Discontinuation symptoms in users of selective serotonin reuptake inhibitors in clinical practice: tapering versus abrupt discontinuation

Objective Tapering of selective serotonin reuptake inhibitor (SSRI) therapy, as opposed to abrupt discontinuation, has been recommended by several guidelines and in the literature in order to diminish the occurrence of discontinuation symptoms. However, the evidence of a favourable effect of tapering is limited, and it is unclear how patients ought to discontinue SSRIs in daily life. The aim of this study was to examine the way in which patients discontinue SSRI therapy in clinical practice and to compare the effect of tapering with that of abrupt discontinuation on the occurrence of discontinuation symptoms.Methods Patients (n=74) who recently discontinued SSRI therapy completed a questionnaire containing questions about discontinuation symptoms (DESS events), the prescribed SSRI, reasons for discontinuation, way of discontinuation, knowledge of discontinuation symptoms, impact on daily life and patient counseling and education. The number of DESS events was compared among groups (abrupt discontinuation versus tapering; age; male versus female; paroxetine versus other SSRIs; knowledge of discontinuation symptoms at start of therapy versus lack of knowledge).Results A total of 66 patients were eligible for analysis. Of all patients ending SSRI therapy, 21% abruptly discontinued therapy. There was a significant difference in the number of DESS events between abrupt discontinuation and tapering of SSRI therapy (12.0 versus 5.9). There was also a tendency for an adverse effect of lack of knowledge of discontinuation symptoms at the start of therapy on the number of DESS events (8.9 versus 5.5).Conclusion One in five patients abruptly discontinued their SSRI therapy in clinical practice. Abrupt discontinuation caused a larger increase in the number of discontinuation symptoms than tapering. We therefore advise tapering SSRI therapy in clinical practice to prevent unnecessary adverse effects of discontinuation.     

Attenuated adrenocorticotropic responses to psychological stress are associated with early smoking relapse

Rationale Research has demonstrated that psychosocial stressors increase smoking and risk for smoking relapse. Alterations in biological systems involved in the stress response caused by chronic smoking may contribute to early relapse. Objectives We examined the extent to which pituitary–adrenocortical and cardiovascular responses to stress following the first 24 h of a quit attempt predict early relapse. Methods Seventy-two smokers interested in cessation attended a laboratory stress session 24 h after the beginning of their cessation attempt. Adrenocorticotropin (ACTH), plasma and salivary cortisol concentrations, systolic and diastolic blood pressure (BP), and heart rate (HR) responses to acute psychological stressors (public speaking and cognitive challenges) were used to predict relapse over a 4-week follow-up period. Results Those who relapsed within 4 weeks showed attenuated hormonal and cardiovascular responses to stress and exaggerated withdrawal symptoms. Cox proportional hazards survival analysis showed that attenuated ACTH, plasma cortisol, systolic and diastolic BP, positive affect, and exaggerated withdrawal symptoms and smoking urges during acute stress predicted early relapse. Stepwise model showed that ACTH, diastolic BP, and exaggerated withdrawal symptoms remain as significant predictors. When baseline smoking and psychological measures were included in the model, changes in ACTH, diastolic BP, and both factors of smoking urges remained significant predictors of relapse. Conclusions These results demonstrate that altered stress response predicts increased vulnerability for smoking relapse.     

Terazosin in the Treatment of Premature Ejaculation: A Short-term Follow-up

Aim: The aim of the present study was to evaluate the efficacy of terazosine in patients with premature ejaculation and lower urinary tract symptoms (LUTS), after excluding other sexual disorders and chronic prostatitis. Methods: A total of 90 patients with premature ejaculation and LUTS were enrolled to the study after excluding sexual disorders, prostatitis and benign prostatic hyperplasia. The patients were divided into two groups. Sixty patients in group 1 were treated with terazosine 5 mg daily for a month. Patients were followed monthly and questioned for their ejaculation problem. The results were classified as cure, improvement and ineffective. If patients showed improvement and ineffectiveness, the treatment was continued with 10 mg daily for the following month. Group 2 was included 30 patients, and placebo was applied for a month. At the end of this period, in patients who did not show any improvement, terazosine 10 mg was started. Results: In the treatment group, at the 1st month follow-up, 21 patients (35%) were cured, 20 (33.3%) showed improvement. In 19 (31.7%) patients, the treatment was ineffective. In group 2, 9 (30%) patients showed improvement and the rest had no-changes after one-month follow up. There was statistically significant difference between two groups (Pearson χ² test=0.000). Later, terazosine 10 mg was given to the patients in group 2 and to the patients who showed improvement or unsuccessful result with terazosine 5 mg. With terazosine 10 mg, 10 (14.5%) patients were cured, 29 (42.2%) patients were improved. Finally, terazosine treatment in patients with premature ejaculation was found to be effective in 60 patients (66.7%).Conclusion: Alpha blockers seem to be physiological medical agents in the treatment of premature ejaculation since ejaculation is under sympathetic control. Moreover, these agents are effective in lower urinary tract and they should be used in patients with premature ejaculation and lower urinary tract symptoms.     

