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Ainsworth NJ, Marawi T, Maslej MM, Blumberger DM, McAndrews MP, Perivolaris A, Pollock BG, Rajji TK, Mulsant BH. Cognitive Outcomes After Antidepressant Pharmacotherapy for Late-Life Depression: A Systematic Review and Meta-Analysis. Am J Psychiatry 2024; 181:234-245. [PMID: 38321915 DOI: 10.1176/appi.ajp.20230392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE The authors evaluated whether treatment of late-life depression (LLD) with antidepressants leads to changes in cognitive function. METHODS A systematic review and meta-analysis of prospective studies of antidepressant pharmacotherapy for adults age 50 or older (or mean age of 65 or older) with LLD was conducted. MEDLINE, EMBASE, and PsycInfo were searched through December 31, 2022. The primary outcome was a change on cognitive test scores from baseline to after treatment. Secondary outcomes included the effects of specific medications and the associations between changes in depressive symptoms and cognitive test scores. Participants with bipolar disorder, psychotic depression, dementia, or neurological disease were excluded. Findings from all eligible studies were synthesized at a descriptive level, and a random-effects model was used to pool the results for meta-analysis. RESULTS Twenty-two studies were included. Thirteen of 19 studies showed an improvement on at least one cognitive test after antidepressant pharmacotherapy, with the most robust evidence for the memory and learning (nine of 16 studies) and processing speed (seven of 10 studies) domains and for sertraline (all five studies). Improvements in depressive symptoms were associated with improvement in cognitive test scores in six of seven relevant studies. The meta-analysis (eight studies; N=493) revealed a statistically significant overall improvement in memory and learning (five studies: effect size=0.254, 95% CI=0.103-0.404, SE=0.077); no statistically significant changes were seen in other cognitive domains. The evaluated risk of publication bias was low. CONCLUSION Antidepressant pharmacotherapy of LLD appears to improve certain domains of cognitive function, particularly memory and learning. This effect may be mediated by an improvement in depressive symptoms. Studies comparing individuals receiving pharmacotherapy with untreated control participants are needed.
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Affiliation(s)
- Nicholas J Ainsworth
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Tulip Marawi
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Marta M Maslej
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Daniel M Blumberger
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Mary Pat McAndrews
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Argyrios Perivolaris
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Bruce G Pollock
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Tarek K Rajji
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health (CAMH), Toronto (Ainsworth, Marawi, Maslej, Blumberger, Pollock, Rajji, Mulsant); Department of Psychiatry, Temerty Faculty of Medicine (Ainsworth, Blumberger, Pollock, Mulsant), Institute of Medical Science, Temerty Faculty of Medicine (Marawi, Perivolaris), and Department of Psychology (McAndrews), University of Toronto, Toronto; Krembil Brain Institute, University Health Network, Toronto (McAndrews); Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto (Perivolaris); Toronto Dementia Research Alliance, Toronto (Rajji)
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Kishi T, Sakuma K, Hatano M, Okumura T, Kato M, Baba H, Iwata N. Antidepressants available in Japan for older people with major depressive disorder: A systematic review and meta-analysis. Neuropsychopharmacol Rep 2024; 44:267-271. [PMID: 38318955 PMCID: PMC10932767 DOI: 10.1002/npr2.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 01/13/2024] [Accepted: 01/22/2024] [Indexed: 02/07/2024] Open
Abstract
AIM To update the major depressive disorder (MDD) treatment guidelines of the Japanese Society of Mood Disorders, we conducted a systematic review and pairwise meta-analysis of double-blind, randomized, placebo-controlled trials of available antidepressants in Japan for older adults with MDD. METHODS Outcome measures included response rate (primary), improvement in depressive symptom scale score, remission rate, all-cause discontinuation, discontinuation due to adverse events, and at least one adverse event. A random-effects model was used to calculate the risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (95% CI). RESULTS Nine double-blind, randomized, placebo-controlled trials (n = 2145) were identified. No study has been conducted in Japan. Our meta-analysis included the following antidepressants: duloxetine, escitalopram, imipramine, sertraline, venlafaxine, and vortioxetine. Antidepressants have significantly higher response rates than placebo (RR [95% CI] = 1.38 [1.04, 1.83], p = 0.02). Antidepressants outperformed placebo in terms of improving depressive symptom scale score (SMD [95% CI] = -0.62 [-0.92, -0.33], p < 0.0001). However, antidepressants were associated with a higher discontinuation rate due to adverse events (RR [95% CI] = 1.94 [1.30, 2.88], p = 0.001) and a higher incidence of at least one adverse event (RR [95% CI] = 1.11 [1.02, 1.21], p = 0.02) compared to placebo. The groups did not differ significantly in terms of remission rate or all-cause discontinuation. CONCLUSIONS Our meta-analysis concluded that treatment with antidepressants available in Japan is only weakly recommended for moderate to severe MDD in older adults.
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Affiliation(s)
- Taro Kishi
- Department of PsychiatryFujita Health University School of MedicineToyoakeAichiJapan
| | - Kenji Sakuma
- Department of PsychiatryFujita Health University School of MedicineToyoakeAichiJapan
| | - Masakazu Hatano
- Department of Pharmacotherapeutics and informaticsFujita Health University School of MedicineToyoakeAichiJapan
| | - Takenori Okumura
- Department of PsychiatryFujita Health University School of MedicineToyoakeAichiJapan
| | - Masaki Kato
- Department of NeuropsychiatryKansai Medical UniversityOsakaJapan
| | - Hajime Baba
- Department of PsychiatryJuntendo University Koshigaya HospitalSaitamaJapan
- Department of Psychiatry and Behavioral ScienceJuntendo University Graduate School of MedicineTokyoJapan
| | - Nakao Iwata
- Department of PsychiatryFujita Health University School of MedicineToyoakeAichiJapan
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3
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Zhao Q, Fu B, Lyu N, Xu X, Huang G, Tan Y, Xu X, Zhang X, Wang X, Wang Z, Li K, Hu Z, Li H, He H, Li S, Zhao J, He R, Guo H, Li Y, Li L, Yang C, Zou S, Wei B, Wang W, Chen C, Lu Z, He S, Wang Q, Zhao J, Pan X, Pan Z, Li J, Wang G. A multicenter, randomized, double-blind, duloxetine-controlled, non-inferiority trial of desvenlafaxine succinate extended-release in patients with major depressive disorder. J Affect Disord 2023; 329:72-80. [PMID: 36813043 DOI: 10.1016/j.jad.2023.02.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 02/09/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Desvenlafaxine and duloxetine are selective serotonin and norepinephrine reuptake inhibitors. Their efficacy has not been directly compared using statistical hypotheses. This study evaluated the non-inferiority of desvenlafaxine extended-release (XL) to duloxetine in patients with major depressive disorder (MDD). METHODS In this study, 420 adult patients with moderate-to-severe MDD were enrolled and randomly assigned (1:1) to receive 50 mg (once daily [QD]) of desvenlafaxine XL (n = 212) or 60 mg QD of duloxetine (n = 208). The primary endpoint was evaluated using a non-inferiority comparison based on the change from baseline to 8 weeks in the 17-item Hamilton Depression Rating Scale (HAMD17) total score. Secondary endpoints and safety were evaluated. RESULTS Least-squares mean change in HAM-D17 total score from baseline to 8 weeks was -15.3 (95% confidence interval [CI]: -17.73, -12.89) in the desvenlafaxine XL group and - 15.9 (95% CI, -18.44, -13.39) in the duloxetine group. The least-squares mean difference was 0.6 (95% CI: -0.48, 1.69), and the upper boundary of 95% CI was less than the non-inferiority margin (2.2). No significant between-treatment differences were found in most secondary efficacy endpoints. The incidence of the most common treatment-emergent adverse events (TEAEs) was lower for desvenlafaxine XL than for duloxetine for nausea (27.2% versus 48.8%) and dizziness (18.0% versus 28.8%). LIMITATIONS A short-term non-inferiority study without a placebo arm. CONCLUSIONS This study demonstrated that desvenlafaxine XL 50 mg QD was non-inferior to duloxetine 60 mg QD in efficacy in patients with MDD. Desvenlafaxine had a lower incidence of TEAEs than duloxetine did.
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Affiliation(s)
- Qian Zhao
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Bingbing Fu
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Nan Lyu
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
| | - Xiangdong Xu
- Department of Psychiatry, The Fourth People's Hospital of Urumqi, Urumqi, China
| | - Guangbiao Huang
- Department of Psychiatry, Huzhou Third Municipal Hospital, Huzhou, China
| | - Yunlong Tan
- Psychiatry Research Center, Beijing Huilongguan Hospital, Beijing, China
| | - Xiufeng Xu
- Department of Psychiatry, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xuehua Zhang
- Hunan Brain Hospital (Hunan Second Municipal Hospital), Changsha, China
| | - Xueyi Wang
- Department of Psychiatry, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiqiang Wang
- Department of Psychiatry, Wuxi Mental Health Center, Wuxi, China
| | - Keqing Li
- Department of Psychiatry, Mental Health Center of Hebei Province, Baoding, China
| | - ZhenYu Hu
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China
| | - Hengfen Li
- Department of Psychiatry, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbo He
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou Mental Health, Guangzhou, China
| | - Shuang Li
- Dalian Seventh People's Hospital, Dalian, China
| | - Jingyuan Zhao
- Department of Psychiatry, Henan Mental Hospital, The Second Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Ruifeng He
- The Mental Health Center of Xi'an, Xi'an, China
| | - Hua Guo
- Zhumadian Psychiatric Hospital, Zhumadian, China
| | - Yi Li
- Wuhan Mental Health Center, Wuhan, China
| | - Lehua Li
- Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Chuang Yang
- Department of Psychiatry, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shaohong Zou
- Department of Clinical Psychology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, China
| | - Bo Wei
- Department of Psychiatry, Jiangxi Mental Hospital, Affiliated Mental Hospital of Nanchang University, Nanchang, China
| | | | - Ce Chen
- Department of Psychiatry, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zheng Lu
- Department of Psychiatry, Tongji Hospital of Tongji University, Shanghai, China
| | - Shunqiang He
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Qian Wang
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Jinghua Zhao
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Xiaoyue Pan
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Zhenyu Pan
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Junqing Li
- Clincal sciences division, CSPC ZhongQi Pharmaceutical Technology (Shijiazhuang) Co., Ltd, Shijiazhuang, China
| | - Gang Wang
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China.
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Abstract
Late-life depression is common but underrecognized and undertreated leading to significant morbidity and mortality, including from suicide. The presence of comorbidities necessitates screening followed by a careful history in order to make the diagnosis of depression. Because older adults tend to take longer to respond to treatment and have higher relapse rates than younger patients, they benefit most from persistent, attentive therapy. Although both pharmacotherapy and psychosocial treatments, or a combination of the two, are considered as the first-line therapy for late-life depression, most data support a combined, biopsychosocial treatment approach provided by an interdisciplinary team.
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Affiliation(s)
- Elizabeth Gundersen
- University of Colorado School of Medicine, Mail Stop B178 Academic Office One, 12631 E. 17th Avenue, Aurora, CO 80045, USA.
