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Bio-behavioural changes in treatment-resistant socially isolated FSL rats show variable or improved response to combined fluoxetine-olanzapine versus olanzapine treatment. IBRO Neurosci Rep 2022; 13:284-298. [PMID: 36204253 PMCID: PMC9529672 DOI: 10.1016/j.ibneur.2022.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/14/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022] Open
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2
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Abstract
Commonly used medications can have neuropsychiatric and behavioral effects that may be idiosyncratic or metabolic in nature, or a function of interactions with other drugs, toxicity, or withdrawal. This article explores an approach to the patient with central nervous system toxicity, depending on presentation of sedation versus agitation and accompanying physical signs and symptoms. The effects of antihypertensives, opioids, antibiotics, antiepileptic agents, steroids, Parkinson's disease medications, antipsychotics, medications for human immunodeficiency virus infection, cancer chemotherapeutics, and immunotherapies are discussed. A look at the prevalence of adverse reactions to medications and the errors underlying such occurrences is included.
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Affiliation(s)
- Sai Krishna J Munjampalli
- Department of Neurology, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Debra E Davis
- Department of Neurology, Louisiana State University Health Sciences Center - Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.
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3
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Zaninotto L, Souery D, Calati R, Camardese G, Janiri L, Montgomery S, Kasper S, Zohar J, De Ronchi D, Mendlewicz J, Serretti A. Dimensions of Delusions in Major Depression: Socio-demographic and Clinical Correlates in an Unipolar-Bipolar Sample. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2015; 13:48-52. [PMID: 25912537 PMCID: PMC4423154 DOI: 10.9758/cpn.2015.13.1.48] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/23/2014] [Indexed: 12/18/2022]
Abstract
Objective The present study aims at exploring associations between a continuous measure of distorted thought contents and a set of demographic and clinical features in a sample of unipolar/bipolar depressed patients. Methods Our sample included 1,833 depressed subjects. Severity of mood symptoms was assessed by the 21 items Hamilton Depression Rating Scale (HAM-D). The continuous outcome measure was represented by a delusion (DEL) factor, extracted from HAM-D items and including items: 2 (“Feelings of guilt”), 15 (“Hypochondriasis”), and 20 (“Paranoid symptoms”). Each socio-demographic and clinical variable was tested by a generalized linear model test, having depressive severity (HAM-D score–DEL score) as the covariate. Results A family history of major depressive disorder (MDD; p=0.0006), a diagnosis of bipolar disorder, type I ( p=0.0003), a comorbid general anxiety disorder (p<0.0001), and a higher number of manic episodes during lifetime (p<0.0001), were all associated to higher DEL scores. Conversely, an older age at onset (p<0.0001) and a longer duration of hospitalization for depression over lifetime (p=0.0003) had a negative impact over DEL scores. On secondary analyses, only the presence of psychotic features (p<0.0001) and depressive severity (p<0.0001) were found to be independently associated to higher DEL scores. Conclusion The retrospective design and a non validated continuous measure for distorted thought contents were the main limitations of our study. Excluding the presence of psychotic features and depressive severity, no socio-demographic or clinical variable was found to be associated to our continuous measure of distorted thinking in depression.
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Affiliation(s)
- Leonardo Zaninotto
- Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart, Rome.,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Daniel Souery
- Laboratoire de Psychologie Medicale, Université Libre de Bruxelles and Psy Pluriel, Centre Européen de Psychologie Medicale, Brussels, Belgium
| | - Raffaella Calati
- IRCCS Centro S. Giovanni di Dio, Fatebenefratelli, Brescia, Italy
| | - Giovanni Camardese
- Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart, Rome
| | - Luigi Janiri
- Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart, Rome
| | | | - Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Joseph Zohar
- Anxiety and Obsessive Compulsive Clinic, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Diana De Ronchi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Julien Mendlewicz
- Laboratoire de Recherches Psychiatriques, Université Libre de Bruxelles, Brussels, Belgium
| | - Alessandro Serretti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
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Jacobsen FM. Second-generation antipsychotics and tardive syndromes in affective illness: a public health problem with neuropsychiatric consequences. Am J Public Health 2014; 105:e10-6. [PMID: 25521884 DOI: 10.2105/ajph.2014.302439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Food and Drug Administration-approved information and public advertisements belie neurodegenerative risks for second-generation antipsychotics in affective illness. Package inserts label tardive syndromes "potentially reversible" while uniformly omitting patient counseling for long-term neurodegenerative side effects. I found that only 2 of 78 outpatients exposed to second-generation antipsychotics reported awareness of tardive syndromes. Updated literature challenges safety advantages of atypical versus typical antipsychotics. Physician and patient information regarding tardive syndromes from second-generation antipsychotics approved for affective illness is inadequate.