Cutaneous lesions and visceral involvement of tuberous sclerosis

Background Tuberous sclerosis (TS) is an autosomal dominant disorder with a significant range of clinical expressions. The involvement of vital organs, such as the brain, kidney, heart and lung is the main cause of death in patients with TS. The aim of this study is to summarize the charateristic cutaneous features and common extracutaneous involvement of TS, which are helpful to the early detection of visceral involvement.Methods The analyzed clinical data from 78 patients with TS included those from detailed history, physical and dermatological examination, cranial computed tomography (CT) and magnetic resonance imaging (MRI),abdominal uhrasonography, chest roentgenography, hand and foot X-ray and ophthalmologic examination.Results The skin, brain and kidney were involved frequently in TS patients. Hypomelanotic macules were the most common and earliest cutaneous lesions. Their number was more than 3 in 81.5% of the patients. They were followed by facial angiofibromas and Shangreen‘s patch in a decreasing frequency. Forehead plaque, facial angiofibromas and Shagreen‘s patch appeared in patients at mean age of 2.6, 6.0 and 8. 1 years respectively.Cranial CT showed a high positive rate in TS patients.Conclusions Cutaneous features of TS are helpful in the early diagnosis of the disease. Hypomelanotic macules are especially important for patients with epilepsy or babies whose number of hypomelanotic malues is more than 3. Cranial CT is of great value in the diagnosis of TS. The involvement of visceral organs such as the brain and kidney should be examined in TS Patients.     

Self-assessed health, sadness and happiness in relation to the total burden of symptoms from the lower urinary tract

OBJECTIVES: To evaluate the effect of lower urinary tract symptoms (LUTS) on self-assessed health, sadness and happiness of men. SUBJECTS AND METHODS: The study included 504 men (aged 40-80 years) in the rural community of Surahammar, Sweden, who a year earlier had reported stress incontinence, urgency or postvoid dribbling in answer to a postal questionnaire, and 504 age-matched control men from the same community. The occurrence of 12 specific LUTS was rated using the Danish Prostatic Symptom Score. Health, sadness and happiness were measured by three questions from the Medical Outcomes Study Short-Form 36 health survey questionnaire. RESULTS: Completed questionnaires were returned by 74.2% of men (748/1008). A low score for health was reported by 34% of men with one to four LUTS, by 67% with five to eight, and by 75% with nine or more LUTS. The total LUTS burden correlated with lower scores for happiness and with higher scores for sadness. For each of the 12 specific LUTS, men with the symptom had lower scores for health and happiness, and higher scores for sadness, than men without the symptom. Comparing men with the symptom of 'other incontinence' to men with no 'other incontinence', the relative risk (95% confidence interval) of impaired health was 2.2 (1.8-2.8), while that of a high score for happiness was 0.5 (0.3-0.7) and that of greater sadness was 2.3 (1.7-3.3). Social status, marital status, education, smoking, physical activity and urinary tract infection all affected the impact of LUTS. CONCLUSIONS: The total burden of LUTS is related to self-assessed health, sadness and happiness.     

Evaluation of urinary and general symptoms and correlation with other clinical parameters in interstitial cystitis patients

AIMS: Interstitial cystitis (IC) has been deemed by some authors as a local manifestation of a systemic disease, particularly one of the autoimmune disorders. In order to provide an answer to the question whether IC patients do or do not indiscriminately report high scores for various somatic symptoms, we compared University of Wisconsin scores (U-W scores), including both urinary and non-urinary symptoms, for 30 IC female patients and 30 female controls. MATERIALS AND METHODS: A total of 30 female patients with IC and 30 healthy female controls were recruited for the study. All patients had to meet the symptom criteria established by the National Institute for Diabetes and Digestive and Kidney Diseases. Each patient completed a University of Wisconsin symptom scale, after translation (WICS). RESULTS: In the IC group median score was zero for all, but two of the reference symptoms: abdominal cramps and dizziness. All urinary symptoms were significantly increased in IC patients compared to controls. In the control group, the median value of urinary symptoms was zero. The duration of the disease was then related to IC symptoms in the patient group. Among the bladder-related symptoms, a good correlation was found for several specific symptoms and urinary symptoms as a whole. An association could be found between a positive potassium sensitivity test (PST) and burning bladder sensation, as well as pelvic discomfort. CONCLUSIONS: IC patients had significantly higher scores for the seven urinary symptoms compared to controls. The duration of disease was found to be correlated with the group of seven urinary symptoms.     

