[Results of using tricyclic antidepressive drugs in the treatment of endogenous depression (comparative analysis of 7 drugs)]

A group of 250 patients with endogenous depression was studied. Amitriptyline proved to be the most effective drug (51% positive responses) followed by noxiptilin (50%), imipramine (42%), dibenzepin (43%). Clomipramine, desipramine, and nomifensine appeared to be the least effective. Demographic or clinical factors such as age, sex, type of affective illness, severity of depressive syndrome or its particular symptoms (depression, fear, anxiety, psychomotor impairment or biological rhythm alteration) did not show any potential for prediction of the treatment outcome. Worse therapeutic results were observed in patients who had already been given antidepressant treatment for the current depressive cycle before the assessment.

Use of tricyclic antidepressants in recipients of heart transplants

Cardiac transplantation has become an accepted treatment for certain endstage cardiac disease patients. Depression and significant psychosocial stress among heart transplant recipients are not uncommon, but published reports about the use of antidepressants in these persons are very rare. The authors of this study report on a group of nine heart transplant recipients treated with antidepressant medicines. Seven patients achieved clinical remissions of their depression, and only two were unable to tolerate the noncardiac side effects of the medication. Indicators of autonomic, electrocardiographic, and hemodynamic functions showed no adverse effects. Although the study is based on a small sample, it appears that tricyclic antidepressants are safe and effective in heart transplant recipients.

2-Hydroxydesipramine and desipramine plasma levels and electrocardiographic effects in depressed younger adults

Desipramine was given to 34 outpatients aged 20 to 51 years who had primary major depressive disorder but who were otherwise in good health. Daily dosage at bedtime was constant for the final 3 weeks of the 5-week study (mean, [SD] 169.1 [46.1] mg). Electrocardiograms done predrug and after 5 weeks were read by a cardiologist blind to the order in which they were performed. Plasma samples drawn 14 hours after the final study dose were assayed by high performance liquid chromatography; mean (SD) levels were 140.2 (140.0) ng/ml for desipramine and 56.5 (29.4) ng/ml for 2-hydroxydesipramine (2-OH-DMI). Heart rate and PR, QRS and QTc intervals were significantly greater at the end of the study than at baseline, while QT intervals were significantly less. Changes in heart rate and PR, QT and QTc intervals were significantly negatively correlated with the value of the respective cardiac parameters at baseline. Changes in PR interval were significantly positively correlated with log desipramine, log 2-OH-DMI and log (desipramine + 2-OH-DMI). Stepwise multiple regression analyses showed that, for PR interval, each of the three plasma level variables showed a significant ability to improve R2 over that obtained from baseline PR alone. These findings suggest that both 2-OH-DMI and desipramine plasma levels predict a prolongation of intracardiac conduction in younger adults and that monitoring both levels may be useful in the clinical management of certain younger adult patients.

Efficacy of desipramine in painful diabetic neuropathy: a placebo-controlled trial

Although amitriptyline relieves pain in many patients with painful diabetic neuropathy, side effects often preclude effective treatment. Desipramine has the least anticholinergic and sedative effects of the first generation tricyclic antidepressants. We compared a 6 week course of desipramine (mean dose, 201 mg/day) to active placebo in 20 patients with painful diabetic neuropathy in a double-blind crossover trial. Pain relief with desipramine was statistically significant in weeks 5 and 6. Eleven patients reported at least moderate relief with desipramine, compared to 2 with placebo. Pain relief tended to be greater in depressed patients, but relief was also observed in patients who did not show an antidepressant effect. We conclude that desipramine relieves pain in many patients with painful diabetic neuropathy, offering an alternative for patients unable to tolerate amitriptyline. Blockade of norepinephrine reuptake, an action shared by desipramine, amitriptyline, and other antidepressants proven effective in neuropathic pain, may mediate this analgesic effect.

A preliminary, open study of the combination of fluoxetine and desipramine for rapid treatment of major depression

Prompted by a recent study suggesting that the combination of desipramine hydrochloride and fluoxetine down-regulates beta-adrenergic receptors more rapidly than either drug alone, we administered both desipramine and fluoxetine to 14 inpatients with major depression in an open, 4-week trial. Desipramine plasma levels drawn 24 hours after an initial standardized dose were used to rapidly adjust desipramine dosage and compensate for the interactive effects of fluoxetine on desipramine levels in the blood. Responses were retrospectively compared with those of 52 inpatients who were descriptively similar and previously treated in the same setting with desipramine alone. Response was significantly more rapid in the group that received both drugs. One week after treatment began, the mean change in Hamilton Depression Rating Scale scores was 42% in the group that received both drugs and 20% in the group that received desipramine alone (Mann-Whitney U test, P = .007). Two weeks after administration of the drugs, the mean change in scores of the group that received both drugs was 60%, while a 30% change was noted in the patients treated with desipramine alone (P = .001). Ten (71%) of the 14 patients in the group that received both drugs completely remitted (change in Hamilton Depression Rating Scale score of greater than 75%, and final score of less than 7) within 4 weeks, while few patients treated with desipramine alone met these criteria within 4 weeks. This preliminary study suggests that treatment with both desipramine and fluoxetine is a rapid and effective strategy for treatment of major depression, and supports recent hypotheses of noradrenergic-serotonergic synergism.