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Affiliation(s)
- Frederick M Jacobsen
- Frederick M. Jacobsen is with the Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC, and the Pharmacy and Therapeutics Committee, George Washington University Hospital, Washington, DC
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Abstract
Psychotic depression is associated with significant morbidity and mortality but is underdiagnosed and undertreated. In recent years, there have been several studies that have increased our knowledge regarding the optimal treatment of patients with psychotic depression. The combination of an antidepressant and antipsychotic is significantly more effective than either antidepressant monotherapy or antipsychotic monotherapy for the acute treatment of psychotic depression. Most treatment guidelines recommend either the combination of an antidepressant with an antipsychotic or ECT for the treatment of an acute episode of unipolar psychotic depression. The optimal maintenance treatment after a person responds to either the antidepressant/antipsychotic combination or the ECT is unclear particularly as it pertains to length of time the patient needs to take the antipsychotic medication. Little is known regarding the optimal treatment of a patient with bipolar disorder who has an episode of psychotic depression or the clinical characteristics of responders to medication treatments vs ECT treatments.
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Affiliation(s)
- Anthony J. Rothschild
- *To whom correspondence should be addressed; 361 Plantation Street, Worcester, MA 01605, US; tel: (508) 856-1027, fax: (508) 856-4854, e-mail:
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Gaudiano BA, Nowlan K, Brown LA, Epstein-Lubow G, Miller IW. An open trial of a new acceptance-based behavioral treatment for major depression with psychotic features. Behav Modif 2013; 37:324-55. [PMID: 23223385 PMCID: PMC4049629 DOI: 10.1177/0145445512465173] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Research suggests that cognitive and behavioral therapies produce significant benefits over medications alone in the treatment of severe, nonpsychotic major depression or primary psychotic disorders such as schizophrenia. However, previous research has not demonstrated the efficacy of psychotherapy for major depression with psychotic features. In this initial treatment development study, we conducted an open trial of a new behavioral intervention that combines elements of behavioral activation and acceptance and commitment therapy for depression and psychosis. Fourteen patients with major depressive disorder with psychotic features were provided with up to 6 months of Acceptance-Based Depression and Psychosis Therapy (ADAPT) in combination with pharmacotherapy. Patients reported a high degree of treatment credibility and acceptability. Results showed that patients achieved clinically significant and sustained improvements through posttreatment follow-up in depressive and psychotic symptoms, as well as psychosocial functioning. In addition, the processes targeted by the intervention (e.g., acceptance, mindfulness, values) improved significantly over the course of treatment, and changes in processes were correlated with changes in symptoms. Results suggest that ADAPT combined with pharmacotherapy is a promising treatment approach for psychotic depression that should be tested in a future randomized trial.
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7
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Does the dexamethasone suppression test reliably discriminate between psychotic and nonpsychotic major depression?: an exploratory analysis of potential confounds. J Nerv Ment Dis 2009; 197:395-400. [PMID: 19525738 PMCID: PMC3676665 DOI: 10.1097/nmd.0b013e3181a775cf] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Previous research has shown that psychotic major depression (PMD) is often associated with higher rates of nonsuppression on the dexamethasone suppression test (DST) compared with nonpsychotic major depression (NMD), suggesting the potential importance of cortisol hypersecretion in the psychotic subtype of the disorder. However, these patient groups also are known to differ from one another on a variety of other clinical variables, and there are numerous factors independent of diagnostic status known to affect the DST. Thus, we investigated possible confounds that could help account for the apparent DST abnormalities in PMD sometimes reported in past research. Hospitalized patients with PMD (n = 11) and NMD (n = 58) were compared on the DST and other clinical variables. As expected, PMD patients showed significantly higher rates of DST nonsuppression (55% vs. 24%; p = 0.04). However, PMD patients also had significantly higher levels of anxiety severity (p = 0.01). The higher rates of nonsuppression in the PMD group were attenuated when these patients were compared with a subsample of NMD patients matched on anxiety severity (55% vs. 55%). Implications for future research on biological markers of PMD are discussed.
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Fleck MP, Berlim MT, Lafer B, Sougey EB, Del Porto JA, Brasil MA, Juruena MF, Hetem LA. [Review of the guidelines of the Brazilian Medical Association for the treatment of depression (Complete version)]. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2009; 31 Suppl 1:S7-17. [PMID: 19565151 DOI: 10.1590/s1516-44462009000500003] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Depression is a frequent, recurrent and chronic condition with high levels of functional disability. The Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present a review of the Guidelines Published in 2003 incorporating new evidence and recommendations. METHOD This review was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. The Brazilian Medical Association proposed this methodology for the whole project. The review was developed from new international guidelines published since 2003. RESULTS The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Strategies for different phases of treatment are also discussed. CONCLUSION The Guidelines are an important tool for clinical decisions and a reference for orientation based on the available evidence in the literature.
