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Wang H, Wang K, Xue Q, Peng M, Yin L, Gu X, Leng H, Lu J, Liu H, Wang D, Xiao J, Sun Z, Li N, Dong K, Zhang Q, Zhan S, Fan C, Min B, Zhou A, Xie Y, Song H, Ye J, Liu A, Gao R, Huang L, Jiao L, Song Y, Dong H, Tian Z, Si T, Zhang X, Li X, Kamiya A, Cosci F, Gao K, Wang Y. Transcranial alternating current stimulation for treating depression: a randomized controlled trial. Brain 2022; 145:83-91. [PMID: 35353887 DOI: 10.1093/brain/awab252] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/08/2021] [Accepted: 06/15/2021] [Indexed: 11/12/2022] Open
Abstract
Treatment of depression with antidepressants is partly effective. Transcranial alternating current stimulation can provide a non-pharmacological alternative for adult patients with major depressive disorder. However, no study has used the stimulation to treat first-episode and drug-naïve patients with major depressive disorder. We used a randomized, double-blind, sham-controlled design to examine the clinical efficacy and safety of the stimulation in treating first-episode drug-naïve patients in a Chinese Han population. From 4 June 2018 to 30 December 2019, 100 patients were recruited and randomly assigned to receive 20 daily 40-min, 77.5 Hz, 15 mA, one forehead and two mastoid sessions of active or sham stimulation (n = 50 for each group) in four consecutive weeks (Week 4), and were followed for additional 4-week efficacy/safety assessment without stimulation (Week 8). The primary outcome was a remission rate defined as the 17-item Hamilton Depression Rating Scale (HDRS-17) score ≤ 7 at Week 8. Secondary analyses were response rates (defined as a reduction of ≥ 50% in the HDRS-17), changes in depressive symptoms and severity from baseline to Week 4 and Week 8, and rates of adverse events. Data were analysed in an intention-to-treat sample. Forty-nine in the active and 46 in the sham completed the study. Twenty-seven of 50 (54%) in the active treatment group and 9 of 50 (18%) in the sham group achieved remission at the end of Week 8. The remission rate was significantly higher in the active group compared to that in the sham group with a risk ratio of 1.78 (95% confidence interval, 1.29, 2.47). Compared with the sham, the active group had a significantly higher remission rate at Week 4, response rates at Weeks 4 and 8, and a larger reduction in depressive symptoms from baseline to Weeks 4 and 8. Adverse events were similar between the groups. In conclusion, the stimulation on the frontal cortex and two mastoids significantly improved symptoms in first-episode drug-naïve patients with major depressive disorder and may be considered as a non-pharmacological intervention for them in an outpatient setting.
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Affiliation(s)
- Hongxing Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China.,Institute of Sleep and Consciousness Disorders, Center of Epilepsy, Beijing Institute for Brain Disorders, Capital Medical University, Beijing 100053, China
| | - Kun Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China.,Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Qing Xue
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Mao Peng
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Lu Yin
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xuecun Gu
- Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Haixia Leng
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Juan Lu
- Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Hongzhi Liu
- Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Di Wang
- Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Jin Xiao
- Department of Neurology, Beijing Puren Hospital, Beijing 100062, China
| | - Zhichao Sun
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Ning Li
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Kai Dong
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Qian Zhang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Shuqin Zhan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Chunqiu Fan
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Baoquan Min
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Aihong Zhou
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Yunyan Xie
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Haiqing Song
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Jing Ye
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Aihua Liu
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Ran Gao
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Liyuan Huang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Lidong Jiao
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Yang Song
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Huiqing Dong
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
| | - Zichen Tian
- Department of Biology, Carleton College, Northfield, MN 55057, USA
| | - Tianmei Si
- Key Laboratory of Mental Health, Ministry of Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University Sixth Hospital and Peking University Institute of Mental Health, Beijing 100191, China
| | - Xiangyang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing 100101, China
| | - Xinmin Li
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Albert T6G 2B7, Canada
| | - Atsushi Kamiya
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore MD 21287, USA
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence 50135, Italy
| | - Keming Gao
- Department of Psychiatry, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA
| | - Yuping Wang
- Division of Neuropsychiatry and Psychosomatics, Department of Neurology, Beijing Psychosomatic Disease Consultation Center, Xuanwu Hospital, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Capital Medical University, Beijing 100053, China
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Gamma camera imaging in psychiatric disorders. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00222-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Prevention of Stress-Induced Depressive-like Behavior by Saffron Extract Is Associated with Modulation of Kynurenine Pathway and Monoamine Neurotransmission. Pharmaceutics 2021; 13:pharmaceutics13122155. [PMID: 34959434 PMCID: PMC8709346 DOI: 10.3390/pharmaceutics13122155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 12/28/2022] Open
Abstract
Depressive disorders are a major public health concern. Despite currently available treatment options, their prevalence steadily increases, and a high rate of therapeutic failure is often reported, together with important antidepressant-related side effects. This highlights the need to improve existing therapeutic strategies, including by using nutritional interventions. In that context, saffron recently received particular attention for its beneficial effects on mood, although the underlying mechanisms are poorly understood. This study investigated in mice the impact of a saffron extract (Safr’Inside™; 6.25 mg/kg, per os) on acute restraint stress (ARS)-induced depressive-like behavior and related neurobiological alterations, by focusing on hypothalamic–pituitary–adrenal axis, inflammation-related metabolic pathways, and monoaminergic systems, all known to be altered by stress and involved in depressive disorder pathophysiology. When given before stress onset, Safr’Inside administration attenuated ARS-induced depressive-like behavior in the forced swim test. Importantly, it concomitantly reversed several stress-induced monoamine dysregulations and modulated the expression of key enzymes of the kynurenine pathway, likely reducing kynurenine-related neurotoxicity. These results show that saffron pretreatment prevents the development of stress-induced depressive symptoms and improves our understanding about the underlying mechanisms, which is a central issue to validate the therapeutic relevance of nutritional interventions with saffron in depressed patients.