Desipramine treatment in panic disorder

Apart from imipramine (IMI), the efficacy of tricyclic antidepressants in panic disorder (PD) has received surprisingly little investigation. The authors report on a 6 week open trial of desipramine (DMI) preceded by a 10 day placebo lead-in, in 15 patients with PD. By week 6, 80% of the patients were globally rated as much or very much improved on a mean dose of 198 mg. Much of the improvement resulted from a reduction in non-panic attack symptomatology (i.e., psychic, somatic and phobic anxiety). Longer duration of illness, male gender and residual psychic anxiety were associated with poorer response in a subgroup of patients. DMI caused minimal intolerable side effects, suggesting possible compliance advantages in comparison to IMI. Beyond supporting the efficacy of DMI in PD, the results of the study point to a significant medication responsive non-panic illness component and caution against over-relying on panic attacks in assessing both illness severity and treatment response.

Kinetic effects of desmethylimipramine treatment on platelet serotonin uptake in depressed patients: a comparison with imipramine

The kinetic effects of desmethylimipramine (DMI) on platelet serotonin (5HT) uptake were compared to those of imipramine (IMI) in eight DMI-treated depressed patients and seven IMI-treated depressed patients, and compared to values after patients were off drug for 19 (+/- 8 SD) and 33 (+/- 15) days. As expected, IMI was a stronger inhibitor of 5HT uptake than DMI during treatment, with the mean apparent Km in treated patients being elevated nearly threefold over that of the drug-free condition. In DMI-treated patients, the mean Km was elevated nearly twofold over that of the drug-free condition. Although DMI is considered a preferential norepinephrine uptake inhibitor, the results suggest the following: (1) Significant decreases in the apparent platelet 5HT affinity are achieved with DMI; (2) the inhibition kinetics in depressed patients are competitive; (3) there was a significant relationship between Km change and depression outcome with DMI discontinuation; and (4) DMI, as a metabolite, appears to contribute to the 5HT uptake inhibition of IMI in vivo.

A comparison of adinazolam and desipramine in the treatment of major depression

Thirty-one patients with a DSM-III (R) diagnosis of Major Depression received adinazolam (n = 16) or desipramine (n = 15) during a 6 week double-blind randomized controlled trial. Both groups showed a significant decline in Hamilton Rating Scale for Depression scores (21.8 +/- 4.5 to 10.7 +/- 8.5 for adinazolam and 23.5 +/- 5.5 to 12.9 +/- 8.6) for desipramine. Melancholic and anxiety symptoms were reduced equally by both drugs. Initial sedation was the most common side-effect with adinazolam. Plasma levels of desipramine and hydroxy-desipramine correlated highly with oral dose after 3 weeks of treatment.

Influence of antidepressant drugs on seizure susceptibility and the anticonvulsant activity of valproate in mice

The tricyclic antidepressants, amitriptyline (20-30 mg/kg, i.p.) and imipramine (30-40 mg/kg), provided a significant protection against electro-convulsions (12 mA, 0.2 s stimulus duration) but desipramine (up to 40 mg/kg) remained ineffective. On the other hand, all drugs, amitriptyline (10 mg/kg), desipramine (20 mg/kg), and imipramine (20 mg/kg) distinctly potentiated the protective efficacy of valproate against maximal electroshock, reducing its ED 50 values from 255 mg/kg to 150, 135, and 128 mg/kg, respectively. In one case the plasma valproate level was measured and it was evident that desipramine (20 mg/kg) did not affect the plasma level of this antiepileptic.

Antidepressant pharmacotherapy of depression associated with multiple sclerosis

In a double-blind clinical trial involving 28 patients with multiple sclerosis and major depressive disorder, 14 patients were randomly assigned to a 5-week trial of desipramine and individual psychotherapy and 14 to placebo plus psychotherapy. Clinical judgments indicated that patients treated with desipramine improved significantly more than the placebo group. This was confirmed by scores on the Hamilton Rating Scale for Depression but not by Beck Depression Inventory scores. Side effects limited desipramine dosage in half of the treated patients. The authors conclude that desipramine has a modest beneficial effect in serious depression associated with multiple sclerosis but that side effects may be more of a limiting factor than in patients without medical or neurologic disease.