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5
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Therapy Strategies for Late-life Depression: A Review. J Psychiatr Pract 2023; 29:15-30. [PMID: 36649548 DOI: 10.1097/pra.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Depression in the elderly requires different treatment options because therapies that are commonly used for depression in younger patients show different effects later in life. Treatment options for late-life depression (LLD) are summarized in this article. METHODS A literature search in Medline/PubMed performed in June 2020 identified 83 relevant studies. RESULTS Pharmacotherapy with selective serotonin reuptake inhibitors can be an effective first-line treatment in LLD, but >50% of elderly patients do not adequately respond. Switching to other selective serotonin reuptake inhibitors or augmenting with mood stabilizers or antipsychotics is often effective in achieving a therapeutic benefit. Severely depressed patients with a high risk of suicidal behavior can be treated with electroconvulsive therapy. Psychotherapy provides a measurable benefit alone and when combined with medication. LIMITATIONS LLD remains an underrepresented domain in research. Paucity of data concerning the effect of specific therapies for LLD, heterogeneity in the quality of study designs, overinterpretation of results from meta-analyses, and discrepancies between study results and guideline recommendations were often noted. CONCLUSIONS Treating LLD is complex, but there are several treatment options with good efficacy and tolerability. Some novel pharmaceuticals also show promise as potential antidepressants, but evidence for their efficacy and safety is still limited and based on only a few trials conducted to date.
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Nishi A, Sawada K, Uchida H, Mimura M, Takeuchi H. Antipsychotic Monotherapy for Major Depressive Disorder: A Systematic Review and Meta-Analysis. PHARMACOPSYCHIATRY 2023; 56:5-17. [PMID: 36257518 DOI: 10.1055/a-1934-9856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Although several randomized controlled trials (RCTs) have compared the effectiveness, efficacy, and safety of antipsychotic monotherapy (APM) versus placebo in patients with major depressive disorder (MDD), no meta-analysis has examined this topic. We conducted a systematic literature search using MEDLINE and Embase to identify relevant RCTs and performed a meta-analysis to compare the following outcomes between APM and placebo: response and remission rates, study discontinuation due to all causes, lack of efficacy, and adverse events, changes in total scores on depression severity scales, and individual adverse event rates. A total of 13 studies were identified, with 14 comparisons involving 3,197 participants that met the eligibility criteria. There were significant differences between APM and placebo in response and remission rates and changes in the primary depression severity scale in favor of APM, and study discontinuation due to adverse events and several individual adverse events in favor of placebo. No significant difference was observed in discontinuation due to all causes. APM could have antidepressant effects in the acute phase of MDD, although clinicians should be aware of an increased risk of some adverse events.
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Affiliation(s)
- Akira Nishi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kyosuke Sawada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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7
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Cardiovascular side effects of non-SSRI antidepressants are of concern in high-risk patients. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00927-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Baba H, Kito S, Nukariya K, Takeshima M, Fujise N, Iga J, Oshibuchi H, Kawano M, Kimura M, Mizukami K, Mimura M. Guidelines for diagnosis and treatment of depression in older adults: A report from the Japanese Society of mood disorders. Psychiatry Clin Neurosci 2022; 76:222-234. [PMID: 35274788 DOI: 10.1111/pcn.13349] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 11/30/2022]
Abstract
The Committee for Treatment Guidelines of Mood Disorders, Japanese Society of Mood Disorders, published a Japanese guideline for the treatment of late-life depression in 2020. Based on that guideline, the present guideline was developed and revised to incorporate the suggestions of global experts and the latest published evidence. In the diagnosis of late-life depression, it is important to carefully differentiate it from bipolar disorders, depressive states caused by physical and organic brain disease, drug effects, and dementia, and to determine the comorbidity between late-life depression and dementia. It is necessary to fully understand the clinical characteristics and psychosocial background of late-life depression, evaluate the patient's condition, and provide basic interventions based on these factors. Problem-solving therapy, reminiscence therapy/life review therapy, and behavioral activation therapy, and other forms of psychotherapy can reduce depressive symptoms. In terms of pharmacotherapy, newer antidepressants or non-tricyclic antidepressants are recommended for late-life depression, and it is recommended that the efficacy of least the minimal effective dosage should first be determined. Switching antidepressants and aripiprazole augmentation can be used to treatment-resistant therapy. Electroconvulsive therapy and repetitive transcranial magnetic stimulation have demonstrated usefulness for late-life depression. Exercise therapy, high-intensity light therapy, and diet therapy also show some effectiveness and are useful for late-life depression. Continuation therapy should be maintained for at least 1 year after remission.
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Affiliation(s)
- Hajime Baba
- Department of Psychiatry, Juntendo University Koshigaya Hospital, Saitama, Japan.,Department of Psychiatry & Behavioral Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shinsuke Kito
- Department of Psychiatry, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan.,Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan
| | - Kazutaka Nukariya
- Department of Psychiatry, Jikei University School of Medicine, Tokyo, Japan.,Department of Psychiatry, Jikei University School of Medicine, Kashiwa Hospital, Chiba, Japan
| | - Minoru Takeshima
- Department of Psychiatry, Meishin-kai Shibata Hospital, Toyama, Japan.,Department of Psychiatry, Tokyo Medical University, Tokyo, Japan
| | - Noboru Fujise
- Health Care Center, Kumamoto University, Kumamoto, Japan
| | - Junichi Iga
- Department of Neuropsychiatry, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hidehiro Oshibuchi
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan.,Department of Child Psychiatry, Kanagawa Children's Medical Center, Kanagawa, Japan
| | | | - Mahiko Kimura
- Department of Neuropsychiatry, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
| | - Katsuyoshi Mizukami
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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9
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Calvi A, Fischetti I, Verzicco I, Belvederi Murri M, Zanetidou S, Volpi R, Coghi P, Tedeschi S, Amore M, Cabassi A. Antidepressant Drugs Effects on Blood Pressure. Front Cardiovasc Med 2021; 8:704281. [PMID: 34414219 PMCID: PMC8370473 DOI: 10.3389/fcvm.2021.704281] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 06/28/2021] [Indexed: 11/16/2022] Open
Abstract
Individuals suffering from depressive disorders display a greater incidence of hypertension compared with the general population, despite reports of the association between depression and hypotension. This phenomenon may depend, at least in part, on the use of antidepressant drugs, which may influence blood pressure through different effects on adrenergic and serotoninergic pathways, as well as on histaminergic, dopaminergic, and cholinergic systems. This review summarizes extant literature on the effect of antidepressant drugs on blood pressure. Selective serotonin reuptake inhibitors are characterized by limited effects on autonomic system activity and a lower impact on blood pressure. Thus, they represent the safest class—particularly among elderly and cardiovascular patients. Serotonin–norepinephrine reuptake inhibitors, particularly venlafaxine, carry a greater risk of hypertension, possibly related to greater effects on the sympathetic nervous system. The norepinephrine reuptake inhibitor reboxetine is considered a safe option because of its neutral effects on blood pressure in long-term studies, even if both hypotensive and hypertensive effects are reported. The dopamine–norepinephrine reuptake inhibitor bupropion can lead to blood pressure increases, usually at high doses, but may also cause orthostatic hypotension, especially in patients with cardiovascular diseases. The norepinephrine–serotonin modulators, mirtazapine and mianserin, have minimal effects on blood pressure but may rarely lead to orthostatic hypotension and falls. These adverse effects are also observed with the serotonin-reuptake modulators, nefazodone and trazodone, but seldomly with vortioxetine and vilazodone. Agomelatine, the only melatonergic antidepressant drug, may also have limited effects on blood pressure. Tricyclic antidepressants have been associated with increases in blood pressure, as well as orthostatic hypotension, particularly imipramine. Oral monoamine–oxidase inhibitors, less frequently skin patch formulations, have been associated with orthostatic hypotension or, conversely, with hypertensive crisis due to ingestion of tyramine-containing food (i.e., cheese reaction). Lastly, a hypertensive crisis may complicate antidepressant treatment as a part of the serotonin syndrome, also including neuromuscular, cognitive, and autonomic dysfunctions. Clinicians treating depressive patients should carefully consider their blood pressure status and cardiovascular comorbidities because of the effects of antidepressant drugs on blood pressure profiles and potential interactions with antihypertensive treatments.
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Affiliation(s)
- Anna Calvi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Ilaria Fischetti
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Ignazio Verzicco
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Martino Belvederi Murri
- Department of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
| | - Stamatula Zanetidou
- Research Group on Mental and Physical Health of the Elderly (ARISMA), Bologna, Italy
| | - Riccardo Volpi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Pietro Coghi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Stefano Tedeschi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics, and Infant-Maternal Science, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Aderville Cabassi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
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10
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Meejuru GF, Somavarapu A, Danduga RCSR, Nissankara Roa LS, Kola PK. Protective effects of duloxetine against chronic immobilisation stress-induced anxiety, depression, cognitive impairment and neurodegeneration in mice. J Pharm Pharmacol 2021; 73:522-534. [PMID: 33793839 DOI: 10.1093/jpp/rgaa003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 10/05/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVES This study aimed to evaluate the effect of duloxetine (10 and 20 mg/kg) against chronic immobilisation stress (CIS)-induced anxiety, depression, cognitive impairment and neurodegeneration in mice. METHODS CIS, 2 h/10 days (11:00 AM-1:00 PM) was applied after 30 min of pretreatment with saline, duloxetine 10 mg/kg and 20 mg/kg to the respective groups of animals, except the control group. Animals were examined for physiological (body weight, locomotion and grip strength), psychological (memory impairment, anxiety and depression), neurochemical (GABA and glutamate), biochemical (MDA, catalase, glutathione, superoxide dismutase) and histopathological changes. KEY FINDINGS CIS exposure revealed anxiety-like behaviour, depression-like behaviour, motor in-coordination and learning and memory impairment in mice. Besides, CIS induction decreased the antioxidant enzymes (GSH, SOD and catalase), GABA and the viable neuronal cell count, whereas CIS exposure significantly elevated the MDA, AChE activity and glutamate content in the cortex and hippocampus. Pretreatment with duloxetine10 and 20 mg/kg showed dose-dependent ameliorated effect against the CIS-induced alterations in mice. CONCLUSION In conclusion, the results of this study demonstrated the protective effect of duloxetine against neuropsychiatric symptoms, memory impairment caused by CIS-induction through inhibition of oxidative stress, AChE activity and glutamate release.
