Time course of depression-symptom improvement during treatment with duloxetine

Duloxetine for Postoperative Pain Control Following Knee or Hip Replacement: A Systematic Review and Meta-Analysis

Background

Duloxetine is a Food and Drug Administration-approved selective norepinephrine reuptake inhibitor for treating depression, anxiety, fibromyalgia, and neuropathic and chronic musculoskeletal pain. This meta-analysis aims to evaluate the efficacy of duloxetine in reducing pain and postoperative opioid use following lower extremity total joint arthroplasty.

Methods

A literature search was performed, identifying randomized controlled trials investigating duloxetine for pain management after total hip and total knee arthroplasty. Data from the visual analog scale (VAS) for pain during movement and at rest were extracted for postoperative days (PODs) 1, 3, 7, and 14, as well as postoperative week 6 and postoperative month 3. Opioid use data were obtained at 24, 48 and 72 hours. All data were analyzed using inverse variance with random effects and presented as weighted mean difference.

Results

Eight unique studies were identified and included, 7 of which were analyzed quantitatively. Duloxetine decreased postoperative opioid consumption at 48 and 72 hours. For VAS for pain at rest, significantly reduced pain was reported by duloxetine-treated patients at POD 3, POD 7, and postoperative week 6. For VAS for pain at movement, significantly reduced pain was reported by duloxetine-treated patients at POD1, POD 3, POD 7, POD 14, postoperative week 6, and postoperative month 3.

Conclusions

Duloxetine appears to decrease postoperative pain and opioid consumption following total joint arthroplasty. However, definitive conclusions are limited by small sample size and study heterogeneity. While there is a need for follow-up studies to determine the optimal dose, duration, and patient population, strong preliminary data provide robust support for future large-scale efficacy studies.

Factors related to the length of stay for major depressive disorder patients in China: A real-world retrospective study

Background

As numerous patients with depression have to be hospitalized because of various reasons, the demand far exceeds the limited bed count in the psychiatry department. Controlling the length of stay (LOS) of the patient is gradually being considered an effective method to alleviate this problem. Given the lack of statistical evidence of the LOS of patients with major depressive disorder (MDD) in China and the strain on the limited psychiatric resources, the purpose of our study was to investigate the LOS of patients with MDD among in-patient samples and to analyze related factors of the LOS in China by building a regression model.

Method

The data were exported from the electronic medical record system. A total of three categories of independent variables were enrolled in our study, namely, demographic, clinical, and biochemical. Univariate analysis and binominal regression analysis were applied comprehensively to find the factors related to the LOS among MDD samples. The discrimination accuracy of the model was evaluated by the receiver operating characteristic (ROC) analysis. ROC analysis indicated that the discrimination accuracy of our model was acceptable (AUC = 0.790, 95% CI = 0.714–0.865, P < 0.001).

Result

A total of 254 patients were finally brought into analysis after filtering. Regression analysis indicated that abnormal LDL was the only risk factor of long LOS (OR = 3.352, 95% CI = 1.087–10.337, P = 0.035) among all the kinds of variables. Notably, in the statistically irrelevant factors of the LOS, the category of anti-depressant drugs [serotonin–norepinephrine reuptake inhibitor (SNRI) or selective serotonin reuptake inhibitor (SSRI)] prescribed to patients with MDD was not associated statistically with the LOS, which was against our initial hypothesis that the LOS of patients with MDD treated with SNRI would vary from that of the patients treated with SSRI.

Conclusion

Up to our knowledge, our research is the first study to show the potential factors related to the LOS from various domains, especially biochemical indexes, and the effect of drugs, among clinical patients with MDD in China. Our results could provide a theoretical reference for efficient psychiatry hospitalization management and prioritization of allocating medical resources. Future studies are required for updating independent variables which are potentially related to the LOS and verifying existing results in a larger sample.

A Look at Commonly Utilized Serotonin Noradrenaline Reuptake Inhibitors (SNRIs) in Chronic Pain

Purpose of Review

Chronic pain continues to be one of the leading healthcare cost burdens in the United States and is typically defined as ongoing pain, lasting longer than six months. Various treatment options exist for chronic pain, including physical therapy, medical management, pain psychology, and interventional therapies. Pain medications have been the mainstay of treatment for chronic pain conditions with an increasing use of membrane stabilizers and antidepressants to treat neuropathic pain conditions. Specifically, serotonin noradrenaline reuptake inhibitors (SNRIs) have been used to treat a range of pain conditions expanding from everyday use for depressive disorders.

Recent Findings

SNRIs, including duloxetine, venlafaxine, and milnacipran, have demonstrated efficacy in reducing pain in musculoskeletal pain (chronic low back pain and osteoarthritis), fibromyalgia, and neuropathic pain conditions (peripheral diabetic neuropathy).

Summary

The article describes the function, role, and use of SNRIs to treat chronic and neuropathic pain by altering the noradrenergic descending inhibitory pathways.