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Nagy G, Roodenrijs NMT, Welsing PMJ, Kedves M, Hamar A, van der Goes MC, Kent A, Bakkers M, Blaas E, Senolt L, Szekanecz Z, Choy E, Dougados M, Jacobs JWG, Geenen R, Bijlsma HWJ, Zink A, Aletaha D, Schoneveld L, van Riel P, Gutermann L, Prior Y, Nikiphorou E, Ferraccioli G, Schett G, Hyrich KL, Mueller-Ladner U, Buch MH, McInnes IB, van der Heijde D, van Laar JM. EULAR definition of difficult-to-treat rheumatoid arthritis. Ann Rheum Dis 2021; 80:31-35. [PMID: 33004335 PMCID: PMC7788062 DOI: 10.1136/annrheumdis-2020-217344] [Citation(s) in RCA: 213] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 06/27/2020] [Accepted: 08/06/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite treatment according to the current management recommendations, a significant proportion of patients with rheumatoid arthritis (RA) remain symptomatic. These patients can be considered to have 'difficult-to-treat RA'. However, uniform terminology and an appropriate definition are lacking. OBJECTIVE The Task Force in charge of the "Development of EULAR recommendations for the comprehensive management of difficult-to-treat rheumatoid arthritis" aims to create recommendations for this underserved patient group. Herein, we present the definition of difficult-to-treat RA, as the first step. METHODS The Steering Committee drafted a definition with suggested terminology based on an international survey among rheumatologists. This was discussed and amended by the Task Force, including rheumatologists, nurses, health professionals and patients, at a face-to-face meeting until sufficient agreement was reached (assessed through voting). RESULTS The following three criteria were agreed by all Task Force members as mandatory elements of the definition of difficult-to-treat RA: (1) Treatment according to European League Against Rheumatism (EULAR) recommendation and failure of ≥2 biological disease-modifying antirheumatic drugs (DMARDs)/targeted synthetic DMARDs (with different mechanisms of action) after failing conventional synthetic DMARD therapy (unless contraindicated); (2) presence of at least one of the following: at least moderate disease activity; signs and/or symptoms suggestive of active disease; inability to taper glucocorticoid treatment; rapid radiographic progression; RA symptoms that are causing a reduction in quality of life; and (3) the management of signs and/or symptoms is perceived as problematic by the rheumatologist and/or the patient. CONCLUSIONS The proposed EULAR definition for difficult-to-treat RA can be used in clinical practice, clinical trials and can form a basis for future research.
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Affiliation(s)
- György Nagy
- Department of Rheumatology, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary .,Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Nadia MT Roodenrijs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Paco MJ Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Melinda Kedves
- Department of Rheumatology, Bács-Kiskun County Hospital, Kecskemét, Hungary
| | - Attila Hamar
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Marlies C van der Goes
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands,Department of Rheumatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Alison Kent
- Salisbury Foundation Trust NHS Hospital, Wiltshire, UK
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Etienne Blaas
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ladislav Senolt
- Department of Rheumatology, 1st Faculty of Medicine, Charles University and Institute of Rheumatology, Prague, Czech Republic
| | - Zoltan Szekanecz
- Department of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ernest Choy
- CREATE Centre, Section of Rheumatology, School of Medicine, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Maxime Dougados
- Université de Paris Department of Rheumatology - Hôpital Cochin. Assistance Publique - Hôpitaux de Paris INSERM (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Johannes WG Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Rinie Geenen
- Department of Psychology, Utrecht University, Utrecht, the Netherlands
| | - Hans WJ Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Angela Zink
- Epidemiology Unit, German Rheumatism Research Centre, and Rheumatology, Charité, University Medicine, Berlin, Germany
| | - Daniel Aletaha
- Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Leonard Schoneveld
- Department of Rheumatology, Bravis Hospital, Roosendaal, the Netherlands
| | - Piet van Riel
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Loriane Gutermann
- Department of Pharmacy, Paris Descartes University, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Yeliz Prior
- School of Health and Society, Centre for Health Sciences Research, University of Salford, Salford, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University of Erlangen-Nuremberg and Universitatsklinikum Erlangen, Erlangen, Germany
| | - Kimme L Hyrich
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK,Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Maya H Buch
- NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK,Centre for Musculoskeletal Research, School of Biological Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK,Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Jacob M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Subtypes of treatment-resistant depression determined by a latent class analysis in a Chinese clinical population. J Affect Disord 2019; 249:82-89. [PMID: 30763799 DOI: 10.1016/j.jad.2019.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/19/2019] [Accepted: 02/05/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study aimed to explore subtypes of treatment-resistant depression (TRD). METHODS Latent class analysis (LCA) was performed on clinical and demographic data collected from 375 patients with TRD. Clinical variables were compared across subtypes. Treatment outcomes across subtypes of TRD were compared separately for those within each subtype with anxiety (those with a HRSD-17 anxiety/somatization factor score ≥ 7) and those without anxiety. LCA subtypes were compared using Cochran's and Mantel-Haenszel χ2 test, respectively. Unordered multinomial logistic regression was used to assess clinical correlates of TRD subtypes. RESULTS Three categories were detected: severe depression (66%), moderate depression with anxiety (9%) and mild depression with anxiety/somatization (25%). Gender, age, age at first onset, family monthly income, number of hospitalizations, HRSD-17 and clinical global impression-severity (CGI) scores were significantly different across the three groups. Remission rates were significantly different among anxious cases with severe (43.75%), moderate (22.73%) and mild (26.25%) depression subtypes. Compared to cases in the mild depression group, those in the severe depression group had a greater likelihood of being male, having a later age of first onset, higher numbers of hospitalization, higher HRSD-17 and CGI total scores, and lower family income. Those in the moderate depression group were more likely to be male and have lower family income than those in the mild depression group. LIMITATIONS Representative bias, relatively small sample size, unbalanced group size and incomplete indicator variables might have a negative effect on the validity and generalization of the findings. CONCLUSIONS Depression severity could be a basis for subtype classification of patients with TRD. The classification of latent class of TRD observed in our study was similar to the structure found in MDD. Longitudinal research into the stability of the latent structure of TRD across illness course is merited as is research into treatment outcomes for TRD subtypes.
