Safety reporting and adverse-event profile of mirtazapine described in randomized controlled trials in comparison with other classes of antidepressants in the acute-phase treatment of adults with depression: systematic review and meta-analysis

Polypharmacy or medication washout: an old tool revisited

There has been a rapid increase in the use of polypharmacy in psychiatry possibly due to the introduction of newer drugs, greater availability of these newer drugs, excessive confidence in clinical trial results, widespread prescribing of psychotropic medications by primary care, and pressure to augment with additional medications for unresolved side effects or greater efficacy. Even the new generation of medications may not hold significant advantages over older drugs. In fact, there may be additional safety risks with polypharmacy being so widespread. Washout, as a clinical tool, is rarely done in medication management today. Studies have shown that augmenting therapy with additional medications resulted in 9.1%-34.1% dropouts due to intolerance of the augmentation, whereas studies of medication washout demonstrated only 5.9%-7.8% intolerance to the washout procedure. These perils justify reconsideration of medication washout before deciding on augmentation. There are unwarranted fears and resistance in the medical community toward medication washout, especially at the moment a physician is trying to decide whether to washout or add more medications to the treatment regimen. However, medication washout provides unique benefits to the physician: it establishes a new baseline of the disorder, helps identify medication efficacy from their adverse effects, and provides clarity of diagnosis and potential reduction of drug treatments, drug interactions, and costs. It may also reduce overall adverse events, not to mention a potential to reduce liability. After washout, physicians may be able to select the appropriate polypharmacy more effectively and safely, if necessary. Washout, while not for every patient, may be an effective tool for physicians who need to decide on whether to add potentially risky polypharmacy for a given patient. The risks of washout may, in some cases, be lower and the benefits may be clearly helpful for diagnosis, understanding medication effects, the doctor/patient relationship, and safer use of polypharmacy if indicated.

Drug treatment for mood disorders in pregnancy

PURPOSE OF REVIEW

During the last few years, several researches, often showing contradictory findings, have investigated the safety of psychotropic medications used for treating mood disorders in pregnancy. Hence, the necessity exists to update this information constantly in order to ensure the safest option for the mother-infant pair.

RECENT FINDINGS

The risk of fetal anomalies associated with early in-utero exposure to antidepressants seems to be increased after paroxetine and clorimipramine exposure, whereas prenatal exposure to nearly all antidepressants is linked to the potential onset of the Prenatal Antidepressant Exposure Syndrome. As regards classic mood stabilizers, the teratogenic risk historically reported with lithium should probably be softened, whereas valproate is the medication which shows the strongest association with fetal anomalies. An increased risk of autism-spectrum disorders and infant neurodevelopmental delay is also associated with valproate exposure through the placenta. No significant reproductive safety data are available on atypical antipsychotics, although such medications may indirectly increase the rate of fetal malformation by inducing gestational diabetes.

SUMMARY

Avoiding the use of clorimipramine, paroxetine, valproate, and atypical antipsychotics during pregnancy is advisable. However, when starting or continuing pharmacological treatment during pregnancy, clinicians should consider not only the intrinsic iatrogenic risk of birth defects or perinatal complications, but also the general safety profile for the expectant mother. Indeed, specific adverse reactions (such as nausea, vomiting, constipation, and excessive weight gain) may aggravate the classic clinical findings of pregnancy, thus indirectly facilitating the occurrence of pregnancy complications and fetal and neonatal problems.

The importance of early symptom relief in antidepressant treatment: focus on agomelatine

Antidepressants were traditionally considered to have delayed onset of action, and clinical opinion often stated that patients may not experience noticeable improvement for 4-6 weeks. Recent studies have shown, however, that antidepressants have more rapid onset of effect, within 1-2 weeks, and that this early response may be associated with later sustained response. Moreover, there is emerging evidence that some medications may have faster onset of therapeutic effect than others. The new antidepressant agomelatine, with its novel pharmacological profile as an agonist at melatonergic (MT(1) and MT(2)) receptors and antagonist at 5-HT(2C) receptors, has in several studies produced earlier symptom improvement than comparator selective serotonin reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors. In particular, beneficial effects on sleep and daytime functioning are noticeable as early as the first week of treatment. These therapeutic benefits may, in part, be related to its regulatory effects on circadian and sleep- wake cycles. Agomelatine therefore combines early symptom relief with a favorable side-effect profile and short-term and long-term antidepressant efficacy. These properties suggest that agomelatine can be considered a first-line treatment for patients with major depression.