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Affiliation(s)
- Glory Florence Meejuru
- Department of Pharmacology, University College of Pharmaceutical Sciences, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, Andhra Pradesh, India
| | - Anushri Somavarapu
- Department of Pharmacology, University College of Pharmaceutical Sciences, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, Andhra Pradesh, India
| | - Ravi Chandra Sekhara Reddy Danduga
- Department of Pharmacology, University College of Pharmaceutical Sciences, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, Andhra Pradesh, India
| | | | - Phani Kumar Kola
- Department of Pharmacology, University College of Pharmaceutical Sciences, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur, Andhra Pradesh, India
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11
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Hoertel N, Rotenberg L, Schuster JP, Blanco C, Lavaud P, Hanon C, Hozer F, Teruel E, Manetti A, Costemale-Lacoste JF, Seigneurie AS, Limosin F. Generalizability of pharmacologic and psychotherapy trial results for late-life unipolar depression. Aging Ment Health 2021; 25:367-377. [PMID: 31726850 DOI: 10.1080/13607863.2019.1691146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Despite evidence of low representativeness of clinical trial results for depression in adults, the generalizability of clinical trial results for late-life depression is unknown. This study sought to quantify the representativeness of pharmacologic and psychotherapy clinical trial results for late-life unipolar depression. METHOD Data were derived from the 2004-2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults from the United States population. To assess the generalizability of clinical trial results for late-life depression, we applied a standard set of eligibility criteria representative of pharmacologic and psychotherapy clinical trials to all individuals aged 65 years and older in NESARC with a DSM-IV diagnosis of MDE and no lifetime history of mania/hypomania (n = 273) and in a subsample of individuals seeking help for depression (n = 78). RESULTS More than four of ten respondents and about two of ten respondents would have been excluded by at least one exclusion criterion in a typical pharmacologic and psychotherapy efficacy trial, respectively. Similar results (i.e.41.1% and 25.9%, respectively) were found in the subsample of individuals seeking help for depression. Excess percentage of exclusion in typical pharmacologic studies was accounted for by the criterion "significant medical condition". We also found that populations typically included in pharmacologic and psychotherapy clinical trials for late-life unipolar depression may substantially differ. CONCLUSION Psychotherapy trial results may be representative of most patients with late-life unipolar depression in routine clinical practice. By contrast, pharmacologic clinical trials may not be readily generalizable to community samples.
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Affiliation(s)
- Nicolas Hoertel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France.,Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France.,Centre Psychiatrie et Neurosciences, Inserm Umr 894, Paris, France.,Université de Paris, Université Paris Descartes, Paris, France
| | - Léa Rotenberg
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Jean-Pierre Schuster
- Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Prilly, Switzerland
| | - Carlos Blanco
- Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, USA
| | - Pierre Lavaud
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Cécile Hanon
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Franz Hozer
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Elisabeth Teruel
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Aude Manetti
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | | | - Anne-Sophie Seigneurie
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France
| | - Frédéric Limosin
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Corentin-Celton, Service de Psychiatrie, Issy-les-Moulineaux, France.,Université Paris Descartes, PRES Sorbonne Paris Cité, Paris, France.,Centre Psychiatrie et Neurosciences, Inserm Umr 894, Paris, France.,Université de Paris, Université Paris Descartes, Paris, France
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12
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The Cardiovascular Effects of Newer Antidepressants in Older Adults and Those With or At High Risk for Cardiovascular Diseases. CNS Drugs 2020; 34:1133-1147. [PMID: 33064291 PMCID: PMC7666056 DOI: 10.1007/s40263-020-00763-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Depression is common in older adults and those with cardiovascular disease. Although selective serotonin reuptake inhibitors generally have been shown to be safe to treat depression in these patients, it is important to identify additional antidepressants when selective serotonin reuptake inhibitors are not effective. This qualitative narrative review summarizes what is known about the cardiovascular side effects of some of the newer antidepressants. Twelve novel non-selective serotonin reuptake inhibitor antidepressants were identified from the literature: venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran, mirtazapine, bupropion, vilazodone, vortioxetine, agomelatine, moclobemide, and ketamine-esketamine. A search restricted to publications written in English was conducted in PubMed and Google Scholar with the following search criteria: the specific antidepressant AND (QT OR QTc OR "heart rate" OR "heart rate variability" OR "hypertension" OR "orthostatic hypotension" OR "cardiovascular outcomes" OR "arrhythmia" OR "myocardial infarction" OR "cardiovascular mortality") AND (geriatric OR "older adults" OR "late life depression" OR "cardiovascular disease" OR "hospitalized" OR "hospitalized"). The recommended use, dosing ranges, cardiovascular effects, and general advantages and disadvantages of each of the drugs are discussed. Levomilnacipran and vilazodone have not received enough study to judge their safety in older patients or in those with, or at high risk for, cardiovascular disease. There is at least some evidence for possible adverse events with each of the other newer antidepressants that could be of concern in these patients. Nevertheless, with careful administration and attention to the potential adverse reactions for each drug, these may provide safe effective alternatives for older adults and patients with cardiovascular disease who do not respond to selective serotonin reuptake inhibitor antidepressants. However, more research on the safety and efficacy of these drugs in these specific patient populations is urgently needed.
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13
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Shin C, Ko YH, Shim SH, Kim JS, Na KS, Hahn SW, Lee SH. Efficacy of Buspirone Augmentation of Escitalopram in Patients with Major Depressive Disorder with and without Atypical Features: A Randomized, 8 Week, Multicenter, Open-Label Clinical Trial. Psychiatry Investig 2020; 17:796-803. [PMID: 32750760 PMCID: PMC7449841 DOI: 10.30773/pi.2020.0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/02/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE This study investigated the treatment response and cognitive enhancement effects of buspirone augmentation of escitalopram in patients with major depressive disorder (MDD), according to atypical feature subtypes of MDD. METHODS An 8 week, randomized, parallel-controlled, open-label study was conducted. The Columbia Atypical Depression Diagnostic Scale was administered to evaluate atypical features. Patients were assigned randomly to the buspirone augmentation or non-buspirone groups. Symptom severity and cognitive function were evaluated using the 17-item Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Beck Depression Inventory, Beck Anxiety Inventory, digit span test, word fluency test, and Trail Making Tests A and B. RESULTS A total of 89 patients were recruited. There were no significant differences in the measures between the groups; however, among the MDD patients without atypical features, the digit span and word fluency tests were improved by treatment. In the MDD patients without atypical features, the buspirone augmentation group showed a significant improvement on the digit span test compared to the non-buspirone group. CONCLUSION Buspirone augmentation did not demonstrate significant benefits in MDD patients; however, buspirone augmentation showed greater efficacy for the improvement of cognitive function in MDD patients without atypical features. Our study suggests that atypical features are an important factor for cognitive enhancement in buspirone augmentation treatment in patients with MDD.
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Affiliation(s)
- Cheolmin Shin
- Department of Psychiatry, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Young-Hoon Ko
- Department of Psychiatry, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Se-Hoon Shim
- Department of Psychiatry, Soonchunhyang University College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Ji Sun Kim
- Department of Psychiatry, Soonchunhyang University College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Kyoung-Sae Na
- Department of Psychiatry, Gachon University College of Medicine, Gil Medical Center, Incheon, Republic of Korea
| | - Sang-Woo Hahn
- Department of Psychiatry, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Seung-Hwan Lee
- Department of Psychiatry, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea.,Clinical Emotion and Cognition Research Laboratory, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
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14
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Gutsmiedl K, Krause M, Bighelli I, Schneider-Thoma J, Leucht S. How well do elderly patients with major depressive disorder respond to antidepressants: a systematic review and single-group meta-analysis. BMC Psychiatry 2020; 20:102. [PMID: 32131786 PMCID: PMC7057600 DOI: 10.1186/s12888-020-02514-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/24/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Depression is one of the leading causes of the global burden of disease, and it has particularly negative consequences for elderly patients. Antidepressants are the most frequently used treatment. We present the first single-group meta-analysis examining: 1) the response rates of elderly patients to antidepressants, and 2) the determinants of antidepressants response in this population. METHODS We searched multiple databases for randomized controlled trials on antidepressants in the elderly with major depressive disorder above 65 years (last search: December 2017). Response was defined as 50% improvement on validated rating scales. We extracted response rates from studies and imputed the missing ones with a validated method. Data were pooled in a single-group meta-analysis. Additionally, several potential moderators of response to antidepressants were examined by subgroup and meta-regression analyses. RESULTS We included 44 studies with a total of 6373 participants receiving antidepressants. On average, 50.7% of the patients reached a reduction of at least 50% on the Hamilton Depression Scale (HAMD). Subgroup and meta-regression analyses revealed a better response to treatment for patients in antidepressant-controlled trials compared to placebo-controlled trials. Mean age, study duration, percentage of woman, severity of illness at baseline, dose of antidepressants in fluoxetine equivalents, year of publication, setting (in- or out-patients), antidepressant groups (SSRI, TCA, SSNRI, α2-antagonist, SNRI, MAO-inhibitor), ITT (intention-to-treat) analysis vs completer analysis, sponsorship and overall risk of bias were not significant moderators of response. CONCLUSIONS Our findings suggest an improvement in symptoms can be found in about 50% of the elderly with major depressive disorder treated with antidepressants.
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Affiliation(s)
- Katharina Gutsmiedl
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Marc Krause
- grid.6936.a0000000123222966Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Irene Bighelli
- grid.6936.a0000000123222966Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johannes Schneider-Thoma
- grid.6936.a0000000123222966Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefan Leucht
- grid.6936.a0000000123222966Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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15
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Rodrigues-Amorim D, Olivares JM, Spuch C, Rivera-Baltanás T. A Systematic Review of Efficacy, Safety, and Tolerability of Duloxetine. Front Psychiatry 2020; 11:554899. [PMID: 33192668 PMCID: PMC7644852 DOI: 10.3389/fpsyt.2020.554899] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/24/2020] [Indexed: 11/17/2022] Open
Abstract
Duloxetine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of patients affected by major depressive disorder (MDD), generalized anxiety disorder (GAD), neuropathic pain (NP), fibromyalgia (FMS), and stress incontinence urinary (SUI). These conditions share parallel pathophysiological pathways, and duloxetine treatment might be an effective and safe alternative. Thus, a systematic review was conducted following the 2009 Preferred Reporting Items (PRISMA) recommendations and Joanna Briggs Institute Critical (JBI) Appraisals guidelines. Eighty-five studies focused on efficacy, safety, and tolerability of duloxetine were included in our systematic review. Studies were subdivided by clinical condition and evaluated individually. Thus, 32 studies of MDD, 11 studies of GAD, 19 studies of NP, 9 studies of FMS, and 14 studies of SUI demonstrated that the measured outcomes indicate the suitability of duloxetine in the treatment of these clinical conditions. This systematic review confirms that the dual mechanism of duloxetine benefits the treatment of comorbid clinical conditions, and supports the efficacy, safety, and tolerability of duloxetine in short- and long-term treatments.