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Yesavage JA, Fairchild JK, Mi Z, Biswas K, Davis-Karim A, Phibbs CS, Forman SD, Thase M, Williams LM, Etkin A, O’Hara R, Georgette G, Beale T, Huang GD, Noda A, George MS. Effect of Repetitive Transcranial Magnetic Stimulation on Treatment-Resistant Major Depression in US Veterans: A Randomized Clinical Trial. JAMA Psychiatry 2018; 75:884-893. [PMID: 29955803 PMCID: PMC6142912 DOI: 10.1001/jamapsychiatry.2018.1483] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Treatment-resistant major depression (TRMD) in veterans is a major clinical challenge given the high risk for suicidality in these patients. Repetitive transcranial magnetic stimulation (rTMS) offers the potential for a novel treatment modality for these veterans. OBJECTIVE To determine the efficacy of rTMS in the treatment of TRMD in veterans. DESIGN, SETTING, AND PARTICIPANTS A double-blind, sham-controlled randomized clinical trial was conducted from September 1, 2012, to December 31, 2016, in 9 Veterans Affairs medical centers. A total of 164 veterans with TRD participated. INTERVENTIONS Participants were randomized to either left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4000 pulses/session) or to sham (control) rTMS treatment for up to 30 treatment sessions. MAIN OUTCOMES AND MEASURES The primary dependent measure of the intention-to-treat analysis was remission rate (Hamilton Rating Scale for Depression score ≤10, indicating that depression is in remission and not a clinically significant burden), and secondary analyses were conducted on other indices of posttraumatic stress disorder, depression, hopelessness, suicidality, and quality of life. RESULTS The 164 participants had a mean (SD) age of 55.2 (12.4) years, 132 (80.5%) were men, and 126 (76.8%) were of white race. Of these, 81 were randomized to receive active rTMS and 83 to receive sham. For the primary analysis of remission, there was no significant effect of treatment (odds ratio, 1.16; 95% CI, 0.59-2.26; P = .67). At the end of the acute treatment phase, 33 of 81 (40.7%) of those in the active treatment group achieved remission of depressive symptoms compared with 31 of 83 (37.4%) of those in the sham treatment group. Overall, 64 of 164 (39.0%) of the participants achieved remission. CONCLUSIONS AND RELEVANCE A total of 39.0% of the veterans who participated in this trial experienced clinically significant improvement resulting in remission of depressive symptoms; however, there was no evidence of difference in remission rates between the active and sham treatments. These findings may reflect the importance of close clinical surveillance, rigorous monitoring of concomitant medication, and regular interaction with clinic staff in bringing about significant improvement in this treatment-resistant population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01191333.
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Affiliation(s)
- Jerome A. Yesavage
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - J. Kaci Fairchild
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Zhibao Mi
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, Maryland
| | - Kousick Biswas
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, Maryland
| | - Anne Davis-Karim
- Department of Veterans Affairs, Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Ciaran S. Phibbs
- Department of Veterans Affairs, Health Economics Resource Center and Center for Implementation to Innovation, Palo Alto, California,Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Steven D. Forman
- Department of Veterans Affairs, Veterans Affairs Medical Center, Pittsburgh, Pennsylvania,Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael Thase
- Department of Veterans Affairs, Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Leanne M. Williams
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Amit Etkin
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California,Stanford Neurosciences Institute, Stanford University, Stanford, California
| | - Ruth O’Hara
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Gerald Georgette
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California
| | - Tamara Beale
- Department of Veterans Affairs, Sierra-Pacific Mental Illness Research Educational and Clinical Center, Palo Alto, California
| | - Grant D. Huang
- Department of Veterans Affairs, Cooperative Studies Program Central Office, Washington, DC
| | - Art Noda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Mark S. George
- Department of Veterans Affairs, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina,Brain Stimulation Laboratory, Psychiatry Department, Medical University of South Carolina, Charleston
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A Naturalistic Evaluation of Change in Antidepressant Prescription in Patients With Affective and Anxiety Disorders in a Tertiary Care Hospital of India. J Clin Psychopharmacol 2018; 38:47-50. [PMID: 29200012 DOI: 10.1097/jcp.0000000000000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although many studies have evaluated prescription patterns, there is lack of information on the choice of antidepressants among patients who do not respond antidepressants. Similarly, information on switching strategies is also limited. This naturalistic study aimed to evaluate the switching strategies and preferred antidepressants by the psychiatrists among patients who do not respond to or who are not able to tolerate an antidepressant. METHODS A cross-sectional observational study design was followed. Patients diagnosed with affective and anxiety disorders, who were recommended a change in antidepressant, were recruited. Details of antidepressant before switching, antidepressants considered at the time of switching, coprescription advised at the time of switching, reasons considered for switching, and strategy advised at the time of switching were noted down. RESULTS A total of 102 patients were recruited. The most common change strategy was selective serotonin reuptake inhibitor (SSRI) to a serotonin norepinephrine reuptake inhibitor (SNRI) (N = 42; 41.17%), and this was followed by SSRI to SSRI (N = 18; 17.64%) and SNRI to SSRI (N = 10; 9.8%). In majority of the patients (N = 79; 77.45%) cross-taper of older antidepressant with gradual increase in dose of newer antidepressants was followed. About 44.1% of the patients were on adjuvant medications at the time of considering change in antidepressants, and 37.25% of the patients were additionally started on some adjuvant medications during the change of antidepressants. CONCLUSIONS The present study suggests that the most common strategy followed during change of antidepressant is from SSRI to SNRI and this is followed by SSRI to SSRI and SNRI to SSRI. Cross-taper switching strategy along with the use of adjuvant medications like benzodiazepines during the process of switching is most commonly followed.
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8
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Mi Z, Biswas K, Fairchild JK, Davis-Karim A, Phibbs CS, Forman SD, Thase M, Georgette G, Beale T, Pittman D, McNerney MW, Rosen A, Huang GD, George M, Noda A, Yesavage JA. Repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) Veteran patients: study protocol for a randomized controlled trial. Trials 2017; 18:409. [PMID: 28865495 PMCID: PMC5581925 DOI: 10.1186/s13063-017-2125-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/02/2017] [Indexed: 01/29/2023] Open
Abstract
Background Evaluation of repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depression (TRMD) in Veterans offers unique clinical trial challenges. Here we describe a randomized, double-blinded, intent-to-treat, two-arm, superiority parallel design, a multicenter study funded by the Cooperative Studies Program (CSP No. 556) of the US Department of Veterans Affairs. Methods We recruited medical providers with clinical expertise in treating TRMD at nine Veterans Affairs (VA) medical centers as the trial local investigators. We plan to enroll 360 Veterans diagnosed with TRMD at the nine VA medical centers over a 3-year period. We will randomize participants into a double-blinded clinical trial to left prefrontal rTMS treatment or to sham (control) rTMS treatment (180 participants each group) for up to 30 treatment sessions. All participants will meet Diagnostic and statistical manual of mental disorders, 4thedition (DSM-IV) criteria for major depression and will have failed at least two prior pharmacological interventions. In contrast with other rTMS clinical trials, we will not exclude Veterans with posttraumatic stress disorder (PTSD) or history of substance abuse and we will obtain detailed history regarding these disorders. Furthermore, we will maintain participants on stable anti-depressant medication throughout the trial. We will evaluate all participants on a wide variety of potential predictors of treatment response including cognitive, psychological and functional parameters. Discussion The primary dependent measure will be remission rate (Hamilton Rating Scale for Depression (HRSD24) ≤ 10), and secondary analyses will be conducted on other indices. Comparisons between the rTMS and the sham groups will be made at the end of the acute treatment phase to test the primary hypothesis. The unique challenges to performing such a large technically challenging clinical trial with Veterans and potential avenues for improvement of the design in future trials will be described. Trial registration ClinicalTrials.gov, NCT01191333. Registered on 26 August 2010. This report is based on the protocol version 4.6 amended in February 2016. All items from the World Health Organization Trial Registration Data Set are listed in Appendix A. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2125-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhibao Mi
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - Kousick Biswas
- Department of Veterans Affairs, Cooperative Studies Program Coordinating Center, Perry Point, MD, USA
| | - J Kaci Fairchild
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Anne Davis-Karim
- Department of Veterans Affairs, Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Ciaran S Phibbs
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven D Forman
- Department of Veterans Affairs, VA Medical Center, Pittsburgh, PA, USA.,Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Thase
- Department of Veterans Affairs, VA Medical Center, Philadelphia, PA, USA
| | - Gerald Georgette
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA
| | - Tamara Beale
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA
| | - David Pittman
- Department of Veterans Affairs, Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Margaret Windy McNerney
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Allyson Rosen
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Grant D Huang
- Department of Veterans Affairs, Cooperative Studies Program Central Office, Washington DC, USA
| | - Mark George
- Department of Veterans Affairs, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,Brain Stimulation Laboratory (BSL), Psychiatry Department, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Art Noda
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jerome A Yesavage
- Department of Veterans Affairs, Sierra-Pacific MIRECC, and WRIISC, Palo Alto, CA, USA. .,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA. .,VISN21 MIRECC, Department of Veterans Affairs, Department of Psychiatry, Stanford University School of Medicine, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.