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Affiliation(s)
- Marcelo P Fleck
- Departamento de Psiquiatria e Medicina Legal, Universidade Federal do Rio Grande do Sul, and Programa de Transtornos de Humor, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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9
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Gaudiano BA, Dalrymple KL, Zimmerman M. Prevalence and clinical characteristics of psychotic versus nonpsychotic major depression in a general psychiatric outpatient clinic. Depress Anxiety 2009; 26:54-64. [PMID: 18781658 PMCID: PMC3111977 DOI: 10.1002/da.20470] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Psychotic major depression (PMD) is a severe mental disorder characterized by high levels of illness severity, chronicity, impairment, and treatment resistance. However, most past research on PMD has been conducted in inpatient hospital samples, and relatively little is known about PMD patients presenting for treatment in the community specifically. METHODS In this study, we examined the prevalence and clinical characteristics of PMD in a large sample (n=2,500) of treatment-seeking outpatients who were administered structured clinical interviews by trained diagnosticians. RESULTS Of the patients diagnosed with major depression, 5.3% had psychotic features. PMD patients were more likely to be members of a racial/ethnic minority and to have lower educational attainment compared to those with nonpsychotic major depression. In addition, PMD patients were found to have greater current depression severity, suicidal ideation, and social and work impairment. These patients also were more likely to have histories of suicide attempts and psychiatric hospitalizations, to report an earlier age of illness onset, and to meet criteria for chronic depression. In terms of psychiatric comorbidity, PMD patients had higher rates of certain anxiety disorders as well as more somatoform and cluster A personality disorders. CONCLUSIONS Results indicated that PMD was present in a relatively small percentage of treatment-seeking outpatients but was associated with disproportionately high levels of severity and impairment. Similarities and differences between the current findings and those from past research are discussed, including clinical implications for the identification and treatment of PMD in routine practice settings.
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Affiliation(s)
- Brandon A. Gaudiano
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island,Psychosocial Research Program, Butler Hospital, Providence, Rhode Island,Correspondence to: Brandon A. Gaudiano, Butler Hospital, Psychosocial Research Program, 345 Blackstone Boulevard, Providence, Rhode Island 02906.
| | - Kristy L. Dalrymple
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island,Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island
| | - Mark Zimmerman
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island,Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island
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Hamoda HM, Osser DN. The Psychopharmacology Algorithm Project at the Harvard South Shore Program: an update on psychotic depression. Harv Rev Psychiatry 2008; 16:235-47. [PMID: 18661366 DOI: 10.1080/10673220802277904] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This new version of the psychotic depression algorithm has been developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The most effective treatment modality for inpatients with severe psychotic depression is electroconvulsive therapy. The first-line psychopharmacological treatment is a combination of an antidepressant (either a tricyclic or a selective serotonin reuptake inhibitor) and an antipsychotic. If one of these combinations has failed, consider switching to the other. If both combinations have failed, the next psychopharmacological option would be to augment the combination with lithium. Another option, though with limited evidence, is monotherapy with clozapine. If there is a good reason to avoid combination therapy with an antipsychotic, then a trial of monotherapy with a TCA or an SSRI can be supported. If that fails, adding an antipsychotic or ECT should be considered.
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Affiliation(s)
- Hesham M Hamoda
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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11
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Baghai TC, Möller HJ. Electroconvulsive therapy and its different indications. DIALOGUES IN CLINICAL NEUROSCIENCE 2008. [PMID: 18472488 PMCID: PMC3181862 DOI: 10.31887/dcns.2008.10.1/tcbaghai] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In spite of recent developments in the pharmacotherapy of depressive disorders, the delay until clinical improvement can be achieved, and the considerable rate of nonresponse and nonremission, are major problems which remain unresolved. Electroconvulsive therapy (ECT) is a nonpharmacologic biological treatment which has been proven to be a highly effective treatment option, predominantly for depression, but also for schizophrenia and other indications. Though there is a lack of controlled investigations on long-term treatments, ECT can also be used for relapse prevention during maintenance therapies. The safety and tolerability of electroconvulsive treatment have been enhanced by the use of modified stimulation techniques and by progress in modern anesthesia. Thus, today a safe treatment can also be offered to patients with higher somatic risks. ECT still represents an important option, especially in the therapy of treatment-resistant psychiatric disorders after medication treatment failures. Earlier consideration of ECT may reduce the rate of chronic and difficult-to-treat psychiatric disorders.
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Affiliation(s)
- Thomas C Baghai
- Dept of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Germany.