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Affiliation(s)
- Daniela Rodrigues-Amorim
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - José Manuel Olivares
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain.,Head of Department of Psychiatry, Health Area of Vigo, Servizo Galego de Saúde (SERGAS), Vigo, Spain.,Director Neuroscience Area, Galicia Sur Health Research Institute (IISGS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - Carlos Spuch
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), University of Vigo, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
| | - Tania Rivera-Baltanás
- Translational Neuroscience Research Group, Galicia Sur Health Research Institute (IISGS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Vigo, Spain
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16
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Mallery L, MacLeod T, Allen M, McLean-Veysey P, Rodney-Cail N, Bezanson E, Steeves B, LeBlanc C, Moorhouse P. Systematic review and meta-analysis of second-generation antidepressants for the treatment of older adults with depression: questionable benefit and considerations for frailty. BMC Geriatr 2019; 19:306. [PMID: 31718566 PMCID: PMC6852920 DOI: 10.1186/s12877-019-1327-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/23/2019] [Indexed: 11/21/2022] Open
Abstract
Background Frail older adults are commonly prescribed antidepressants. Yet, there is little evidence to determine the efficacy and safety of antidepressants to treat depression with concomitant frailty. To better understand this issue, we examined the efficacy and safety of second-generation antidepressants for the treatment of older adults with depression and then considered implications for frailty. Methods Due to the absence of therapeutic studies of frail older adults with depression, we conducted a systematic review and meta-analysis of double-blind, randomized controlled trials that compared antidepressants versus placebo for adults with depression, age 65 years or older. We searched PubMed/MEDLINE, Cochrane Library, reference lists from meta-analyses/studies, hand searches of publication lists, and related articles on PubMed. Outcomes included rates of response, remission, and adverse events. After evaluating the data, we applied a frailty-informed framework to consider how the evidence could be applied to frailty. Results Nine trials were included in the meta-analysis (n = 2704). Subjects had moderate to severe depression. For older adults with depression, there was no statistically significant difference in response or remission to second-generation antidepressants compared to placebo. Response occurred in 45.3% of subjects receiving an antidepressant compared to 40.5% receiving placebo (RR 1.15, 95% CI: 0.96 – 1.37, p = 0.12, I2 = 71%). Remission occurred in 33.1% with antidepressant versus 31.3% with placebo (RR 1.10, 95% CI: 0.92 – 1.31, p = 0.30, I2 = 56%) (Figure 2 and 3). There were more withdrawals due to adverse events with antidepressants, 13% versus 5.8% (RR 2.30, 95% CI: 1.45–3.63; p < 0.001; I2 = 61%; NNH 14, 95% CI:10–28). Implications for frailty Subjects in the meta-analysis did not have obvious characteristics of frailty. Using framework questions to consider the implications of frailty, we hypothesize that, like older adults, frail individuals with depression may not respond to antidepressants. Further, observational studies suggest that those who are frail may be less responsive to antidepressants compared to the non-frail. Given the vulnerability of frailty, adverse events may be more burdensome. Conclusions Second-generation antidepressants have uncertain benefit for older adults with depression and cause more adverse events compared to placebo. Until further research clarifies benefit, careful consideration of antidepressant prescribing with frailty is warranted.
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Affiliation(s)
- Laurie Mallery
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Tanya MacLeod
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Allen
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Pamela McLean-Veysey
- Drug Evaluation Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Natasha Rodney-Cail
- Drug Evaluation Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Evan Bezanson
- Sobeys National Pharmacy Group, Halifax, Nova Scotia, Canada
| | - Brian Steeves
- RK MacDonald Nursing Home, Halifax, Nova Scotia, Canada
| | - Constance LeBlanc
- Continuing Professional Development, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paige Moorhouse
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Krause M, Gutsmiedl K, Bighelli I, Schneider-Thoma J, Chaimani A, Leucht S. Efficacy and tolerability of pharmacological and non-pharmacological interventions in older patients with major depressive disorder: A systematic review, pairwise and network meta-analysis. Eur Neuropsychopharmacol 2019; 29:1003-1022. [PMID: 31327506 DOI: 10.1016/j.euroneuro.2019.07.130] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/25/2019] [Accepted: 07/09/2019] [Indexed: 01/01/2023]
Abstract
As there is currently no comprehensive evaluation about the efficacy and safety of interventions in elderly patients with major depressive disorder, we did a systematic review and network meta-analysis about all interventions in this population. We searched the specialised register of the Cochrane common mental disorders group, MEDLINE, EMBASE, PsycINFO, CochraneLibrary, ClinicalTrials.gov and the WHO registry until Dec 12, 2017 to identify all randomized controlled trials about the treatment of major depressive disorder in patients over an age of 65. The primary outcome was response defined as reduction of at least 50% on the Hamilton Depression Scale or any other validated depression scale. Secondary outcomes were remission, depressive symptoms, dropouts total, dropouts owing to inefficacy and dropouts due to adverse events, quality of life and social functioning. Additionally, we analysed 116 adverse events. We identified 129 references from 53 RCTs with 9274 participants published from 1990 to 2017. The mean participant age was 73.7 years. In terms of the primary outcome response to treatment the network-meta-analysis showed significant superiority compared to placebo for quetiapine and duloxetine; in addition, agomelatine, imipramine and vortioxetine outperformed placebo in pairwise meta-analyses, and there were also significant superiorities of several antidepressants compared to placebo in secondary efficacy outcomes. Very limited evidence suggests that competitive memory training, geriatric home treatment group and detached mindfulness condition reduce depressive symptoms. Several antidepressants and quetiapine have been shown to be efficacious in elderly patients with major depressive disorder, but due to the comparably few available data, the results are not robust. Differences in the multiple side-effects analysed should also be considered in drug choice. Although there were significant effects for some non-pharmacological treatments, the overall evidence for non-pharmacological treatments in major depressive disorder is insufficient, because it is based on a few trials with usually small sample sizes.
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Affiliation(s)
- Marc Krause
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany; Faculty of Medicine, Institute for Evidence in Medicine (for Cochrane Germany Foundation) Medical Center, University of Freiburg, Germany.
| | - Katharina Gutsmiedl
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
| | - Anna Chaimani
- Paris Descartes University, Paris, France; INSERM, UMR1153 Epidemiology and Statistics, Sorbonne Paris Cité Research Center (CRESS), METHODS Team, Paris, France; Cochrane France, Paris, France
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaningerstraße 22, 81675 Munich, Germany
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18
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The glycine site of NMDA receptors: A target for cognitive enhancement in psychiatric disorders. Prog Neuropsychopharmacol Biol Psychiatry 2019; 92:387-404. [PMID: 30738126 DOI: 10.1016/j.pnpbp.2019.02.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/29/2019] [Accepted: 02/01/2019] [Indexed: 01/05/2023]
Abstract
Cognitive dysfunction is a principal determinant of functional impairment in major depressive disorder (MDD) and often persists during periods of euthymia. Abnormalities in the glutamate system, particularly in N-methyl-d-aspartate receptors (NMDARs) activity, have been shown to contribute to both mood and cognitive symptoms in MDD. The current narrative review aims to evaluate the potential pro-cognitive effects of targeting the glycine site of NMDARs in the treatment of psychiatric disorders, with a special focus on how these results may apply to MDD. Literature databases were searched from inception to May 2018 for relevant pre-clinical and clinical studies evaluating antidepressant and pro-cognitive effects of NMDAR glycine site modulators in both MDD and non-MDD samples. Six glycine site modulators with pro-cognitive and antidepressant properties were identified: d-serine (co-agonist), d-cycloserine (partial agonist), d-alanine (co-agonist), glycine (agonist), sarcosine (co-agonist) and rapastinel (partial agonist). Preclinical animal studies demonstrated improved neuroplasticity and pro-cognitive effects with these agents. Numerous proof-of-concept clinical trials demonstrated pro-cognitive and antidepressant effects trans-diagnostically (e.g., in healthy participants, MDD, schizophrenia, anxiety disorders, major neurocognitive disorders). The generalizability of these clinical studies was limited by the small sample sizes and the paucity of studies directly evaluating cognitive effects in MDD samples, as most clinical trials were in non-MDD samples. Taken together, preliminary results suggest that the glycine site of NMDARs is a promising target to ameliorate symptoms of depression and cognitive dysfunction. Additional rigorously designed clinical studies are required to determine the cognitive effects of these agents in MDD.
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19
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Sobieraj DM, Martinez BK, Hernandez AV, Coleman CI, Ross JS, Berg KM, Steffens DC, Baker WL. Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults. J Am Geriatr Soc 2019; 67:1571-1581. [DOI: 10.1111/jgs.15966] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Adrian V. Hernandez
- University of Connecticut School of Pharmacy Storrs Connecticut
- Vicerrectorado de Investigacion, Universidad SanIgnacio de Loyola (USIL) Lima Peru
| | | | - Joseph S. Ross
- Yale University School of Medicine and School of Public Health New Haven Connecticut
| | - Karina M. Berg
- University of Connecticut School of Medicine Farmington Connecticut
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Wang G, Bi L, Li X, Li Z, Zhao D, Chen J, He D, Wang CN, Wu T, Dueñas H, Skljarevski V, Yue L. Maintenance of effect of duloxetine in Chinese patients with pain due to osteoarthritis: 13-week open-label extension data. BMC Musculoskelet Disord 2019; 20:174. [PMID: 31010413 PMCID: PMC6477726 DOI: 10.1186/s12891-019-2527-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/24/2019] [Indexed: 01/21/2023] Open
Abstract
Background The objectives of this study were to assess the maintenance of effect of duloxetine 60 mg once-daily (QD) in Chinese patients with chronic pain due to osteoarthritis (OA) of the knee or hip and to provide additional long-term safety data. Methods This was an open-label, extension phase of a randomized, double-blind, placebo-controlled clinical trial. Eligible patients were outpatients who met the American College of Rheumatology clinical and radiographic criteria for OA with a rating ≥4 on Brief Pain Inventory (BPI) 24-h average pain. After completing the 13-week placebo-controlled phase, patients originally assigned to placebo were titrated to duloxetine 60 mg QD (PLA_DLX), whereas patients originally assigned to duloxetine 60 mg QD remained on the same dose of duloxetine (DLX_DLX) for another 13 weeks. The maintenance effect of duloxetine 60 mg QD during the extension phase was evaluated by a 1-sided 97.5% confidence interval (CI) of the baseline-to-endpoint change in the extension phase for patients who took duloxetine and reported ≥30% reduction in BPI average pain at the end of placebo-controlled phase (placebo-controlled phase duloxetine responders). Other BPI severity and interference items, as well as safety and tolerability, were assessed. Results Of 342 patients entering the extension phase, 162 (97.6%) DLX_DLX-treated patients and 157 (89.2%) PLA_DLX-treated patients completed this phase. Most patients (76.0%) were female. Mean age was 60.6 years. Mean BPI average pain was 5.5 at baseline of the placebo-controlled phase. Among 113 placebo-controlled phase duloxetine responders, mean change in BPI average pain during the extension phase was − 0.59 (from 2.47 to 1.88); the upper bound of the 1-sided 97.5% CI was − 0.31 and less than the pre-specified non-inferiority margin of a 1.5-point increase (p < 0.001). Significant within-group improvements in all BPI items were observed for both PLA_DLX and DLX_DLX groups during the extension phase (all p < 0.01). No deaths or suicide-related events occurred. Seven (4.0%) PLA_DLX-treated patients and no DLX_DLX-treated patients discontinued due to an adverse event. Conclusion The analgesic effect of duloxetine 60 mg QD among treatment responders was maintained for the entire duration of the extension phase. Duloxetine 60 mg QD was well tolerated during the extension phase. Trial registration ClinicalTrials.gov identification number NCT01931475. Registered 29 August 2013.
