Preventing Recurrence of Depression: Cognitive Therapy or Medication?
SOURCE: Kuyken W, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): A randomised controlled trial. Lancet 2015;386:63-73.
After an initial episode of depression, unless preventive treatment is initiated, recurrence is the rule rather than the exception (50-80%). As a result, national guidelines support maintenance treatment, especially for persons with demonstrated recurrence or with other high-risk indicators (e.g., history of bipolar disorder, family history of recurrences, or early age at initial diagnosis). The United Kingdom NICE Guidelines endorse at least 2 years of maintenance antidepressants when depression is recurrent.
PREVENT was a randomized, controlled trial (n = 424) comparing mindfulness-based cognitive therapy (MBCT) to antidepressant pharmacotherapy for prevention of depression recurrence. Inclusion required at least three prior episodes of major depression. Study subjects randomized to MBCT had been on pharmacotherapy, which was tapered/discontinued during the MBCT phase of treatment (71% fully discontinued, 17% reduced dose, 13% no dose reduction [total > 100% due to rounding]).
Over a 24-month interval, slightly fewer than half of the subjects experienced relapse (44-47%), with no significant difference demonstrable between MBCT and pharmacotherapy.
The comparable efficacy of MBCT and pharmacotherapy should prompt clinicians to offer patients treatment as per their preference.
Predicting Which Patients with Non-alcoholic Fatty Liver Disease Will Progress
SOURCE: Bazick J, et al. Clinical model for NASH and advanced fibrosis in adult patients with diabetes and NAFLD: Guidelines for referral in NAFLD. Diabetes Care 2015;38:1347-1355.
The language of progressive steps in liver disease used to be simpler: You had cirrhosis, or you didn’t.
But things have gotten much more complicated. Non-alcoholic fatty liver disease (NAFLD) is now reported to be the most common cause of chronic liver disease in the United States, and is present in 50-75% of diabetics, thus representing as many as 18 million people among diabetics alone.
Were NAFLD to simply stay NAFLD, we would have much less to discuss. Unfortunately, 10-22% of NAFLD patients have a progressive type called non-alcoholic steatohepatitis (NASH), which itself may progress to cirrhosis and hepatocellular carcinoma.
One way to identify NAFLD patients with NASH is to perform liver biopsy; appraisal of the degree and pattern of fibrosis seen on liver biopsy provides grounds for staging of NASH. But since there is risk, expense, and discomfort associated with this procedure, identification of other biologic markers indicative of NASH has been sought.
Bazick et al reported on the development of a panel of markers that have suitable sensitivity and specificity to identify which patients with NAFLD are most likely to have NASH, potentially benefitting from referral for liver biopsy and confirmation of degree of fibrosis. The panel includes age, ethnicity, body mass index, waist:hip ratio, liver function tests, international normalized ratio, serum proteins, complete blood count, and serum insulin levels, all of which are obtainable with minimum of patient inconvenience.
Tramadol for Premature Ejaculation
SOURCE: Kirby EW, et al. Tramadol for the management of premature ejaculation: A timely systematic review. Int J Impot Res 2015;27:121-127.
Premature ejaculation is reported to be the most common sexual dysfunction among men, although it may not appear that way to clinicians since patients often do not seek help for the problem.
Since routine inquiry into sexual health issues often does not occur, and since there are no FDA-approved medications to treat premature ejaculation, it is not surprising that patients fail to bring forward the problem. As late as 1998 (the year of the advent of Viagra), 90% of impotent men reported they did not discuss their sexual health problem with a clinician, citing 1) their complaint might be disregarded, 2) there might not be any remedy, and 3) the clinician might be embarrassed by discussing such issues.
To date, selective serotonin reuptake inhibitors (SSRIs) have been the most commonly used effective treatment for premature ejaculation. SSRIs have shown efficacy on both a scheduled and pro re nata basis. Kirby et al recently reported on the efficacy of tramadol for premature ejaculation.
Based on results from eight articles published in peer-reviewed journals, most of which were placebo-controlled or comparison trials to paroxetine (the most commonly used SSRI for premature ejaculation), the authors concluded that on-demand doses of 25-50 mg tramadol administered 2-4 hours prior to intercourse is effective in prolonging vaginal ejaculatory latency time and compares well with SSRIs in head-to-head trials.
In this issue: preventing recurrence of depression; predicting which patients with non-alcoholic fatty liver disease will progress; and treating premature ejaculation with tramadol.
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