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Neonatal tactile stimulation decreases depression‐like and anxiety‐like behaviors and potentiates sertraline action in young rats. Int J Dev Neurosci 2015; 47:192-7. [DOI: 10.1016/j.ijdevneu.2015.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 01/03/2023] Open
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10
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Damulin IV, Suvorova IA. The current concept of augmentation of treatment efficeincy with antidepressant medication. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:106-112. [DOI: 10.17116/jnevro201511531106-112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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11
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Culpepper L. Reducing the Burden of Difficult-to-Treat Major Depressive Disorder: Revisiting Monoamine Oxidase Inhibitor Therapy. Prim Care Companion CNS Disord 2013; 15:PCC.13r01515. [PMID: 24511450 PMCID: PMC3907330 DOI: 10.4088/pcc.13r01515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 07/22/2013] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Difficult-to-treat depression (eg, depression with atypical or anxious symptoms, treatment-resistant depression, or depression with frequent recurrence) is a challenging real-world health issue. This critical review of the literature focuses on monoamine oxidase inhibitor (MAOI) therapy and difficult-to-treat forms of depression. DATA SOURCES A literature search was performed in November 2012 and refreshed through January 2013 with no date restrictions using key search terms including MAO inhibitor therapy or MAOI and depression and anxiety, atypical, treatment-resistant, recurrent, relapse, or refractory. STUDY SELECTION Articles were selected to summarize the current needs in difficult-to-treat depression as well as the use of MAOI therapies in this area. RESULTS Two strategies have fallen out of favor in the care of patients with major depressive disorder. The first is the use of MAOI therapy and the second is the proactive recognition of difficult-to-treat depression that may not respond as well to more frequently used antidepressants. The infrequent use of MAOIs stems from the perception that other oral therapies for depression are safer and easier to use than oral MAOIs; however, transdermal delivery is one potential strategy to improve the safety of this class of agents. Although food-related interactions with transdermal delivery of MAOI therapy can be lessened, clinicians still need to be vigilant for drug-drug interactions and serotonin syndrome. CONCLUSIONS Clinicians should consider MAOIs for patients who have had several unsuccessful trials of antidepressants. Guidelines generally reserve MAOIs as third- and fourth-line treatments due to concerns over safety and tolerability; however, transdermal delivery of an MAOI may allay some of the safety and tolerability concerns. Patients should be provided education about MAOIs and their risks.
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Affiliation(s)
- Larry Culpepper
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
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12
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Paslakis G, Blum W, Deuschle M. Intranasal insulin-like growth factor I (IGF-I) as a plausible future treatment of depression. Med Hypotheses 2012; 79:222-5. [DOI: 10.1016/j.mehy.2012.04.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 03/27/2012] [Accepted: 04/27/2012] [Indexed: 12/15/2022]
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Rosso G, Rigardetto S, Bogetto F, Maina G. A randomized, single-blind, comparison of duloxetine with bupropion in the treatment of SSRI-resistant major depression. J Affect Disord 2012; 136:172-176. [PMID: 21862138 DOI: 10.1016/j.jad.2011.07.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/27/2011] [Accepted: 07/27/2011] [Indexed: 12/17/2022]
Abstract
INTRODUCTION For patients who continue to experience depressive symptoms despite an adequate antidepressant SSRI trial, across-class switch is considered one of the best treatment options. The goal of the present work was to compare in terms of efficacy two different dual-action compounds, duloxetine and bupropion, in patients who failed to respond in two consecutive antidepressant trials with SSRIs. METHODS The patients were allocated randomly to duloxetine (120 mg daily) or bupropion extended release (300 mg daily). The intended medication period was 6 weeks. The primary measure of efficacy was depressive symptoms severity. RESULTS A total of 49 participants were randomly assigned to duloxetine 120 mg (n=27) or bupropion 300 mg (n=22). The ITT efficacy patient sample consisted of 46 patients. Relatively high response and remission rates in treatment groups were found: from 60 to 70% of patients responded to treatment, and approximately 30 to 40% were in remission by the endpoint (week 6). No statistically significant difference emerged between the two groups at any post-baseline assessment, neither on mean scores of rating scales nor on qualitative efficacy measures. LIMITS Limitations of the study are the lack of a placebo arm, difficult to include owing to ethical reasons, and the relatively small size of the sample. CONCLUSIONS These preliminary results seem to support the hypothesis that in patients unresponsive to SSRIs the administration of antidepressants with different mechanisms of action is an effective switching strategy. Further studies are needed in light of the challenge posed by resistant depression.
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Affiliation(s)
- G Rosso
- Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin, Turin, Italy
| | - S Rigardetto
- Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin, Turin, Italy
| | - F Bogetto
- Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin, Turin, Italy
| | - G Maina
- Mood and Anxiety Disorders Unit, Department of Neuroscience, University of Turin, Turin, Italy.
