Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate

Serotonin reuptake inhibitor antidepressants (SSRIs) against atherosclerosis

Selective serotonin reuptake inhibitors (SSRIs) are a class of drug widely used for treatment of mood disorders, including depression and cardiovascular disease. A search for related articles in the PubMed database was attempted. It covered studies, reports, reviews and editorials of the last 5 years.

Pro-inflammatory cytokines, such as TNF-α, IL-1 and IL-6, stimulate central serotonin (5-HT) neurotransmission and are over-expressed in depression, which has been linked with hypothalamic-pituitary-adrenal axis (HPA) hyperactivity. They have also been implicated in the pathogenesis and progression of other stress-induced disorders, like myocardial infarction (MI) and coronary heart disease (CHD), as they seem to modulate cardiovascular function by a variety of mechanisms. Biological mechanisms like these may explain the link between depression and CHD. There are a variety of environmental factors as well as genetic factors that might influence the pharmacogenetics of antidepressant drugs. New generation selective serotonin reuptake inhibitor antidepressants (SSRIs) causing a reduced cardiovascular morbidity and mortality may be related to serotonin platelet abnormalities in depressed patients that are effectively treated by SSRIs. SSRIs such as fluoxetine, paroxetine, sertraline and citalopram are not only considered to be free from the cardiotoxicity of their predecessors but also to function as safe and efficacious agents against depression, platelet activation, atherosclerosis and development and prognosis of coronary heart disease. However, there is a need for more studies in order to establish the exact biochemical mechanisms that are responsible for these diseases and the immunoregulatory effects of chronic use of SSRI medications.

The effects of agomelatine on sexual function in depressed patients and healthy volunteers

BACKGROUND

Selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor antidepressants are associated with high rates of treatment-emergent sexual dysfunction (TESD) due to stimulation of serotonin receptors.

OBJECTIVE

The objective is to evaluate the effect of agomelatine on sexual function in depressed patients.

METHODS

This paper reviews published and unpublished data on sexual function with agomelatine in depressed patients and healthy volunteers.

RESULTS

Agomelatine, an agonist of melatonergic MT1 and MT2 receptors and antagonist of 5-HT2 receptors, is associated with similar rates of sexual dysfunction compared with placebo and lower rates compared with other antidepressants. Twice as many sexually active depressed patients (n = 193) reported a deterioration of sexual function during 12 weeks of treatment with venlafaxine compared with agomelatine (15.2% vs. 8.2%, p < 0.0001); however, no differences were found with respect to arousal. Using the Arizona Sexual Experience Scale in depressed patients (n = 399), the incidence of treatment-emergent sexual dysfunction (TESD) with agomelatine (3%) was significantly lower than placebo (8.6%) and selective serotonin reuptake inhibitors (10.1%). Among healthy male volunteers (n = 92), TESD was not increased compared with placebo in either agomelatine (25 and 50 mg/day) group over 8 weeks, and both were significantly lower than TESD with paroxetine (p < 0.0001). Moderate or severe TESD occurred in less than 5% of subjects receiving agomelatine versus 62% who received paroxetine (p < 0.001).

CONCLUSION

Agomelatine demonstrates favorable sexual acceptability.

Efficacy and tolerability of extended release quetiapine fumarate (quetiapine XR) monotherapy in patients with generalised anxiety disorder: an analysis of pooled data from three 8-week placebo-controlled studies

OBJECTIVE

Prospectively planned pooled analysis evaluating efficacy and tolerability of acute quetiapine XR monotherapy in generalised anxiety disorder.

METHODS

Data from three 10-week, randomised, double-blind, placebo-controlled studies of similar design were analysed.

RESULTS

At Week 8, Hamilton Anxiety Rating Scale (HAM-A) total score significantly improved with quetiapine XR: least squares means change -13.31, p < 0.001 (50 mg/day, n = 452), -14.39, p < 0.001 (150 mg/day, n = 673) and -12.50, p < 0.05 (300 mg/day, n = 444) versus -11.30 placebo; significant (p < 0.001, n = 665) improvements versus placebo were observed with each dose at Week 1. Significant improvements versus placebo at Week 8 are as follows: HAM-A psychic symptom subscale, Montgomery-Åsberg Depression Rating Scale total, Pittsburgh Sleep Quality Index global scores for all quetiapine XR doses; HAM-A response and remission rates, HAM-A somatic symptom subscale score, Clinical Global Impression-Severity of Illness total score, % patients with Clinical Global Impression-Improvement score ≤2 with quetiapine XR 50 and 150 mg/day; and Quality of Life Enjoyment and Satisfaction Questionnaire short form % maximum total score with quetiapine XR 150 mg/day. In the quetiapine XR 50, 150 and 300 mg/day and placebo groups, 13.2%, 16.5%, 24.0% and 5.4% of patients discontinued because of an adverse event, and 1.9%, 1.4%, 3.7% and 1.8% of patients experienced clinically significant changes in glucose. The most common adverse events with quetiapine XR included dry mouth, somnolence, sedation and constipation.

CONCLUSION

Quetiapine XR monotherapy reduced the symptoms of generalised anxiety disorder, with improvement from Week 1. Adverse events were consistent with the known tolerability profile of quetiapine.

Subjective recognition of adverse events with antidepressant in people with depression: a prospective study

BACKGROUND

While it has been reported that physicians may under-recognize adverse effects of antidepressants thoroughly in clinical settings, subjective bias in recognition of adverse effects (AEs) with antidepressants has not been specifically investigated.

METHODS

Four-hundred ninety-three participants with depressive disorders (ICD-10) were assessed for the severity of 20 common AEs and their inferred causal relationship with antidepressants, together with the Quick Inventory for Depressive Symptoms (QIDS). These assessments occurred twice at the 1st visit (when they were antidepressant free) and 2nd visit (10 days after the initiation of antidepressants). 'Possible AEs' and 'under-recognized AEs' were defined as 'events with exacerbation in the severity' and 'events with negative causal attribution to antidepressants' at the time of the 2nd visit, respectively.

RESULTS

Three-hundred sixty-three participants (73.6%) experienced ≥ 1 under-recognized AEs. Flu like symptoms (96.5% of participants who experienced possible AEs), sexual dysfunction (94.2%), blurred vision (93.4%), anxiety/tension (91.1%) and sweating (89.2%) were found to be prevalent as under-recognized AEs. Participants with under-recognized AEs had less improvement in the QIDS than those without (27.1% vs. 11.1% decrease, p<0.001).

LIMITATIONS

It is intrinsically challenging to exactly differentiate between antidepressant AEs and symptoms of depression. And the severity of depression, that of AEs and causal relationship between AEs and antidepressants were assessed not by objective but subjective scales.

CONCLUSIONS

An overall trend to under-recognize AEs of antidepressants was found and people with a lesser degree of early improvement tend to understate the causality, which has an implication in interpreting voluntarily expression of AEs.

Childhood treatment with psychotropic medication and development of comorbid medical conditions in adolescent-onset bipolar disorder

OBJECTIVE

This study aims to investigate the association between early treatment with psychotropic medications and the development of medical comorbidities in pediatric patients who develop bipolar disorder (BD).