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12
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Depressive symptom profiles and severity patterns in outpatients with psychotic vs nonpsychotic major depression. Compr Psychiatry 2008; 49:421-9. [PMID: 18702928 PMCID: PMC2601715 DOI: 10.1016/j.comppsych.2008.02.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 02/10/2008] [Accepted: 02/14/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Previous research suggests that patients with psychotic major depression (PMD) may differ from those with nonpsychotic major depression (NMD) not only in psychotic features but also in their depressive symptom presentation. The present study contrasted the rates and severity of depressive symptoms in outpatients diagnosed with PMD vs NMD. METHOD The sample consisted of 1112 patients diagnosed with major depression, of which 60 (5.3%) exhibited psychotic features. Depressive symptoms were assessed by trained diagnosticians at intake using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and supplemented by severity items from the Schedule for Affective Disorders and Schizophrenia. RESULTS Patients with PMD were more likely to endorse the presence of weight loss, insomnia, psychomotor agitation, indecisiveness, and suicidality compared with NMD patients. Furthermore, PMD patients showed higher levels of severity on several depressive symptoms, including depressed mood, appetite loss, insomnia, psychomotor disturbances (agitation and retardation), fatigue, worthlessness, guilt, cognitive disturbances (concentration and indecisiveness), hopelessness, and suicidal ideation. The presence of psychomotor disturbance, insomnia, indecisiveness, and suicidal ideation was predictive of diagnostic status even after controlling for the effects of demographic characteristics and other symptoms. CONCLUSIONS These findings are consistent with past research suggesting that PMD is characterized by a unique depressive symptom profile in addition to psychotic features and higher levels of overall depression severity. The identification of specific depressive symptoms in addition to delusions/hallucinations that can differentiate PMD vs NMD patients can aid in the early detection of the disorder. These investigations also provide insights into potential treatment targets for this high-risk population.
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Gaudiano BA, Miller IW, Herbert JD. The treatment of psychotic major depression: is there a role for adjunctive psychotherapy? PSYCHOTHERAPY AND PSYCHOSOMATICS 2007; 76:271-7. [PMID: 17700047 DOI: 10.1159/000104703] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Psychotic depression is a relatively prevalent mood disorder associated with greater symptom severity, a poorer course of illness and higher levels of functional impairment compared with nonpsychotic depression. Separate lines of investigation suggest that various forms of cognitive-behavioral therapy are efficacious for treating severe forms of nonpsychotic depression as well as primary psychotic disorders. However, there currently are no empirically supported psychotherapies specifically designed for treating psychotic depression. METHOD We review the efficacy of current somatic treatments for the disorder and discuss the limited data to date on potentially useful psychotherapeutic approaches. In particular, we describe the clinical improvement observed in a subgroup of hospitalized patients with psychotic depression treated with Acceptance and Commitment Therapy as part of a larger clinical trial. RESULTS Pilot results demonstrated that Acceptance and Commitment Therapy was associated with clinically significant reductions in acute symptom severity and impairment compared with treatment as usual. CONCLUSION The findings suggest that patients with psychotic depression can benefit from psychotherapy. Clinical and research recommendations in this area are presented.
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Affiliation(s)
- Brandon A Gaudiano
- Department of Psychiatry and Human Behavior, Brown Medical School and Butler Hospital, Providence, RI 02906, USA.
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Gaudiano BA, Miller IW. Dysfunctional cognitions in hospitalized patients with psychotic versus nonpsychotic major depression. Compr Psychiatry 2007; 48:357-65. [PMID: 17560957 DOI: 10.1016/j.comppsych.2007.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 03/12/2007] [Accepted: 03/12/2007] [Indexed: 10/23/2022] Open
Abstract
Previous research suggests that psychotic major depression (PMD) is associated with greater illness severity and functional impairment as well as poorer treatment response to antidepressants and psychotherapies compared with nonpsychotic major depression. Although patients with PMD exhibit a number of neurobiological abnormalities, little research has been conducted to date on possible psychological factors that are related to illness in this depression subtype. In the current study, baseline data were pooled from 2 clinical trials in which depressed patients (n = 235) were recruited during a psychiatric hospitalization for an acute episode. Twelve percent (n = 28) of this treatment-seeking sample met criteria for PMD and showed elevated levels of depression severity and dysfunctional beliefs compared with individuals with nonpsychotic major depression. However, even after controlling for depression severity and other relevant baseline variables, only a measure of common dysfunctional beliefs differentiated those with vs those without psychotic features. Furthermore, higher levels of depressive cognitions were related to poorer psychosocial functioning and suicidality in PMD patients. Results suggest that elevated levels of common negative cognitions in depressed patients may be associated with the presence of more severe psychotic symptoms. Adapted cognitive-behavioral treatments may be useful for treating patients with PMD specifically.
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Affiliation(s)
- Brandon A Gaudiano
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island 02906, USA.