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14
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Fang Y, Yuan C, Xu Y, Chen J, Wu Z, Cao L, Yi Z, Hong W, Wang Y, Jiang K, Cui X, Calabrese JR, Gao K. A pilot study of the efficacy and safety of paroxetine augmented with risperidone, valproate, buspirone, trazodone, or thyroid hormone in adult Chinese patients with treatment-resistant major depression. J Clin Psychopharmacol 2011; 31:638-42. [PMID: 21869688 DOI: 10.1097/jcp.0b013e31822bb1d9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To compare the efficacy and safety of augmenting paroxetine with risperidone, buspirone, valproate, trazodone, or thyroid hormone in patients with treatment-resistant depression (TRD), 225 patients with retrospectively and/or prospectively identified stage II TRD were randomly assigned to receive an 8-week treatment of paroxetine 20 mg/d augmented with risperidone 2 mg/d (n = 45), sodium valproate 600 mg/d (n = 39), buspirone 30 mg/d (n = 46), trazodone 100 mg/d (n = 47), or thyroid hormone 80 mg/d (n = 48). The primary outcome was the remission rate defined as the 17-item Hamilton Rating Scale for Depression score of 7 or less at the end of study. Secondary outcomes included remission rate based on the Self-rating Depression Scale score of 50 or less at the end of study, response rate based on 17-item Hamilton Rating Scale for Depression total score of 50% improvement or greater from baseline, and the change in scores of Clinical Global Impression-Improvement scale, the Short Form 36 Health Survey, and the Life Satisfaction Rating Scale. The remission rates were 26.7% for risperidone, 48.7% for valproate, 32.6% for buspirone, 42.6% for trazodone, and 37.5% for thyroid hormone. There was no statistical significance among treatment arms in remission rates, secondary outcome measures, and adverse events. Risperidone, valproate, buspirone, trazodone, or thyroid hormone augmentation to paroxetine 20 mg/d was effective and well tolerated in Chinese patients with TRD. Large-sample studies are warranted to support or refute these findings.
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Affiliation(s)
- Yiru Fang
- Division of Mood Disorders, Shanghai Mental Health Center, Department of Psychiatry, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Gulrez G, Badyal DK, Deswal RS, Sharma A. Bupropion as an augmenting agent in patients of depression with partial response. Basic Clin Pharmacol Toxicol 2011; 110:227-30. [PMID: 21895979 DOI: 10.1111/j.1742-7843.2011.00788.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of this study is to evaluate the effects of bupropion as an add-on therapy to selective serotonin reuptake inhibitor (SSRI) on patients of major depressive disorder with partial response. This prospective, randomized, controlled and single-blind study was conducted in sixty patients suffering from major depressive disorder as per Diagnostic and Statistical Manual (DSM)-IV TR criteria, who were having Hamilton depression rating scale (HDRS) score ≥16 after 4 weeks of treatment with SSRIs. Group A received SSRI plus placebo and group B received SSRI plus bupropion. Evaluation was performed based on changes in HDRS score, Montgomery and Asberg depression rating scale (MADRS), Amritsar depressive inventory (ADI) and spontaneously reported adverse effects. There was a significant decrease in the HDRS, MADRS and ADI scores as compared to baseline in both groups. However, the mean decrease in depression score was more in group B than in group A. The percentage decrease of remitters was also significantly more in group B (60% as per HDRS score and 63% as per MADRS score), as compared to group A (24% as per HDRS score and 27% as per MADRS score) (p < 0.05), at the end of treatment. In conclusion, bupropion add-on can act as augmenting agent in patients of depression with partial response to SSRIs.
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Affiliation(s)
- Gaurav Gulrez
- Department of Pharmacology, Christian Medical College and Hospital, Ludhiana, India
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Culpepper L, Kovalick LJ. A review of the literature on the selegiline transdermal system: an effective and well-tolerated monoamine oxidase inhibitor for the treatment of depression. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 10:25-30. [PMID: 18311418 DOI: 10.4088/pcc.v10n0105] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Accepted: 10/01/2007] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To provide a narrative review of the properties of the selegiline transdermal system (STS) for the treatment of depression and its subtypes. BACKGROUND Monoamine oxidase inhibitors (MAOIs) once represented the mainstay of therapy for the treatment of major depressive disorder (MDD). However, despite their efficacy, these agents fell from favor due to the risk of acute hypertensive reactions following ingestion of foods containing high concentrations of tyramine. Recent efforts to develop MAOIs that overcome these limitations have resulted in the introduction of the first transdermal formulation of the MAOI selegiline for the treatment of MDD. DATA SOURCES A PubMed literature search was conducted in January 2007 using the keyword selegiline transdermal system. STUDY SELECTION Articles retrieved were reviewed and selected for inclusion based on their being randomized, double-blind, placebo-controlled studies that appeared between the years 2000 and 2007 and examined efficacy, safety, and tolerability data from clinical trials of patients with MDD who were treated with the STS. Four articles, including 3 acute trials and 1 long-term prevention of relapse trial, were included in this review based on these criteria. CONCLUSIONS The selegiline transdermal system provides several advantages compared to orally administered MAOIs, including minimal interaction with dietary tyramine and prolonged exposure to the parent compound, while offering a favorable side effect profile. As a result, treatment at the lowest effective dose of 6 mg/24 hours can be administered without the need for dietary modifications.
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Affiliation(s)
- Larry Culpepper
- Department of Family Medicine, Boston University Medical Center, Boston, Mass. ; and Bristol-Myers Squibb, Princeton, N.J
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Clinically relevant pharmacokinetic interaction between venlafaxine and bupropion: a case series. J Clin Psychopharmacol 2010; 30:473-4. [PMID: 20631572 DOI: 10.1097/jcp.0b013e3181e5c0e4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Comparisons of the efficacy and tolerability of extended-release venlafaxine, mirtazapine, and paroxetine in treatment-resistant depression: a double-blind, randomized pilot study in a Chinese population. J Clin Psychopharmacol 2010; 30:357-64. [PMID: 20571433 DOI: 10.1097/jcp.0b013e3181e7784f] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To compare the efficacy and tolerability of antidepressants switch with extended-release venlafaxine (venlafaxine-XR), mirtazapine, and paroxetine in Chinese patients with major depressive disorder who had 2 consecutive unsuccessful antidepressant trials. One hundred fifty adult patients with treatment-resistant depression according to their medical records and/or response to current treatments were randomly assigned to receive fixed-dosage treatment of venlafaxine-XR 225 mg/d (n = 50), mirtazapine 45 mg/d (n = 55), or paroxetine 20 mg/d (n = 45) for 8 weeks. The primary outcome was the remission rates that were defined as a score 7 or lower on the 17-item Hamilton Rating Scale for Depression (HRSD-17). Secondary outcomes included the remission rate defined by the Self-Rating Depression Scale of 50 or lower and the response rate defined by a 50% reduction or greater on the HRSD-17 total score, and the improvement of patients' general health functions. The completion rates were 82% for venlafaxine-XR, 81.8% for mirtazapine, and 82.2% for paroxetine. Only one patient in paroxetine arm discontinued the study owing to an adverse event. The remission rates based on the HRSD-17 were 42.0% for venlafaxine-XR, 36.4% for mirtazapine, and 46.7% for paroxetine. There were no statistical significances between treatment arms in remission rates. Similarly, there were also no significant differences between groups in secondary outcome measure. Venlafaxine-XR, mirtazapine, and paroxetine were equally effective in the treatment of Chinese patients with major depressive disorder who failed at least 2 previous antidepressant treatments. Selecting any of these 3 antidepressants as a third-step antidepressant is a reasonable choice for this group of patients.