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Affiliation(s)
- Guochun Wang
- Rheumatology Department, China-Japan Friendship Hospital, Beijing, China
| | - Liqi Bi
- Rheumatology Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Xiangpei Li
- Rheumatology Department, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Zhijun Li
- Rheumatology Department, Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Dongbao Zhao
- Rheumatology Department, Shanghai Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jinwei Chen
- Rheumatology Department, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Dongyi He
- Rheumatology Department, Shanghai Guanghua Hospital, Shanghai, China
| | - Chia-Ning Wang
- Asian-Pacific Statistical Sciences, Lilly Suzhou Pharmaceutical Co. Ltd., Shanghai, China
| | - Tao Wu
- Medical Department, Lilly Suzhou Pharmaceutical Co. Ltd. Shanghai Branch, Shanghai, China
| | - Héctor Dueñas
- Corporate Affairs Manager, Latin America Caribbean and Mexico, Eli Lilly de Mexico, Mexico City, Mexico
| | | | - Li Yue
- Medical Department, Lilly Suzhou Pharmaceutical Co. Ltd. Shanghai Branch, 19F, Centre T1, HKRI Taikoo, No. 288, Shimen No.1 Road, Shanghai, 200021, China.
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Abstract
Depression is a common disorder in late life that is associated with poor quality of life, increased disability, and increased all-cause mortality. Rates of completed suicide are the highest in older depressed men compared with any other age group. In this age group, depression is often concurrent with medical illness and it can aggravate the course of medical illness. Cognitive impairment is frequently present and may be the result of the depression itself or may be the consequence of a neurodegenerative disorder such as Alzheimer's disease. Evidence-based psychotherapies, antidepressants, and somatic treatments such as electroconvulsive therapy are employed in the treatment of older depressed adults. Treatment may be complicated by the presence of cognitive impairment, other comorbid medical disorders, and medications used to treat these disorders. Certain safety issues such as increased bleeding risk, hyponatremia, decreased bone density and falls may be associated with antidepressant treatment, may be more common in older depressed adults, and their consequences may be more severe in late life. These risks, however, need to be weighed against the hazards of untreated depression. With appropriate care, most older depressed patients can be successfully treated and a positive outcome can have a significant effect on the patient's quality of life.
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Affiliation(s)
- J Craig Nelson
- Leon J. Epstein Professor of Psychiatry, University of California San Francisco, San Francisco, CA, USA.
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Abstract
UNLABELLED This paper reviews recent research on late-life depression (LLD) pharmacotherapy, focusing on updated information for monotherapy and augmentation treatments. We then review new research on moderators of clinical response and how to use the information for improved efficacy. RECENT FINDINGS A recent review shows that sertraline, paroxetine, and duloxetine were superior to placebo for the treatment of LLD. There is concern that paroxetine could have adverse outcomes in the geriatric population due to anticholinergic properties; however, studies show no increases in mortality, dementia risk, or cognitive measures. Among newer antidepressants, vortioxetine has demonstrated efficacy in LLD, quetiapine has demonstrated efficacy especially for patients with sleep disturbances, and aripiprazole augmentation for treatment resistance in LLD was found to be safe and effective. Researchers have also been identifying moderators of LLD that can guide treatment. Researchers are learning how to associate moderators, neuroanatomical models, and antidepressant response. SSRI/SNRIs remain first-line treatment for LLD. Aripiprazole is an effective and safe augmentation for treatment resistance. Studies are identifying actionable moderators that can increase treatment response.
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Frame LA, Fischer JP, Geller G, Cheskin LJ. Use of Placebo in Supplementation Studies-Vitamin D Research Illustrates an Ethical Quandary. Nutrients 2018. [PMID: 29533982 PMCID: PMC5872765 DOI: 10.3390/nu10030347] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
History has shown that without explicit and enforced guidelines, even well-intentioned researchers can fail to adequately examine the ethical pros and cons of study design choices. One area in which consensus does not yet exist is the use of placebo groups in vitamin supplementation studies. As a prime example, we focus on vitamin D research. We aim to provide an overview of the ethical issues in placebo-controlled studies and guide future discussion about the ethical use of placebo groups. Research in the field of vitamin D shows variation in how placebo groups are used. We outline four types of control groups in use: active-control, placebo-control with restrictions on supplementation, placebo-control without supplementation restrictions, and placebo-control with rescue repletion therapy. The first two types highlight discrete ethical issues: active-control trials limit the ability to detect a difference; placebo-control trials that restrict supplementation potentially place subjects at risk of undue harm. The final two, placebo-control without supplementation restrictions or with rescue repletion therapy, offer potential solutions to these ethical challenges. Building on this, guidelines should be established and enforced on the use of placebo in supplementation studies. Furthermore, the field of vitamin D research has the potential to set an example worthy of emulation.
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Affiliation(s)
- Leigh A Frame
- The George Washington School of Medicine and Health Sciences, Washington, DC 20052, USA.
| | - Jonathan P Fischer
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA.
| | - Gail Geller
- The Johns Hopkins School of Medicine, Baltimore, MD 21205, USA.
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
- The Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.
| | - Lawrence J Cheskin
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
- The Johns Hopkins Weight Management Center, Baltimore, MD 21205, USA.
- The Global Obesity Prevention Center at Johns Hopkins, Baltimore, MD 21205, USA.
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Hatzinger M, Hemmeter U, Hirsbrunner T, Holsboer-Trachsler E, Leyhe T, Mall JF, Mosimann U, Rach N, Trächsel N, Savaskan E. [Not Available]. PRAXIS 2018; 107:127-144. [PMID: 29382263 DOI: 10.1024/1661-8157/a002883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Diese Empfehlungen sollen dazu dienen, Fachpersonen das Wissen über die aktuelle Evidenz von Diagnostik und Therapie der Depression im Alter zur Verfügung zu stellen und damit zur frühzeitigen Erkennung und evidenzbasierten Behandlung beizutragen. Da für einige Behandlungsansätze nur rudimentär kontrollierte Studien vorliegen, wird auch das klinische Expertenwissen in die Beurteilung einbezogen. Im diagnostischen Vorgehen wird die besondere Symptomatik der Depression im Alter beleuchtet, auf die Suizidalität eingegangen und werden die häufig vorkommenden somatischen Komorbiditäten hervorgehoben. Auch Hypothesen zur Pathogenese, wie Neuroendokrinologie, Neurodegeneration und vaskuläre Faktoren, werden erläutert. In der Behandlung gilt heute ein integrierter biopsychosozialer Ansatz mit gezielten psychosozialen Interventionen, spezifischer Psychotherapie und einer antidepressiven Pharmakotherapie bei schweren Depressionen als sinnvoll. Daneben kommen auch chronobiologische oder Neurostimulationsverfahren zum Einsatz.
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Affiliation(s)
- Martin Hatzinger
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
- 2 Schweizerische Gesellschaft für Biologische Psychiatrie (SGBP)
| | - Ulrich Hemmeter
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
| | - Therese Hirsbrunner
- 4 Schweizerischer Berufsverband der Pflegefachfrauen und Pflegefachmänner (SBK)
| | | | - Thomas Leyhe
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
| | - Jean-Frédéric Mall
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
| | - Urs Mosimann
- 2 Schweizerische Gesellschaft für Biologische Psychiatrie (SGBP)
| | - Nicole Rach
- 5 Schweizerische Fachgesellschaft für Gerontopsychologie (SFGP)
| | - Nathalie Trächsel
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
| | - Egemen Savaskan
- 1 Schweizerische Gesellschaft für Alterspsychiatrie und Alterspsychotherapie (SGAP)
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Zimmerman M, Multach MD, Clark HL, Walsh E, Rosenstein LK, Gazarian D. Inclusion/exclusion criteria in late life depression antidepressant efficacy trials. Int J Geriatr Psychiatry 2017; 32:1009-1016. [PMID: 27546477 DOI: 10.1002/gps.4560] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/06/2016] [Accepted: 07/07/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The generalizability of antidepressant efficacy trials (AETs) has been questioned. No studies have examined the inclusion/exclusion criteria used in placebo-controlled studies of late life depression and compared them to the criteria used in non-late life AETs. METHOD We conducted a comprehensive literature review of placebo-controlled AETs published from January, 1995 through December, 2014. We compared the inclusion/exclusion criteria used in the 18 studies of late life depression to those used in non-late life depression. RESULTS There were nine inclusion/exclusion criteria that were used in more than half of the late life depression AETs: minimum severity on a symptom severity scale (100.0%), significant suicidal ideation (77.8%), psychotic features during the current episode of depression or history of a psychotic disorder (94.4%), history of bipolar disorder (77.8%), diagnosis of alcohol or drug abuse or dependence (83.3%), presence of a comorbid nondepressive, nonsubstance use Axis I disorder (55.6%), episode duration too short (66.7%), and an insufficient score on a cognitive screen (88.3%) or the presence of a cognitive disorder (55.6%). There were some differences between the late life and non-late life depression studies-use of a screening measure of cognitive functioning, presence of a cognitive disorder such as dementia, and the minimum depression severity cutoff score required at baseline. CONCLUSIONS The inclusion/exclusion criteria in AETs of late life depression were generally similar to the criteria used in non-late life depression AETs. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Matthew D Multach
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Heather L Clark
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Emily Walsh
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Lia K Rosenstein
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
| | - Douglas Gazarian
- Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA
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Patel K, Abdool PS, Rajji TK, Mulsant BH. Pharmacotherapy of major depression in late life: what is the role of new agents? Expert Opin Pharmacother 2017; 18:599-609. [DOI: 10.1080/14656566.2017.1308484] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Kinjal Patel
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Petal S. Abdool
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Outpatient Geriatric Mental Health Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tarek K. Rajji
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Geriatric Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benoit H. Mulsant
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
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27
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Braun C, Bschor T, Franklin J, Baethge C. Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:171-9. [PMID: 27043848 DOI: 10.1159/000442293] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use. METHODS We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs). RESULTS Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01). CONCLUSIONS Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.
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Affiliation(s)
- Cora Braun
- Department of Psychiatry and Psychotherapy, University of Cologne Medical School, Cologne, Germany
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28
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Abstract
BACKGROUND Pain is a common symptom in patients with depressive disorders, which, if present, worsens the prognosis. However, there is little empirical knowledge of the therapeutic effects of antidepressants on painful physical symptoms of patients with depressive disorders. Furthermore, tricyclic/tetracyclic antidepressants (TCAs) have not yet been included in existing meta-analyses. METHODS A broad, systematic search of PubMed literature on antidepressant drug treatment of patients with depressive disorders with comorbid pain symptoms was carried out. A random-effects meta-analysis has been performed among 3 different groups of drugs for the 2 end points: pain and depression. RESULTS Fourteen placebo-controlled studies with selective serotonin-noradrenaline reuptake inhibitors (SSNRIs) could be included, with 3 of them also investigating selective serotonin reuptake inhibitors (SSRIs). Three further placebo-controlled SSRI studies were identified, but only 2 placebo-controlled TCA studies.Both SSNRIs and SSRIs, but not TCAs, were significantly superior to placebo as regards their analgesic effects. However, all effects were small. For SSNRIs, there was a strong positive correlation between their effectiveness for pain relief and their positive effect on the mood of the patients. DISCUSSION The analgesic effects of SSNRIs and SSRIs in patients with primary depressive disorders can be interpreted as largely equivalent. Because of a lack of placebo-controlled TCA studies, the results for TCAs would be comparable only to those of SSRIs and SSNRIs, if non-placebo-controlled TCA studies were included. The positive correlation found indicates a close relationship of pain relief and antidepressant treatment effects. These results refer merely to patients with primary depressive disorders, not to patients with primary pain disorders. Further studies comparing the effects of different types of antidepressant drugs on pain in depressive patients are warranted.