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Nemeroff CB, Lieberman JA, Weiden PJ, Harvey PD, Newcomer JW, Schatzberg AF, Kilts CD, Daniel DG. From clinical research to clinical practice: a 4-year review of ziprasidone. CNS Spectr 2005; 10:1-20. [PMID: 16381088 DOI: 10.1017/s1092852900019842] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ziprasidone is a second-generation antipsychotic that received Food and Drug Administration approval in February 2001. It has a unique receptor profile that includes high-affinity antagonist activity at dopamine D2 receptors, inverse agonist activity at serotonin (5-HT)2A receptors, agonist activity at 5-HTlA receptors, and a relatively high affinity for the serotonin and norepinephrine transporters. The 5-HTIA affinity, together with the inhibitory effect on mono-amine reuptake, may underlie the hypothesized beneficial effects on comorbid affective and cognitive abnormalities in schizophrenia and schizoaffective disorder. The short-term efficacy of ziprasidone for core positive symptoms of schizophrenia appears to be comparable to other conventional and atypical antipsychotics. The short-term efficacy of ziprasidone in acute mania has been established based on two 3-week, double-blind, placebo-controlled trials.Open-label treatment for up to 52 weeks confirms the sustained efficacy and safety of ziprasidone in bipolar disorder. Maintenance studies in schizophrenia and schizoaffective disorder indicate that long-term ziprasidone therapy is effective in preventing relapse, while maintaining cognitive and psychosocial benefits. The safety database suggests that the overall cardiovascular and cerebrovascular risk associated with ziprasidone is lower than with other atypicals, with notably lower risk of drug-related increases in weight, glucose, or lipids. The data also suggest a modestly increased risk of QTc prolongation that is not dose related or linked to torsades de pointes. Switching to ziprasidone from other atypicals appears to improve both clinical symptoms and metabolic parameters, though more studies are needed to fully characterize these benefits. This monograph summarizes the efficacy, tolerability, and safety of oral ziprasidone in the treatment of schizophrenia, schizoaffective disorder, and bipolar mania.
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Affiliation(s)
- Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322, USA.
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Abstract
This article discusses current practices in the treatment of bipolar depression. In the absence of more definitive research, the treatment of bipolar depression is guided by clinical experience and expert opinion, and sometimes by marketing and popular trends, as much as it is by hard data. Considering the limitations of current knowledge is an essential component of the scientific practice of psychiatry.
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Affiliation(s)
- Steven L Dubovsky
- Department of Psychiatry, State University of New York at Buffalo, 462 Grider Street, Buffalo, NY 14215, USA.
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Rothschild AJ, Williamson DJ, Tohen MF, Schatzberg A, Andersen SW, Van Campen LE, Sanger TM, Tollefson GD. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol 2004; 24:365-73. [PMID: 15232326 DOI: 10.1097/01.jcp.0000130557.08996.7a] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to compare the efficacy and safety of olanzapine (OLZ) monotherapy and an olanzapine/fluoxetine combination (OFC) with placebo (PLA) for unipolar major depression with psychotic features. Under a single protocol, two 8-week, double-blind trials were conducted at 27 sites. Patients (n = 124 trial 1, n = 125 trial 2) were randomized to 1 of 3 treatment groups: OLZ (5 to 20 mg/d), PLA, or OFC (olanzapine 5 to 20 mg/d + fluoxetine 20 to 80 mg/d). The primary outcome measure was the 24-item Hamilton Depression Rating Scale total score. For trial 1, endpoint improvement for the OLZ group (-14.9) was not significantly different from the PLA or OFC groups. The OFC group had significantly greater endpoint improvement (-20.9) than the PLA group (-10.4, P = 0.001); this significant difference was present within 7 days of therapy and maintained at every subsequent visit. The OFC group also had significantly higher response rate (63.6%) than the PLA (28.0%, P = 0.004) or OLZ (34.9%, P = 0.027) groups. For trial 2, there were no significant differences among treatment groups on the 24-item Hamilton Depression Rating Scale total scores or response rates. The combination exhibited a comparable safety profile with OLZ monotherapy and no significant increases in extrapyramidal symptoms compared with placebo. Patients with major depression with psychotic features treated with OLZ monotherapy did not demonstrate significant depressive symptom improvement compared with placebo in either trial; however, an olanzapine/fluoxetine combination was associated with significant improvement compared with placebo in one trial and was well tolerated.
