[Present-day approach to pharmacological and clinical aspects of novel antidepressants]

Depression is the most common illness that affects a large number of individuals in all countries. Recent evidence suggest that depressive episodes if left untreated may heighten severity of subsequent episodes and may increase need for more health care resources. The first antidepressants, tricyclics and monoamine oxidase inhibitors, became available in the late 1950s. A progressive tightening of requirements by drug licensing authorities has ensured that efficacy evidence is good for most antidepressants that are in use. Contemporary antidepressant classification system is based on the mechanism of action, which is presumed to be responsible for their antidepressant effects. A pharmacodynamic system of classification has advantages because it incorporates the current theories of disease pathophysiology. Understanding the basic aspects of mechanism of action of antidepressants is important for treatment of depressive episode, for development of augmenting strategies and combining antidepressants with other antidepressants or antipsychotics. Antidepressants as a class of psychotropic medication have the broad range of indications. The choice of initial antidepressant legitimately varies considerably among clinicians and countries. Referring to some differences of recommendations for the first line treatment of depressive episode we suppose that the choice of antidepressant medication must be individualized for a particular patient. Novel antidepressants (SSRI, SNRI, NaSSA, NARI, NDRI and other) are safe and better tolerated. Metabolism of novel antidepressants is much improved compared with MAOIs and TCAs. The combination of antidepressants is an important clinical issue. There are the following principles of combining antidepressants: 1. to combine mechanisms of action not just drugs, 2. to combine antidepressants and to promote pharmacological synergy and tolerability, 3. to use important synergies within the serotonin, noradrenaline and even dopamine monoaminergic systems. Adequate treatment of depression including modern treatment approaches has the potential to reduce suffering and disability substantially and minimise the risk of suicide.

[Treatment with antidepressants in geriatric departments. Occurrence and record keeping]

INTRODUCTION

The aim of the present study was to describe the occurrence of antidepressant treatment in geriatric departments in Denmark and assess the notes of the patient records in connection with prescription.

MATERIAL AND METHODS

Patient records for consecutively referred patients in seven geriatric departments were examined and basic information was noted. For users of antidepressants further information about the treatment was noted.

RESULTS

A total of 1211 patients records were examined and out of these 338 patients were in treatment with antidepressants (29.7%). The users of antidepressants used more drugs on their discharge from the hospital. For 61.8% (209/338) of the users the treatment had started before the admission and in more than three-fourths the treatment remained unchanged at their discharge, in 9% the treatment was discontinued. 38.2% (129/338) started their treatment during the admission. Depression was stated as being the main reason in 54% of those who continued an ongoing treatment, and in 78% of those who started their treatment during admission. In 98.4%, the beginning of treatment with antidepressants was based upon the file notes. In 34.8% of the records of ongoing treatment no file notes were given.

DISCUSSION

Treatment with antidepressants is common in geriatric departments and most often it is a question of continuation of a treatment that had started before the admission. The study shows that there is a need for an optimization of the file notes.

Drug treatment in depressed elderly in the Dutch community

OBJECTIVES

In older people, a diagnosis of depression is frequently missed, and proper treatment is subsequently hampered. We investigated antidepressant and benzodiazepine use in an older community sample, and assessed possible risk factors associated with non-treatment in depressed elderly.

METHODS

Data were used from the baseline measurements of the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified community sample of 3107 older Dutch people (55 to 85 years), respondents were screened on depression with the Center for Epidemiologic Studies Depression Scale (CES-D). In the depressed subsample depressive disorder according to DSM-III was assessed using the Diagnostic Interview Schedule (DIS). The use of antidepressants and anxiolytics (benzodiazepines) in the depressed subsample was measured, and associations with age, sex, cognitive impairment, physical health and anxiety symptoms were investigated.

RESULTS

Only 16% of the respondents with a major depressive disorder used antidepressants. More than half of them used non-therapeutic dosages. Lower antidepressant use was associated with cognitive impairment. Benzodiazepine use was more likely than antidepressant use, which was especially evident in females in the major depressive disorder group.

CONCLUSIONS

Depressed older people were undertreated, particularly when they were cognitively impaired. A high rate of benzodiazepine use was found, particularly in females.