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29
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Efficacy and tolerability of antidepressants in people aged 65 years or older with major depressive disorder - A systematic review and a meta-analysis. J Affect Disord 2016; 205:1-12. [PMID: 27389296 DOI: 10.1016/j.jad.2016.06.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/31/2016] [Accepted: 06/03/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND There has been a steady increase in the prescription of antidepressants for the elderly. This study comprises a systematic review of randomized, placebo-controlled trials of antidepressants for treatment of depressive disorder in people aged 65 years or more. METHODS PubMed, EMBASE, Cochrane Library, CINAL, and PsycINFO were searched until May 2016. Where appropriate, the results were synthesized in meta-analyses. RESULTS Twelve trials met the inclusion criteria. For patients with major depressive disorder, selective serotonin re-uptake inhibitors (SSRI) were not superior to placebo in achieving remission (OR: 0.79, 95% CI: 0.61-1.03) or response (OR=0.86, 95% CI: 0.51-1.10) after 8 weeks of treatment (three trials). However, maintenance treatment with SSRIs was superior to placebo in preventing relapse (OR: 0.22, 95% CI: 0.13-0.36; NNT=5, 95% CI: 3-6; two trials). Duloxetine was superior to placebo in achieving remission (OR: 1.78, 95% CI: 1.20-2.65; NNT=9, 95% CI: 6-20; three trials) and response (OR: 1.83, 95% CI: 1.96-4.08; two trials) in recurrent major depression after 8 weeks, but increased the risk of adverse events that can be problematic in the elderly. LIMITATIONS The quality of evidence was generally low or moderate, emphasizing the uncertainty of the results. Study populations only partly covered the heterogeneous population of elderly with depressed mood, limiting the generalizability. CONCLUSION The results underscore the importance of close monitoring of the effects of antidepressants in treatment of elderly patients with a depressive disorder. Methods for early detection of non-responders and effective treatment options for this group are needed.
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Benraad CEM, Kamerman-Celie F, van Munster BC, Oude Voshaar RC, Spijker J, Olde Rikkert MGM. Geriatric characteristics in randomised controlled trials on antidepressant drugs for older adults: a systematic review. Int J Geriatr Psychiatry 2016; 31:990-1003. [PMID: 26924120 DOI: 10.1002/gps.4443] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/10/2016] [Accepted: 01/20/2016] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Meta-analyses of antidepressant drug treatment trials have found that increasing age is associated with a less favourable outcome. Because the prevalence of geriatric characteristics, like disability, medical co-morbidity, malnutrition, cognitive (dys)function and frailty increase with age and are associated with depression, these characteristics are likely to modify the treatment outcome of antidepressant drugs in late-life depression. This review examines how these five characteristics are taken into account in randomised controlled trials (RCTs) with antidepressant drugs for major depressive disorder in patients aged 60 years or above. DESIGN A systematic search in PubMED, PsychInfo and EMBASE, from the year 2000 onwards, yielded 27 RCTs, with a total of 6356 subjects with a median age of 71 years. Two reviewers independently assessed whether each characteristic was considered as inclusion or exclusion criterion, descriptive variable, stratification variable, co-variable, outcome measure, or in adverse effect monitoring. RESULTS Malnutrition and frailty were not taken into account in any study. Disability was used as an outcome measure in five studies. Two studies explicitly included a population with possibly serious medical co-morbidity. Cognitive status was the only condition taken into account as co-variable (n = 3) or stratifying variable (n = 1) and was used as outcome measure in seven studies. CONCLUSIONS We conclude that geriatric characteristics are rarely taken into account in RCTs on antidepressant drugs in late-life depression, and studies including the oldest adults are underrepresented. This warrants recruitment of the oldest adults and adjustment of treatment strategies in future studies. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Carolien E M Benraad
- Department of Geriatrics/Radboudumc Alzheimer Center, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Old Age Psychiatry and Geriatrics, Pro Persona Mental Health Care, Nijmegen, The Netherlands
| | - Floor Kamerman-Celie
- Department of Old Age Psychiatry and Geriatrics, Pro Persona Mental Health Care, Nijmegen, The Netherlands
| | - Barbara C van Munster
- Department of Old Age Psychiatry and Geriatrics, Pro Persona Mental Health Care, Nijmegen, The Netherlands.,Department of Internal Medicine, Section of Geriatrics, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jan Spijker
- Program for Mood Disorders, Pro Persona Mental Health Care, Nijmegen, The Netherlands.,Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Marcel G M Olde Rikkert
- Department of Geriatrics/Radboudumc Alzheimer Center, Radboud University Medical Center, Nijmegen, The Netherlands
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Mattingly G, Anderson RH, Mattingly SG, Anderson EQ. The impact of cognitive challenges in major depression: the role of the primary care physician. Postgrad Med 2016; 128:665-71. [PMID: 27500820 DOI: 10.1080/00325481.2016.1221318] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nearly 1 in 5 Americans will struggle with major depression in their lives; some will have recurring bouts. Recent psychiatric research has given new attention to the prevalence of cognitive deficits in major depression and the impact such deficits have on remission and overall life functioning. When depression is partially treated i.e., leaving residual symptoms, patients have higher rates of relapse and lower functional outcomes. Impaired cognitive functioning is a frequent residual symptom, persisting in about 45% of patients even when emotional symptoms have improved, and results in a disproportionate share of the functional impairment, particularly in the workplace. Patients with depression have disrupted circuitry in brain regions responsible for cognition and it is therefore important to screen depressed patients for cognitive as well as emotional symptoms. Cognitive dysfunction should be evaluated in every mood disordered patient with validated self-report scales such as the Patient Health Questionnaire-9 or the Beck Depression Inventory and objective measures of cognitive function are also very very useful. Two easily administered tests are the Trails B Test and the Digit Symbol Substitution Test. Each take less than two minutes and measure working memory, executive function, and processing speed and can track cognitive improvement in depressed patients. Treatment of cognitive dysfunction in major depression is complicated by the 'serotonin conundrum': SSRI's frequently do not treat to full remission, and can cause cognitive blunting-actually adding to cognitive problems. Based on recent data including results from a recently completed meta-analysis by McIntyre and colleagues, an evidence-based algorithm for treating cognitive symptoms in depression is presented. A hierarchy of antidepressants and augmentation strategies based on the best available evidence is discussed. In conclusion, cognitive symptoms in major depressive disorder have been recognized as a target of therapeutic improvement by the FDA and have become a focus of clinical importance.
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Affiliation(s)
- Gregory Mattingly
- a Department of Psychiatry , Washington University School of Medicine , Saint Charles , MO , USA
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32
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Reddy S, Fayyad R, Edgar CJ, Guico-Pabia CJ, Wesnes K. The effect of desvenlafaxine on cognitive functioning in employed outpatients with major depressive disorder: a substudy of a randomized, double-blind, placebo-controlled trial. J Psychopharmacol 2016; 30:559-67. [PMID: 27009044 DOI: 10.1177/0269881116631649] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this substudy was to examine the effect of desvenlafaxine 50 mg/day compared with placebo on cognitive function in employed outpatients with major depressive disorder. A total of 11/55 (20%) study sites in a 12-week, randomized, double-blind, placebo-controlled trial administered cognitive assessments in memory, attention, and executive functioning domains using the cognitive drug research system. Changes from baseline were subjected to analysis of covariance with baseline levels as covariates, using last observation carried forward data. A significant improvement with desvenlafaxine 50 mg/day (n=52) compared with placebo (n=29) was observed on the quality of working memory composite measure (0.081 units (0.005, 0.156); P=0.0365) at last observation carried forward. Improvement from baseline on the speed of working memory composite was significant for desvenlafaxine (-226.6 msec (-316.7, -136.4); P<0.0001) and for placebo (-133.3 msec (-257.2, -9.4); P=0.0354); however, the treatment effect was not significant. No significant differences between groups were observed on composite measures for attention. Treatment of depression with desvenlafaxine 50 mg/day may improve aspects of cognitive functioning, including working memory.Clinical Trial Registry No.: Clinicaltrials.gov identifier: NCT00824291.
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Affiliation(s)
- Sujana Reddy
- Formerly of Pfizer Inc., formerly Wyeth Research, Collegeville, PA, USA Pottstown Memorial Hospital, Pottstown, PA, USA
| | | | | | - Christine J Guico-Pabia
- Formerly of Pfizer Inc., formerly Wyeth Research, Collegeville, PA, USA CGP Strategic Solutions LLC, Landsdale, PA, USA
| | - Keith Wesnes
- Formerly of Bracket Global, Goring-on-Thames, UK Swinburne University, Melbourne, VIC, Australia Northumbria University, Newcastle, UK
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Harada E, Kato M, Fujikoshi S, Wohlreich MM, Berggren L, Tokuoka H. Changes in energy during treatment of depression: an analysis of duloxetine in double-blind placebo-controlled trials. Int J Clin Pract 2015; 69:1139-48. [PMID: 25980552 PMCID: PMC4682452 DOI: 10.1111/ijcp.12658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim of this study was to assess how quickly and effectively duloxetine improves energy compared with placebo in patients with major depressive disorder (MDD). METHODS Data from 10 randomised, double-blind, placebo-controlled clinical trials examining duloxetine (40-60 mg/day) vs. placebo in patients diagnosed with MDD were analysed. Change from baseline at Week 1 through Week 8 in Hamilton Depression Rating Scale (HAM-D) retardation subscale score (Item 1 - depressed mood, Item 7 - work and activities, Item 8 - retardation and Item 14 - genital symptoms) was assessed with mixed model repeated measures analysis. Positive predictive values and negative predictive values were calculated for predictor analysis. RESULTS Patients treated with duloxetine (N = 1522) experienced statistically significantly (p ≤ 0.05) greater reductions in HAM-D retardation subscale scores vs. placebo (N = 1180) starting at Week 1 throughout Week 8 of treatment. Of the patients with early energy improvement (≥ 20% reduction in HAM-D retardation subscale scores) at Week 1, 48% achieved remission (HAM-D total score ≤ 7) at Week 8; 48% and 46% of patients who experienced early energy improvement at Weeks 2 and 4, respectively, achieved remission at Week 8. DISCUSSION We demonstrated that treatment with duloxetine, quickly and with increasing magnitude over treatment time, improves low energy symptoms. As early as 1 week after starting treatment with duloxetine, improvement of low energy may serve as a predictor of remission at end-point. CONCLUSIONS Treatment with duloxetine improves energy in patients with MDD and early response in retardation may serve as a modest predictor of remission at end-point. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov. Study Identifiers: NCT00036335; NCT00073411; NCT00406848 and NCT00536471. Studies HMAQa, HMAQb, HMATa, HMATb, HMBHa and HMBHb predate the registration requirement. DATA POSTING ClinicalTrials.gov. Study Identifiers: NCT00406848; NCT00536471.