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Affiliation(s)
- Anthony J Rothschild
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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18
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Koch S, Perry KW, Bymaster FP. Brain region and dose effects of an olanzapine/fluoxetine combination on extracellular monoamine concentrations in the rat. Neuropharmacology 2004; 46:232-42. [PMID: 14680761 DOI: 10.1016/j.neuropharm.2003.09.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Clinical studies of patients with treatment-resistant depression have shown that combined treatment with fluoxetine and olanzapine rapidly and significantly improved depressive symptoms. The present study used in vivo microdialysis to investigate the brain regional and dose effects of these drugs on extracellular monoamine concentrations in the rat prefrontal cortex, hypothalamus, nucleus accumbens and striatum. In the prefrontal cortex, the olanzapine/fluoxetine combination (3/10 mg/kg, respectively) increased catecholamine concentrations to a significantly greater extent than either drug alone (dopamine mean+/-S.E.M. percent of baseline: olanzapine (120 +/- 12.4), fluoxetine (123 +/- 6.2), combination (185 +/- 8.8); norepinephrine: olanzapine (124 +/- 7.2), fluoxetine (126 +/- 5.0), combination (215 +/- 15.8)). The combination also increased serotonin concentrations to 156 +/- 11.0% of baseline, but to a lesser extent than fluoxetine alone (210 +/- 14.5%). Similar synergistic effects of the combination were observed in the hypothalamus, but not in the other regions studied. The dose response effects of the drugs alone and in combination were complex, but larger doses of the combinations produced greater monoamine concentration increases than smaller dose combinations. The effects of the olanzapine/fluoxetine combination are meaningful in prefrontal cortex and hypothalamus due to their hypothesized role in the etiology and pharmacotherapy of depression. The wide-ranging neurochemical effects of this drug combination may make it particularly useful as a treatment for complex, resistant depressions.
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Affiliation(s)
- Susanne Koch
- Neuroscience Research Division, Lilly Research Laboratories, Lilly Corporate Center, Indianapolis, IN 46285-0510, USA
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Fleck MPDA, Lafer B, Sougey EB, Del Porto JA, Brasil MA, Juruena MF. [Guidelines of the Brazilian Medical Association for the treatment of depression (complete version)]. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2003; 25:114-22. [PMID: 12975710 DOI: 10.1590/s1516-44462003000200013] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Depression is a frequent and chronic condition with high levels of functional disability. Brazilian Medical Association Guidelines project proposed guidelines for diagnosis and treatment of the most common medical disorders. The objective of this paper is to present the original document that originated the abbreviated version available at the electronic address of Brazilian Medical Association. METHODS This paper was based on guidelines developed in other countries and systematic reviews, randomized clinical trials and when absent, observational studies and recommendations from experts. Brazilian Medical Association proposed this methodology for the whole project. RESULTS The following aspects are presented: prevalence, demographics, disability, diagnostics and sub-diagnosis, efficacy of pharmacological and psychotherapeutic treatment, costs and side-effects of different classes of available drugs in Brazil. Planning of different phases of treatment is22 also discussed. CONCLUSIONS Guidelines are a good tool helping clinical decisions and are a reference for an attitude based on levels of evidence.
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Affiliation(s)
- Marcelo Pio de Almeida Fleck
- Programa de Transtornos de Humor do Hospital de Clínicas de Porto Alegre. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil.
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Abstract
Major depression with psychotic features (MDpsy), a disorder with considerable morbidity and mortality, is more common than is generally realized and is a most difficult form of depression to treat. Patients with MDpsy exhibit more frequent relapses and recurrences and have increased use of services, greater disability, and a poorer clinical course when compared with nonpsychotically depressed patients. Patients with MDpsy demonstrate distinct biological abnormalities in studies of the hypothalamic-pituitary-adrenal (HPA) axis, dopaminergic activity, enzyme studies, brain imaging, electroencephalogram sleep profiles, and measures of serotonergic function when compared with nonpsychotic depression. The social and occupational impairment in MDpsy has been hypothesized to be secondary to subtle cognitive deficits caused by the higher cortisol levels frequently observed in MDpsy patients. Several studies support a relationship between bipolar disorder and MDpsy, particularly in young-onset MDpsy. The most efficacious treatments for MDpsy include the combination of an antidepressant and an antipsychotic, amoxapine, or electroconvulsive therapy. Atypical antipsychotic medications may have particular relevance for the treatment of MDpsy because of the potential for reduced risk of extrapyramidal side effects and tardive dyskinesia, as well as antipsychotic and possibly antidepressant qualities. Based on the observations that MDpsy patients exhibit marked dysregulation of the HPA axis and elevated cortisol levels, several antiglucocorticoid strategies have been employed to treat MDpsy patients. Many questions regarding the acute and long-term treatment of MDpsy remain for future studies to address.
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Affiliation(s)
- Anthony J Rothschild
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA
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Abstract
The term 'mood stabilizer' has been applied to a number of medications for the treatment of patients with bipolar disorder. The operational definition of the properties of a mood-stabilizing medication has varied according to the properties of specific medications and the clinical characteristics of the illness. Randomized controlled trials of agents accepted or proposed as mood stabilizers are reviewed to marshall the available evidence in support of this claim. In addition, potential pharmacological mechanisms underlying mood-stabilizing effects of established compounds are reviewed.
