Intravenous antidepressant treatment: focus on citalopram

During the last decade, the number of patients who consult primary care physicians or psychiatrists for symptoms of depression has doubled. The majority of depressed patients are prescribed oral medication; however, in several European countries antidepressant therapy may be initiated with a daily intravenous infusion. The choice of intravenous antidepressants was previously limited to agents such as dibenzepine, doxepin, clomipramine and viloxazine. More recently, the selective serotonin reuptake inhibitor (SSRI) citalopram has been administered as an intravenous infusion to severely depressed patients. The results from both open and double-blind clinical studies with intravenous citalopram suggest that it is an effective and well-tolerated treatment for depression. Moreover, when treatment is initiated by infusion and continued orally, citalopram is at least as effective as clomipramine, doxepin and viloxazine. As with oral treatment, adverse events experienced by patients are mild to moderate in severity with 50 % of patients reporting no adverse events. The high bioavailability of citalopram indicates that the switch from intravenous to oral citalopram would prevent a deterioration of symptoms as plasma drug concentrations would be maintained. Thus citalopram, the only SSRI available as an intravenous formulation, may be a useful addition for the treatment of severely depressed patients who may benefit from more intensive therapy. The aim of this paper is to review available data detailing the clinical outcome of intravenously administered citalopram in depressed patients.

Successful treatment of reboxetine-induced urinary hesitancy with tamsulosin

Urinary hesitancy can be an uncomfortable side effect during antidepressant treatment. Clinicians often use the selective alpha(1A)-adrenoceptor antagonist, tamsulosin, to treat urinary hesitancy associated with prostate enlargement. We report here a series of case studies in which tamsulosin has been successfully used in the management of urinary hesitancy during therapy with the selective noradrenaline reuptake inhibitor reboxetine for major depressive disorder (MDD). Eight male adults (aged 43-64 years; DSM-IV diagnosis of MDD) who were receiving treatment with reboxetine (4-8 mg/day) were considered candidates for concomitant tamsulosin (0.4 mg/day) therapy. Tamsulosin was administered either as prophylaxis (n=4) or as treatment (n=4) for emergent urinary hesitancy. All patients experienced relief of urinary hesitancy within 20 min of tamsulosin therapy and this effect was sustained. Concomitant treatment with tamsulosin should be considered for those patients in whom urinary hesitancy may lead to withdrawal from reboxetine therapy.

Changes of clinical pattern in seasonal affective disorder (SAD) over time in a German-speaking sample

OBJECTIVE

The goals of this study are to provide estimates of clinical and demographic variables of patients with seasonal affective disorder (SAD) in Germany and Austria, to compare our results with those of previously published SAD studies, and to find out whether the clinical pattern of SAD remained stable over several years.

METHOD

We investigated 610 SAD patients from the outpatient clinics in Bonn (n = 190) and Vienna (n = 420). Patients in Bonn were recruited in the fall-winter season of the years 1989-1992, those in Vienna in the years 1993-2001.

RESULTS

We observed a change in the clinical pattern in our patients: patients from Bonn, who were diagnosed and treated about 5 years earlier, were more likely to suffer from melancholic depression, whereas Viennese patients rather suffered from atypical depression (chi(2) = 54.952, df = 2, p < 0.001). The symptoms of hypersomnia, daytime fatigue, increased eating and carbohydrate-craving were more frequent in the Viennese sample, anxiety and deterioration of patients' capacity to perform at work predominated in Bonn. In addition, patients from Vienna obtained a higher GSS (global seasonality score, measured by the SPAQ - Seasonal Pattern Assessment Questionnaire) than those from Bonn (15.7 +/- 3.3 and 14.6 +/- 4.1 respectively; t = 3.104, p = 0.002). Taken together, our results were in good accordance to other published SAD materials, but we were able to demonstrate that our patients reported "feeling worst" (measured by item 13H of the SPAQ) in November and December, whereas SAD patients in the USA clearly had their worst months in January and February.