Modeling brain, symptom, and behavior in the winds of change

Neuropsychopharmacology addresses pressing questions in the study of three intertwined complex systems: the brain, human behavior, and symptoms of illness. The field seeks to understand the perturbations that impinge upon those systems, either driving greater health or illness. In the pursuit of this aim, investigators often perform analyses that make certain assumptions about the nature of the systems that are being perturbed. Those assumptions can be encoded in powerful computational models that serve to bridge the wide gulf between a descriptive analysis and a formal theory of a system's response. Here we review a set of three such models along a continuum of complexity, moving from a local treatment to a network treatment: one commonly applied form of the general linear model, impulse response models, and network control models. For each, we describe the model's basic form, review its use in the field, and provide a frank assessment of its relative strengths and weaknesses. The discussion naturally motivates future efforts to interlink data analysis, computational modeling, and formal theory. Our goal is to inspire practitioners to consider the assumptions implicit in their analytical approach, align those assumptions to the complexity of the systems under study, and take advantage of exciting recent advances in modeling the relations between perturbations and system function.

Item-based analysis of the effects of duloxetine in depression: a patient-level post hoc study

Oft-cited trial-level meta-analyses casting doubt on the usefulness of antidepressants have been based on re-analyses of to what extent the active drug has outperformed placebo in reducing the sum score of the Hamilton Depression Rating Scale (HDRS-17-sum) in clinical trials. Recent studies, however, suggest patient-level analyses of individual HDRS items to be more informative when assessing the efficacy of an antidepressant. To shed further light on both symptom-reducing and symptom-aggravating effects of a serotonin and noradrenaline reuptake inhibitor, duloxetine, when used for major depression in adults, we hence applied this approach to re-analyse data from 13 placebo-controlled trials. In addition, using patient-level data from 28 placebo-controlled trials of selective serotonin reuptake inhibitors (SSRIs), the response profile of duloxetine was compared to that of these drugs. Duloxetine induced a robust reduction in depressed mood that was not dependent on baseline severity and not caused by side-effects breaking the blind. A beneficial effect on depressed mood was at hand already after one week; when outcome was assessed using HDRS-17-sum as effect parameter, this early response was however masked by a concomitant deterioration with respect to adverse event-related items. No support for a suicide-provoking effect of duloxetine was obtained. The response profile of duloxetine was strikingly similar to that of the SSRIs. We conclude that the use of HDRS-17-sum as effect parameter underestimates the true efficacy and masks an early effect of duloxetine on core symptoms of depression. No support for major differences between duloxetine and SSRIs in clinical profile were obtained.

Influence of painful physical symptoms in the treatment of Japanese patients with melancholic major depressive disorder: A prospective cohort study

The aim of this study was to clarify how painful physical symptoms affect treatment outcomes in patients with melancholic major depressive disorder. The subjects comprised 100 consecutive Japanese outpatients with melancholic major depressive disorder who visited our clinic from October 2011 to October 2014. All subjects were interviewed for Diagnostic and Statistical Manual of Mental Disorders Axis 2, 3, and 4 and family history of major depressive disorder, and then grouped according to the presence of painful physical symptoms. We evaluated painful physical symptoms at baseline and after 12, 24, and 36 weeks of treatment and scores on the 17-item Hamilton Rating Scale for Depression, compared major depressive disorder remission between groups, and assessed responsiveness to antidepressants. The group with painful physical symptoms had a significantly more positive family history of major depressive disorder. The major depressive disorder remission rate was high in both groups, and no significant differences were observed. However, a significant relationship between major depressive disorder and painful physical symptoms remission was observed in the group with painful physical symptoms. A significantly higher number of remitted patients with painful physical symptoms (N=61) were administered serotonin-noradrenaline reuptake inhibitors, with significantly more receiving duloxetine than milnacipran.

Neuronal and immunological basis of action of antidepressants in chronic pain - clinical and experimental studies

The current knowledge of the pharmacological actions of the tricyclic antidepressants (TCAs) has slowly evolved through their over 40-year history. Chronic pain represents one of the most important public health problems, and antidepressants are an essential part of the therapeutic strategy in addition to classical analgesics. This article reviews the available evidence on the efficacy and safety of antidepressants in chronic pain conditions; namely, headaches, low back pain, fibromyalgia, cancer pain and especially neuropathic pain. TCAs are traditionally the main type of depression medication used to treat chronic pain. Recently, new antidepressants were introduced into clinical use, with a significant reduction in side effects and equivalent efficacy on mood disorders. These new drugs that are effective for chronic pain belong to the tetracyclic antidepressants (TeCAs) group (amoxapine, maprotiline), the serotonin and noradrenaline reuptake inhibitors (SNRIs) group (duloxetine, venlafaxine, milnacipran) and the atypical antidepressants group (bupropion, trazodone, mirtazapine, nefazodone). In this review, we present the available publications on TCAs (amitriptyline, doxepin, imipramine, desipramine, nortriptyline), TeCAs (amoxapine, maprotiline), selective serotonin reuptake inhibitors (SSRIs) (citalopram, fluoxetine, paroxetine), SNRIs (duloxetine, venlafaxine, milnacipran) and atypical antidepressants (bupropion) for the treatment of neuropathic pain. We also review analgesics acting as both opioid receptor agonists and also acting as aminergic reuptake inhibitors. Existing data are insufficient to conclude which of these new classes of antidepressants has the best clinical profile and will be the most effective in the treatment of neuropathic pain; in addition, a lower incidence of side effects should be considered. Increased experimental and translational research is a key for further improvement of the treatment of chronic pain with antidepressants. However, evidence from basic science is needed to improve our understanding of the mechanisms of action and their possible pharmacodynamic interactions.

