the importance of continuing the oral antipsychotic until therapeutic levels of the injectable agent are achieved . The experts considered psychosocial interventions the first choice strategy for partially compliant patients , with pharmacologic interventions the first choice for patients with clear evidence of noncompliance . However , because it can be difficult to distinguish partially compliant from noncompliant patients , the editors recommended combining psychosocial and pharmacologic interventions to improve compliance whenever possible . When patients relapse because of compliance problems or if there is any doubt about compliance , the experts recommended the use of a long-acting injectable antipsychotic and would select an injectable atypical when this option becomes available . The experts would also consider using an injectable atypical antipsychotic ( when available ) in many clinical situations that do not involve compliance problems . The experts stressed the importance of monitoring for health problems-especially obesity , diabetes , cardiovascular problems , HIV risk behaviors , medical complications of substance abuse , heavy smoking and its effects , hypertension , and amenorrhea-in patients being treated with antipsychotics . Although many patients are prescribed adjunctive treatments , multiple antipsychotics , and combinations of different classes of drugs ( e.g. , antipsychotics plus mood stabilizers or antidepressants ) in an effort to enhance response , the experts gave little support to any of these strategies , with the exception of antidepressants for patients with  dysphoria/depression  , antidepressants or ECT for patients with suicidal behavior , and mood stabilizers for patients with aggression/violence . When asked about indicators of remission and recovery , the experts considered acute improvement in psychotic symptoms the most important indicator of remission , whereas they considered more sustained improvement in multiple outcome domains ( e.g. , occupational/educational functioning , peer relationships , independent living ) important in assessing recovery . CONCLUSIONS The experts reached a high level of consensus on many of the key treatment questions in the survey . Within the limits of expert opinion and with the expectation that future research data will take precedence , these guidelines provide direction for addressing common clinical dilemmas that arise in the pharmacologic treatment of psychotic disorders . They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions . Clinicians should keep in mind that no guidelines can address the complexities involved in the care of each individual patient and that sound clinical judgment based on clinical experience should be used in applying these recommendations Background No clear recommendations exist regarding which antipsychotic drug should be prescribed first for a patient suffering from psychosis . The primary aims of this naturalistic study were to assess the head-to-head effectiveness of first-line second-generation antipsychotics with regards to time until drug discontinuation , duration of index admission , time until readmission , change of psychopathology scores and tolerability outcomes . Methods Patients ≥ 18 years of age admitted to the emergency ward for symptoms of psychosis were consecutively r and omized to risperidone ( n = 53 ) , olanzapine ( n = 52 ) , quetiapine ( n = 50 ) , or ziprasidone ( n = 58 ) , and followed for up to 2 years . Results A total of 213 patients were included , of which 68 % were males . The sample represented a diverse population suffering from psychosis . At admittance the mean Positive and Negative Syndrome Scale ( PANSS ) total score was 74 points and 44 % were antipsychotic drug naïve . The primary intention-to-treat analyses revealed no substantial differences between the drugs regarding the times until discontinuation of initial drug , until discharge from index admission , or until readmission . Quetiapine was superior to risperidone and olanzapine in reducing the PANSS total score and the positive subscore .  Quetiapine was superior to the other drugs in decreasing the PANSS general psychopathology subscore ; in decreasing the Clinical Global Impression - Severity of Illness scale score ( CGI-S ) ; and in increasing the Global Assessment of Functioning - Split version , Functions scale score ( GAF-F ) .  