CONCLUSIONS

We suggest that an increase in awareness of fall-winter depression in the last decade by both doctors, who referred patients, as well as patients or the entire population must have caused patients to sign up for light therapy at the Viennese SAD clinic because of having heard about the atypical symptom profile. This increased awareness of SAD can also be measured by a statistically significant reduction in the diagnostic latency (from the age of onset to the diagnosis of SAD) when comparing the two study locations.

Successful treatment of recurrent brief depression with reboxetine -- a single case analysis

Recurrent Brief Depression (RBD) is a prevalent condition among the depressive illnesses, and is characterized by depressive episodes of a few days' duration occurring almost every month that are unrelated to the menstruation cycle. So far, RBD has not been shown to respond to antidepressive treatment in controlled clinical trials with citalopram, fluoxetine, flupenthixol, paroxetine, or mianserin using a "classical" parallel group design. However, successful RBD treatment on about sixty patients has so far been reported in one open trial with fluoxetine and in several cases with lithium, mirtazapine, and tranylcypromine. Furthermore, successful treatment of RBD has been reported in a few patients with carbamazepine, nimodipine, and verapamil in controlled double-blind single-case analyses using a flexible cross-over design.

Intravenous mirtazapine in the treatment of depressed inpatients

Mirtazapine is a novel antidepressant with a noradrenergic and specific serotonergic mode of action. So far, mirtazapine has been administered orally. This naturalistic study evaluates the antidepressant efficacy, safety, and tolerability of mirtazapine 15 mg/day administered intravenously to 27 inpatients with moderate to severe major depression. Compared with baseline, we found a significant decrease of the Hamilton Depressive Rating Scale (HDRS) total score (P<0.001). Side effects were mild and transient. Altogether, the results of this preliminary study show that intravenous mirtazapine is an effective, safe and well tolerated treatment for depressed inpatients.

[Pharmacotherapy of seasonal depression]

Seasonal affective disorder (SAD), first described in 1984, is a condition characterized by recurring depressive episodes in fall and winter alternating with nondepressive episodes in spring and summer. Various neurotransmitters have been implicated in the etiology of SAD, with the strongest evidence for an involvement of serotonin. Moreover, researchers have focused on the development of treatment modalities for SAD. Despite the proven efficacy of light therapy in SAD, some patients do not experience sufficient relief of depressive symptoms with light, and a number of them feel unable to comply because of logistical difficulties in administering bright light therapy. Comparatively few studies have examined the role of pharmacotherapy in the treatment of SAD. So far, selective serotonin reuptake inhibitors and possibly compounds with a distinct noradrenergic mechanism of action seem to be the treatment of choice for seasonal depression. There is, however, a clear need for further placebo-controlled studies to evaluate pharmacological treatment options for SAD.

Sertindole: safety and tolerability profile

Sertindole is a novel generation or atypical antipsychotic drug that has recently been re-introduced to the market. The safety and tolerability profile of sertindole have demonstrated a positive benefit/risk ratio in clinical trials and post-marketing studies. The number of patients who experienced extrapyramidal symptoms (EPS) while taking sertindole in clinical trials was similar to that of patients on placebo, and significantly less than that of patients on haloperidol. The relative lack of EPS is probably the result of the drug's highly selective blockade of limbic dopamine D 2 receptors and its lack of effect on other dopamine D 2 receptors, but may be due to low occupancy at dopamine D 2 striatal receptors. Sertindole also has a high affinity for serotonin 5-HT 2 and &#102 1 receptors. It has been shown not to cause sedation and its propensity to cause anticholinergic side effects is low, probably due to its lack of antihistamine and antimuscarinic activity. Sertindole does not cause any clinically significant changes in serum prolactin levels. QT interval prolongation does occur in some patients. The sertindole mortality rate is comparable to that of both risperidone and olanzapine (1.46, 1.75 and 1.20, respectively). Overall, sertindole is a well-tolerated drug that does not cause EPS, sedation or hyperprolactinaemia.