Usefulness of the combined application of the Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale in screening for bipolar disorder

OBJECTIVE

This study aimed to examine whether combined application of the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) is more effective than exclusive application of either tool in screening for bipolar disorder (BD).

METHOD

The MDQ and BSDS were completed by a total of 113 patients diagnosed with BD and major depressive disorder who were experiencing a current major depressive episode. The initial diagnosis of the subject was confirmed during a 1-year follow-up period. When each MDQ and BSDS optimal cutoff score was calculated, a modified scoring method for the MDQ that considered only one item was used to increase its performance in this population. The following three combinations of the cutoff scores for the two tools were used to screen for BD: (A) The score on either the MDQ or BSDS was greater than or equal to the cutoff score; (B) the scores on both the MDQ and BSDS were greater than or equal to the cutoff score; and (C) Reducing either cutoff score by 1 point resulted in the MDQ and BSDS scores being greater than or equal to the cutoff score. The sensitivity, specificity, positive predictive value, and negative predictive value of the three methods, the MDQ, and the BSDS were compared for screening BD.

RESULTS

The sensitivity and specificity of the MDQ were 0.741 and 0.844, respectively, and those for the BSDS were 0.731 and 0.742, respectively. These indicators for the combined application of the MDQ and BSDS were as follows, respectively: method A 0.901 and 0.688, method B 0.580 and 0.875, and method C 0.691 and 0.844. Method A was superior to using one measure alone as well as to methods B and C with regard to sensitivity and negative predictive values. Method A also showed a higher sensitivity for BD subtypes than did the individual tools. Compared with the use of individual instruments, method A showed a similar positive predictive value.

CONCLUSION

This study suggests that combined use of the MDQ and BSDS is more effective than the individual use of either of these measures in screening for BD. The data also showed that when both tools were used, the most effective interpretation of the results in terms of screening for BD was achieved when positive scores were defined as those that were equal to or greater than the cutoff for the MDQ or BSDS.

Early vs. conventional switching of antidepressants in patients with MDD and moderate to severe pain: a double-blind randomized study

BACKGROUND

Concomitant painful physical symptoms in depressive patients frequently impair functioning and failure to treat these symptoms may adversely impact treatment outcomes of depression. Early vs. conventional switch of antidepressants were compared in patients with major depressive disorder (MDD) and moderate to severe pain.

METHOD

Pre-specified subgroup analysis of a 16-week, randomized, double-blind clinical study on MDD patients with >30 mm overall pain visual analog scale (VAS). Patients not achieving 30% reduction Hamilton Depression Rating Scale (HAM-D) after 4 weeks escitalopram (10 mg/day) were randomized to duloxetine 60-120 mg/day (early switch) or continued on escitalopram (conventional switch) with non-responders at week 8 switching to duloxetine. Endpoints were time to confirmed response and remission, VAS pain severity, and Sheehan disability scale (SDS). Switch strategies were compared using Kaplan-Meier, logistic regression, and repeated measures analyses.

RESULTS

No differences between early and conventional switching were found in time to confirmed response after randomization (3.9 vs. 4.1 weeks, p=0.511) or remission (6.0 vs. 8.0 weeks, p=0.238). Significantly lower VAS mean pain levels at for overall pain, headache, back pain, shoulder pain, interference with daily activities, and time being awake in pain were found for patients in the early switching group. Time to achieving normal functioning (SDS total score <6) was shorter in the early switching group (p=0.042). Safety results were comparable between switch strategies.

CONCLUSIONS

In MDD patients with moderate to severe painful physical symptoms not improving after 4 weeks of treatment with escitalopram, an earlier switch to duloxetine may lead to better pain and functional outcomes.