Ziprasidone was superior to risperidone in decreasing the PANSS positive symptoms subscore and the CGI-S score , and in increasing the GAF-F score . The drugs performed equally with regards to most tolerability outcomes except a higher increase of hip-circumference per day for olanzapine compared to risperidone , and more galactorrhoea for risperidone compared to the other groups . Conclusions Quetiapine appears to be a good starting drug c and i date in this sample of patients admitted to hospital for symptoms of psychosis . Trial Registration Clinical Trials.gov ID ; URL : http://www . clinical trials.gov/ : The present study was carried out to investigate the routine use of second-generation antipsychotic drugs in the Italian psychiatric care system . Seven outpatient psychiatric services enrolled a consecutive case series of patients who were being treated , or had started treatment , with clozapine , olanzapine , risperidone , or quetiapine .  Information on sociodemographic and clinical variables , current psychotropic drug use , side-effects and past use of typical drugs was collected . In addition , patient symptoms and functional status were evaluated by the Health of the Nation Outcome Scale . Patients receiving off-label prescribing of second-generation antipsychotics were identified . A total of 209 patients were collected . In comparison with patients receiving other second-generation antipsychotics , living in residential facilities , unemployment , long psychiatric histories , and problems with activities of daily living and living conditions were more common in clozapine-treated patients . Nearly 80 % of patients receiving clozapine had schizophrenia compared to less than 50 % of those receiving other second-generation antipsychotics . Overall , 109 patients ( 52 % ) received off-label prescriptions of second-generation antipsychotic drugs . This survey indicates that clozapine was mostly reserved for severe cases and poor responders ; the high rate of off-label prescriptions highlights the gap existing between recommendations derived from r and omised clinical trials and the current use of drugs BACKGROUND Comorbid anxiety is common in bipolar disorder ( BD ) and associated with worse clinical outcomes including increased suicidality . Despite effective psychological treatments for anxiety , research into treating anxiety in BD is underdeveloped . This paper describes a novel psychological intervention to address anxiety in context of bipolar disorder ( AIBD ) . METHODS Adults with BD and clinical ly significant anxiety symptoms were r and omized to AIBD plus treatment as usual ( TAU ) or TAU alone . AIBD offered 10 sessions of psychological therapy using a formulation-based approach . Feasibility and acceptability were evaluated through recruitment , retention , therapy attendance , alliance , fidelity , and qualitative feedback . Clinical outcomes were assessed at baseline , 16 , 48 , and 80 weeks : interim assessment s of relapse at 32 and 64 weeks . RESULTS Seventy-two participants were recruited with 88 % retention to 16 weeks and 74 % to 80 weeks ( similar between arms ) . Therapy participants attended x ¯ 7.7 ( SD 2.8 ) sessions . Therapeutic alliance and therapy fidelity were acceptable . Qualitative interviews indicated that participants valued integrated support for anxiety with BD and coping strategies . Some suggested a longer intervention period . Clinical outcomes were not significantly different between arms up to 80 weeks follow-up . CONCLUSIONS AIBD is feasible and acceptable but lack of impact on clinical outcomes indicates that adaptations are required . These are discussed in relation to qualitative feedback and recent literature published since the trial completed In this report , which is an up date of a guideline published in 2002 ( B and elow et al. 2002 , World J Biol Psychiatry 3:171 ) , recommendations for the pharmacological treatment of anxiety disorder , obsessive-compulsive disorder ( OCD ) and post-traumatic stress disorder ( PTSD ) are presented . Since the publication of the first version of this guideline , a substantial number of new r and omized controlled studies of anxiolytics have been published . In particular , more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs . The recommendations , developed by the World Federation of Societies of Biological Psychiatry ( WFSBP ) Task Force for the Pharmacological Treatment of Anxiety , Obsessive-Compulsive and Post-traumatic Stress Disorders , a consensus panel of 30 international experts , are now based on 510 published r and omized , placebo- or comparator-controlled clinical studies ( RCTs ) and 130 open studies and case reports . First-line treatments for these disorders are selective serotonin reuptake inhibitors ( SSRIs ) , serotonin-noradrenaline reuptake inhibitors ( SNRIs ) and the calcium channel modulator pregabalin . Tricyclic antidepressants ( TCAs ) are equally effective for some disorders , but many are less well tolerated than the SSRIs/SNRIs . In treatment-resistant cases , benzodiazepines may be used when the patient does not have a history of substance abuse disorders . Potential treatment options for patients unresponsive to st and ard