METHODS

Data from the South Carolina Medicaid program covering all medical services and medication prescriptions between January 1996 and December 2005 were used to determine the association between childhood exposure to psychotropic medications (i.e., psychostimulants, antidepressants, and antipsychotics) and the diagnosis of select comorbid medical conditions in 1841 children and adolescents diagnosed with Diagnostic and Statistical Manual IV defined BD.

RESULTS

In separate regressions controlling for all psychotropic medications prescribed and all comorbid medical conditions diagnosed prior to the BD, hypertension and cardiovascular disorders were more likely in those prescribed second generation antipsychotics or psychostimulants, whereas obesity/overweight was more likely in those taking serotonin norepinephrine reuptake inhibitor/heterocyclic antidepressants, and asthma was more likely in those taking selective serotonin reuptake inhibitors.

CONCLUSION

Childhood cardiometabolic events appear to be systematically associated with specific classes of psychotropic medications, but no innate, developmental sequencing of cardiometabolic abnormalities was apparent before early adolescence in patients subsequently diagnosed and treated for BD.

Breast cancer medications and vision: effects of treatments for early-stage disease

This review concerns the effects on vision and the eye of medications prescribed at three phases of treatment for women with early-stage breast cancer (BC): (1) adjuvant cytotoxic chemotherapy, (2) adjuvant endocrine therapy, and (3) symptomatic relief. The most common side effects of cytotoxic chemotherapy are epiphora and ocular surface irritation, which can be caused by any of several different regimens. Most notably, the taxane docetaxel can lead to epiphora by inducing canalicular stenosis. The selective-estrogen-receptor-modulator (SERM) tamoxifen, long the gold-standard adjuvant-endocrine-therapy for women with hormone-receptor-positive BC, increases the risk of posterior subcapsular cataract. Tamoxifen also affects the optic nerve head more often than previously thought, apparently by causing subclinical swelling within the first 2 years of use for women older than ∼50 years. Tamoxifen retinopathy is rare, but it can cause foveal cystoid spaces that are revealed with spectral-domain optical coherence tomography (OCT) and that may increase the risk for macular holes. Tamoxifen often alters the perceived color of flashed lights detected via short-wavelength-sensitive (SWS) cone response isolated psychophysically; these altered perceptions may reflect a neural-response sluggishness that becomes evident at ∼2 years of use. The aromatase inhibitor (AI) anastrozole affects perception similarly, but in an age-dependent manner suggesting that the change of estrogen activity towards lower levels is more important than the low estrogen activity itself. Based on analysis of OCT retinal thickness data, it is likely that anastrozole increases the tractional force between the vitreous and retina. Consequently, AI users, myopic AI users particularly, might be at increased risk for traction-related vision loss. Because bisphosphonates are sometimes prescribed to redress AI-induced bone loss, clinicians should be aware of their potential to cause scleritis and uveitis occasionally. We conclude by suggesting some avenues for future research into the visual and ocular effects of AIs, particularly as relates to assessment of cognitive function.

A randomized, double-blind study of once-daily extended release quetiapine fumarate (quetiapine XR) monotherapy in patients with generalized anxiety disorder

This study evaluated once-daily, extended-release quetiapine fumarate (quetiapine XR) monotherapy in generalized anxiety disorder (GAD). This was a 10-week (8-week active treatment/2-week posttreatment drug-discontinuation/tapering phase), double-blind, randomized, placebo-controlled study (D1448C00009). Primary end point was change from randomization at week 8 in Hamilton Anxiety Rating Scale (HAM-A) total score. Overall, 951 patients with GAD were randomized (quetiapine XR: 50 mg/d, n = 234; 150 mg/d, n = 241; 300 mg/d, n = 241; placebo, n = 235). At week 8, HAM-A total scores significantly (P < 0.001) improved versus placebo (-11.10) with quetiapine XR 50 mg/d (-13.31) and 150 mg/d (-13.54), but not 300 mg/d (-11.87; P = 0.240). At week 1, HAM-A total scores significantly improved versus placebo (-5.94) with quetiapine XR 50 mg/d (-7.47; P < 0.01), 150 mg/d (-8.19; P < 0.001), and 300 mg/d (-7.23; P < 0.01). Versus placebo at week 8, quetiapine XR 50 and 150 mg/d significantly improved HAM-A psychic (P < 0.01 and P < 0.001, respectively) and somatic (P < 0.001; P < 0.01, respectively) cluster scores, HAM-A response (≥ 50% total score reduction; P < 0.05), and Clinical Global Impression-Improvement categorical changes (P < 0.05). For quetiapine XR 150 mg/d, significant (P < 0.05) improvements were seen for HAM-A remission (total score, ≤ 7) and Clinical Global Impression-Severity of Illness scores. For quetiapine XR 300 mg/d, improvements in these secondary variables were not significantly different versus placebo. Pittsburgh Sleep Quality Index global scores improved with all 3 doses (quetiapine: XR 50 mg/d, -4.07 [P < 0.05]; 150 mg/d, -4.38 [P < 0.05]; 300 mg/d, -3.97 [P < 0.05], versus -3.31 with placebo). Adverse events (>10% with quetiapine XR) were dry mouth, somnolence, sedation, dizziness, headache, and fatigue. Quetiapine XR (50/150 mg/d) monotherapy was effective at week 8 in patients with GAD; symptom improvement was seen at week 1 for all doses (50/150/300 mg/d). Safety and tolerability were consistent with the known profile of quetiapine.

Mirtazapine augmentation for selective serotonin reuptake inhibitor-induced sexual dysfunction: a retropective investigation

The aim of the present study was to retrospectively identify sexual dysfunction changes in the patients under mirtazapine-augmented serotonin reuptake inhibito (SSRI) treatment. The study comprised medical records of 20 outpatients, under mirtazapine-augmented SSRI treatment for their major depressive disorder, who had been selected among the patients that had developed sexual dysfunction to previous treatment as monotherapy, with SSRI for at least six weeks. These drugs were maintained and mirtazapine were added (15-45 mg/day). There was a significant difference in scores between baseline and week 4 or week 8 on the both Hamilton Depression Rating and Arizona Sexual Experience Scale. According to Clinical Global Impression-Improvement, 68.4% of the patients were responders. The use of low-dose mirtazapine as an add-on treatment to SSRIs appears to be an effective and well-tolerated augmenttaion for sexual dysfunction caused by SSRIs.