Duloxetine in the acute and continuation treatment of major depressive disorder

Duloxetine is a serotonin-noradrenaline reuptake inhibitor with indications for use in the short term, continuation and maintenance treatment of major depression. Although clinicians currently have access to a range of medications for the treatment of depression, a significant number of patients fail to respond or remit from their illness despite adequate trials of treatment with multiple agents. A developing concept is that antidepressant strategies that combine multiple mechanisms of action may have advantages over agents with single mechanisms (i.e., selective serotonin reuptake inhibitors). As a dual-acting agent, duloxetine offers the promise of advantages in terms of efficacy over selective serotonin reuptake inhibitors while retaining a favorable safety and tolerability profile in comparison to older agents. Likewise, duloxetine is of interest in the treatment of certain conditions commonly seen in conjunction with major depression, particularly anxiety and pain, both of which may respond more favorably to agents that act on both serotonin and noradrenaline neurotransmitter systems.

Attributes of response in depressed patients switched to treatment with duloxetine

BACKGROUND

This study was designed to assess clinical and functional outcomes associated with switching to duloxetine treatment in patients with major depressive disorder (MDD) experiencing emotional and painful physical symptoms in their current episode.

METHODS

In this 8-week, multinational, multicentre, single-arm, open-label clinical trial, 242 MDD patients were switched to duloxetine 60 mg/day after selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI) treatment. The primary analysis compared mean change from baseline in Brief Pain Inventory-Modified Short Form (BPI-SF) interference score between initial responders [≥ 50% reduction from baseline on the 17-item Hamilton Depression Rating Scale (HAMD(17)) Maier subscale] and initial non-responders after 4 weeks. Initial responders continued with duloxetine 60 mg/day. Initial non-responders received duloxetine 120 mg/day for the remaining 4 weeks. Depression, pain, anxiety and functional outcomes were also compared after 8 weeks.

RESULTS

BPI-SF interference decreased from baseline in initial responders (n = 108) and initial non-responders (n = 85) after 4 weeks of duloxetine treatment, with greater reductions in initial responders [BPI-SF mean difference in reduction: 1.01 (95% CI 0.42-1.61); p < 0.001]. Reductions in pain interference favouring initial responders were also apparent after 8 weeks [0.68 (95% CI: 0.03-1.33); p = 0.042]. Depression, pain, anxiety and function improved over 8 weeks across patient groups.

CONCLUSIONS

Elements of core mood and pain are important residual symptoms following poor treatment response in MDD. Early improvement in these symptoms after switching to duloxetine indicated an increased chance of functional recovery.

Effects of duloxetine treatment on brain response to painful stimulation in major depressive disorder

Major depressive disorder (MDD) is characterized by a constellation of affective, cognitive, and somatic symptoms associated with functional abnormalities in relevant brain systems. Painful stimuli are primarily stressful and can trigger consistent responses in brain regions highly overlapping with the regions altered in MDD patients. Duloxetine has proven to be effective in treating both core emotional symptoms and somatic complaints in depression. This study aimed to assess the effects of duloxetine treatment on brain response to painful stimulation in MDD patients. A total of 13 patients and a reference group of 20 healthy subjects were assessed on three occasions (baseline, treatment week 1, and week 8) with functional magnetic resonance imaging (fMRI) during local application of painful heat stimulation. Treatment with duloxetine was associated with a significant reduction in brain responses to painful stimulation in MDD patients in regions generally showing abnormally enhanced activation at baseline. Clinical improvement was associated with pain-related activation reductions in the pregenual anterior cingulate cortex, right prefrontal cortex, and pons. Pontine changes were specifically related to clinical remission. Increased baseline activations in the right prefrontal cortex and reduced deactivations in the subgenual anterior cingulate cortex predicted treatment responders at week 8. This is the first fMRI study addressed to assess the effect of duloxetine in MDD. As a novel approach, the application of painful stimulation as a basic neural stressor proved to be effective in mapping brain response changes associated with antidepressant treatment and brain correlates of symptom improvement in regions of special relevance to MDD pathophysiology.

Clinical outcome and tolerability of duloxetine in the treatment of major depressive disorder: a 12-week study with plasma levels

Duloxetine (DLX) is a dual serotonin and norepinephrine reuptake inhibitor that has been recently approved for the treatment of major depressive disorder (MDD). However, little is known about the relationship between DLX plasma levels and clinical response. The aims of this open-label study were 1) to assess clinical outcome and tolerability of DLX by means of clinician and patient assessments and 2) to evaluate the value of plasma DLX levels as predictors of clinical response and tolerability. This was a naturalistic, open-label study of 45 outpatients affected with MDD (16 men and 29 women), who received DLX at doses of 30-120 mg/day and were evaluated at baseline (T0) and after 2, 4 and 12 weeks (T1-3). The assessments included the Hamilton Rating Scales for Depression (HRSD) and Anxiety (HRSA), Clinical Global Impression-Severity (CGI-S), Beck's Depression Inventory (BDI) and a mood visual analogue scale (VAS). Compared with T0, there were significant improvements in HRSD at T1, T2 and T3 (P < 0.001), in HRSA, CGI-S and the self-administered BDI at T2 and T3 (P < 0.001), and in the VAS scores shown at T3 (P = 0.01). DLX treatment was safe and well tolerated. Plasma DLX levels at T2 ranged from 5 to 135 ng/mL (mean +/- SD = 53.56 +/- 39.45) and correlated almost significantly with the DLX dose (r = 0.35; P = 0.069). There was a significant curvilinear quadratic relationship between the improvement of HRSA scores and plasma DLX levels (R(2) = 0.27; P = 0.02). The incidence of anxiety or irritability was associated with the highest plasma levels. Our findings suggest that monitoring plasma DLX levels may be helpful in predicting better treatment responses and tolerability. The present data seem to suggest an optimal anxiolytic efficacy of DLX at intermediate plasma levels.