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Affiliation(s)
- P E Keck
- Biological Psychiatry Program, Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0559, USA.
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22
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Hausmann A, Fleischhacker WW. Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review. Acta Psychiatr Scand 2002; 106:83-96. [PMID: 12121205 DOI: 10.1034/j.1600-0447.2002.02120.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To review the available literature on depressive symptomatology in schizophrenia in order to establish a diagnostic algorithm of depressive syndromes in schizophrenia. METHOD A literature search was performed using PubMed and Medline. Additional information was gained by cross-referencing from papers found in the database. Data from controlled studies as well as supplementary information from review articles and psychiatric manuals pertinent to the topic were used. Depressive symptoms were classified with respect to their temporal relationship to acute psychotic symptoms before the background of nosological entities as operationalized by Diagnostic Statistical Manual IV (DSM IV). RESULTS Depression is a common and devastating comorbid syndrome in patients suffering from schizophrenic disorder. The paper summarizes the relevant diagnostic steps to guide the clinician towards therapeutic interventions, which differ depending on the nature of the depressive syndrome. CONCLUSION Differentiating depressives states in schizophrenia has consequences in terms of choosing therapeutic strategies. An algorithm which leads the practitioner to a reliable diagnosis and in consequence to a valid therapy is presented.
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Affiliation(s)
- A Hausmann
- Department of General Psychiatry, Innsbruck University Hospital, Innsbruck, Austria.
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23
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Cubells JF, Price LH, Meyers BS, Anderson GM, Zabetian CP, Alexopoulos GS, Nelson JC, Sanacora G, Kirwin P, Carpenter L, Malison RT, Gelernter J. Genotype-controlled analysis of plasma dopamine beta-hydroxylase activity in psychotic unipolar major depression. Biol Psychiatry 2002; 51:358-64. [PMID: 11904129 DOI: 10.1016/s0006-3223(01)01349-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Plasma activity of dopamine beta-hydroxylase (DbetaH), the enzyme that converts dopamine to norepinephrine, is reportedly lower in patients with unipolar major depression with psychotic features (UDPF) than in those with nonpsychotic unipolar major depression (UD). Plasma DbetaH is under genetic control by the structural locus encoding DbetaH protein, DBH. This study tested the hypothesis that diagnosis-specific allelic variation at DBH accounts for lower plasma DbetaH in UDPF. METHODS Plasma DbetaH activity was measured in samples from patients with UDPF (n = 33) and UD (n = 45). Genotypes were determined at several functional DBH polymorphisms, including C-1021T, a single nucleotide polymorphism (SNP) in the proximal 5' region that associates with variation in plasma DbetaH activity. RESULTS Mean plasma DbetaH activity was significantly lower in UDPF than in UD. Genotyping at DBH did not reveal genetic associations distinguishing UDPF from UD. A two-way analysis of variance showed significant effects of genotype and diagnostic group but no significant interaction. CONCLUSIONS Although the effects of the diagnosis of UDPF, and of DBH allele status, on plasma DbetaH activity were replicated, the lower plasma DbetaH in patients with UDPF was not accounted for by DBH genotype. Several explanations for this result are possible. First, other variants at DBH, or at other loci, could account for the findings. Second, nongenetic factors could account for the differences in plasma DbetaH. In this regard, we hypothesize that abnormal regulation of hypothalamic-pituitary-adrenal function in UDPF lowers expression of DbetaH protein, which could in turn alter the ratio of dopamine and norepinephrine in noradrenergic neurons, thereby promoting development of psychotic symptoms.
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Affiliation(s)
- Joseph F Cubells
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06516, USA
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24
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Abstract
The atypical antipsychotics have a low incidence of extrapyramidal side effects (EPS), have improved tardive dyskinesia profiles, and have a broad range of therapeutic efficacy. These agents offer important therapeutic advantages that extend beyond their initial regulatory approval in several conditions and patient groups. The use of atypical antipsychotics is most relevant in the treatment of mood disorders, where these medications are being used increasingly for acute mood stabilization and in patients who are resistant to other treatments. Similar circumstances and clinical advantages pertain to the use of atypical antipsychotics in the treatment of behavioral disturbances in patients with dementia and in the management of personality disorders-both circumstances where conventional antipsychotics were initially poorly tolerated because of EPS. The low incidence of EPS associated with atypical antipsychotics is highly beneficial in several neuropsychiatric conditions. The extent to which endocrine and metabolic dysregulations associated with atypical antipsychotics will influence antipsychotics' role remains to be determined. As therapeutic opportunities evolve and diversify, atypical antipsychotics, because of favorable adverse-effect profiles, will have enhanced patient tolerability and use in nonpsychiatric conditions.