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Lieberman DZ, Massey SH. Desvenlafaxine in major depressive disorder: an evidence-based review of its place in therapy. CORE EVIDENCE 2010; 4:67-82. [PMID: 20694066 PMCID: PMC2899788 DOI: 10.2147/ce.s5998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Desvenlafaxine, the active metabolite of venlafaxine, is a serotonin norepinephrine reuptake inhibitor (SNRI) recently approved for the treatment of major depressive disorder. It is one of only three medications in this class available in the United States. AIMS The objective of this article is to review the published evidence for the safety and efficacy of desvenlafaxine, and to compare it to other antidepressants to delineate its role in the treatment of depression. EVIDENCE REVIEW At the recommended dose of 50 mg per day the rate of response and remission was similar to other SNRIs, as was the adverse effect profile. The rate of discontinuation was no greater than placebo, and a discontinuation syndrome was not observed at this dose. Higher doses were not associated with greater efficacy, but they did lead to more side effects, and the use of a taper prior to discontinuation. The most common side effects reported were insomnia, somnolence, dizziness, and nausea. Some subjects experienced clinically significant blood pressure elevation. PLACE IN THERAPY Like duloxetine, desvenlafaxine inhibits the reuptake of both norepinephrine and serotonin at the starting dose. Dual reuptake inhibitors have been shown to have small but statistically significantly greater rates of response and remission compared to selective serotonin reuptake inhibitors, and they have also shown early promise in the treatment of neuropathic pain. Desvenlafaxine may prove to be a valuable treatment option by expanding the limited number of available dual reuptake inhibitors.
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Affiliation(s)
- Daniel Z Lieberman
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Suena H Massey
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Parallel-group placebo-controlled trial of testosterone gel in men with major depressive disorder displaying an incomplete response to standard antidepressant treatment. J Clin Psychopharmacol 2010; 30:126-34. [PMID: 20520285 DOI: 10.1097/jcp.0b013e3181d207ca] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Exogenous testosterone therapy has psychotropic effects and has been proposed as an antidepressant augmentation strategy for depressed men. We sought to assess the antidepressant effects of testosterone augmentation of a serotonergic antidepressant in depressed, hypogonadal men. For this study, we recruited 100 medically healthy adult men with major depressive disorder showing partial response or no response to an adequate serotonergic antidepressant trial during the current episode and a screening total testosterone level of 350 ng/dL or lower. We randomized these men to receive testosterone gel or placebo gel in addition to their existing antidepressant regimen. The primary outcome measure was the Hamilton Depression Rating Scale (HDRS) score. Secondary measures included the Montgomery-Asberg Depression Rating Scale, the Clinical Global Impression Scale, and the Quality of Life Scale. Our primary analysis, using a mixed effects linear regression model to compare rate of change of scores between groups on the outcome measures, failed to show a significant difference between groups (mean [95% confidence interval] 6-week change in HDRS for testosterone vs placebo, -0.4 [-2.6 to 1.8]). However, in one exploratory analysis of treatment responders, we found a possible trend in favor of testosterone on the HDRS. Our findings, combined with the conflicting data from earlier smaller studies, suggest that testosterone is not generally effective for depressed men. The possibility remains that testosterone might benefit a particular subgroup of depressed men, but if so, the characteristics of this subgroup would still need to be established.
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&NA;. Atypical antipsychotics may be useful as adjuncts to antidepressant therapy in treatment-resistant depression. DRUGS & THERAPY PERSPECTIVES 2010. [DOI: 10.2165/11204310-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Abstract
OBJECTIVE Non-response to treatment with antidepressants (AD) is a clinical problem. METHOD The algorithm for pharmacological treatment of the Dutch multidisciplinary guideline for depression is compared with four other algorithms. RESULTS The Dutch algorithm consists of five subsequent steps. Treatment is started with one out of many optional ADs (step 1); in case of non-response after 4-10 weeks, best evidence is for switching to another AD (step 2); next step is augmentation with lithium as the best option (step 3); the next step is a monoamine oxidase inhibitor (MAOI) (step 4); and finally electroconvulsive therapy (step 5). There are major differences with other algorithms regarding timing of augmentation step, best agents for augmentation and role of MAOI. CONCLUSION Algorithms for AD treatment vary according to national and local preferences. Although the evidence for most of the treatment strategies is rather meagre, an AD algorithm appears to be an useful instrument in clinical practice.
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Affiliation(s)
- J Spijker
- De Gelderse Roos, Mental Health Care, Ede, the Netherlands.