Use of duloxetine in patients with an anxiety disorder, or with comorbid anxiety and major depressive disorder: a review of the literature

IMPORTANCE OF THE FIELD

Except for generalized anxiety disorder, few reports have been published on the efficacy, safety and tolerability of duloxetine in patients with anxiety disorders individually or in comorbidity with major depressive disorder (MDD).

AREAS COVERED IN THIS REVIEW

The literature search in Medline (dating back to 1966) and Embase (dating back to 1988) databases was conducted using the OVID interface on 9 April 2009, restricted to any article or abstract in English, per title, reporting any information on the use of duloxetine in patients with any anxiety disorder with or without concomitant MDD. A systematic review approach was taken.

WHAT THE READER WILL GAIN

The reader will gain knowledge of the current data available on the use of duloxetine to treat patients with anxiety disorders individually or in comorbidity with MDD.

TAKE HOME MESSAGE

Duloxetine could be considered an effective treatment option in the treatment of anxiety disorders individually or in comorbidity with each other, or with MDD; however, apart from the well-demonstrated efficacy, tolerability and safety of duloxetine in the treatment of MDD with or without anxiety and GAD, data on this subject are preliminary and very limited, and more research is warranted.

Efficacy and tolerability of duloxetine in the treatment of patients with borderline personality disorder: a pilot study

Guidelines of the American Psychiatric Association for borderline personality disorder (BPD) indicate selective serotonin reuptake inhibitors and the serotonin and noradrenaline reuptake inhibitor (SNRI) venlafaxine for treating affective dysregulation and impulsive behavioural dyscontrol symptoms. The SNRI duloxetine has been studied in patients with major depression, generalized anxiety disorder and fibromyalgia, showing particular efficacy on somatic complaints. This study investigates duloxetine in the treatment of patients with BPD. Eighteen outpatients with a DSM-IV-TR diagnosis of BPD were treated with open-label duloxetine, 60 mg/day, for 12 weeks. Patients were assessed at baseline, week 4 and 12 with the CGI Severity item, the BPRS, the HAM-D, the HAM-A, the SOFAS, the BPD Severity Index (BPDSI) and the HSCL-90-Somatization Subscale (HSCL-90 SOM). Adverse effects were evaluated using the Dosage Record Treatment Emergent Symptom Scale. Statistics were performed with the analysis of variance. Significant P values were <or=0.05. Fourteen patients completed the study. Four patients (22.2%) discontinued treatment in the first 4 weeks because of non-compliance. A significant change was found for: BPRS, HAM-D, SOFAS, BPDSI total score and items 'impulsivity', 'outbursts of anger' and 'affective instability' and HSCL-90 SOM. Adverse effects were mild headache and nausea. Initial results suggest that duloxetine is an effective and well-tolerated treatment for BPD, with positive effects on somatic symptoms.

The relationship between antidepressant and analgesic responses: findings from six placebo-controlled trials assessing the efficacy of duloxetine in patients with major depressive disorder

OBJECTIVE

Debate continues regarding whether onset of analgesia is faster than antidepressant effect in antidepressants with both properties. Duloxetine hydrochloride (from here on referred to as duloxetine) is effective in both major depressive disorder and diabetic peripheral neuropathic pain. This post-hoc analysis of six placebo-controlled duloxetine trials in patients with major depressive disorder was designed to compare onset of antidepressant activity to pain relief.

RESEARCH DESIGN AND METHODS

Duloxetine was administered at 40-120 mg/day versus placebo for up to 9 weeks in outpatient clinic settings. The primary depression measure was the HAMD(17) and pain severity was measured using visual analog scale (VAS) measuring overall pain, headache, back and shoulder pain, and pain while awake. The time course of improvement was profiled using repeated measures modeling and Kaplan-Meier product limit estimation.

RESULTS

In all but one case, significant reductions in HAMD(17) and VAS scores were seen within 2 weeks of treatment. Median time to VAS response was consistently shorter across all VAS measures than that to HAMD(17) response in both placebo- and duloxetine-treated patients with at least modest levels of pain at study entry. Regression analyses consistently demonstrated little association between analgesic and antidepressant responses. Limitations of these findings include that the studies used in these analyses did not require the patients to enroll with any specific level of pain. Moreover, the type of pain exhibiting at presentation was not routinely identified; therefore, the impact of different pain types on these findings is unknown.