Physical signs in psychiatry: a step towards evidence-based medicine

INTRODUCTION

The descriptive nature of psychiatry is embedded in the traditions of Kraepelin, Bleuler and Freud. Diagnostic guidelines in both ICD10 and DSM-IV are stated to be based on the "clinical description of the variety of concepts" and are based on the subjective complaints, i.e. symptoms.

METHOD

In particular, we argue that no significant effort has been made to segregate the presence of accompanying physical signs in Major Depressive Illness, DSM-IV 296.2x, and Panic Disorder Without Agoraphobia, DSM-IV 300.01.

RESULT

These physical signs are psychophysiological correlates of clinically significant depression and anxiety. Advances in structural biology, genetic engineering and brain imaging provide an opportunity to narrow the gap between physical signs and psychiatric symptoms in psychiatry.

CONCLUSION

Therefore we suggest that the next revisions of the DSM and the ICD classifications lead the way in incorporating physical signs alongside those symptoms pertaining to each psychiatric illness. (Int J Psych Clin Pract 2002; 6: 69-72).

Monoaminergic function in the pathogenesis of seasonal affective disorder

Seasonal affective disorder/winter type (SAD) is characterized by recurrent depressive episodes during autumn and winter alternating with non-depressive episodes during spring and summer. Light therapy with full-spectrum, bright white light has been shown to be effective for this condition. Several hypotheses have been discussed in the literature about the pathogenesis of SAD. The most prominent includes disturbances in central monoaminergic transmission. Evidence can be inferred from studies showing a seasonal rhythm of central and peripheral serotonergic functioning which may be a predisposing factor for SAD. Some of the symptoms of SAD are believed to represent an attempt to overcome a putative deficit in brain serotonergic transmission. Moreover, 5-HT receptor challenge studies suggest altered activity at or downstream to central 5-HT receptors. Monoamine depletion studies support hypotheses about serotonergic and catecholaminergic dysfunctions in SAD and suggest that light therapy may well compensate for this underlying deficit. Further, albeit indirect, support for the importance of monoaminergic mechanisms in SAD and its involvement in the mechanism of the action of light therapy comes from studies showing antidepressant efficacy of serotonergic and noradrenergic antidepressants in the treatment of SAD. Altogether, disturbances in brain monoaminergic transmission seem to play a key role in the pathogenesis of SAD; monoaminergic systems may also play an important role in the mechanisms of the action of light therapy.

[St. John's wort extract WS 5572 in minor to moderately severe depression. Effectiveness and tolerance of 600 and 1200 mg active ingredient daily]

BACKGROUND AND METHOD

In this multi-centre study, the effectiveness and tolerability of an extract of herba hyperici WS 5572 were examined. The total of 2,166 participating patients, all suffering from mild to moderate depression, were prescribed to take 600 mg (one tablet) or 1,200 mg (two tablets) daily. Four-hundred-forty-six general practitioners, psychiatrists and neurologists conducted the survey. Three quarters of the participating patients were female at an average age of 50 years. Most of the patients suffered from a depression which was diagnosed for the first time. Approximately in one third of the patients, a recurrent depression was diagnosed.

RESULTS

The average severity of the depression was "moderate" (basing on CGI; Clinical Global Impression Scale) at the beginning of the survey and was reduced to less than "mild" after an average observation time of seven weeks. 83.7% patients (600 mg) and 88.6% (1,200 mg) responded respectively. During this observation period, an improvement in symptoms, measured in 17 items, was of clinical relevance. The treating physicians described the drug tolerance as being good or very good for 99% in all cases. This observation was confirmed by adverse drug reactions, which amounted to 0.41%. The low ratio of adverse drug reactions of 0.41% confirmed the physicians' judgement.

CONCLUSION

The results obtained from this observational study were similar to those of an equally designed observation performed in 1998, where St. John's wort was observed in a dosage of 300 mg per tablet (standard dosage 3 x 300 mg/d). This is a good proof of the effectiveness and the tolerability of this drug in patients who are suffering from mild and moderate depressive episodes.