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Abstract
Treatment-resistant depression (TRD) presents major challenges for both patients and clinicians. There is no universally accepted definition of TRD, but results from the US National Institute of Mental Health's (NIMH) STAR*D (Sequenced Treatment Alternatives to Relieve Depression) programme indicate that after the failure of two treatment trials, the chances of remission decrease significantly. Several pharmacological and nonpharmacological treatments for TRD may be considered when optimized (adequate dose and duration) therapy has not produced a successful outcome and a patient is classified as resistant to treatment. Nonpharmacological strategies include psychotherapy (often in conjunction with pharmacotherapy), electroconvulsive therapy and vagus nerve stimulation. The US FDA recently approved vagus nerve stimulation as adjunctive therapy (after four prior treatment failures); however, its benefits are seen only after prolonged (up to 1 year) use. Other nonpharmacological options, such as repetitive transcranial stimulation, deep brain stimulation or psychosurgery, remain experimental and are not widely available. Pharmacological treatments of TRD can be grouped in two main categories: 'switching' or 'combining'. In the first, treatment is switched within and between classes of compounds. The benefits of switching include avoidance of polypharmacy, a narrower range of treatment-emergent adverse events and lower costs. An inherent disadvantage of any switching strategy is that partial treatment responses resulting from the initial treatment might be lost by its discontinuation in favour of another medication trial. Monotherapy switches have also been shown to have limited effectiveness in achieving remission. The advantage of combination strategies is the potential to build upon achieved improvements; they are generally recommended if partial response was achieved with the current treatment trial. Various non-antidepressant augmenting agents, such as lithium and thyroid hormones, are well studied, although not commonly used. There is also evidence of efficacy and increasing use of atypical antipsychotics in combination with antidepressants, for example, olanzapine in combination with fluoxetine (OFC) or augmentation with aripiprazole. The disadvantages of a combination strategy include multiple medications, a broader range of treatment-emergent adverse events and higher costs. Several experimental pharmaceutical treatment alternatives for TRD are also being explored in combination with antidepressants or as monotherapy. These less studied alternative compounds include pindolol, inositol, CNS stimulants, hormones, herbal supplements, omega-3 fatty acids, S-adenosyl-L-methionine, folic acid, lamotrigine, modafinil, riluzole and topiramate. In summary, despite an increasing variety of choices for the treatment of TRD, this condition remains universally undefined and represents an area of unmet medical need. There are few known approved pharmacological agents for TRD (aripiprazole and OFC) and overall outcomes remain poor. This might be an indication that depression itself is a heterogeneous condition with a great diversity of pathologies, highlighting the need for careful evaluation of individuals with depressive symptoms who are unresponsive to treatment. Clearly, more research is needed to provide clinicians with better guidance in making those treatment decisions--especially in light of accumulating evidence that the longer patients are unsuccessfully treated, the worse their long-term prognosis tends to be.
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Affiliation(s)
- Richard C Shelton
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Wu EQ, Ben-Hamadi R, Yu AP, Tang J, Haim Erder M, Bose A. Healthcare utilization and costs incurred by patients with major depression after being switched from escitalopram to another SSRI for non-medical reasons. J Med Econ 2010; 13:314-23. [PMID: 20504111 DOI: 10.3111/13696998.2010.488985] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare healthcare utilization and costs for major depressive disorder (MDD) patients treated with escitalopram and who were switched to another SSRI for non-medical reasons versus those who did not switch. RESEARCH DESIGN AND METHODS Patients were identified in the Ingenix Impact Database (2003-2006). The analysis group included patients who remained on escitalopram for ≥ 90 days and switched to another SSRI within 45 days of end of supply days for non-medical reasons; the control group included matched individuals who did not switch within 45 days. Switching for medical reasons was defined as switching within 7 days after having a hospitalization, an emergency room (ER) visit, or a psychotherapy visit. Outcomes (all-cause and MDD-related) were analyzed over 3 months and included use of hospital, ER, outpatient visits and professional services, and healthcare costs. Outcomes were compared between the two groups using descriptive statistics and regression analyses controlling for differences in baseline characteristics. Costs were inflation adjusted to 2006 US dollars. RESULTS The study included 2,805 matched pairs. Compared to controls, switchers had higher rates of all-cause and MDD-related hospitalizations (relative risk [RR] = 1.4 and 2.0, respectively) and all-cause and MDD-related ER visits (RR = 1.2 and 1.6, respectively, all p ≤ 0.05). Results from multivariate analyses show that switchers had higher medical costs (+$138), drug costs (+$149) and total healthcare costs (+$322) compared to patients in the control group (all p < 0.0001). LIMITATIONS This study's limitations include its short observational period and definition of switching for non-medical reasons. CONCLUSION Patients who were switched to another SSRI for non-medical reasons after being stabilized on escitalopram used more resources and had higher healthcare costs within 3 months of switching than patients who did not switch.
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Affiliation(s)
- Eric Q Wu
- Analysis Group, Inc., 111 Huntington Avenue, Boston, MA 02199, USA.
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Nandagopal JJ, DelBello MP. Selegiline transdermal system: a novel treatment option for major depressive disorder. Expert Opin Pharmacother 2009; 10:1665-73. [PMID: 19527191 DOI: 10.1517/14656560903048942] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of monoamine oxidase inhibitors has declined owing to the risk of hypertensive crisis following the consumption of tyramine-rich foods and the consequent need for dietary tyramine restriction. However, owing to their superior efficacy in treating depression, continued efforts have been made to develop more selective and reversible monoamine oxidase inhibitors. Oral selegiline, at low doses, is a selective monoamine oxidase B (MAO-B) inhibitor, but at higher doses it loses its selectivity and can potentially interact with tyramine. Unfortunately, antidepressant effects of selegiline have been observed only at higher doses. The selegiline transdermal system was developed to deliver sustained selegiline blood concentrations sufficient to selectively inhibit MAO-A and MAO-B in the brain, producing antidepressant effects, without substantially inhibiting MAO-A in the gastrointestinal tract, thereby reducing the risk of hypertensive crisis. OBJECTIVES This article reviews the basic pharmacology, as well as efficacy and safety data of selegiline transdermal system for the treatment of depression. CONCLUSIONS Selegiline transdermal system is safe and effective in treating major depressive disorder at the dose range of 6 - 12 mg/24 h, without the need for dietary precautions at the 6 mg/24 h dose. No cases of hypertensive crisis were reported in clinical trials, even without dietary restrictions.
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Affiliation(s)
- Jayasree J Nandagopal
- University of Cincinnati, Department of Psychiatry, 260 Stetson Street, Suite 3200, Cincinnati, OH 45267-0559, USA.
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Abstract
Many patients fail to achieve an adequate response to antidepressant medication. Growing evidence suggests that atypical antipsychotics may augment antidepressant effects, resulting in a greater potential for response. Atypical antipsychotics possess pharmacological actions that are associated with antidepressant properties, including serotonin 5-HT(2) receptor antagonist and 5-HT(1A) and dopamine receptor partial agonist activity. In fact, the term 'atypical antipsychotic' is an unfortunate remnant of the early indication of these drugs in the treatment of schizophrenia. Soon after their introduction, the usefulness of atypical antipsychotics in bipolar disorder was firmly established and their use in the treatment of mood disorders has far outpaced their use in schizophrenia and other psychotic disorders. Aripiprazole has become the first agent to receive US FDA approval for the adjunctive treatment of unipolar depression. Most recently, Symbyax, a fluoxetine/olanzapine combination, received FDA approval for the acute treatment of treatment-resistant depression. This is the first medication to be FDA approved for this indication. In the present article, the usefulness of antipsychotics in the treatment of resistant unipolar depression is reviewed.