Long-term body weight outcomes of antidepressant-environment interactions

Both obesity rates and antidepressant use have escalated in the last 20 years. Most people who start antidepressant treatment discontinue it on their own. Meanwhile, obesity rates continue to increase. To test the hypothesis that antidepressant use is a risk factor for obesity, even after long-term discontinuation, we developed a novel animal paradigm consisting of short-term exposure to stress and antidepressants, followed by long-term high-fat diet. We show here that recurrent restraint stress (RRS)-related weight loss is recovered 2 weeks after the end of stress in young growing rats receiving a high-fat diet. It is noteworthy that animals that received short-term antidepressant treatment with either imipramine or fluoxetine during 7 days of RRS showed behavioral evidence of antidepressant effects. When exposed to a high-fat diet after stress and when antidepressant treatment had ended, the animals had significant increases in caloric intake, body weight (BW) and size from 17 to 22 weeks following antidepressant discontinuation when compared with (control) RRS animals treated with saline and fed with a high-fat diet. These data are consistent with the previously described phenomenon of time-dependent sensitization, and support the notion that enduring effects of short-term antidepressant treatment become manifest on a long-term basis after antidepressant discontinuation, during conditions of high stress followed by high-fat intake. Analyses of open field and body size measurements obtained in a small subset of animals show that animals previously exposed to antidepressant had no deficits in locomotor activity and were larger. Antidepressant exposure may therefore be a covert, insidious and enduring risk factor for obesity, even after discontinuation of antidepressant treatment. Our data support the concept of persistent, long-term effects of pharmacological-environment interactions on BW regulation.

Metabolic, digestive, and reproductive adverse events associated with antimanic treatment in children and adolescents: a retrospective cohort study

OBJECTIVE

To identify factors associated with incident metabolic and reproductive adverse events in children and adolescents.

METHOD

A retrospective cohort design evaluating Medicaid medical and pharmacy claims made in South Carolina between January 1996 and December 2005 was employed for 3,657 children and adolescents (aged 17 years old and younger) prescribed 1 of 3 antimanic medications (ie, lithium, carbamazepine, or valproic acid derivatives) and a random sample of 4,500 children and adolescents not treated with psychotropic medications.

RESULTS

Compared to the control sample, the treated cohort was more likely to be diagnosed with obesity/weight gain (odds ratio [OR] = 1.89), type 2 diabetes mellitus (OR = 2.50), dyslipidemia (OR = 1.89), nausea (OR = 1.61), anorexia (OR = 3.85), and sexual/reproductive adverse events (OR = 2.04). Within the treated cohort, incident dyslipidemia was more likely for those prescribed carbamazepine (OR = 1.52) compared to valproate and coprescribed antipsychotics (OR = 1.47) or selective serotonin reuptake inhibitors (SSRIs) (OR = 1.49) compared to those not taking antipsychotics or taking serotonin-norepinephrine reuptake inhibitor/heterocyclic (SNRI/other) antidepressants. The odds of developing nausea/vomiting were higher for those prescribed carbamazepine (OR = 1.70) or lithium (OR = 1.49) compared to valproate, and those coprescribed psychostimulants (OR = 1.25) compared to those not taking psychostimulants. The odds of developing obesity/weight gain and type 2 diabetes mellitus were higher for those coprescribed SSRIs (ORs = 1.72, 2.58) or antipsychotics (ORs = 1.69, 1.77) compared to those taking SNRI/other antidepressants or not taking antipsychotics. Incident sexual/reproductive adverse events were more likely for those coprescribed SSRIs (OR = 2.02) compared to those taking SNRI/other antidepressants.

CONCLUSION

Commonly employed psychotropic agents are associated with clinically significant metabolic, digestive, and reproductive-related adverse events. Treatment decisions in young populations are usefully informed by the somatic consequences of the medication options.

Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review

BACKGROUND

Over the past several decades, complementary and alternative medications have increasingly become a part of everyday treatment. With the rising cost of prescription medications and their production of unwanted side effects, patients are exploring herbal and other natural remedies for the management and treatment of psychological conditions. Psychological disorders are one of the most frequent conditions seen by clinicians, and often require a long-term regimen of prescription medications. Approximately 6.8 million Americans suffer from generalized anxiety disorder. Many also suffer from the spectrum of behavioural and physical side effects that often accompany its treatment. It is not surprising that there is universal interest in finding effective natural anxiolytic (anti-anxiety) treatments with a lower risk of adverse effects or withdrawal.

METHODS

An electronic and manual search was performed through MEDLINE/PubMed and EBSCO. Articles were not discriminated by date of publication. Available clinical studies published in English that used human participants and examined the anxiolytic potential of dietary and herbal supplements were included. Data were extracted and compiled into tables that included the study design, sample population, intervention, control, length of treatment, outcomes, direction of evidence, and reported adverse events.

RESULTS

A total of 24 studies that investigated five different CAM monotherapies and eight different combination treatments and involved 2619 participants met the inclusion criteria and were analyzed. There were 21 randomized controlled trials and three open-label, uncontrolled observational studies. Most studies involved patients who had been diagnosed with either an anxiety disorder or depression (n = 1786). However, eight studies used healthy volunteers (n = 877) who had normal levels of anxiety, were undergoing surgery, tested at the upper limit of the normal range of a trait anxiety scale, had adverse premenstrual symptoms or were peri-menopausal, reported anxiety and insomnia, or had one month or more of elevated generalized anxiety. Heterogeneity and the small number of studies for each supplement or combination therapy prevented a formal meta-analysis. Of the randomized controlled trials reviewed, 71% (15 out of 21) showed a positive direction of evidence. Any reported side effects were mild to moderate.

CONCLUSIONS

Based on the available evidence, it appears that nutritional and herbal supplementation is an effective method for treating anxiety and anxiety-related conditions without the risk of serious side effects. There is the possibility that any positive effects seen could be due to a placebo effect, which may have a significant psychological impact on participants with mental disorders. However, based on this systematic review, strong evidence exists for the use of herbal supplements containing extracts of passionflower or kava and combinations of L-lysine and L-arginine as treatments for anxiety symptoms and disorders. Magnesium-containing supplements and other herbal combinations may hold promise, but more research is needed before these products can be recommended to patients. St. John's wort monotherapy has insufficient evidence for use as an effective anxiolytic treatment.

Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated. GAD is chronic, disabling, and associated with other health problems. Treatment response is often unsatisfactory, but the clinical evidence base for new treatments has expanded substantially in the past decade and suggests a growing range of options for reducing the burden of GAD. The objective of this article was to review current literature on GAD and its management to provide an overview of the clinical importance of GAD in primary care and available treatments.

DATA SOURCES

Recent studies (ie, over the past decade) on the epidemiology and treatment of GAD were identified by searching Medline using the term generalized anxiety disorder only and in combination with the terms epidemiology and treatment and for each drug class (benzodiazepines, azapirones, antidepressants, antihistamines, alpha-2-delta ligands, and antipsychotics) and for named drugs (buspirone, venlafaxine, duloxetine, fluoxetine, escitalopram, olanzapine, paroxetine, pregabalin, quetiapine, and risperidone in addition to psychological therapies and cognitive-behavioral therapy. The literature search was conducted in August 2008 for the period 1987-2009.

STUDY SELECTION

Studies were included if judged to be relevant to a review of the epidemiology and management of GAD. Articles were excluded if they were not written in English or were published more than 10 years before the literature search was conducted. A few older studies were included for which more recent research evidence was not available. Recent national and international guidelines for the management of GAD were also reviewed.