Predictors of response to pharmacotherapy with citalopram in obsessive-compulsive disorder

Although serotonin reuptake inhibitors (SRIs) are the medications of choice in the treatment of obsessive-compulsive disorder (OCD), only 50-60% of patients respond to a single trial of any of these agents. Improved knowledge of the predictors of response to treatment may have important clinical implications. Data from a large randomized placebo-controlled trial of citalopram in OCD was analysed using logistic regression to determine predictors of response. Demographic (age, sex), clinical (OCD severity and duration, depression severity, prior treatment) and trial variables (citalopram dose, treatment duration) were included. Subjects with longer duration of OCD, more severe OCD symptoms or previous selective SRI use were less likely to be responders in the citalopram trial. In contrast, subjects who received adequate medication doses for sufficient periods of time in the citalopram trial were more likely to be responders. Despite greater awareness of OCD in recent years, there is evidence that the disorder continues to be underdiagnosed and undertreated. The data here emphasize the crucial importance of early diagnosis and treatment of OCD, and of pharmacotherapy with appropriate dose and duration.

Dopamine transporter availability in symptomatic depressed patients with seasonal affective disorder and healthy controls

BACKGROUND

During recent years hypotheses about the pathophysiology of seasonal affective disorder/winter type (SAD) have focused monoaminergic mechanisms. There is substantial evidence that serotonergic systems play an important role. The potential role of catecholaminergic pathways has not been fully explored.

METHODS

Eleven drug-free, symptomatic depressed patients with SAD and 11 healthy age- and gender-matched healthy controls were invited to participate in a 123Ibeta-CIT single photon emission computed tomography (SPECT) study to assess striatal density of dopamine transporters (DATs). The cerebellum was used as reference region. Ratios were calculated between mean counts in left and right striatum and cerebellum. These ratios minus I represent specific/non-displaceable binding and are assumed to be directly related to DAT availability at the time of binding equilibrium.

RESULTS

Displaceable 153Ibeta-CIT binding in the area corresponding to the left striatum was significantly reduced in SAD patients compared to healthy controls (10.49+/-0.91 v. 1195+/-1.54, respectively; 2-tailed P = 0.017, Mann-Whitney U test).

CONCLUSIONS

These data suggest reductions in the availability of striatal DAT binding sites in untreated symptomatic depressed SAD patients. It remains unclear whether these reductions represent a primary defect or an attempt to overcome a state of possible lowered dopamine availability in the synaptic cleft during a depressive episode of SAD. However, these findings provide evidence that brain dopaminergic systems may be involved in the pathophysiology of SAD.

The effects of light therapy on mini-mental state examination scores in demented patients

BACKGROUND

Preliminary evidence suggests that demented patients may experience beneficial effects of light therapy. The authors tested whether bright light therapy (BLT) is capable of improving cognitive functions in patients with Alzheimer-type dementia (AD) or vascular dementia (VD).

METHODS

Twenty-three patients with AD or VD were randomly assigned to either evening BLT or dim light therapy (DLT). Effects of light therapy on cognitive functions were assessed before and after light therapy using Mini-Mental State Examination (MMSE) scores. Body temperature rhythm (BTR) was additionally recorded pre- and posttreatment.

RESULTS

Irrespective of their diagnosis, patients treated with BLT (p =.0012) but not with DLT (p =.73) showed a statistically significant increase in MMSE total scores after light therapy. Evening BLT simultaneously induced a significant phase delay of 56 min on BTR (p =.025).

CONCLUSION

Our preliminary results suggest that short-term evening BLT may exert beneficial effects on cognitive functioning in patients with dementia.

Study of family history in seasonal affective disorder

OBJECTIVE

In our investigation we assessed the risk of morbidity for psychiatric disorders among the first-degree relatives of patients with seasonal affective disorders (SAD) and compared it with a control group of patients suffering from nonseasonal mood disorders (NSMD).

