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Am J Psychiatry 2014;171:A30. doi:10.1176/appi.ajp.2013.17101issue
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Copyright © 2014 by the American Psychiatric Association

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CBT had a greater effect on bulimic behaviors despite less therapist contact (Poulsen et al., p. 109)

Clinical Guidance: Psychotherapies for Bulimia Nervosa Show Clear Contrast 

Two years of psychoanalytic psychotherapy and 5 months of cognitive-behavior therapy with follow-up visits (CBT) for bulimia nervosa were compared by Poulsen et al. (p. 109) (figure). The proportions of patients who had stopped binging and purging at 2 years were 15% for psychoanalytic psychotherapy and 44% for CBT. Both treatments improve other eating disorder features and general psychopathology, but CBT does so faster, and therapists can learn CBT through videoconferencing, note Hollon and Wilson in an editorial (p. 13).

Clinical Guidance: Citalopram Dose and Cardiac Safety 

The rarity of torsade de pointes, a potentially fatal cardiac arrhythmia, complicates calculation of drug-related risk. In a previous issue, the FDA warning about arrhythmias related to citalopram doses above 40 mg/day was assessed by Zivin et al. (Am J Psychiatry 2013; 170:642–650) in a large database showing no increased risk of arrhythmia or death. Bird et al. from the FDA (p. 17) respond that large databases are not able to reliably identify drug-induced torsade de pointes and that citalopram was the third most commonly implicated drug in 88 spontaneous torsade cases in Sweden. In their reply, Zivin et al. (p. 20) point to the extensive literature indicating citalopram’s safety.

Clinical Guidance: Separation Anxiety and Treatment for Anxiety Disorders 

Psychotherapies focusing on relationships and separation anxiety may be helpful for adults with anxiety disorders who experienced separation anxiety in childhood. The fear extinction model of anxiety calls for desensitization to threatening stimuli and does not consider the role of earlier childhood separation anxiety disorder in adult panic disorder and other anxiety disorders. In these patients, unaddressed separation anxiety lessens the effects of both medication and psychotherapy. Milrod et al. (p. 34) add that patients may be unaware of separation anxiety, as it clusters in families and may be considered normal behavior.

Clinical Guidance: Next-Step Strategies for Social Anxiety Disorder 

Adding clonazepam increases the likelihood of response in patients with social anxiety disorder who remain symptomatic after a trial of a selective serotonin reuptake inhibitor (SSRI). Research by Pollack et al. (CME, p. 44) supports the common clinical practice of combining a benzodiazepine with an SSRI. Among 181 nonresponders to sertraline alone, those who had up to 3 mg/day of clonazepam added to sertraline had a response rate of 56% after 12 weeks, compared with 36% for those who continued to take sertraline alone and 46% for patients switched to venlafaxine. Remission rates were 27%, 17%, and 19%, respectively, but did not show a statistical difference. In an editorial, Peter Roy-Byrne (p. 1) points out there is also value of longer SSRI treatment, as a third of the patients who simply stayed on the same sertraline regimen continued to improve.

Clinical Guidance: Short-Term SSRI Use and Upper Gastrointestinal Bleeding 

The risk of upper gastrointestinal bleeding rises in the first 7–28 days of treatment with selective serotonin reuptake inhibitors (SSRIs), particularly fluoxetine and sertraline. Tricyclic antidepressants, monoamine oxidase inhibitors, and serotonin-norepinephrine reuptake inhibitors do not increase risk and may be better choices for patients with a history of upper gastrointestinal tract disorders. The findings come from a national database on psychiatric inpatients reported by Wang et al. (p. 54), who also found that men taking SSRIs are more prone to upper gastrointestinal bleeding than women.

CBT had a greater effect on bulimic behaviors despite less therapist contact (Poulsen et al., p. 109)



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