By Q. Peer. Washington & Jefferson College.

Obsessive-compulsive those subjects who received an adequate trial of an SSRI symptoms were more severe in only 10 of the subjects at and those who did not receive adequate pharmacotherapy cheap 150mg fildena with mastercard erectile dysfunction medications otc. However generic fildena 25 mg line erectile dysfunction pump australia, only three subjects (6%) were con- subsequently underwent adequate behavior therapy during sidered to be in true remission (defined as no obsessions or the course of the study were lower than the mean GAF 1600 Neuropsychopharmacology: The Fifth Generation of Progress scores of patients who did not undergo behavior therapy. More recently, emerging data The change in GAF score at 2 years was significantly greater have clarified that OCDis a heterogeneous disorder and in the group of patients who received behavior therapy, so have begun to point to the existence of discrete subtypes that these patients in effect 'caught up'; their final GAF of illness. It will be important to determine whether these scores were similar to the scores of the patients who did not 'subtypes' influence the likelihood of remission or relapse. The most likely prediction variables are reviewed below. Although this study was conducted at a time when cur- One subtype of OCDis associated with a family or life- rent behavioral and pharmacotherapies were available, the time history of tic disorders. Although variation between results again support the findings that for the majority of studies is considerable, it is generally accepted that approxi- patients, the course of illness in OCDis continuous with mately 20% of patients with OCDhave a lifetime history of fluctuations in severity rather than episodic with clear pe- tics, and that 5% to 10% have a lifetime history of Tourette riods of remission between periods of exacerbation of symp- disorder (47,48). No longitudinal follow-up study of OCDhas systematically OCDpatients with tics appear to be less likely to respond measured psychosocial functioning and quality of life over to SSRIs, and their OCDsymptoms respond differentially time. Most treatment outcome studies have primarily fo- to augmentation of an SSRI with a neuroleptic (51). Also, no attempt has been OCDsymptoms have been shown to develop more com- made to examine the relationship between symptom severity monly in this subgroup, including the need for symmetry, and psychosocial functioning over time. For a significant ordering, arranging, and hoarding (52). The presence of a percentage of OCDpatients, impairment in function and tic disorder predicted more severe symptoms of OCDat quality of life is severe (45). It is the only major psychiatric follow-up in children (47). The predictive power of a per- disorder for which neurosurgery continues to be a treatment sonal or family history of multiple tics in regard to remission option. It will be important in future studies to gather pro- and relapse rates should be investigated. In the National Collab- been investigated in a number of acute treatment studies orative Study of Depression, even subsyndromal symptoms with inconsistent findings. In a study by Baer et suggest that psychosocial functioning continues to be im- al. A subsequent single-site study of the effect of a personality disorder on the response to fluoxetine failed to confirm that a cluster PREDICTORS OF LONG-TERM COURSE OF A diagnosis is a negative predictor of outcome (55). ILLNESS The DSM-IV field trial of OCD established that a signif- icant percentage of patients with OCDhave poor insight Although a number of studies have examined predictors of (56). The validity of this new diagnostic category is still in outcome in OCD, the results have been inconsistent. Data pertaining to the effect of poor insight or have focused on identifying predictors of short-term out- overvalued ideation on behavioral treatment response have come following pharmacologic or behavioral treatment. Eisen and Rasmussen (59) retro- None of the existing studies has examined predictors of spectively assessed the course of illness in four subgroups remission or relapse rates. These studies have been methodo- of OCD: OCDand schizophrenia, OCDand schizotypal logically compromised by small sample size, inclusion or personality disorder, OCDwith poor insight, and OCD exclusion criteria that led to sample bias, and inadequate without psychotic features. A deteriorative course was noted duration of follow-up. Characteristics such as age at onset in 82% of the patients with coexisting schizophrenia, 69% of OCD, duration of illness, severity of illness at baseline, of those with coexisting schizotypal personality disorder, and phenomenologic subtype have not been associated with 17% of those with poor insight, and only 8% of those with- Chapter 111: Obsessive-Compulsive Disorder 1601 out psychotic features. This study was hampered by the lack tomography (PET) have shown that regional activation of of a valid and reliable scale to measure poor insight and by the prefrontal cortex varies according to factor (69), and the retrospective assessment of the course. We have recently emerging genetic data suggest that familial loading varies published data on the reliability and validity of a new scale, according to factor (70). Symmetry and certain obsessions, the Brown Assessment of Beliefs Scale (BABS), that has such as aggressive and sexual obsessions, are more frequent demonstrated excellent sensitivity to change with short-term in patients with OCDand chronic tics (71). The phase of a double-blinded relapse study of sertraline in analytic technique used to identify factors from the Y-BOC OCD. They found no significant correlation between de- Symptom Checklist may be fruitful in predicting the course gree of insight as measured by the BABS and outcome after of OCD. Evidence is increasing that patients in whom 16 weeks of sertraline. The role of insight in remission and hoarding is a primary obsessive-compulsive symptom are relapse deserves further scrutiny. In addition, hoarding was the only com- tions in neurologic function involving the basal ganglia after pulsion associated with a lower probability of remission in head trauma, encephalitis, and birth events (62). In a number of studies, an earlier age psychological abnormalities in comparison with a control at onset of OCDwas associated with a worse prognosis. Thomsen (36) reported that attainment ceiver operating characteristic analysis found that a cutoff of puberty by the time of referral predicted a better prog- of three or more signs yielded the minimum number of nosis than a prepubertal onset. In a reanalysis of the multi- combined errors of sensitivity and specificity in blindly dis- center efficacy and safety data for clomipramine, Ackerman tinguishing OCDsubjects from controls.