[Treatment of refractory irritable bowel syndrome with subclinical dosage of antidepressants]

OBJECTIVE

To investigate the effect of antidepressant on irritable bowel syndrome (IBS).

METHODS

A self-control and follow-up study on subclinical dosage of antidepressants therapy (fluoxetine 10 mg/d, paroxetine 10 mg/d or doxepin 45 mg/d) for 9-12 wks in 46 patients with refractory IBS symptoms according to Rome II criteria was performed, the clinical outcomes were evaluated by scales changes of symptom-related-anxiety, severity index of symptom, and quality of life specific of IBS, as well as general psychiatric health by SCL-90 during treatment and follow-up periods.

RESULTS

All 46 cases completed therapy and first follow-up unit (12 wks after treatment) (FFU), at the end of FFU, clinical symptoms in all patients were improved (P < 0.01). Comparison of the scores of symptom-related-anxiety, index of symptom, and quality of life specific of IBS at the end of FFU with that at basal level, indexes of the severity (3.4 +/- 1.5 vs 1.8 +/- 0.84) and frequency (3.8 +/- 1.60 vs 2.0 +/- 0.76) of symptoms were subsided significantly (P < 0.01, respectively); the scores of symptom-anxiety questionnaire including body anxiety (16.04 +/- 1.65 vs 10.83 +/- 1.64, P < 0.001), cognitive anxiety (18.78 +/- 2.12 vs 11.17 +/- 1.89, P < 0.001), fear (15.80 +/- 1.76 vs 10.78 +/- 1.85, P < 0.001) and avoiding (15.47 +/- 1.53 vs 10.16 +/- 1.59, P < 0.001) were also subsided significantly. In the meantime, IBS-QoL improved significantly (P < 0.05), dysphoria, body image, interference with activity, health worry, social reaction and overall scores were improved significantly (P < 0.01, respectively). The status of general psychiatric health was also improved significantly (P < 0.01).

CONCLUSIONS

Treatment of refractory IBS with subclinical dosage antidepressant is rational and effective, However a further study on its mechanisms is suggested.

Relapse of major depression after complete and partial remission during a 2-year follow-up

BACKGROUND

Rates of remission and relapse were studied over more than 2 years in a sample of Spanish outpatients with DSM-III-R criteria of unipolar major depressive episodes.

METHODS

Patients were treated following standardised pharmacological protocols at our centre. In the first visit, the structured clinical interview for DSM-III-R (SCID) was used. The following visits were held monthly. Phases of evolution were recorded using the Hamilton Depression Rating Scale (HDRS), applying the Frank criteria.

RESULTS

A significantly greater proportion of relapse was observed in the partial remission group compared to the complete remission one. The rate of relapses for patients in complete remission was 15.18%, while for patients in partial remission was 67.61%. Partial remission was significantly associated with relapses.

LIMITATIONS

The short duration of the study and the decreasing sample size during the follow-up.

CONCLUSIONS

Partial remission after a depressive episode seems to be strongly associated with relapses. Moreover, this clinical factor could by itself fully predict short-term relapses.

CLINICAL RELEVANCE

The study shows the importance of reaching complete remission to decrease the rate of short-term relapses.

Autoradiographic quantification of neurochemical markers of serotonin, dopamine and opioid systems in rat brain mesolimbic regions following chronic St John's wort treatment

Effects of chronic treatment with St John's wort (SJW, Hypericum perforatum) on neurochemical markers of serotonin, dopamine and opioid systems in mesolimbic regions of the fawn-hooded rat were investigated by quantitative autoradiography. After 10 days' treatment, SJW significantly increased [(3)H]citalopram binding to 5-HT transporters in multiple mesolimbic regions. In contrast, SJW resulted in a region-specific alteration of [(3)H]mazindol binding to dopamine transporters, such as increased binding of [(3)H]mazindol in the olfactory tubercle and decreased binding in the ventral tegmental area. In addition, SJW also resulted in differential modulation of the binding properties of 5-HT(1A)-, 5-HT(2A)- and mu-opioid receptors in a region-specific manner. The ability of SJW to affect 5-HT, dopamine and opioid systems in mesolimbic regions in the CNS, either by a direct or by indirect (adaptation) mechanism, may help to explain the efficacy of SJW in the treatment of depression clinically and in some of the behavioural effects observed in experimental rodents.