DATA EXTRACTION/SYNTHESIS

Most currently available interventions have similar overall efficacy, and treatment choices should reflect the situation of individual patients. Important unmet needs exist for treatments (1) that work rapidly, with (2) broad spectrum benefits, (3) that can improve rates of remission and well-being, (4) are devoid of risk for withdrawal symptoms, and (5) have few if any adverse interactions with other drugs. Additional needs include (6) safer drugs for the elderly, (7) safe and effective drugs for children with GAD, (8) further evaluation of psychotherapy, and (9) understanding the appropriate circumstances for, and optimal choices of, drug combination.

CONCLUSION

While the development of novel treatments evolves, current management approaches can focus on improving identification and defining optimal use of available therapies for GAD.

Selected summaries from the XVII World Congress of Psychiatric Genetics, San Diego, California, USA, 4-8 November 2009

The XVII World Congress of Psychiatric Genetics, sponsored by The International Society of Psychiatric Genetics (ISPG) took place in San Diego, California from 4 to 8 November 2009. Approximately 550 participants gathered to discuss the latest molecular genetic findings relevant to serious mental illness, including schizophrenia, mood disorders, substance abuse, autism, and attention deficit disorder. Recent advances in the field were discussed, including the genome-wide association studies results, copy number variation (CNV) in the genome, genomic imaging, and large multicenter collaborations. The following report, written by junior travel awardees who were assigned sessions as rapporteurs represents some of the areas covered in oral presentation during the conference, and reports on some of the notable major new findings described at this 2009 World Congress of Psychiatric Genetics.

A generalist's guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy

This review provides a guide to the primary care physician for diagnosing and managing depression. To identify relevant articles, a PubMed search (ending date parameter, October 15, 2009) was conducted using the keywords depression, antidepressants, side effects, adverse effects, weight gain, sexual dysfunction, and sleep disturbance, and the reference lists of relevant articles were hand searched. This review explores the challenges in diagnosing depression that will and will not respond to antidepressants (ADs) and describes the value of 2-question screening instruments followed by in-depth questioning for positive screening results. It underscores the implications of veiled somatic presentations in which underlying depression is missed, leading to fruitless and expensive medical work-ups. Following this survey of the difficulties in diagnosing depression, the 4 options generalists have for treating a patient with depression are discussed: watchful waiting, antidepressant therapy, psychotherapy, and psychiatric referral. This review proposes that physicians, once they decide to prescribe, use AD side effects to advantage by selecting medications to minimize negative and maximize positive possibilities, thereby improving adherence. It focuses on the 3 most troubling adverse effects-sleep disturbance, sexual dysfunction, and weight gain. It provides AD-prescribing principles to assist primary care physicians in successfully managing depression and appropriately referring patients to a psychiatrist. Antidepressant therapy is not a panacea for treating patients with depression. An approach blending enlightened observation, medications, and psychotherapy often helps depressed patients recover to their former baselines.

Early adverse events and attrition in selective serotonin reuptake inhibitor treatment: a suicide assessment methodology study report

Adverse events during selective serotonin reuptake inhibitor (SSRI) treatment are frequent and may lead to premature treatment discontinuation. If attrition is associated with early worsening of adverse effects or the frequency, intensity, or burden of adverse effects, interventions to maximize retention could be focused on patients with these events. Outpatient participants (n = 265) with nonpsychotic major depressive disorder entered an 8-week trial with an SSRI. At baseline and week 2, specific adverse effects were evaluated with the Systematic Assessment for Treatment Emergent Events--Systematic Inquiry, and at week 2, the Frequency, Intensity, and Burden of Side Effects Rating globally assessed adverse effects. Attrition was defined by those participants who left treatment after week 2 but before week 8. No specific week 2 adverse effect, either treatment-emergent or with worsening intensity, was independently associated with attrition. Global ratings of adverse effect frequency, intensity, or burden at week 2 were also not associated with subsequent attrition. Neither global ratings nor specific adverse effects at week 2 were related to patient attrition during SSRI treatment. Other factors seem to contribute to patient decisions about continuing with treatment.

Fluoxetine-induced decrements in sexual responses of female rats and hamsters are reversed by 3α,5α-THP

INTRODUCTION

Sexual dysfunction, as a result of selective-serotonin reuptake inhibitor (SSRI) treatment among women, is relatively common and is a factor in medication compliance. The mechanisms that underlie these side-effects of SSRIs are not well-understood. SSRIs can alter activity of catabolic enzymes that are involved in progesterone's conversion to 5 α-pregnan-3 α-ol-20-one (3 α,5 α-THP). 3 α,5 α-THP plays a key role in female reproductive physiology and behavior.

AIMS

This study aimed to determine whether 3 α,5 α-THP, in the midbrain ventral tegmental area (VTA) may be a potential mechanism for fluoxetine's reduction in sexual responding of female rodents. We hypothesized that if fluoxetine induces decrements in sexual responding in part through actions of 3 α,5 α-THP, then fluoxetine will inhibit sexual receptivity concomitant with reducing 3 α,5 α-THP levels, effects which can be reversed by 3 α,5 α-THP administration.

METHODS

  Experiment 1 investigated effects of acute systemic fluoxetine [20 mg/kg intraperitoneal (IP)] and/or 3 α,5 α-THP [500 µg, subcutaneous (SC)] administration on sexual responding of ovariectomized, hormone-primed rats. Experiment 2 examined effects of 3 α,5 α-THP administration to the midbrain VTA (100 ng) on fluoxetine-induced decrements in lordosis of ovariectomized, hormone-primed rats and hamsters.

MAIN OUTCOME MEASURES

Sexual responding was determined in rats and hamsters. For rats, the percentage of times that the lordosis response occurred following mounting by a sexually-vigorous male (lordosis quotients) was utilized. For hamsters, lateral displacement, the pelvic movement that females will make to facilitate intromissions by a male hamster, was utilized.

RESULTS

Fluoxetine significantly reduced lordosis, and this was reversed SC 3 α,5 α-THP. Intra-VTA 3 α,5 α-THP attenuated fluoxetine's detrimental effects on lordosis quotients and lateral displacement of rats and hamsters, respectively.

CONCLUSIONS

Thus, fluoxetine's effects to disrupt female sexual responses may involve its effects on progestogens in the midbrain VTA.

The effect on serotonin and MDA levels in depressed patients with insomnia when far-infrared rays are applied to acupoints

Little is known about the effect of far-infrared rays (FIR) on serotonin and malondialdehyde levels in depressed patients with insomnia. The purpose of this study is to assess the effect of far-infrared rays on depressed people with insomnia. A randomized design was used to determine this effect. A total of 70 inpatients were recruited with the clinical diagnosis of depression with sleep disturbance. In the experimental group, FIR was applied to three chosen acupuncture points by a patch-like sticker for a period of 15 minutes twice a week. The three acupuncture points are Nei-Kuan (PC6), Shenmen (HT7) and Sanyinjiao (SP6). The total duration of experiment was four weeks. For both experimental and control groups, serum levels of serotonin (5HT) and malondialdehyde (MDA) were examined before and after the introduction of FIR. The experimental group revealed disparate changes over different dependent variables, in which serotonin increased but MDA decreased after the introduction of FIR. These observations indicate that the serotonin pathway is involved in the pathophysiological mechanism responsible for the damaging effects of MDA on depressed patients with insomnia.