Ten studies were conducted in Europe; one was 155 302 conducted in the United States and Canada only; one was conducted in Asia only; one was 301 conducted in the United States discount fildena 100 mg on-line erectile dysfunction caused by supplements, Canada fildena 100mg fast delivery erectile dysfunction medication south africa, South America, and Israel; and one did not report the 304 155,156,159,296,297,299-301,304 location. Nine studies were of good quality, three were of fair 295,298,302 303,305 quality, and two were of poor quality. The funding source was the government for 155,299,305 295,297,302 three studies, industry for three studies, government and industry for three 156,301,304 159,296,298,300,303 studies, and not reported for five studies. Studies enrolled patients between 305 155 1995 and 2009. The number of patients included ranged from 41 to 4,060 for a total of 302 7,556 patients across the 14 studies. The mean age of study participants ranged from 39 years 300 155,295,299,301,302 to 72 years. When reported, study duration varied from 2 years to 6 years. Duration of AF at 297 295 baseline ranged from 103 days to 3,285 days. Four studies included only patients with heart 300,301,304,305 155,156,159,295- failure. None of the remaining studies was limited to a special population. Six studies allowed different rate-controlling medications in the rate-control strategy (usually digoxin, beta blockers and calcium channel blockers), and different antiarrhythmic medications, along with electrical cardioversion when needed, in the rhythm-control strategy. The latter strategy restricts the use of some of these antiarrhythmic medications based on the presence of absence of structural heart 155,156,296,299,301,303 disease like heart failure and/or coronary artery disease. Two studies mandated AVN ablation and pacemaker as the rate-controlling strategy and allowed different 159,295 antiarrhythmic medications for rhythm control. In one of these two studies, AVN ablation with VVIR pacing was specified as the rate-control strategy, and AVN ablation with DDDR 159 pacing and use of antiarrhythmic medication was specified as the rhythm-control strategy. One study specified using amiodarone with or without electrical cardioversion in the rhythm-control 97 298 group versus digoxin or metoprolol in the rate-control group. One study specified using placebo versus amiodarone in the rhythm-control group, with or without cardioversion, and 302 diltiazem in the rate-control group. One study specified using digoxin or beta blockers in the rate-control group versus amiodarone with or without electrical cardioversion in the rhythm- 300 control group. One study compared PVI as the rhythm-control strategy with AVN ablation and 304 pacemaker as the rate-control strategy. Finally, one poor-quality study compared PVI as the 305 rhythm-control strategy versus rate-controlling medications. Detailed Synthesis Comparison 1: Rate-Control Strategy Versus Rhythm-Control Strategy Using Antiarrhythmic Drugs Quantitative Analysis This analysis addressed the comparative safety and effectiveness of a rate-control strategy versus a rhythm-control strategy using pharmacological agents. We identified 12 RCTs for this comparison, and the available data were deemed appropriate for meta-analysis for the following outcomes: maintenance of sinus rhythm, all-cause mortality, cardiovascular mortality, cardiovascular hospitalizations, heart failure symptoms, stroke, mixed embolic events including stroke, and bleeding events. Maintenance of Sinus Rhythm Seven studies representing 1,473 patients were included in our meta-analysis of maintenance 156,159,295,296,299,302,303 of sinus rhythm. Figure 19 shows that the OR of rate control versus rhythm control for maintenance of sinus rhythm was 0. There was evidence of heterogeneity; however, the demonstration of a benefit of rhythm-control strategies was consistent, and therefore this heterogeneity did not reduce the strength of evidence rating. Forest plot of maintenance of sinus rhythm for rate- versus rhythm-control strategies Study name Odds ratio and 95% CI Odds Lower Upper ratio limit limit Brignole, 2002 0. In one, ventricular rate control was significantly better in the rhythm-control group than in the rate-control group 156 (mean±SD, 79. In the other study, the mean heart rate in the resting state was significantly better during rhythm control (73±18 bpm) than during rate control (82±16 bpm) (low strength of evidence). All-Cause Mortality Eight studies representing 6,413 patients were included in our meta-analysis of all-cause 155,159,296,298,299,301-303 mortality. Figure 20 shows that the OR of rate control versus rhythm control for all-cause mortality was 1. In addition, 6 of the 8 studies had ORs that crossed 1, including 6,069 (95%) of the patients. We therefore assessed these eight studies as demonstrating comparable efficacy between rate and rhythm control strategies for all-cause mortality (moderate strength of evidence). Forest plot of all-cause mortality for rate- versus rhythm-control strategies Study name Statistics for each study Odds ratio and 95% CI Odds Lower Upper ratio l i mi t l i mi t Wyse, 2002 0. Figure 21 shows that the OR of rate control versus rhythm control for cardiac mortality was 0. Although the point estimates were inconsistent and confidence intervals wide for two of the included 296,299 studies, there was no evidence of heterogeneity, and therefore our strength of evidence rating was not lowered.

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