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Affiliation(s)
- P F Buckley
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta 30912, USA
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25
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Wheeler Vega JA, Mortimer AM, Tyson PJ. Somatic treatment of psychotic depression: review and recommendations for practice. J Clin Psychopharmacol 2000; 20:504-19. [PMID: 11001234 DOI: 10.1097/00004714-200010000-00003] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The diagnosis, classification, and course of psychotic major depression (PMD) is considered with regard to its status as a distinct syndrome. Several factors, especially biological markers, suggest, although as yet do not confirm, that PMD is distinct from nonpsychotic major depression (NPMD), particularly for the purposes of treatment. This article provides a critical review of somatic treatments for PMD, with attention to problems of inadequate treatment, as well as underused and more recently introduced treatments. The somatic treatment options reviewed include (1) combined antidepressant (AD) and antipsychotic (AP) therapy with tricyclic antidepressants (TCAs) and typical APs; (2) electroconvulsive therapy (ECT); (3) amoxapine; (4) selective serotonin reuptake inhibitors (SSRIs), alone and in combination; (5) several atypical APs, alone and in combination; (6) mood stabilizers and anticonvulsants; and (7) some experimental treatments and surgery. A comprehensive treatment algorithm (heuristic) is presented, which draws on some previous guidelines and the critical review. This heuristic is conservative in its aims, but forward-looking in its recommendations. The status of the TCA plus typical AP regime is challenged as the default first-line treatment, and preferable alternatives are discussed. ECT has been shown to be at least as effective in short-term treatment and should be considered more frequently, especially in severe presentations and as a maintenance treatment. Some single compounds should be considered as first-line monotherapies in less severe cases. For cases in which combined AD+AP regimes are instituted, SSRIs and atypical APs should be used before older classes of drugs are considered. These recommendations aim to minimize the number of treatments used and unwanted effects experienced.
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Abstract
Psychotic depression is characterized by greater severity, higher rate of recurrence, greater incapacitation, more frequent hospitalization, and longer episodes than nonpsychotic depression. The use of combined tricyclic antidepressants (TCAs) and neuroleptic therapy, as well as electroconvulsive therapy, has proven effectiveness in the treatment of psychotic depression. Although it is limited, evidence for efficacy of selective serontonin reuptake inhibitors both alone and in combination with antipsychotics in psychotic depression suggests that these strategies may provide a desirable alternative to the traditional TCA- neuroleptic therapy. These treatments, in addition to the continual introduction of new psychotropic agents suggest that the prospect of future research in this area is promising.
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Affiliation(s)
- B L O'Neal
- Depression and Anxiety Disorders Program, University of Texas Southwestern Medical Center at Dallas, St. Paul POB I, Suite 520, 5959 Harry Hines Boulevard, Dallas, TX 75390-9101, USA
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Zanardi R, Franchini L, Gasperini M, Lucca A, Smeraldi E, Perez J. Faster onset of action of fluvoxamine in combination with pindolol in the treatment of delusional depression: a controlled study. J Clin Psychopharmacol 1998; 18:441-6. [PMID: 9864075 DOI: 10.1097/00004714-199812000-00004] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This double-blind, controlled study was undertaken to investigate whether the addition of pindolol could improve the therapeutic response to fluvoxamine of depressed patients with psychotic features. After a 1-week placebo run-in period, 72 patients received fluvoxamine 300 mg/day in combination with placebo or pindolol 7.5 mg/day. At study completion, 28 (80%) of 35 patients treated with fluvoxamine plus placebo and 29 (80.5%) of 36 patients treated with fluvoxamine plus pindolol were categorized as responders (reduction of their score on the 21-item Hamilton Rating Scale for Depression to 8 or less and on the Dimension for the Delusional Experience Rating Scale to 0). In the third and fourth weeks, the response rates were significantly superior in the fluvoxamine plus pindolol group (p = 0.0001, p = 0.023, respectively). Treatment response seemed to be unrelated to the demographic and the clinical characteristics recorded. No significant difference was found comparing plasma levels of fluvoxamine between groups, thus excluding a pharmacokinetic interaction. Other than mild nausea and sedation in a few patients, treatments were well tolerated. No medically significant adverse events occurred. Depressed patients with psychotic features who were administered pindolol experienced a more rapid improvement during fluvoxamine treatment. Thus, the combination of fluvoxamine with pindolol may be a useful pharmacologic strategy in the treatment of this disorder. A rapid clinical response in such patients is of relevance in clinical practice as well as in economic fields, given the direct and indirect costs of depression.
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Affiliation(s)
- R Zanardi
- Istituto Scientifico Ospedale San Raffaele, Department of Neuropsychiatric Sciences, School of Medicine, University of Milan, Italy.
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