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Affiliation(s)
- E Harada
- Medical Science, Eli Lilly Japan K.K.Hyogo, Japan
| | - M Kato
- Department of Neuropsychiatry, Kansai Medical UniversityOsaka, Japan
| | - S Fujikoshi
- Statistical Science, Eli Lilly Japan K.K.Hyogo, Japan
| | - M M Wohlreich
- Neuroscience, Eli Lilly and CompanyIndianapolis, IN, USA
| | - L Berggren
- Global Statistical Sciences, Eli Lilly and CompanyBad Homburg, Germany
| | - H Tokuoka
- Medical Science, Eli Lilly Japan K.K.Hyogo, Japan
- Correspondence to:
, Hirofumi Tokuoka, Lilly Research Laboratories Japan, Eli Lilly Japan K.K., 6510086, Kobe, Japan, Tel.: + 81 3 5574 9234, Fax: +81 3 5574 9979,
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Locher C, Kossowsky J, Gaab J, Kirsch I, Bain P, Krummenacher P. Moderation of antidepressant and placebo outcomes by baseline severity in late-life depression: A systematic review and meta-analysis. J Affect Disord 2015; 181:50-60. [PMID: 25917293 DOI: 10.1016/j.jad.2015.03.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Baseline severity is a crucial moderator of trial outcomes in adult depression, with the advantage of antidepressants over placebo increasing as severity increases. However, this relationship has not been examined in late-life depression. METHODS PubMed, Embase, Web of Science, PsycINFO, and Cochrane were searched for studies published through September 2014. Randomized, acute phase, and double-blind studies comparing an antidepressant group with a placebo group in depressed elderly patients were included. RESULTS Nineteen studies met all inclusion criteria. Within-group effect sizes revealed significant improvement in antidepressant groups (g=1.35, p<.000), as well as in placebo groups (g=.96, p<.000). Change in depressive symptoms assessed by Hamilton Depression Rating Scale (HDRS) was moderated by baseline severity in antidepressant groups (Z=2.67, p=.008) and placebo groups (Z=4.46, p<.000). However, this would be expected as a result of regression toward the mean, and mean differences between groups did not increase (r=.19, p=.469) as a function of baseline severity. LIMITATIONS Limited to published data and information was only analyzed at the level of treatment groups. CONCLUSION Baseline severity was not associated with an antidepressant-placebo difference and placebo responses are large in the treatment of depressed elderly people. We propose a stepwise approach, i.e., to initially offer elderly depressed patients psychosocial interventions and only consider antidepressants if patients do not respond.
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Affiliation(s)
- Cosima Locher
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland.
| | - Joe Kossowsky
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, USA; Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Jens Gaab
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland
| | - Irving Kirsch
- Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Paul Bain
- Countway Library of Medicine, Harvard Medical School, Boston, USA
| | - Peter Krummenacher
- Department of Clinical Psychology and Psychotherapy, University of Basel, Basel, Switzerland; Collegium Helveticum, University of Zurich and ETH Zurich, Zurich, Switzerland
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Rosenblat JD, Kakar R, McIntyre RS. The Cognitive Effects of Antidepressants in Major Depressive Disorder: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Int J Neuropsychopharmacol 2015; 19:pyv082. [PMID: 26209859 PMCID: PMC4772818 DOI: 10.1093/ijnp/pyv082] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cognitive dysfunction is often present in major depressive disorder (MDD). Several clinical trials have noted a pro-cognitive effect of antidepressants in MDD. The objective of the current systematic review and meta-analysis was to assess the pooled efficacy of antidepressants on various domains of cognition in MDD. METHODS Trials published prior to April 15, 2015, were identified through searching the Cochrane Central Register of Controlled Trials, PubMed, Embase, PsychINFO, Clinicaltrials.gov, and relevant review articles. Data from randomized clinical trials assessing the cognitive effects of antidepressants were pooled to determine standard mean differences (SMD) using a random-effects model. RESULTS Nine placebo-controlled randomized trials (2 550 participants) evaluating the cognitive effects of vortioxetine (n = 728), duloxetine (n = 714), paroxetine (n = 23), citalopram (n = 84), phenelzine (n = 28), nortryptiline (n = 32), and sertraline (n = 49) were identified. Antidepressants had a positive effect on psychomotor speed (SMD 0.16; 95% confidence interval [CI] 0.05-0.27; I(2) = 46%) and delayed recall (SMD 0.24; 95% CI 0.15-0.34; I(2) = 0%). The effect on cognitive control and executive function did not reach statistical significance. Of note, after removal of vortioxetine from the analysis, statistical significance was lost for psychomotor speed. Eight head-to-head randomized trials comparing the effects of selective serotonin reuptake inhibitors (SSRIs; n = 371), selective serotonin and norepinephrine reuptake inhibitors (SNRIs; n = 25), tricyclic antidepressants (TCAs; n = 138), and norepinephrine and dopamine reuptake inhibitors (NDRIs; n = 46) were identified. No statistically significant difference in cognitive effects was found when pooling results from head-to-head trials of SSRIs, SNRIs, TCAs, and NDRIs. Significant limitations were the heterogeneity of results, limited number of studies, and small sample sizes. CONCLUSIONS Available evidence suggests that antidepressants have a significant positive effect on psychomotor speed and delayed recall.
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Affiliation(s)
| | | | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, Department of Psychiatry, University of Toronto, Canada (Drs Rosenblat, Kakar, and McIntyre); Departments of Psychiatry and Pharmacology, University of Toronto, Toronto, Canada (Drs Rosenblat and McIntyre); Department of Psychiatry, Western University, London, and Windsor, Ontario, Canada (Dr Kakar).
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Chen SC, McCullumsmith C, Kim SYH. Disclosing the potential impact of placebo controls in antidepressant trials. BJPsych Open 2015; 1:1-5. [PMID: 27703715 PMCID: PMC4995553 DOI: 10.1192/bjpo.bp.115.000109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/26/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although placebo-control clinical trials that withhold effective treatments can be permissible, how best to inform participants of the placebo design has received little attention. AIMS To determine the effect of disclosing quantitative outcome estimates of individual treatment v. entering placebo-control randomised control trial (RCT) on willingness to enrol in such an RCT. METHOD We randomised 278 adult patients at a depression clinic to receive standard disclosure (n = 129) or enhanced (n = 149) quantitative outcome estimates (based on decision analysis) of individual treatment v. RCT, and assessed their willingness to enrol in the RCT. RESULTS A greater proportion of those in the standard arm preferred enrolling in RCT (41.3% v. 23.8%, P = 0.002). Those in the standard arm preferred RCT more for direct benefit than altruism reasons, whereas the opposite was true in the enhanced arm. CONCLUSIONS Disclosing the quantitative outcome implications of placebos may select for fewer but more altruistic participants. DECLARATION OF INTEREST S.Y.H.K. was a DSMB member of a clinical trial sponsored by Hoffman-LaRoche and he receives royalties from Oxford University Press for his book Evaluation of Capacity to Consent to Treatment and Research. C.M. has served in the past year on a scientific advisory board and as a consultant for Janssen Pharmaceuticals. COPYRIGHT AND USAGE This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Stephanie C Chen
- , BA, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda
| | | | - Scott Y H Kim
- , MD, PhD, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda and Department of Psychiatry, University of Michigan, Ann Arbor
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Barros BR, Schacht A, Happich M, Televantou F, Berggren L, Walker DJ, Dueñas HJ. Impact of pretreatment with antidepressants on the efficacy of duloxetine in terms of mood symptoms and functioning: an analysis of 15 pooled major depressive disorder studies. Prim Care Companion CNS Disord 2015; 16:14m01661. [PMID: 25667808 DOI: 10.4088/pcc.14m01661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/19/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE This post hoc analysis aimed to determine whether patients with major depressive disorder (MDD) in duloxetine trials who were antidepressant naive or who were previously exposed to antidepressants exhibited differences in efficacy and functioning. METHOD Data were pooled from 15 double-blind, placebo- and/or active-controlled duloxetine trials of adult patients with MDD conducted by Eli Lilly and Company. The individual studies took place between March 2000 and November 2009. Data were analyzed using 4 pretreatment subgroups: first-episode never treated, multiple-episode never treated, treated previously only with selective serotonin reuptake inhibitors (SSRIs), and previously treated with antidepressants other than just SSRIs. Measures included the 17-item Hamilton Depression Rating Scale (HDRS-17) total and somatic symptom subscale scores, Montgomery-Asberg Depression Rating Scale (MADRS) total score, and Sheehan Disability Scale total score. Response rates (50% and 30%) were based on the HDRS-17 total score and remission rates on either the HDRS-17 or MADRS total score. RESULTS Response and remission rates were significantly greater (P < .05 in 11 of 12 comparisons) for duloxetine versus placebo in the 4 subgroups. A trend of greater response and remission occurred for first-episode versus multiple-episode patients; both groups were generally higher than the antidepressant-treated groups. Mean changes in efficacy measures were mostly significantly greater (P < .05 in 13 of 16 comparisons) for duloxetine versus placebo within each pretreatment subgroup, with some (P < .05 in 2 of 24 comparisons) significant interaction effects between subgroups on HDRS-17 total and somatic symptoms scores. CONCLUSIONS Duloxetine was generally superior to placebo on response and remission rates and in mean change on efficacy measures. Response and remission rates were numerically greater for first-episode versus multiple-episode and drug-treated patients. Mean change differences on efficacy measures among the 4 subgroups were inconsistent. Duloxetine showed a similar therapeutic effect independent of episode frequency and antidepressant pretreatment.
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Affiliation(s)
- Bruno R Barros
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Alexander Schacht
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Michael Happich
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Foula Televantou
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Lovisa Berggren
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Daniel J Walker
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
| | - Hector J Dueñas
- Eli Lilly-Brazil, Brazil Medical Affairs, Sao Paulo, Brazil (Dr Barros); Eli Lilly and Company, Global Statistical Sciences, Bad Homburg, Germany (Drs Schacht, Happich, and Ms Berggren); Lilly UK, Lilly Research Centre, Windlesham, Surrey, United Kingdom (Ms Televantou); Lilly USA, LLC, Indianapolis, Indiana (Dr Walker); and Eli Lilly de México, Mexico City, Mexico (Dr Dueñas)
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Pharmacological and non-pharmacological interventions to improve cognitive dysfunction and functional ability in clinical depression--a systematic review. Psychiatry Res 2014; 219:25-50. [PMID: 24863864 DOI: 10.1016/j.psychres.2014.05.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 04/12/2014] [Accepted: 05/05/2014] [Indexed: 01/11/2023]
Abstract
Cognitive dysfunction is of clinical significance and exerts longstanding implication on patients׳ function. Pharmacological and non-pharmacological treatments of cognitive dysfunction are emerging. This review evaluates pharmacological and non-pharmacological treatments of cognitive impairment primarily in the domains of memory, attention, processing speed and executive function in clinical depression. A total of 35 studies were retrieved from Pubmed, PsycInfo and Scopus after applying inclusion and exclusion criteria. Results show that various classes of antidepressants exert improving effects on cognitive function across several cognitive domains. Specifically, studies suggest that SSRIs, the SSRE tianeptine, the SNRI duloxetine, vortioxetine and other antidepressants such as bupropion and moclobemide may exert certain improving effects on cognitive function in depression, such as in learning and memory and executive function. Class-specific cognitive domains or specific dose-response relationships were not identified yet. The few non-pharmacological studies conducted employing cognitive orientated treatments and cognitive remediation therapy show promising results for the improvement of cognitive impairment in depression. However, several methodological constraints of studies limit generalizability of the results and caution the interpretation. Future direction should consider the development of a neuropsychological consensus cognitive battery to support the discovery, clinical assessment, comparison of studies and registration of new agents in clinical depression.