Impact of drug tolerability on the selection of antidepressant treatment in patients with major depressive disorder

Despite significant progress in the development of antidepressant therapies, tolerability remains an important factor associated with the selection of appropriate antidepressant treatment. Side effects commonly reported by depressed patients taking antidepressants include weight gain, sexual dysfunction, and gastrointestinal effects.Tolerability issues associated with antidepressants can negatively impact treatment outcomes for patients with major depressive disorder. In addition, a drug's tolerability profile substantially influences a physician's choice of specific antidepressant therapy, Despite the availability of many antidepressants, empirical clinical evidence to guide physicians in making the best choice is limited and not always clear.Thus, it is key for clinicians to understand the short- and long-term outcomes and side effect profiles of the available antidepressants.

Exercise increases BDNF levels in the striatum and decreases depressive-like behavior in chronically stressed rats

Early life stress in humans can affect the development of neurons and neurotransmitter systems and predispose an individual to the subsequent development of depression. Similarly, in rats, maternal separation causes anxiety and depressive-like behavior and decreased corticosterone levels. Patients receiving pharmacological treatment for depression often experience negative side-effects or do not respond optimally and therefore the use of exercise as alternative antidepressant treatment is investigated. The aim of the study was to see whether rats subjected to both early life stress and chronic stress later in life show differences in depressive-like behavior, neurotrophin levels, stress hormone levels and antioxidant capacity of serum after chronic voluntary exercise as treatment. Rat pups were maternally separated and one group were allowed access to running wheels for 6 weeks while control rats were also handled and put in cages without running wheels. All rats were subjected to chronic restraint stress during adulthood. A forced swim test was done to test for depressive-like behavior. Neurotrophins were measured in the ventral hippocampus and striatum; baseline stress hormones were measured in blood plasma as well as the anti-oxidative potential of serum. Compared to controls, rats that exercised had no difference in baseline stress hormones, but had decreased immobility times in the forced swim test, increased brain derived neurotrophic factor (BDNF) levels in the striatum and decreased anti-oxidative potential of their serum. The mechanism by which depressive-like behavior was improved may have been mediated through increased striatal BDNF levels, resulting in increased neuroplasticity and the prevention of neuronal death.

Factors that impact choice of antidepressant treatment in medically complex patients

In medically complex patients with multiple comorbid illnesses who require concomitant medications, selecting the optimal antidepressant (ie, low risk of adverse effects and/or pharmacokinetic interactions) for an individual patient is critical for positive long-term patient outcomes. The serotonin-norepinephrine reuptake inhibitors (SNRls) are increasingly being used as first-line treatment for major depressive disorder (MDD) and may prove beneficial for treatment of medically complex patients.Thus, it is key for clinicians to evaluate the differences in the pharmacokinetic and tolerability profiles of the SNRI class of antidepressants, evaluating differences both within the class and compared with other antidepressants used to treat MDD.

Problems associated with long-term treatment with selective serotonin reuptake inhibitors

Although the selective serotonin reuptake inhibitors (SSRIs), which are now widely used as a first-line treatment for depression and many other psychiatric conditions, are generally well tolerated, they are not devoid of side effects. Most short-term treatment-related side effects of SSRIs are transient and disappear after a few days or weeks. However, following long-term treatment with the SSRIs, some serious adverse events may occur. Some of them can be difficult to recognise because they can resemble residual symptoms of depression. The most serious can be life threatening. They all have a negative influence on the patient's quality of life and are frequently a prime reason for a lack of long-term compliance with the associated increased risk of recurrence of a depressive episode. This article is an overview of the more common adverse events, which are seen with non-acute treatment with the SSRIs.

Neurological and cardiovascular adverse events associated with antimanic treatment in children and adolescents

To identify the factors associated with incident neurological and cardiovascular adverse events in children and adolescents treated with antimanic agents, a retrospective, longitudinal study was conducted. Medicaid medical and pharmacy claims between January 1996 and December 2005 were used to identify 3657 children and adolescents prescribed antimanic medications, and a random sample of 4500 children not treated with psychotropic medications. All adverse events examined (sedation/drowsiness, headaches, involuntary movements/extrapyramidal symptoms (EPS), cardiovascular events, hypertension, and orthostatic hypotension) were more prevalent in the antimanic-treated cohort. The odds of developing incident sedation/drowsiness and headaches were significantly higher for those prescribed carbamazepine, and co-prescribed selective serotonin reuptake inhibitors or antipsychotics. The odds of incident involuntary movements/EPS were significantly higher for those co-prescribed antimanic and antipsychotic agents, and those with comorbid central nervous system (CNS), organic brain disorders/mental retardation, or epilepsy. Incident cardiovascular events, hypertension, and orthostatic hypotension odds were significantly higher for those co-prescribed antimanic agents and antipsychotics, or those with comorbid epilepsy or metabolic conditions. Co-prescription of antimanic and antipsychotic agents is more likely associated with neurological and cardiovascular adverse reactions, especially in young patients with preexisting CNS/neurological disorders.

Neuroendocrine-related adverse events associated with antidepressant treatment in children and adolescents

There is only limited community-based practice safety information available regarding antidepressant use in pediatric patients. This study identifies the factors associated with incident neuroendocrine-related metabolic, digestive, and sexual/reproductive adverse events in children and adolescents treated with antidepressants. A retrospective cohort design evaluating Medicaid medical and pharmacy claims between January, 1996 and December, 2005 was employed for 11970 children and adolescents prescribed an antidepressant medication, and a random sample of 4500 children not treated with psychotropic medications. Incident obesity/weight gain, Type 2 diabetes mellitus, and dyslipidemia were more likely for those prescribed selective serotonin reuptake inhibitors (SSRIs) (OR = 1.49; 1.37; 1.44), whereas Type 2 diabetes mellitus and dyslipidemia were more likely for those prescribed weight-inducing antidepressants (ORs = 1.26; 1.24), and those with pre-existing endocrinopathies (ORs = 3.96; 1.90), controlling for the effects of co-prescribed mood stabilizers or antipsychotics. Incident nausea/vomiting was less likely for those taking SSRIs (OR = 0.78). Females and children under 12 years of age were more likely to develop these adverse effects. Practitioners need to carefully consider the neuroendocrine- related adverse effects of SSRI antidepressant agents in particular, especially in individuals with comorbid endocrine conditions, and those co-prescribed other classes of psychotropic medications.

Hyperprolactinemia-related adverse events associated with antipsychotic treatment in children and adolescents

PURPOSE

To characterize factors related to the development of hyperprolactinemia and the ensuing reproductive/sexual adverse events in children and adolescents treated with antipsychotic and other psychotropic agents, and the additional risk posed for those with comorbid obesity, metabolic, or endocrine disorders.

METHODS

A retrospective cohort design evaluating medical and pharmacy claims from South Carolina's Medicaid program was used to compare incidence rates for sexual/reproductive adverse events in 4140 children and adolescents who were newly prescribed one of six atypical or two conventional antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications, January 1998 to December 2005. Logistic and Cox Proportional Hazards regression and Kaplan-Meier survival analysis were performed.