Desipramine induces cardiac beta-adrenergic sensitivity decrease in major depressed patients without relationship to therapeutic response

Nineteen major depressed inpatients were treated over three weeks with desipramine. Cardiac beta-adrenergic receptor sensitivity was evaluated by an isoproterenol test before and after the three-week treatment. Desipramine induced a beta-adrenergic sensitivity decrease in most of the patients: I 20 (isoproterenol dose necessary to increase by 20 beats/min. the basal heart rate) before treatment: 89 +/- 37 ng/kg (mean +/- SD); after treatment: 170 +/- 135 ng/kg; p(t) less than 0.03. Despite a linear relationship between pretreatment beta-adrenergic sensitivity and post-treatment clinical state, there was no relation between post-treatment cardiac beta-adrenergic sensitivity and therapeutic response or even desipramine plasma levels.

Value of the DST for predicting response of patients with major depression to hospitalization and desipramine

The authors examined the value of the dexamethasone suppression test (DST) for predicting response of patients with unipolar, nonpsychotic major depression to 1 week of hospitalization without antidepressant drugs and to a 4-week trial of desipramine at a fixed plasma level. The rates of response to hospitalization without drug treatment (defined as a score of 12 or less on the Hamilton Rating Scale for Depression) were not significantly different for the patients with a positive DST and those with a negative DST. This finding differs from those of prior studies of the DST and response to placebo. The responses of the DST-positive and DST-negative patients to desipramine also did not differ, a finding that replicates those in some prior reports.

Clomipramine vs desipramine vs placebo in the treatment of diabetic neuropathy symptoms. A double-blind cross-over study

1. The effect of clomipramine and desipramine on diabetic neuropathy symptoms was examined in a double-blind, randomised, placebo controlled, cross-over study for 2 + 2 + 2 weeks. Drug doses were adjusted according to the sparteine phenotype, i.e. extensive metabolisers were treated with 75 mg clomipramine day-1 and 200 mg desipramine day-1 whereas poor metabolisers were treated with 50 mg day-1 of both drugs. Nineteen patients completed the study. 2. Plasma concentration of clomipramine plus desmethylclomipramine was 70-510 nM in extensive metabolisers, vs 590 and 750 nM in two poor metabolisers. Desipramine levels were 130-910 nM, vs 860 and 880 nM. 3. Both clomipramine and desipramine significantly reduced the symptoms of neuropathy as measured by observer- and self rating in comparison with placebo. Clomipramine tended to be more efficacious than desipramine. Patients with a weak or absent response on clomipramine had lower plasma concentrations (clomipramine plus desmethyl-clomipramine less than 200 nM) than patients with a better response. For desipramine a relationship between plasma concentration and effect was not established. 4. Side effect ratings did not differ for clomipramine and desipramine and on both drugs three patients withdrew due to side effects. 5. Compared with earlier results obtained with imipramine dosed on the basis of plasma level monitoring, clomipramine and desipramine on fixed doses appeared less efficacious whereas the side effect profiles were the same. At least for clomipramine, appropriate dose adjustment on the basis of plasma level monitoring may increase the efficacy.

Successful treatment of nonpurging bulimia nervosa with desipramine: a double-blind, placebo-controlled study

Twenty-three women with nonpurging bulimia underwent a 12-week, double-blind, placebo-controlled trial of desipramine hydrochloride. Repeated standardized rating scales, mood assessments, and self-reports of dietary habits were used to measure changes in binge frequency and cognitive processes associated with food intake. The women who received desipramine reduced their frequency of binge eating by 63%, but women receiving placebo increased their frequency of binge eating by 16%. Twelve weeks after initiating treatment, 60% of the treatment group but only 15% of the placebo group abstained from binge eating. The women who received desipramine showed significantly more dietary restraint and reported significantly less hunger, suggesting that desipramine acts to suppress appetite. These preliminary findings suggest that the therapeutic effects of desipramine established in the treatment of purging bulimia nervosa extend to patients with nonpurging bulimia.

Challenging the amphetamine challenge test: report of an antidepressant treatment study

The primary goal of this study was to determine whether the amphetamine challenge test (ACT) response, as measured by a subjective rating scale, the How I Feel Scale (HIF), could predict antidepressant treatment outcome. Following a 1-day non-blind ACT with dextroamphetamine (d-AMPH), patients were treated double-blind for 6 weeks with either desipramine, alprazolam, or a desipramine-alprazolam combination. Regression (true score) analyses were carried out on pre- and post-ACT HIF scores and on baseline and end of study Hamilton Depression Rating Scale (HDRS) scores to determine the magnitudes of improvement measured in response to the ACT and antidepressant treatment, respectively. Regression analyses were performed on the residuals (true scores of improvement) to determine the best fitting (linear) prediction equation. Improvement in the HIF total score predicted HDRS improvement for the whole sample. Possible sources of error contributing to the outcome are identified and the results are discussed in relation to previous clinical investigations of the potential usefulness of the ACT as a predictor of antidepressant response.