CONCLUSIONS

Duloxetine's analgesic effect is independent of the drug's antidepressant effect. Additionally, faster onset of the analgesic effect appears to be a population-specific phenomenon that is unmodified in the presence of active agents.

Rapid onset of antidepressant action: a new paradigm in the research and treatment of major depressive disorder

OBJECTIVE

Current therapeutics of depression are similar in their time to antidepressant action and often take weeks to months to achieve response and remission, which commonly results in considerable morbidity and disruption in personal, professional, family, and social life, as well as risk for suicidal behavior. Thus, treatment strategies presenting a rapid improvement of depressive symptoms--within hours or even a few days--and whose effects are sustained would have an enormous impact on public health. This article reviews the published data related to different aspects of rapid improvement of depressive symptoms.

DATA SOURCES

Literature for this review was obtained through a search of the MEDLINE database (1966-2007) using the following keywords and phrases: rapid response, antidepressant, time to, glutamate, sleep, therapeutics, latency, and depression. The data obtained were organized according to the following topics: clinical relevance and time course of antidepressant action, interventions showing evidence of rapid response and its potential neurobiological basis, and new technologies for better understanding rapid anti-depressant actions.

DATA SYNTHESIS

A limited number of prospective studies evaluating rapid antidepressant actions have been conducted. Currently, only a few interventions have been shown to produce antidepressant response in hours or a few days. The neurobiological basis of these rapid antidepressant actions is only now being deciphered.

CONCLUSIONS

Certain experimental treatments can produce antidepressant response in a much shorter period of time than existing medications. Understanding the molecular basis of these experimental interventions is likely to lead to the development of improved therapeutics rather than simply furthering our knowledge of current standard antidepressants.

Time to response for duloxetine 60 mg once daily versus placebo in elderly patients with major depressive disorder

BACKGROUND

Rapid response to antidepressant therapy is desirable and may be particularly critical in elderly patients with major depressive disorder (MDD).

METHODS

Findings are based on post-hoc analyses from a double-blind trial of elderly patients with MDD > or = 65 years, randomly assigned 2:1 to duloxetine 60 mg QD (N = 207) or placebo (N = 104) for 8 weeks. Depression and pain measures included the Geriatric Depression Scale (GDS), 17-item Hamilton Depression Scale (HAMD17), CGI-Severity, and Visual Analog Scale (VAS) for overall pain. The time to response and remission for duloxetine compared with placebo was evaluated using Cox proportional hazards (PH) modeling, Kaplan-Meier estimation, and categorical repeated measures analysis.

RESULTS

Significant improvements of estimated HAMD17 response and remission rates for duloxetine started at week 2 (P = 0.022 and P = 0.033, respectively). Time to HAMD17 response and remission were significantly shorter for duloxetine versus placebo (P 0.10 for all PH treatment-by-age interactions). The placebo-referenced duloxetine HR for time to 50% reduction in overall pain was 1.75 (P = 0.024) for patients with moderate to severe pain.

CONCLUSION

Duloxetine demonstrated a faster time to antidepressant response and improvement in self-reported pain as compared with placebo. CLINICAL TRIAL REGISTRY NUMBER FOR THIS STUDY: NCT00062673, at www.clinicaltrials.gov.

Stability of somatoform symptoms--implications for classification

OBJECTIVE

To investigate the stability of somatoform symptoms/disorders.

METHODS

A literature search was done to select studies reporting data on stability of medically unexplained physical symptoms.

RESULTS

Whereas individual symptoms vary over time, grouping symptoms into syndromes seems to create stable features. There are substantial problems with the use of lifetime diagnosis, favoring classification approaches that require only present state symptoms. Further, doctors' ratings that symptoms are "medically unexplained" is highly problematic and reduces interrater reliability. Misdiagnoses and overlooking of organic conditions are in the same range as for other psychiatric (and many organic) disorders; therefore, this does not seem to reduce the stability of the diagnoses of somatoform disorders.

CONCLUSIONS

These results indicate how the classification of somatoform disorders can be improved. Some new diagnostic criteria are suggested that could be considered in the revision of Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V).