RESULTS

The treated cohort was not significantly more likely to evince hyperprolactinemia-related disorders than the control sample, but females and adolescents 13 and older were. Incident reproductive/sexual conditions were more likely for females (odds ratio [OR] = 9.52; confidence interval [CI] = 7.63-11.90), adolescents (OR = 3.91; CI = 3.25-4.70), those also taking selective serotonin reuptake inhibitors (SSRIs) (OR = 2.04; CI = 1.56-2.37) or valproic acid derivatives (OR = 1.29; CI = 1.03-1.64), and those with comorbid obesity/weight gain (OR = 1.92; CI = 1.56-2.37), metabolic (OR = 1.41; CI = 1.12-1.78), or endocrine disorders (OR = 2.76; CI = 1.98-3.84).

CONCLUSION

In this treated cohort, female adolescents exposed to SSRIs or valproic acid derivatives and those with comorbid obesity, metabolic, or endocrine disorders while taking antipsychotics were at higher risk of developing hyperprolactinemia and ensuing sexual/reproductive adverse events.

Prevalence of dry eye disease among US men: estimates from the Physicians' Health Studies

OBJECTIVE

To estimate the prevalence and risk factors for dry eye disease (DED) among US men.

METHODS

Cross-sectional prevalence survey among male participants 50 years and older in the Physicians' Health Studies I (N = 18,596) and II (N = 6848). We defined DED as the presence of clinically diagnosed dry eye or severe symptoms (both dryness and irritation constantly or often). We calculated the age-standardized prevalence of DED adjusted to the age distribution of US men in 2004 and projected estimates forward to 2030. We compared DED prevalence with a similar cohort of women and examined associations with possible risk factors.

RESULTS

The prevalence of DED increased with age, from 3.90% among men aged 50 to 54 years to 7.67% among men 80 years and older (P for trend <.001). High blood pressure (odds ratio, 1.28; 95% confidence interval, 1.12-1.45) and benign prostatic hyperplasia (odds ratio, 1.26; 95% confidence interval, 1.09-1.44) were associated with a higher risk of DED. Use of antidepressants, antihypertensives, and medications to treat benign prostatic hyperplasia were also associated with increased risk of DED. The age-standardized prevalence of DED was 4.34%, or 1.68 million men 50 years and older, and is expected to affect more than 2.79 million US men by 2030.

CONCLUSIONS

Dry eye disease is prevalent and increases with age, hypertension, benign prostatic hyperplasia, and antidepressant use.

Antidepressant-induced jitteriness/anxiety syndrome: systematic review

BACKGROUND

Early worsening of anxiety, agitation and irritability are thought to be common among people commencing antidepressants, especially for anxiety disorders. This phenomenon, which may be termed jitteriness/anxiety syndrome, is cited as an explanation for early treatment failure and caution in using selective serotonin reuptake inhibitors (SSRIs). However, we believe that it is inconsistently defined and that robust evidence to support the phenomenon is lacking.

AIMS

To review systematically all evidence relating to jitteriness/anxiety syndrome to identify: constituent symptoms; medications implicated; disorders in which it was reported; incidence; time course; management strategies; relationship of this syndrome to therapeutic response; distinction between syndrome and akathisia; relationship between syndrome and suicide; and genetic predispositions.

METHOD

A systematic search identified articles and these were included in the review if they addressed one of the above aspects of jitteriness/anxiety syndrome.

RESULTS

Of 245 articles identified, 107 articles were included for review. No validated rating scales for jitteriness/anxiety syndrome were identified. There was no robust evidence that the incidence differed between SSRIs and tricyclic antidepressants, or that there was a higher incidence in anxiety disorders. Published incidence rates varied widely from 4 to 65% of people commencing antidepressant treatment. Common treatment strategies for this syndrome included a slower titration of antidepressant and the addition of benzodiazepines. Conclusive evidence for the efficacy of these strategies is lacking. There was conflicting and inconclusive evidence as to whether the emergence of this syndrome had a predictive value on the response to treatment. It appears to be a separate syndrome from akathisia, but evidence for this assertion was limited. The effect of jitteriness/anxiety syndrome on suicide rates has not been evaluated. Three studies examined genetic variations and side-effects from treatment, but none was specifically designed to assess jitteriness/anxiety syndrome.

CONCLUSIONS

Jitteriness/anxiety syndrome remains poorly characterised. Despite this, clinicians' perception of this syndrome influences prescribing and it is cited to support postulated mechanisms of drug action. We recommend systematised evaluation of side-effects at earlier time points in antidepressant trials to further elucidate this clinically important syndrome.

Sexual dysfunction, depression, and the impact of antidepressants

Sexual dysfunction is a common symptom of depression. Although decreased libido is most often reported, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse effect of treatment with most antidepressants and is one of the predominant reasons for premature drug discontinuation. Selective serotonin reuptake inhibitors are the most widely prescribed antidepressants and have significant effects on arousal and orgasm compared with antidepressants that target norepinephrine, dopamine, and melatonin systems. The availability of an antidepressant that does not cause or exacerbate sexual dysfunction represents an advance in pharmacotherapy for mood disorders and should reduce treatment noncompliance and decrease the need for switching antidepressants or adding antidotes. The purpose of this review was to provide an update on the prevalence, psychobiology, and relative adverse effect burden of sexual dysfunction associated with different antidepressants.

Perceptions of efficacy, safety, and tolerability: impact on evaluating new treatments

Efficacy, safety, and tolerability are primary parameters for evaluation of any pharmacologic treatment. However, in order to evaluate the effectiveness of a new treatment in everyday clinical practice, these parameters must be assessed in the context of a number of societal, patient, and methodological variables.

Cardiovascular and neurological adverse events associated with antidepressant treatment in children and adolescents

A retrospective cohort design of Medicaid medical and pharmacy claims for 1996 through 2005 was employed for 14,171 children and adolescents prescribed an antidepressant medication and a random sample of 4500 children not treated with any class of psychotropic medication to compare the prevalence rates of cardiovascular and neurological adverse events. The treated cohort evinced a higher prevalence of cardiovascular events, orthostatic hypotension, seizures, insomnia, and headaches. In the treated cohort, patients were at a significantly higher risk for incident cardiovascular events when exposed to selective serotonin reuptake inhibitors and weight-inducing antidepressants, mood stabilizers, and antipsychotics. Incident orthostatic hypotension was associated with weight-inducing antidepressants and mood stabilizers. Incident seizures and extrapyramidal symptoms were unrelated to antidepressant or co-prescribed psychotropic medications, but both were significantly associated with comorbid central nervous system, organic brain/mental retardation, or preexisting cardiovascular or cerebrovascular conditions. Headaches and dizziness were significantly related to taking mood stabilizers.