Moclobemide (Ro 11-1163) versus desipramine in the treatment of endogenous depression

Moclobemide was compared with desipramine in 30 patients with endogenous depression. The Hamilton Rating Scale for Depression showed significantly greater improvement for moclobemide (69%) than for desipramine (45%). The final assessment of tolerance was good or very good in 87% of moclobemide patients compared with 13% of desipramine patients; 5 patients in the first group and all 15 in the second group complained of adverse effects. One patient on moclobemide and 5 on desipramine stopped treatment prematurely because of poor tolerance; no patients stopped treatment because of lack of efficacy. Assessment in this study was made difficult by concomitant treatment with benzodiazepines and/or mild neuroleptics in both groups, but the results of efficacy and tolerance clearly favour moclobemide over desipramine in the treatment of endogenous depression in hospitalized patients.

Fluvoxamine in the treatment of tricyclic-resistant depression

Following an initial double-blind, randomized, parallel treatment group comparison of fluvoxamine, desipramine, and placebo in 89 outpatients with major depression at two centers, double-blind crossover to fluvoxamine was offered to 13 of 22 desipramine-treated completers of the initial phase who were considered failures on desipramine. Twelve elected to cross over to blinded fluvoxamine, and eleven continued on fluvoxamine for at least eight weeks. Nine of these eleven improved, and overall there was a statistically significant decrease in average Hamilton Depression Scores, from 24 to 13, for these fluvoxamine-treated desipramine-resistant patients.

The role of neuropharmacologic selectivity in antidepressant action: fluvoxamine versus desipramine

Forty patients with a diagnosis of major depressive disorder were entered in a double-blind study to assess comparative clinical response and pharmacologic parameters of fluvoxamine, a highly selective blocker of serotonin reuptake, and desipramine, a noradrenergic agent. Eighteen patients receiving desipramine and 17 patients receiving fluvoxamine completed the study. Fluvoxamine was comparable to desipramine in its antidepressant efficacy and was better tolerated and caused minimal side effects. There was a direct linear relationship between plasma fluvoxamine levels and clinical response and a nonlinear relationship between plasma desipramine levels and clinical response. The pharmacologic specificity of the two drugs was assessed by determining uptake inhibition of serotonin and norepinephrine. The authors found a positive relationship between Hamilton Rating Scale for Depression scores and norepinephrine uptake inhibition for desipramine but found no such relationship between fluvoxamine and serotonin uptake inhibition. Although there was a clear-cut difference in the quality of pharmacologic specificity and a partial relationship to clinical response, the authors were unable to identify neuropharmacologic factors that would predict either treatment response or selective amelioration of symptomatologies in this patient population.

Hyperamylasemia in bulimia nervosa

To determine the value of total serum amylase levels and salivary and pancreatic isoenzyme levels as biologic indices of behavioral disturbance in bulimia nervosa, the authors monitored these levels in 40 bulimic patients participating in a placebo-controlled trial of desipramine and in 25 controls. In the patients, the total and salivary amylase levels were significantly elevated and a significant correlation existed between the frequencies of binge eating and vomiting and the level of salivary amylase. However, the ability to discriminate patients from controls on the basis of serum amylase levels was limited. In addition, a significant positive relationship between binge frequency and level of serum amylase was observed in less than one quarter of 22 patients with five or more amylase determinations. Therefore, although hyperamylasemia is associated with bulimia nervosa, we believe that serum amylase determinations have limited utility in the assessment of patients with this syndrome.

A scale for rating tricyclic response in major depression: the TRIM

We describe the construction and validation of the TRIM, an empirically derived scale designed to rate tricyclic antidepressant response in major depression. Symptoms selected were those that improved in direct association with therapeutic desipramine plasma levels, were frequently present, were substantially correlated with the scale total, could be reliably rated, and for which interview ratings were concordant with observed behavior. Eight symptoms met these criteria and were included. The sensitivity of the TRIM was tested and compared with the Hamilton Rating Scale for Depression (HAM-D) and the Montgomery Asberg Depression Scale (MADS) in a new 4-week prospective desipramine study of nonpsychotic unipolar inpatients with major depression. TRIM 4-week totals were significantly associated with total desipramine plus hydroxydesipramine plasma concentrations, r = -0.32, p less than 0.05, but HAM-D and MADS scores were not. Using multiple regression to control for pretreatment severity, TRIM scores were significantly associated with desipramine plus hydroxydesipramine levels, while HAM-D and MADS scores were not. The data appear to validate the sensitivity of the TRIM and illustrate that scales designed for drug response may detect drug effects that global scales do not.