Evidence for the efficacy of duloxetine in treating mild, moderate, and severe depression

Clinicians need to know whether duloxetine is effective in patients across a broad range of depressive symptoms and depression severity. Data were pooled from nine randomized, double-blind, placebo-controlled studies in major depressive disorder (total N=2227) comparing duloxetine (40-120 mg/day) with placebo for 8-9 weeks. Patients were retrospectively stratified by baseline score on the HAMD17 into mild (< or =19; n=682), moderate (n=1099), or severe (> or =25; n=446) groups. Duloxetine produced significantly greater baseline-to-endpoint mean change than placebo in HAMD17 total score, Maier and retardation subscales, and the Clinical Global Impressions-Severity of Illness scale in all three cohorts. Significant improvement was seen in HAMD17 items 1 (depressed mood), 3 (suicide), 7 (work and activities), and 10 (psychic anxiety) regardless of severity. The HAMD17 anxiety subscale and items 13 (somatic symptoms-general) and 15 (hypochondriasis) showed significant improvement only in moderately and severely ill patients. Significant improvement in the HAMD17 Maier subscale was seen in all groups by week 1. In all three groups, placebo was significantly superior to duloxetine at early visits on HAMD17 item 12 (somatic symptoms-GI). Mildly and severely ill patients exhibited significant reduction in visual analog scale overall pain severity at the study endpoint. The studies contained fewer patients with very mild or very severe illness, limiting our ability to draw conclusions in these patient populations. Duloxetine demonstrated superior efficacy in the treatment of major depressive disorder, when compared with placebo, regardless of the baseline severity of depressive symptoms, although effect sizes were largest in the most severely depressed patients.

Duloxetine: a review of its use in the treatment of major depressive disorder

Duloxetine (Cymbalta) is an orally administered, selective serotonin and noradrenaline reuptake inhibitor (SNRI) that has been approved for the treatment of major depressive disorder (MDD). Based on a considerable body of evidence, duloxetine at dosages ranging from 40 to 120 mg/day was effective in the short- and long-term treatment of MDD. Significant improvements versus placebo in core emotional symptoms as well as painful physical symptoms associated with depression, were seen in most, but not all, appropriately designed studies; results of meta-analyses suggested that improvements in these efficacy measures were apparent after 1-2 weeks' treatment with the highest recommended dosage of 60 mg once daily. Short-term (< or =15 weeks) administration of duloxetine at fixed or flexible dosages between 60 and 120 mg/day was noninferior to paroxetine 20 mg once daily, noninferior or inferior to escitalopram 10-20mg once daily, and had a similar global benefit-risk (GBR) profile to that of venlafaxine extended-release (XR) 150-225 mg/day in the treatment of MDD. Longer-term (6-8 months) treatment with duloxetine was similar in efficacy to paroxetine and escitalopram. Duloxetine is generally well tolerated, although it may be appropriate to avoid initiating treatment with the 60 mg/day dosage, as this has been associated with a higher discontinuation rate due to adverse events in some (but not all) comparative studies with escitalopram and venlafaxine XR. Definitive comparisons are awaited, although duloxetine seemingly provides a useful alternative to SSRIs and other SNRIs for the treatment of MDD. It also appears to be an attractive option for MDD patients presenting with painful physical symptoms.

Patterns of depressive symptom response in duloxetine-treated outpatients with mild, moderate or more severe depression

AIMS

This was a post hoc analysis to determine whether baseline severity of depression influenced the efficacy of duloxetine in treating major depressive disorder (MDD) and to better characterise the symptom response profile for duloxetine in patients with mild, moderate or more severe depression.

METHODS

Data were pooled from four double-blind, placebo-controlled studies in which outpatients with MDD were randomised to duloxetine (60 mg/day) or placebo for 8-9 weeks. Patients were retrospectively stratified according to baseline 17-item Hamilton Depression Rating scale (HAMD17) total scores: mild=total score<or=19 (duloxetine, n=246; placebo, n=184); moderate=20-24 (duloxetine, n=333; placebo, n=217); severe=25+ (duloxetine, n=127; placebo, n=87).

RESULTS

Duloxetine produced significantly greater baseline-to-end-point improvement vs. placebo (p<0.05) on the HAMD17 total score, Maier and retardation subscales, HAMD17 items 1 (depressed mood), 7 (work and activities) and 10 (psychic anxiety) in all three patient cohorts. The largest effect sizes were observed in assessments of core emotional depressive symptoms. A significant improvement for duloxetine vs. placebo was not observed for sleep-related symptoms at end-point or genital symptoms at any time point during acute treatment. With respect to the time course of depressive symptom improvement, the data show that regardless of baseline severity, the most rapid and consistent improvement for duloxetine compared with placebo was observed in the core symptoms of MDD (measured by the Maier subscale).

CONCLUSION

Regardless of baseline MDD severity, duloxetine at one dose (60 mg/day) produced a significant improvement compared with placebo on the core emotional symptoms of MDD.

Are somatoform disorders 'mental disorders'? A contribution to the current debate

PURPOSE OF REVIEW

During the last 2 years, a debate has started over whether the somatoform symptoms/medically unexplained symptoms are wrongly placed under the category of mental disorders (section F in International classification of diseases-10 and in Diagnostic and statistical manual for mental disorders-IV).