Toward achieving optimal response: understanding and managing antidepressant side effects

The safety and tolerability of antidepressants have improved considerably over the past two decades. Nevertheless, antidepressant side effects are still common and problematic. The majority of patients treated with contemporaty agents experience one or more bothersome side effects. These side effects often create barriers to achieving depressive remission, as well as to preventing relapse and recurrence. Clinicians tend to underestimate the prevalence of side effects, and as many as one quarter of patients discontinue their antidepressants because of difficult-to-tolerate side effects; others may continue on antidepressant therapy but experience diminished quality of life related to troublesome side effects. This article reviews the prevalence of side effects, the impact of side effects on treatment adherence, and methodological issues including the challenge of distinguishing side effects from residual depressive symptoms, discontinuation effects, and general medical problems. In addition, we address the most common side effects such as sexual dysfunction, gastrointestinal problems, sleep disturbance, apathy and fatigue, and offer strategies for management that may help patients achieve optimal response to pharmacotherapy

Primary care physicians' evaluation and treatment of depression: Results of an experimental study using video vignettes

Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

Review: Bupropion and SSRI-induced side effects

Selective serotonin reuptake inhibitors (SSRIs) are a first line treatment option for millions of patients, due to the positive balance between efficacy and tolerability. However, some side effects associated with their use, can impair quality of life and compliance with treatment. This paper reviews the prevalence of sexual dysfunction, weight gain and emotional detachment during SSRI treatment, the profile of bupropion for each of these events and the ability of bupropion to reverse them. Double-blind trials, open-label trials and anecdotical reports derived from Medline were included. First, there is robust evidence that SSRIs can induce sexual side effects and that bupropion causes less sexual dysfunction than SSRIs. There is limited, mainly open-label evidence that bupropion can reverse SSRI-induced sexual side effects. Second, there is good evidence that long-term treatment with some SSRIs can result in weight gain and that long-term treatment with bupropion can result in a small weight loss. There is only anecdotical evidence that bupropion can reverse SSRI-induced weight gain. Third, treatment with SSRIs has been associated with ;emotional detachment', although controversy exists about this concept. No data are available on the profile of bupropion for ;emotional detachment' or for the reversal of SSRI-induced ;emotional detachment' by bupropion-addition.

Sexual difficulties and help-seeking among mature adults in Australia: results from the Global Study of Sexual Attitudes and Behaviours

Background: The Global Study of Sexual Attitudes and Behaviours was a survey of 27 500 men and women in 29 countries. Here we report the sexual activity, the prevalence of sexual difficulties and related help-seeking behaviour among participants in Australia. Methods: A telephone survey was conducted in Australia in 2001–2002, with interviews based on a standardised questionnaire. A total of 1500 individuals (750 men and 750 women) aged 40 to 80 years completed the survey. The questionnaire covered demographic information, overall health, and sexual behaviours, attitudes and beliefs. Results: Overall, 83% of men and 74% of women had engaged in sexual intercourse during the 12 months preceding the interview, and 38% of all men and 29% of all women engaged in sexual intercourse more than once a week. Early ejaculation (23%), erectile difficulties (21%) and a lack of sexual interest (18%) were the most common male sexual difficulties. The most frequently reported female sexual difficulties were: lack of sexual interest (33%), lubrication difficulties (26%) and an inability to reach orgasm (25%). Older age was a significant predictor of male erectile difficulties and of lubrication difficulties in women. Only a minority of men and women had sought help for their sexual difficulty(ies) from a health professional. Conclusions: Many middle-aged and older adults in Australia report continued sexual interest and sexual activity. Several sexual difficulties are highly prevalent in this population, but those experiencing these difficulties rarely seek medical help. This may be because they do not perceive such difficulties as serious or sufficiently upsetting.

Selective serotonin reuptake inhibitor discontinuation: side effects and other factors that influence medication adherence

OBJECTIVE

Patients with major depression discontinue taking their antidepressants for many reasons. Although side effects are often cited as the reason for discontinuation, few prospective studies have addressed this question, and none has specifically examined discontinuation in patients with severe depression.

METHOD

Inpatients and outpatients treated with a selective serotonin reuptake inhibitor for major depressive disorder were identified after admission. Three months later, patients were contacted and interviewed to determine antidepressant usage and the side effects experienced, including when these were experienced and their severity.

RESULTS

Between October 2001 and April 2003, 406 English- or Spanish-speaking patients aged 18 to 75 years were followed up. One in 4 patients discontinued the index antidepressant. Among specific side effects noted, only "change in weight" and "anxiety" were significant predictors of discontinuation after controlling for confounders. Experiencing 1 or more "extremely" bothersome side effects was associated with more than a doubling of the risk of discontinuation, but the presence of side effects and side effects less severe than "extremely" bothersome were not significant predictors. There were no differences among selective serotonin reuptake inhibitor antidepressants in either the presence/absence of side effects or in the discontinuation rates.

CONCLUSION

The results suggest that the contribution of side effects to antidepressant discontinuation is more complex than previously suggested. Disparate findings from earlier studies may reflect aspects of study design, such as examining populations whose severity of depression varied widely or not controlling for important confounding factors. Future research should separately examine high-risk groups (or control for severity of depression) and carefully rule out other potential contributors to discontinuation.

Evaluation of patients' experiences with antidepressants reported by means of a medicine reporting system

OBJECTIVE

To assess experiences related to antidepressant use reported to an internet-based medicine reporting system and to compare the nature of the side effects reported by patients with those reported by health care professionals (HCPs).

METHODS

All reports submitted from May 2004 to May 2005 to an internet-based medicine reporting system in The Netherlands related to the use of antidepressants were analysed. Spontaneous reports of adverse drug reactions on antidepressants from HCPs received by The Netherlands Pharmacovigilance Centre Lareb from May 2004 to May 2005 were included for comparison.

RESULTS

Of the 2232 individuals who submitted a report to the internet-based medicine reporting system, 258 submitted a report on antidepressants. Of these, 92 individuals (36%) reported on effectiveness, 40 (16%) of whom reported on ineffectiveness, and 217 (84%) submitted a report on side effects, with 202 (78%) reporting a total of 630 side effects that were experienced as negative. Fourteen individuals (5%) reported a practical issue and four (2%) reported a reimbursement issue. Of all 630 side effects reported, 48% resulted in the patient discontinuing the antidepressant therapy; of these 29% did not inform their HCP. Of all the side effects reported, 52% were perceived as "very negative". In comparison to the side effects reported by HCPs, patients more often reported apathy, excessive sweating, ineffectiveness, somnolence, insomnia, sexual problems and weight increase.

CONCLUSION

Patients report the ineffectiveness and side effects of antidepressant therapy as negative and leading to discontinuation of the therapy. Patients and HCPs differ in the nature of the reported side effects. Patient experiences should be included in the evaluation of antidepressant treatment in clinical practice.