Differential effects of K(ATP) channel blockers on [(3)H]-noradrenaline overflow after short- and long-term exposure to (+)-oxaprotiline or desipramine

To test whether prolonged uptake blockade can lead to changes in the function of ATP-dependent potassium (K(ATP)) channels we investigated in rat neocortex slices the effects of K(ATP) channel blockers on electrically evoked [(3)H]-noradrenaline ([(3)H]-NA) overflow after short- (45 min) and long-term (210 min) exposure to the NA uptake blockers (+)-oxaprotiline or desipramine (1 microM each). The K(ATP) channel blocker glibenclamide (1 micro M) increased the evoked [(3)H]-NA overflow by 42% after short-term uptake inhibition. This effect was confirmed by tolbutamide and glipizide, two other K(ATP) channel antagonists. The evoked [(3)H]-NA overflow was enhanced by 73% following short-term uptake blockade (15 min) and by 110% following long-term blockade (180 min). After long-term blockade (210 min), however, glibenclamide failed to further enhance the overflow of [(3)H]-NA. The alpha(2)-autoreceptor-mediated feedback control was not involved in the glibenclamide-induced increase in [(3)H]-NA overflow after short-term uptake blockade or in the increase in [(3)H]-NA overflow due to long-term uptake blockade per se. The Na(+)/K(+)-ATPase inhibitor ouabain diminished the glibenclamide-induced enhancement of [(3)H]-NA overflow after short-term uptake blockade, suggesting that an operative Na(+)/K(+)-ATPase is the prerequisite of activation of K(ATP) channels. These results suggest that short-term uptake blockade activates the Na(+)/K(+)-ATPase, thereby reducing intracellular ATP which allows transient opening of K(ATP) channels. Activation of the Na(+)/K(+)-ATPase may increase the Na(+) gradient, probably over the membrane of noradrenergic nerve terminals. The resulting hyperpolarisation leads to inhibition of the evoked overflow which can be reversed, i.e. enhanced, by K(ATP) channel blockers. In contrast, longer lasting uptake blockade seems to reduce the activity of the Na(+)/K(+)-ATPase and hence the consumption of ATP. As a consequence, reduced Na(+) and K(+) gradients may facilitate transmitter release. Closure of K(ATP) channels by accumulating ATP may further promote membrane depolarisation and transmitter release. The unexpected effect of longer exposure to uptake blockers could be somehow related to the clinical time latency of the antidepressant efficacy of monoamine uptake blockers.

[Characteristics of the choice of psychotropic drugs in suicide attempts]

Review of results of Pecs centre in WHO/EURO Multicentre Study on Suicidal Behaviour.

OBJECTIVE

Studies concerning the choice of methods and psychotropics in the suicidal acts have a great importance because the outcome of suicides is decisively determined by the potential lethality of the method. In the sample of patients who attempted suicides, the features of overdoses have been investigated as well as their relations to the age, sex and repetition.

METHOD

Within the framework of the WHO/EURO Multicentre Study on Suicidal Behaviour data, 1158 cases with suicide attempts were collected from 1997 to 2001.

RESULTS

Among methods of suicide attempts the most frequents were overdoses, while cutting, and hanging were more rarely, and alcohol consumption associated with 15% of attempts. Psychotropics were found in three-quarters of overdoses. A more detailed analysis of the methods used by suicidal patients shows that benzodiazepines represented almost two-thirds of all the drugs taken followed by meprobamate, carbamazepine and antidepressants. Repeaters used frequently antidepressants, antipsychotics, carbamazepine, while benzodiazepines and meprobamate poisoning were rather typical of first-ever group.

CONCLUSION

Considerable differences in the use of psychotropics for parasuicide related to gender, age and repetition were found. The results suggest, that the features of overdoses may be in connection with the availability of drugs and the special national characteristics of drug-prescribing. The differences of repeaters may reflect the insufficiency of the mental health care system. The authors emphasize the importance of these facts among the possibilities of prevention.

Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) have been suspected of increasing the risk of bleeding. We examined the risk of upper gastrointestinal tract (GI) bleeding with use of antidepressant medication.