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Alaka KJ, Noble W, Montejo A, Dueñas H, Munshi A, Strawn JR, Lenox-Smith A, Ahl J, Bidzan L, Dorn B, Ball S. Efficacy and safety of duloxetine in the treatment of older adult patients with generalized anxiety disorder: a randomized, double-blind, placebo-controlled trial. Int J Geriatr Psychiatry 2014; 29:978-86. [PMID: 24644106 PMCID: PMC4285965 DOI: 10.1002/gps.4088] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/15/2014] [Accepted: 01/16/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This was a flexible-dosed study to evaluate the efficacy and safety of duloxetine 30-120 mg once daily in the treatment of generalized anxiety disorder (GAD) in older adult patients. METHODS Patients with GAD, who were at least 65 years of age, were randomly assigned to double-blind treatment with either duloxetine (N = 151) or placebo (N = 140). The primary efficacy measure was the Hamilton Anxiety Rating Scale (HAM-A) total score, and the primary endpoint was at week 10. Global functioning was assessed by the Sheehan Disability Scale (SDS). Safety and tolerability was assessed by the occurrence of treatment-emergent adverse events, serious adverse events, laboratory analyses, and vital signs. Analyses were conducted on an intent-to-treat basis. RESULTS The overall baseline mean HAM-A total score was 24, and SDS global score was 14. Completion rates were 75% for placebo and 76% for duloxetine. At week 10, duloxetine was superior to placebo on mean changes from baseline in HAM-A total scores (-15.9 vs. -11.7, p < 0.001) and in SDS global scores (-8.6 vs. -5.4, p < 0.001). Treatment-emergent adverse events occurred in ≥5% of duloxetine-treated patients and twice the rate than with placebo including constipation (9% vs. 4%, p = 0.06), dry mouth (7% vs. 1%, p = 0.02), and somnolence (6% vs. 2%, p = 0.14). CONCLUSION Duloxetine treatment was efficacious in the improvement of anxiety and functioning in older adult patients with GAD, and the safety profile was consistent with previous GAD studies.
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Affiliation(s)
| | | | - Angel Montejo
- Universidad de SalamancaSalamanca, Spain,Instituto de Investigación Biomédica de SalamancaSalamanca, Spain
| | | | | | - Jeffrey R Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of MedicineCincinnati, OH, USA
| | | | - Jonna Ahl
- Eli Lilly and CompanyIndianapolis, IN, USA
| | | | | | - Susan Ball
- Eli Lilly and CompanyIndianapolis, IN, USA,Indiana University School of MedicineIndianapolis, IN, USA
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Mulsant BH, Blumberger DM, Ismail Z, Rabheru K, Rapoport MJ. A systematic approach to pharmacotherapy for geriatric major depression. Clin Geriatr Med 2014; 30:517-34. [PMID: 25037293 DOI: 10.1016/j.cger.2014.05.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The broadening use of antidepressants among older Americans has not been associated with a notable decrease in the burden of geriatric depression. This article, based on a selective review of the literature, explores several explanations for this paradox. The authors propose that the effectiveness of antidepressants depends in large part on the way they are used. Evidence supports that antidepressant pharmacotherapy leads to better outcomes when guided by a treatment algorithm as opposed to attempting to individualize treatment. Several published guidelines and pharmacotherapy algorithms developed for the treatment of geriatric depression are reviewed, and an updated algorithm proposed.
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Affiliation(s)
- Benoit H Mulsant
- Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada.
| | - Daniel M Blumberger
- Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada; Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada
| | - Zahinoor Ismail
- Centre for Addiction and Mental Health, 1001 Queen Street West, Toronto, Ontario M6J 1H4, Canada; Hotchkiss Brain Institute, Foothills Hospital, University of Calgary, 1403 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada
| | - Kiran Rabheru
- Geriatric Psychiatry & ECT Program, Department of Psychiatry, The Ottawa Hospital, University of Ottawa, 75 Bruyere Street, Suite 137 Y, Ottawa, Ontario K1N 5C7, Canada
| | - Mark J Rapoport
- Department of Psychiatry, Faculty of Medicine, University of Toronto, 250 College Street, Toronto, ON, M5T 1R8, Canada; Sunnybrook Health Sciences Centre, FG37-2075 Bayview Avenue, Toronto, Ontario M4C 5N6, Canada
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Mancini M, Wade AG, Perugi G, Lenox-Smith A, Schacht A. Impact of patient selection and study characteristics on signal detection in placebo-controlled trials with antidepressants. J Psychiatr Res 2014; 51:21-9. [PMID: 24462042 DOI: 10.1016/j.jpsychires.2014.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/06/2013] [Accepted: 01/03/2014] [Indexed: 12/19/2022]
Abstract
An increasing rate of antidepressant trials fail due to large placebo responses. This analysis aimed to identify variables influencing signal detection in clinical trials of major depressive disorder. Patient-level data of randomized patients with a duloxetine dose ≥ 60 mg/day were obtained from Lilly. Total scores of the Hamilton Depression Rating scale (HAM-D) were used as efficacy endpoints. In total, 4661 patients from 14 studies were included in the analysis. The overall effect size (ES), based on the HAM-D total score at endpoint, between duloxetine and placebo was -0.272. Although no statistically significant interactions were found, the following results for factors influencing ES were seen: a very low ES (-0.157) in patients in the lowest baseline HAM-D category and in patients recruited in the last category of the recruitment period (-0.122). A higher ES in patients recruited in centers with a site-size at but not more than 2.5 times the average site-size for the study (-0.345). Study characteristics that resulted in low signal detection in our database were: <80% study completers, a HAM-D placebo response >5 points, a high variability of placebo response (SD > 7 points HAM-D), >6 post baseline visits per study, and use of an active control drug. Simpler trial designs, more homogeneous and mid-sized study sites, a primary analysis based on a higher cutoff blinded to investigators to avoid the influence of score inflation in mild patients and, if possible, studies without an active control group could lead to a better signal detection of antidepressive efficacy.
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Affiliation(s)
- Michele Mancini
- Eli Lilly Italia S.p.A., Neuroscience, Via A. Gramsci 731/733, 50019 Sesto Fiorentino, FI, Italy.
| | | | - Giulio Perugi
- University of Pisa, Institute of Psychiatry, Pisa, Italy
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Dhillon S. Duloxetine: a review of its use in the management of major depressive disorder in older adults. Drugs Aging 2014; 30:59-79. [PMID: 23239363 DOI: 10.1007/s40266-012-0040-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Duloxetine (Cymbalta(®)) is a selective serotonin norepinephrine reuptake inhibitor indicated for the treatment of major depressive disorder (MDD). This article reviews the therapeutic efficacy and tolerability of duloxetine in older adults with MDD and summarizes its pharmacological properties. Treatment with duloxetine significantly improved several measures of cognition, depression, anxiety, pain and health-related quality-of-life (HR-QOL) in older adults with MDD in two 8-week, double-blind, placebo-controlled trials. However, no significant improvements in measures of depression were observed at week 12 (primary endpoint) of a 24-week, double-blind trial, although symptoms of depression did improve significantly at earlier timepoints. Benefit of treatment was also observed during continued therapy in the 24-week study (i.e. after the 12-week primary endpoint) and in an open-label, 52-week study, with improvements being observed in some measures of depression, pain and HR-QOL. Duloxetine was generally well tolerated in these studies, with nausea, dizziness and adverse events reflecting noradrenergic activity (e.g. dry mouth, constipation) being the most common treatment-emergent adverse events during treatment for up to 52 weeks. Duloxetine therapy had little effect on cardiovascular parameters and bodyweight. Although further well designed and long-term studies in this patient population are required to confirm the efficacy of duloxetine and to compare it with that of other antidepressants, current evidence suggests that treatment with duloxetine may be beneficial in older adults with MDD.
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Affiliation(s)
- Sohita Dhillon
- Adis, 41 Centorian Drive, Mairangi Bay, Private Bag 65901, North Shore, Auckland, New Zealand.
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Devanand DP, Roose SP. Antidepressants in older adults: complexities, confounds and clinical effects. Am J Geriatr Psychiatry 2014; 22:1-3. [PMID: 24314886 DOI: 10.1016/j.jagp.2013.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 09/19/2013] [Indexed: 10/25/2022]
Affiliation(s)
- D P Devanand
- Division of Geriatric Psychiatry, Columbia University, New York, NY.
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Altin M, Harada E, Schacht A, Berggren L, Walker D, Dueñas H. Does Early Improvement in Anxiety Symptoms in Patients with Major Depressive Disorder Affect Remission Rates? A Post-Hoc Analysis of Pooled Duloxetine Clinic Trials. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojd.2014.33015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hahn M, Raithel M, Hagel A, Biermann T, Manger B. Chronic calcium pyrophosphate crystal inflammatory arthritis induced by extreme hypomagnesemia in short bowel syndrome. BMC Gastroenterol 2012; 12:129. [PMID: 22998213 PMCID: PMC3527343 DOI: 10.1186/1471-230x-12-129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 09/19/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Short bowel syndrome (SBS) may induce a plethora of clinical symptoms ranging from underweight to nutrient-, vitamin- and electrolyte deficiencies. The objective of this case report is to illustrate how demanding the management of a 60 year old patient with SBS and recurrent joint attacks was for different medical disciplines. CASE PRESENTATION The patient with SBS presented with a body mass index of 16.5 kg/m2 after partial jejunoileal resection of the small intestine with a six year long history of recurrent pain attacks in multiple peripheral joints, chronic diarrhoea and food intolerances. Pain attacks occurred 4-5 times a week with a median consumption of 15 mg prednisone per day. The interdisciplinary workup after several gastroenterologic, rheumatologic, radiologic, psychiatric and orthopedic consultations is shown including successful treatment steps.Clinical diagnosis revealed no systemic inflammatory disease, but confirmed extreme hypomagnesemia (0.2 mmol/l) after reproducible pathological magnesium resorption tests as causative for chronic calcium pyrophosphate crystal inflammatory arthritis (pseudogout, chondrocalcinosis).Multidisciplinary treatment included application of colchicines, parenteral nutrition and magnesium substitution, antiperistaltic agents and avoidance of intolerant foods. Normalization of magnesium levels and a marked remission of joint attacks were achieved after six months with significant reduction of prednisone to 1.5 mg/day. CONCLUSION Despite the rarity of this condition, it is important to know that hypomagnesaemia may be associated with calcium pyrophosphate crystal inflammatory arthritis (chondrocalcinosis) and that SBS patients may be prone to develop extreme hypomagnesaemia causing recurrent joint attacks without systemic inflammation.
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Affiliation(s)
- Markus Hahn
- Department of Medicine I, Gastroenterology, University Erlangen-Nürnberg, Ulmenweg 18, Erlangen 91054, Germany
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