Involuntary emotional expression disorder: treating the untreated

Patients with involuntary emotional expression disorder (IEED) have impaired social and occupational functioning and there is currently no Food an Drug Administration-approved treatment. Treatment options include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), dopaminergic agents, and a combination of dextromethorphan and quinidine. Studies of monaminergic agents have typically been small and executed in single-center settings. Assessment measures generally show significant symptomatic improvements, including a reduction in the number of laughing or crying episodes and improvements in patients' clinical condition. The tolerability profiles of these agents are well defined, and include dizziness, tachycardia and QTc prolongation (TCAs), and sleep and sexual disturbances (SSRIs). The combination of dextromethorphan and quinidine has also been assessed in two large multicenter studies in patients with amyotrophic lateral sclerosis and multiple sclerosis. Compared with placebo and either agent alone, there were significant improvements in symptoms, quality of life, and relationships. The most common side effects were dizziness and nausea, and potential drug interactions with quinidine should also be considered. Choice of treatment should be evidence-based, taking into account both efficacy and tolerability.

Treatment-associated suicidal ideation and adverse effects in an open, multicenter trial of fluoxetine for major depressive episodes

BACKGROUND

Some reports suggest that a subset of depressed patients may experience suicidality - that is increase or emergence of suicidal ideation (SI) or behavior--after initiation of an antidepressant. The time course and clinical correlates of this phenomenon have not been characterized in detail.

METHOD

We conducted a secondary analysis of a multicenter, prospective, open, 12-week trial of fluoxetine 20 mg in outpatients with nonpsychotic major depressive episodes. Adverse effects and other clinical features associated with the emergence of suicidality, defined using item 3 of the Hamilton Depression Rating Scale, were examined using Cox regression models.

RESULTS

Among 414 subjects without SI at baseline, 59 (14.3%) reported SI on at least 1 postbaseline visit. In a Cox regression, emergence of activation and worsening of depression severity were independently associated with emergence of SI, along with female gender, younger age and having thoughts that life was not worth living prior to treatment. Treatment response and remission were significantly less likely among subjects who developed SI.

CONCLUSIONS

New SI was relatively common in this trial of fluoxetine and associated with the emergence of activation and overall symptomatic worsening. Whether prophylaxis against or aggressive treatment of adverse events can decrease emergence of SI merits further study.

Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: an integrated analysis of two double-blind, randomised controlled trials

BACKGROUND

No drugs are approved for treatment of premature ejaculation. Our aim was to determine the efficacy and tolerability of on-demand dapoxetine in patients with severe premature ejaculation.

METHODS

We determined the efficacy of dapoxetine in a prospectively predefined integrated analysis of two 12-week randomised, double-blind, placebo-controlled, phase III trials of identical design done independently, in parallel, at 121 sites in the USA. Men with moderate-to-severe premature ejaculation in stable, heterosexual relationships took placebo (n=870), 30 mg dapoxetine (874), or 60 mg dapoxetine (870) on-demand (as needed, 1-3 h before anticipated sexual activity). The primary endpoint was intravaginal ejaculatory latency time (IELT) measured by stopwatch. Safety and tolerability were assessed. All analyses were done on an intention-to-treat basis. The trials are registered at ClinicalTrials.gov, numbers NCT00211107 and NCT00211094.

FINDINGS

672, 676, and 610 patients completed in the placebo, 30 mg dapoxetine, and 60 mg dapoxetine groups, respectively. Dapoxetine significantly prolonged IELT (p<0.0001, all doses vs placebo). Mean IELT at baseline was 0.90 (SD 0.47) minute, 0.92 (0.50) minute, and 0.91 (0.48) minute, and at study endpoint (week 12 or final visit) was 1.75 (2.21) minutes for placebo, 2.78 (3.48) minutes for 30 mg dapoxetine, and 3.32 (3.68) minutes for 60 mg dapoxetine. Both dapoxetine doses were effective on the first dose. Common adverse events (30 mg and 60 mg dapoxetine, respectively) were nausea (8.7%, 20.1%), diarrhoea (3.9%, 6.8%), headache (5.9%, 6.8%), and dizziness (3.0%, 6.2%).

INTERPRETATION

On-demand dapoxetine is an effective and generally well tolerated treatment for men with moderate-to-severe premature ejaculation.

Open-label sildenafil treatment of partial and non-responders to double-blind treatment in men with antidepressant-associated sexual dysfunction

Fifty partial and non-responders (Clinical Global Impression-Sexual Function (CGI-SF) score>2), out of 76 men who completed a 6-week, double-blind, placebo-controlled trial of sildenafil treatment for serotonergic antidepressant-associated sexual dysfunction, were eligible for an additional 6-week trial of open-label sildenafil (50 mg adjustable to 100 mg) under the same protocol, with blind maintained to initial assignment. Participation (double-blind and open-label) required major depressive disorder in remission (MDD-R) and continuing antidepressant medication. Forty-three entered open-label study: 16/17 initially randomized to sildenafil (sildenafil/sildenafil) and 27/33 initially randomized to placebo (placebo/sildenafil). Thirty-five of 43 (81%) achieved full response (CGI-SF<or=2): placebo/sildenafil 23/27 (85%); sildenafil/sildenafil 12/16 (75%); P<0.0001 for changes and P=0.4 between groups. Secondary measures of erectile function and overall satisfaction improved in both groups (P<0.03). Hamilton Depression Rating Scale scores improved (placebo/sildenafil; P<or=0.05) or remained stable (sildenafil/sildenafil). In men with MDD-R who maintained antidepressant adherence, 81% of double-blind partial and non-responders treated with open-label sildenafil responded fully.

Adverse drug reactions of antidepressants and antipsychotics: experience, knowledge and attitudes among Norwegian psychiatrists

Efficient prevention of adverse drug reactions (ADRs) requires knowledge about their severity and pharmacological mechanisms and is dependent on reliable data on their frequencies and possible risk factors. The study was conducted to investigate the prescribers' experience and understanding of the ADRs of psychotropic drugs, and their attitude towards reporting these. In a questionnaire, physicians treating adult psychiatric patients were asked which ADRs that they regarded bothersome for some of the most widely used antidepressants and antipsychotics. Questions about the relationship between blockade of drug receptors and ADRs, and about the physicians' personal experience of and attitudes towards reporting of ADRs were also included. In total, 70 of 91 questionnaires (78%) were returned. The mean number of ADRs regarded bothersome ranged from 2.4 to 9.3 for the various drugs/drug classes. Qualified psychiatrists stated a significantly higher number of bothersome ADRs than did the residents. The percentage of physicians associating blockade of a receptor with a specific ADR varied from 76% (histamine receptor blockade and sedation) to 37% (alpha(1)-adrenergic blockade and tachycardia). Thirty-nine per cent of the physicians had never reported an ADR to the Norwegian Medicines Agency. The number of ADRs considered bothersome was relatively high. The pattern of these ADRs generally mirrored the typical ADR profiles of the drugs. The knowledge of the underlying mechanisms of ADRs was more or less incomplete. The reporting rate of ADRs to the national regulatory authorities was low.

Paroxetine-associated spontaneous sexual stimulation

The sexual side-effects of selective serotonin reuptake inhibitors have been widely accepted and clinicians should only prescribe these agents for the treatment of premature ejaculation in the real clinical practice. We recently experienced three cases of paroxetine-associated sexual stimulation in the outpatient clinic. Because there is little information in the existing literature on this issue, we report three female cases who developed frequent spontaneous orgasm and increased libido during paroxetine treatment.