METHODS

All users of antidepressants in the county of North Jutland, Denmark, from January 1, 1991, to December 31, 1995, were identified in the Pharmaco-Epidemiologic Prescription Database of North Jutland. In the Hospital Discharge Register, hospitalizations for upper GI bleeding were searched among the 26 005 users of antidepressant medications and compared with the number of hospitalizations in the population of North Jutland who did not receive prescriptions for antidepressants.

RESULTS

During periods of SSRI use without use of other drugs associated with upper GI bleeding, we observed 55 upper GI bleeding episodes, which was 3.6 times more than expected (95% confidence interval, 2.7-4.7), corresponding to a rate difference of 3.1 per 1000 treatment years. Combined use of an SSRI and nonsteroidal anti-inflammatory drugs or low-dose aspirin increased the risk to 12.2 (95% confidence interval, 7.1-19.5) and 5.2 (95% confidence interval, 3.2-8.0), respectively. Non-SSRIs increased the risk of upper GI bleeding to 2.3 (95% confidence interval, 1.5-3.4), while antidepressants without action on the serotonin receptor had no significant effect on the risk of upper GI bleeding. The risk with SSRI use returned to unity after termination of SSRI use, while the risks were similarly increased during periods of use and nonuse of non-SSRIs.

CONCLUSION

Selective serotonin reuptake inhibitors increase the risk of upper GI bleeding, and this effect is potentiated by concurrent use of nonsteroidal anti-inflammatory drugs or low-dose aspirin, whereas an increased risk of upper GI bleeding could not be attributed to other types of antidepressants.

[Pharmacotherapy in heroin addiction: pharmacological approaches to remission stabilization and recurrence prevention]

After withdrawal arrest in many heroin addicts, they displayed the syndrome of anhedonia including affective disorders (depression, dysphoria, anxiety), dyssomnia and a pathologic craving for opiates. Anhedonia is often the cause for recurrence in heroine addiction, therefore, an appropriate treatment is an important aspect in recurrence prevention and remission stabilization. Since depression and drive for heroin are the key symptoms in anhedonia, we undertook the efficiency study of therapy (in anhedonia) by antidepressants belonging to the selective serotonin reuptake inhibitors (SSRI) and NMDA receptor antagonists, citalopram and memantine, respectively, which have a clinical antidepressant action and an experimental anti-addictive action. Both drugs were found to arrest effectively virtually all signs of anhedonia, however, their action on remission stabilization was rather moderate. It looked to be more promising to use, in remission stabilization, the uttermost antagonist of opiate receptors (naltrexone) blocking reliably all heroine effects. A double blind placebo-controlled study, undertaken by us, convincingly showed a significantly smaller number of relapses with naltrexone in heroin addicts. At the same time, the drug had no valuable effect on the anhedonia symptoms, which worsened the compliance entailing a poorer therapy efficiency. Finally, a combination of naltrexone (blocking the heroin action and reducing the recurrence rate) with SSRI antidepressants (effectively arresting the anhedonia symptoms and improving the compliance with naltrexone medication and remission quality) is a most promising approach to remission stabilization and recurrence prevention.

Treatment of antidepressant-induced sexual dysfunction

This article reviews the prevalence of antidepressant-induced sexual dysfunction and the strategies available for managing sexual adverse events. A high incidence of sexual dysfunction has been observed in patients treated with antidepressants. In particular, it has been reported in more than half of the patients treated with selective serotonin reuptake inhibitors. There are various pharmacotherapeutic strategies that can lead to reversal of sexual dysfunction. This article will review clinical studies on pharmacotherapeutic agents used to treat antidepressant-induced sexual dysfunction, as well as agents used to treat depression with a favorable sexual side-effect profile. Because sexual dysfunction can lead to treatment noncompliance and depression relapse, this is an issue that should be addressed by clinicians at initiation and throughout the course of treatment.