Prevalence of conditions potentially associated with lower urinary tract symptoms in men

OBJECTIVE: To estimate the frequency of conditions associated with lower urinary tract symptoms (LUTS, typically included when assessing benign prostatic hyperplasia, BPH), as other causes of LUTS should be excluded when diagnosing BPH, using data from the Olmsted County Study of Urinary Symptoms and Health Status among Men. SUBJECTS AND METHODS: During 1989-91, Caucasian men aged 40-79 years were randomly selected from the Olmsted County population. Before contact, eligibility was determined by reviewing the community medical records. Baseline exclusion criteria included comorbid pre-existing conditions or treatments, e.g. prostate, bladder or lower back surgery, bladder neck contracture or cancer, diabetes with lower extremity amputation, and neurological diseases, including Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, tabes dorsalis and stroke. Men with these conditions were excluded from the Olmsted County Study at baseline, because these conditions are potentially associated with LUTS. RESULTS: Of the 5100 randomly sampled men, 13.4% met at least one of the pre-existing exclusion criteria. Individually, the frequency of exclusions was 7.8% for prostate cancer or surgery, 4.8% for back surgery, 1.3% for bladder surgery and 1.4% for neurological conditions. All other conditions represented <1.0% of the study exclusions. Older men were more likely to meet at least one of the exclusion criteria, with men in their fifth to eighth decade having a total exclusion frequency of 1.4%, 5.4%, 8.5% and 32.8%, respectively. The most common reason for men in their fifth decade to be excluded was lower back surgery (0.9%), whereas the most common reason in the eighth was prostate surgery (21.8%). CONCLUSIONS: In men, conditions that may contribute to LUTS, other than BPH, are prevalent in the community and increase in frequency with age. It is important that other conditions associated with LUTS be excluded before a definitive diagnosis of BPH. Any oversight in this initial evaluation can potentially result in misclassification bias, misdiagnosis and incorrect treatment of patients.     

Diabetes-related symptoms and negative mood in participants of a targeted population-screening program for type 2 diabetes: The Hoorn Screening study

Objective: To determine the level of diabetes-related symptom distress and its association with negative mood in subjects participating in a targeted population-screening program, comparing those identified as having type 2 diabetes vs. those who did not. Research design and methods: This study was conducted within the framework of a targeted screening project for type 2 diabetes in a general Dutch population (age 50–75 years). The study sample consisted of 246 subjects, pre-selected on the basis of a high-risk profile; 116 of whom were subsequently identified as having type 2 diabetes, and 130 who were non-diabetic subjects. Diabetes-related symptom distress and negative mood was assessed ∼2 weeks, 6 months, and 12 months after the diagnosis of type 2 diabetes, with the Type 2 Diabetes Symptom Checklist and the Negative well-being sub scale of the Well-being Questionnaire (W-BQ12), respectively. Results: Screening-detected diabetic patients reported significantly greater burden of hyperglycemic (F=6.0, df=1, p=0.015) and of fatigue (F=5.3, df=1, p=0.023) symptoms in the first year following diagnosis type 2 diabetes compared to non-diabetic subjects. These outcomes did not change over time. The total symptom distress (range 0–4) was relatively low for both screening-detected diabetic patients (median at ∼2 weeks, 6 months, and 12 months; 0.24, 0.24, 0.29) and non-diabetic subjects (0.15, 0.15, 0.18), and not significantly different. No average difference and change over time in negative well-being was found between screening-detected diabetic patients and non-diabetic subjects. Negative well-being was significantly positive related with the total symptom distress score (regression coefficient β=2.86, 95% CI 2.15–3.58). Conclusions: The screening-detected diabetic patients were bothered more by symptoms of hyperglycemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetic subjects. More symptom distress is associated with increased negative mood in both screening-detected diabetic patients and non-diabetic subjects.