RECENT FINDINGS

Most experts on medically unexplained symptoms agree that there is a substantial need for revision of the diagnoses of somatoform disorders. While some authors suggest moving the somatoform disorders from axis I to axis III, others suggest improving the classification of these syndromes on axis I, such as by using empirically derived criteria and by introducing psychological descriptors which justify the categorization as a mental disorder. In contrast to the situation when the last version of Diagnostic and statistical manual for mental disorders was published, new empirical data has shown some psychological and behavioural characteristics of patients with somatoform symptoms. These and other empirically founded approaches can be landmarks for the revision of this section in Diagnostic and statistical manual for mental disorders-V and International classification of diseases-11.

SUMMARY

The classification of somatoform disorders as 'mental disorders' could be justified if empirically founded psychological and behavioural characteristics are included into the classification process. Attention focusing, symptom catastrophizing, and symptom expectation are outlined as possible examples of involved psychological processes.

Duloxetine treatment of pediatric chronic pain and co-morbid major depressive disorder

In the United States, the novel compound duloxetine has been approved for the treatment of major depressive disorder (MDD) and diabetic peripheral neuropathic pain in the adult population. There are currently no published data on the use of duloxetine in children and adolescents. This report describes the successful treatment of 2 adolescent females with chronic pain and co-morbid MDD. Both patients required admission to a tertiary-care pediatric hospital due to the chronicity, severity, and treatment resistance of their pain syndromes. In both cases, duloxetine provided rapid improvement in the experience of pain, as well as mood symptoms, at minimum dosages. Pain symptom reduction and restoration of a euthymic state was maintained at 4- and 3-month follow-up visits, respectively, with minimal to no adverse effects being reported. These cases present preliminary evidence of promising uses for duloxetine in the pediatric population.

Sleep and psychiatric disorders: future directions

Understanding of the relationship between co-occurring sleep and psychiatric disorders has undergone a radical change. The longstanding perspective that sleep problems invariably are a symptom of a psychiatric disorder is giving way to understanding that complex bidirectional relationships may exist. This change has opened doors to new directions in research and led to changes in guidelines for clinical practice. This article discusses promising future directions for building on this foundation, including developing lines of research currently underway, studying mechanisms that underlie the relationships between sleep and psychiatric disorders; and developing treatment strategies that target these mechanisms to lead to better treatment of sleep disorders and psychiatric disorders.

Duloxetine in the management of depression

Duloxetine is a serotonin and noradrenalin reuptake inhibitor, and is hence in the same pharmacological class as venlafaxine. Randomized controlled trials have demonstrated it to be effective in the treatment of depression and also that it has analgesic properties in diabetic neuropathic pain, fibromyalgia and depressed patients with pain. To date, there is limited published data comparing duloxetine with other antidepressants. However, what data are available suggest that duloxetine is more effective than selective serotonin reuptake inhibitors in severely depressed patients (although the magnitude of this difference is uncertain) and equally effective as venlafaxine. While, theoretically, a serotonin and noradrenalin reuptake inhibitor may be more effective than a selective serotonin reuptake inhibitor in depressed patients with pain, there are no randomized, controlled trial data to support this hypothesis. Generally, duloxetine is well tolerated and there is no suggestion of the recent concerns of cardiotoxicity and toxicity in overdose that have been raised over venlafaxine. Duloxetine is an appropriate drug to consider for second-line treatment, after a selective serotonin reuptake inhibitor, for the management of depression.

Diagnostic and treatment interventions for hypochondriasis in the neurology setting

Many patients who present to neurology settings with somatic complaints have underlying fear of illness, anxiety, or depression. Hypochondriasis, which is one of the somatoform disorders, contributes to high use of services and frustration on the part of clinicians, because diagnostic and treatment interventions often fail. The challenges for clinicians include how to distinguish true somatic symptoms from those associated with fear or other psychiatric symptoms. Our goal is to provide the clinician with an integrated approach for the triage, assessment (history, screening tools, examination, and diagnostic tests), and treatment of these challenging patients. Recommendations are made regarding psychiatric consultation and comanagement between fields for complex patients.

Duloxetine 60 mg once daily in the treatment of milder major depressive disorder

There is ongoing debate regarding the effectiveness of antidepressants in patients with milder major depressive disorder (MDD). This post-hoc analysis evaluated the efficacy and tolerability of duloxetine in the subset of 159 (75 duloxetine and 84 placebo) patients with milder MDD (baseline HAMD17 total score > or = 15 and < or = 18) who were treated once daily with duloxetine 60 mg or placebo in two identical, 9-week, randomised, double-blind trials. At endpoint, change from baseline on HAMD17 was greater in the duloxetine group (-7.0) than in the placebo group (-4.1) (p = 0.005). Response and remission rates, and improvement on the Clinical Global Impressions-Severity (CGI-S) scale, the Patient Global Impressions-Improvement (PGI-I) scale, and measures of painful symptoms were also significantly better in the duloxetine group (p < 0.05). Tolerability was consistent with that seen in previous studies of duloxetine in patients with more severe depression. In conclusion, duloxetine 60 mg/day is effective and well tolerated in milder MDD.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.