Reboxetine versus paroxetine versus placebo: effects on cognitive functioning in depressed patients

Impaired cognitive functioning is often associated with major depressive disorder (MDD). Moreover, a number of agents used to treat MDD are known to have negative effects on cognitive functioning. We report an assessment of the effects of the selective norepinephrine reuptake inhibitor reboxetine, the selective serotonin reuptake inhibitor paroxetine, and placebo on a variety of measures of cognitive functioning in patients with MDD. Cognitive functioning in 74 adult patients (aged 18-65 years) with a confirmed diagnosis of MDD (DSM-IV) was assessed as part of two identical, randomized, double-blind, placebo- and active-treatment-controlled, fixed/flexible dose comparisons of 8 weeks of treatment with reboxetine (8-10 mg/day), paroxetine (20-40 mg/day) and placebo. Cognitive function was assessed at baseline, day 14 and day 56 using a selection of tasks from the Cognitive Drug Research computerized assessment system, including Simple Reaction Time, Digit Vigilance, Choice Reaction Time, Numeric Working Memory, Word Recognition and Critical Flicker Frequency. The results in the 74 patients (reboxetine n = 25, paroxetine n = 23, placebo n = 26) showed that reboxetine significantly improved the ability to sustain attention at day 56 compared with baseline (P = 0.023). In addition, patients who received reboxetine experienced significant improvements in their speed of cognitive functioning when tested at day 56 compared to baseline (P = 0.024). No significant changes or trends in this direction were seen among patients who received either placebo or paroxetine. The results of the present study provide objective data to support the possibility that reboxetine favourably affects cognitive processes in depressed patients.

Testosterone gel supplementation for men with refractory depression: a randomized, placebo-controlled trial

OBJECTIVE

Testosterone supplementation may produce antidepressant effects in men, but until recently it has required cumbersome parenteral administration. In an 8-week randomized, placebo-controlled trial, the authors administered a testosterone transdermal gel to men aged 30-65 who had refractory depression and low or borderline testosterone levels.

METHOD

Of 56 men screened, 24 (42.9%) displayed morning serum total testosterone levels of 350 ng/dl or less (normal range=270-1070). Of these men, 23 entered the study. One responded to an initial 1-week single-blind placebo period, and 22 were subsequently randomly assigned: 12 to 1% testosterone gel, 10 g/day, and 10 to identical-appearing placebo. Each subject continued his existing antidepressant regimen. Ten subjects receiving testosterone and nine receiving placebo completed the 8-week trial.

RESULTS

The groups were closely matched on baseline demographic and psychiatric measures. Subjects receiving testosterone gel had significantly greater improvement in scores on the Hamilton Depression Rating Scale than subjects receiving placebo. These changes were noted on both the vegetative and affective subscales of the Hamilton Depression Rating Scale. A significant difference was also found on the Clinical Global Impression severity scale but not the Beck Depression Inventory. One subject assigned to testosterone reported increased difficulty with urination, suggesting an exacerbation of benign prostatic hyperplasia; no other subject reported adverse events apparently attributable to testosterone.

CONCLUSIONS

These preliminary findings suggest that testosterone gel may produce antidepressant effects in the large and probably underrecognized population of depressed men with low testosterone levels.

Treating depression comorbid with anxiety--results of an open, practice-oriented study with St John's wort WS 5572 and valerian extract in high doses

Depressive disorders in comorbidity with anxiety disorders represent an frequently diagnostic and therapeutic problem. The studies quoted here prove that the symptoms associated with anxiety that severely afflict patients can be clearly improved more quickly with a combination therapy of St John's wort extract and valerian extract than with St John's wort monotherapy. The combination therapy was well tolerated, no significant side-effects occurred. Further studies are necessary to compare the combination treatment with other forms of therapy (serotonin- and noradrenalin re-uptake inhibitors).

Treatment of depression with comorbid anxiety disorders: differential efficacy of paroxetine versus moclobemide