treatments are described in this overview . Although these guidelines focus on medications , non-pharmacological were also considered . Cognitive behavioural therapy ( CBT ) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders , OCD , and PTSD to support them being recommended either alone or in combination with the above medicines Ninety-four children ( aged 9 - 13 years ) with anxiety disorders were r and omly assigned to cognitive behavioral treatment or waiting-list control . Outcomes were evaluated using diagnostic status , child self-reports , parent and teacher reports , cognitive assessment and behavioral observation : maintenance was examined using 1-year follow-up data . Analyses of dependent measures indicated significant improvements over time , with the majority indicating greater gains for those receiving treatment . Treatment gains returned cases to within nondeviant limits ( i.e. , normative comparisons ) and were maintained at 1-year follow-up . Client age and comorbid status did not moderate outcomes . A preliminary examination of treatment segments suggested that the enactive exposure ( when it follows cognitive-educational training ) was an active force in beneficial change . Discussion includes suggestions for future research This preliminary r and omized controlled trial ( RCT ) examines the feasibility of dismantling cognitive behavioral therapy ( CBT ) for childhood anxiety disorders . Fourteen children ( 10 girls ) ages 7 to 14 ( m = 10.2 ) with social phobia , generalized anxiety disorder , separation anxiety disorder , or panic disorder were r and omized to receive 6 sessions of either a ) the pre-exposure anxiety management strategies presented in traditional CBT , or b ) parent-coached exposure therapy . The sample was selected from a treatment seeking population and is representative of children in clinical setting s. Examination of fidelity ratings , dropouts , and satisfaction ratings indicated that the interventions were distinguishable , safe , and tolerable . The overall sample improved significantly with pre-post effect sizes generally in the large range for both conditions . Between-group effect sizes indicating greater improvement with parent-coached exposure therapy were moderate or large for ten of 12 variables ( i.e. , 0.53 to 1.52 ) . Re-evaluation after three months of open treatment suggested that the intervention emphasizing exposure early maintained its superiority while requiring fewer appointments Two years after completion of a controlled outcome study of treatments for panic disorder with agoraphobia , patients were revisited and interviewed about their complaints . In the initial study , four treatments had been compared : ( i ) fluvoxamine combined with exposure ; ( ii ) placebo medication plus exposure ; ( iii ) psychological panic management plus exposure : and ( iv ) exposure alone . Comparison of the results at post‐test had revealed superior efficacy of fluvoxamine combined with exposure over the other three treatments in reducing agoraphobic avoidance . The current naturalistic follow‐up study investigated the long‐term efficacy of the treatments with regard to abatement of complaints and reduced dem and for further treatment . In addition , we examined whether patients were able to taper off the study medication without a recurrence of complaints . In total , 71 of the 76 patients of the original trial ( 93 % ) were interviewed . Comparison of the mean level of psychopathology at follow‐up revealed no difference between the original treatment groups . The effect in the fluvoxamine plus exposure group was maintained , but was no longer superior , due to further improvements in the other treatment groups . Most patients received additional treatment during the follow‐up period , usually because the 12 treatment sessions in the controlled study had yielded insufficient improvement . There was a trend for patients who received the fluvoxamine plus exposure treatment to require less aftercare than those who received the other treatments . Finally , almost 50 % of the patients who had received medication in the original trial were able to taper off the use of fluvoxamine without a recurrence of complaints
Monotherapy with quetiapine seems to be efficacious in reducing symptoms of generalised anxiety disorder and this effect may be similar to that of antidepressants .
BACKGROUND Anxiety disorders are common and disabling conditions , with a lifetime prevalence of 17 % in the general population .
Due to high rates of treatment resistance , there is interest in new pharmacological treatment options such as second-generation antipsychotics .
OBJECTIVES To evaluate the efficacy and tolerability of second-generation antipsychotics as monotherapy or adjunctive treatment for people with anxiety disorders .