METHODS

Over a period of 12 months (June 1994 to May 1995) we recruited patients consecutively admitted to our psychiatric university outpatient clinic in a prospective study. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, revised 4th edition. A total of 344 patients presented themselves with a diagnosis of affective disorder. Out of these, 36 were diagnosed as having SAD. From the same group of 344 patients, we selected a matched control group of 36 patients suffering from NSMD. The experimental and control groups were matched according to sex, age, severity of illness and number of siblings.

RESULTS

There was no significant difference concerning the lifetime prevalences for psychiatric disorders among the fist-degree relatives in both groups (SAD = 16.5% and NSMD = 19%).

CONCLUSION

It seems that there is no difference in familiarity for psychiatric disorders between SAD and NSMD.

Quetiapine: efficacy and tolerability in schizophrenia

Quetiapine, in common with clozapine, has a greater affinity for 5-HT(2) receptors than D(2) receptors and preclinical studies have consistently predicted efficacy against schizophrenia, with a low potential for causing extrapyramidal symptoms (EPS). In clinical trials, the efficacy of quetiapine was consistently superior to placebo and it was effective against both positive and negative symptoms. Quetiapine was also at least as effective as chlorpromazine or haloperidol in improving the symptoms of acute schizophrenia and moreover was associated with higher response rates. The consistent, placebo-level incidence of EPS associated with quetiapine in clinical trials was not seen with haloperidol. Thus, the combination of efficacy comparable to other antipsychotic agents, with an acceptable side effect and tolerability profile, provides support for the use of quetiapine as a first-line antipsychotic agent in the long-term treatment of schizophrenia.

Use of the probasin promoter ARR2PB to express Bax in androgen receptor-positive prostate cancer cells

BACKGROUND

Adenovirus-mediated overexpression of the apoptosis-inducing protein Bax can induce apoptosis in prostate cancer cell lines. Constitutive overexpression of Bax could result in unwanted apoptosis in every site of accidental Bax accumulation in vivo. Therefore, we developed an adenoviral construct (Av-ARR2PB-Bax) in which the probasin promoter, modified to contain two androgen response elements, drives Bax expression. This promoter would be expected to limit expression of Bax to cells expressing the androgen receptor.

METHODS

A variety of androgen receptor (AR)-positive and -negative cell lines of prostatic or nonprostatic origin were infected with Av-ARR2PB-Bax or a control virus, Av-ARR2PB-CAT, in which the same promoter drives expression of the chloramphenicol acetyl transferase-reporter gene. Bax expression and apoptosis in vitro were assessed by western blot analysis. Tumor size and apoptosis in vivo were assessed after four weekly injections of Av-ARR2PB-Bax or Av-ARR2PB-CAT into subcutaneous LNCaP xenografts growing in uncastrated male mice. All statistical tests were two-sided.

RESULTS

Bax was overexpressed in an androgen-dependent way in AR-positive cell lines of prostatic origin but not in AR-positive cells of nonprostatic origin or in AR-negative cell lines of either prostatic or nonprostatic origin. The androgen dihydrotestosterone activated apoptosis in LNCaP cells infected with Av-ARR2PB-Bax but not in those infected with Av-ARR2PB-CAT. Av-ARR2PB-Bax-injected LNCaP xenograft tumors decreased in tumor size from 34.1 mm3 (95% confidence interval [CI] = 25.1 mm3 to 43.1 mm3) to 24.6 mm3 (95% CI = -2.5 mm3 to 51.7 mm3), but the difference was not statistically significant (P =.5). Tumors injected with Av-ARR2PB-CAT increased in size, from 28.9 mm3 (95% CI = 12.7 mm3 to 45.1 mm3) to 206 mm3 (95% CI = 122 mm3 to 290 mm3) (P =.002) and contained statistically significant more apoptotic cells (23.3% [95% CI = 21.1% to 25.6%] versus 9.5% [95% CI = 8.0% to 11.1]) (P<.001).

CONCLUSIONS

Av-ARR2PB-Bax induces androgen-dependent therapeutic apoptosis in vitro and in vivo by activating apoptosis in AR-positive cells derived specifically from prostatic epithelium and does not affect nonprostatic cells.