To compare the efficacy and tolerability of moclobemide versus paroxetine for the treatment of depression with comorbid anxiety disorders. Outpatients fulfilling DSM-III-R criteria for major depression or dysthymia and for a co-occurring comorbid anxiety disorder (panic disorder, generalized anxiety disorder or obsessive-compulsive disorder) after a 1-week run-in phase were randomly assigned to open-label moclobemide (300-600 mg/day) or paroxetine (20-40 mg/day) for 4 months. Primary criterion for response was a 50% score reduction from baseline on Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale scores. Mean changes in Clinical Global Impressions Severity of Illness and Improvement Scales (CGI-I) were also used to evaluate treatment response. Of the 123 patients included in the study, 65 were randomly assigned to moclobemide and 58 to paroxetine. At study end, the two treatment groups did not differ significantly in terms of proportion of responders. Treatment group differences emerged when comorbid anxiety diagnoses were considered. In patients with comorbid panic disorder, paroxetine was superior to moclobemide in improving both anxiety and depression (five patients out of 18 in the moclobemide group and nine out of 14 in the paroxetine group were rated as responders according to CGI-I, P = 0.04). Neither medication was superior in treating comorbid generalized anxiety disorder. These findings indicate that both moclobemide and paroxetine are effective for treatment of depression with comorbid anxiety disorders. However, in the subgroup with comorbid panic disorder, paroxetine is more effective than moclobemide in reducing both depressive and anxiety symptoms.

[The experience of pyrazidol use in the treatment of non-psychotic depression]

Pirazidolum ("Masterlek", Russia) was used in the treatment of 30 patients with recurrent depression (ICD-10 item F33) and depression episode (F32), mild and moderate types. The initial dose was 50-75 mg daily, mean dose--200-350 mg daily, treatment course--28 days. The efficacy of the treatment was evaluated by Clinical Global Impression (CGI) scale, Hamilton depression (HAM-D) scale and side effects scale (UKU). Significant improvement was revealed in 73% of the patients. A trend to improvement scored on HAM-D was detected by 2 treatment week 2, and pronounced improvement (more than a half-decreased total score)--by week 4. Only 27.6% of the patients had weak side effects (dry mouth, sweatiness, tachycardia etc) that did not demand any changes in the treatment course. The authors believe that pirazidolum may be referred to antidepressants which are effective for depression with a prevalent positive affect.

[Current views on migraine and anti-migraine preparations]

On the basis of comprehensive experimental and clinical research the authors defined a variety of migraine-related mechanisms and schemes of migraine-correction by drugs, which should be both of the vascular- and general-actions to ensure an effective medication.

Differences in community mental health literacy in older and younger Australians

BACKGROUND

Depression has been traditionally considered to increase with age, although that may be due to sampling of those who have presented with depressive conditions. It is now recognised that patients' understanding of depression and beliefs about its appropriate treatment, mental health literacy, influences treatment-seeking behaviour.

OBJECTIVES

This study delineates depression, recent use of health services and mental health literacy in a random and representative community sample of younger and older South Australians.

METHODS

Depression, health service utilisation and mental health literacy were assessed in a random and representative sample of 2010 South Australians. Results for those aged between 65 and 74 years (n=300) and those aged 15 to 24 years (n=521) were compared.

RESULTS

Compared with the younger group, older subjects did not report greater levels of current depression although they were more likely to have seen a medical practitioner in the last 12 months and be taking antidepressants. However, their mental health literacy in terms of recognition of a mental health problem in a vignette was somewhat poorer and fewer recommended treatment from a counsellor, telephone service or psychologist and more considered that a psychiatrist would be harmful. They also more often perceived the clergy as helpful.

CONCLUSIONS

Depression was not more common among older than younger members of the community. Despite recognising depression in a vignette less often and perceiving less likelihood of help from several different mental health professionals, those in the older group were more likely to receive antidepressant medication and to have recently consulted a medical practitioner.

[Pyrazidol in the treatment of depression in patients with ischemic heart disease]

AIM

To study efficacy and safety of pirazidol administration in depressive patients with ischemic heart disease (IHD).

MATERIAL AND METHODS

Pirazidol was given in a dose 0.15-0.3 g/day for 4 weeks to 30 IHD patients aged 21-65 years. 21 of them had nosogenic depression, 9 patients had dysthymia. The efficacy of the antidepressive action was assessed by the Hamilton scale.

RESULTS

The trend to a decrease in Hamilton scale scores was manifest by the end of the treatment week 2. To the end of the study the overall score median lowered from 17 to 9, most of the patients had the score sum under 11. Side effects were insignificant. In pirazidol combination with beta-blockers, blockers of calcium channels, antiaggregant, diuretic drugs, nitrates and other cardio- and angiotropic drugs unfavorable interactions were not registered.

CONCLUSION

Pirazidol can be effectively used in the treatment of psychosomatic disorders in patients with cardiovascular diseases.