A 28-week, double-blind, placebo-controlled study with Cerebrolysin in patients with mild to moderate Alzheimer's disease

Cerebrolysin (Cere) is a compound with neurotrophic activity which has been shown to be effective in the treatment of Alzheimer's disease (AD) in earlier trials. The efficacy and safety of repeated treatments with Cere were investigated in this randomized, double-blind, placebo-controlled, parallel-group study. One hundred and forty-nine patients were enrolled (76 Cere; 73 placebo). Patients received i.v. infusions of 30 ml Cere or placebo 5 days per week for 4 weeks. This treatment was repeated after a 2-month therapy-free interval. Effects on cognition and clinical global impressions were evaluated 4, 12, 16, and 28 weeks after the beginning of the infusions using the Clinical Global Impression (CGI) and the Alzheimer's Disease Assessment Scale-cognitive subpart (ADAS-cog). All assessments, including the 28-week follow-up visit were performed under double-blind conditions. At week 16, the responder rate of the Cere group was 63.5% on the CGI, compared to 41.4% in the placebo group (P < 0.004). In the ADAS-cog, an efficacy difference of 3.2 points in favour of Cere was observed (P < 0.0001). Notably, improvements were largely maintained in the Cere group until week 28, 3 months after the end of treatment. Adverse events were recorded in 43% of Cere and 38% of placebo patients. Cere treatment was well tolerated and led to significant improvement in cognition and global clinical impression. A sustained benefit was still evident 3 months after drug withdrawal.

In vivo (123)I IBZM SPECT imaging of striatal dopamine 2 receptor occupancy in schizophrenic patients

RATIONALE

Single photon emission computed tomography (SPECT) using (123)I iodobenzamide (IBZM) as tracer substance has been shown to be a useful tool to visualize dopamine 2 (D2) receptor occupancy.

OBJECTIVES

We investigated the striatal D2 receptor occupancy of zotepine which is referred to the class of atypical antipsychotic drugs.

METHODS

(123)I IBZM and SPECT were used to visualize striatal dopamine 2 (D2) receptor occupancy in zotepine-treated schizophrenic patients. Two groups of schizophrenic patients receiving either 150 mg/day zotepine (n=6) or 300 mg/day (n=6) underwent examination. For the quantification of striatal D2 receptor occupancy, striatal IBZM binding in patients treated with antipsychotics was compared to untreated healthy controls (n=8) reported earlier.

RESULTS

Zotepine led to a mean overall striatal D2 receptor occupancy of 73%. Patients with 150 mg daily showed a significantly lower occupancy (65.8%, SD=6.2) than patients with 300 mg/day (77.8%, SD=10.7; P<0.05). No clinically relevant extrapyramidal side effects occurred during treatment with zotepine.

CONCLUSIONS

There was no correlation between the degree of striatal D2 receptor occupancy and clinical improvement.

Topiramate as a mood stabilizer

Topiramate is a novel anticonvulsant agent with a broad spectrum mechanism of action, and recent clinical reports indicate that it may have mood stabilizing properties in bipolar disorder. Therefore, we treated a 41-year-old woman who had 12 previous hospitalizations for acute mania during a 10-year history of bipolar I disorder with this compound. Since 1991, the patient had been treated with carbamazepine, valproate and lamotrigine with limited success. At the beginning of a new manic episode, topiramate was started in the outpatient clinic. Eight weeks after initiation of treatment, the patient was hospitalized. This inpatient treatment lasted less than 3 weeks. Subsequently, the patient has not been hospitalized again. Topiramate was well tolerated. Even though, during subsequent topiramate treatment, a serious life event (suicide attempt of brother) induced re-occurence of the patient's psychopathology, which did not require hospitalization. Fortunately, inpatient treatment was not necessary due to an increase of topiramate dosage and addition of risperidone and clonazepam. The patient, now on 200 mg/day, is mostly asymptomatic and has functioned well for over 17 months, in contrast to 13 hospitalizations during the previous 10 years.