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Affiliation(s)
- Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, California 94305, USA.
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Effects of testosterone replacement in middle-aged men with dysthymia: a randomized, placebo-controlled clinical trial. J Clin Psychopharmacol 2009; 29:216-21. [PMID: 19440073 DOI: 10.1097/jcp.0b013e3181a39137] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mid-life onset male dysthymic disorder (DD) seems to be a distinct clinical condition with limited therapeutic options. Testosterone replacement is mood-enhancing and has been proposed as an antidepressant therapy, though this strategy has received limited systematic study. We therefore conducted a six-week double-blind placebo-controlled clinical trial in 23 men with DD and with low or low-normal testosterone (T) level (i.e, screening total serum testosterone <350 ng/dL). Enrolled men were randomized to receive intramuscular injections of 200 mg of testosterone cypionate or placebo every 10 days. The primary outcome measures were the Clinical Global Impression (CGI) improvement score and the 21-item Hamilton Depression Rating Scale (HDRS) score.Twenty-three patients were randomized. The mean (SD) age of the enrolled patients was 50.6 (7.0) years and that of total testosterone level was 339 (93) ng/dL. The median duration of the current dysthymic episode was 3.6 (2.3) years, and the mean (SD) HDRS was 14.0 (2.9). After the intervention, the mean HDRS score decreased significantly more in the testosterone group (7.46 [4.56]) than in the placebo group (1.8 [4.13], t21 = -3.07, P = 0.006). Remission, defined as a CGI improvement score of 1 or 2 and a final HDRS score lower than 8, was achieved by 7 (53.8%) of 13 in the testosterone group and 1 (10%) of 10 in the placebo group (P = 0.03). Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.
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Escitalopram versus SNRI antidepressants in the acute treatment of major depressive disorder: integrative analysis of four double-blind, randomized clinical trials. CNS Spectr 2009; 14:326-33. [PMID: 19668123 DOI: 10.1017/s1092852900020320] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Recent data suggest that escitalopram may be more effective in severe depression than other selective serotonin reuptake inhibitors. METHODS Individual patient data from four randomized, double-blind comparative trials of escitalopram versus a serotonin/norepinephrine reuptake inhibitor (SNRI) (two trials with duloxetine and two with venlafaxine extended release) in outpatients (18-85 years of age) with moderate-to-severe major depressive disorder were pooled. The primary efficacy parameter in all four trials was mean change in the Montgomery-Asberg Depression Rating Scale (MADRS) score. RESULTS Significantly fewer escitalopram (82/524) than SNRI (114/527) patients prematurely withdrew from treatment due to all causes (15.6% vs. 21.6%, Fisher Exact: P=.014) and adverse events (5.3% vs. 12.0%, Fisher Exact: P<.0001). Mean reduction in MADRS score from baseline to Week 8 was significantly greater for the escitalopram group versus the SNRI group using the last observation carried forward (LOCF) approach [mean treatment difference at Week 8 of 1.7 points (P<.01)]. Similar results were observed in the severely depressed (baseline MADRS score >or= 30) patient subset (mean treatment difference at Week 8 of 2.9 points [P<.001, LOCF]). Observed cases analyses yielded no significant differences in efficacy parameters. CONCLUSION This pooled analysis indicates that escitalopram is at least as effective as the SNRIs (venlafaxine XR and duloxetine), even in severe depression, and escitalopram treatment was better tolerated.
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Novel treatments for major depressive disorder. CNS Spectr 2009; 14:11-3. [PMID: 19407718 DOI: 10.1017/s1092852900003588] [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: 11/06/2022]
Abstract
Data from a variety of studies, including the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, have shown that fewer patients achieve remission from symptoms of major depressive disorder (MDD) and other depressive disorders after taking the first-prescribed antidepressant treatment than was expected. The goal of treatment is true remission: the complete absence of symptoms. Achieveing less than true remission is associated with MDD recurrence and continued impairment.
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Trivedi MH, Daly EJ. Treatment strategies to improve and sustain remission in major depressive disorder. DIALOGUES IN CLINICAL NEUROSCIENCE 2009. [PMID: 19170395 PMCID: PMC3181893 DOI: 10.31887/dcns.2008.10.4/mhtrivedi] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Major depressive disorder (MDD) is an often chronic, recurrent illness affecting large numbers of the general population. In recent years, the goal of treatment for MDD has moved from mere symptomatic response to that of full remission (i.e., minimal/no residual symptoms). The recent Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial showed that even with systematic measurement-based treatment, approximately one third of patients reach full remission after one treatment trial, with only two thirds reaching remission after four treatment trials. Treatment-resistant depression (TRD) is therefore a common problem in the treatment of MDD, with 60% to 70% of all patients meeting the criteria for TRD. Given the huge burden of major depressive illness, the low rate of full recovery remains suboptimal. The following article reports on some current treatment strategies available to improve rates of, and to sustain, remission in MDD.
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Affiliation(s)
- Madhukar H Trivedi
- Mood Disorders Program, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9119, USA.
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Abstract
The recent increase in radioligands available for neuroimaging major depressive disorder has led to advancements in our understanding of the pathophysiology of this illness and improved antidepressant development. Major depressive disorder can be defined as an illness of recurrent major depressive episodes of persistently low mood, dysregulated sleep, appetite and weight, anhedonia, cognitive impairment, and suicidality. The main target sites investigated with radioligand neuroimaging include receptor sites that regulate in response to lowered monoamine levels, targets related to removal of monoamines, uptake of ligands related to regional brain function, and target sites of antidepressants.
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Affiliation(s)
- Jeffrey H Meyer
- Department of Psychiatry, University of Toronto, Toronto, Canada.
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Early Intervention for Adults at High Risk of Recurrent/Chronic Depression: Cognitive Model and Clinical Case Series. Behav Cogn Psychother 2008. [DOI: 10.1017/s1352465808004426] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Papakostas GI, Fava M, Thase ME. Treatment of SSRI-resistant depression: a meta-analysis comparing within- versus across-class switches. Biol Psychiatry 2008; 63:699-704. [PMID: 17919460 DOI: 10.1016/j.biopsych.2007.08.010] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 08/11/2007] [Accepted: 08/14/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Two broad treatment options exist for switching antidepressants for depressed patients who fail to respond to a selective serotonin reuptake inhibitor (SSRI): either a second course of SSRI therapy or a different class of antidepressants. The goal of the present work was to conduct a meta-analysis of studies comparing these two switch strategies. METHODS Several sources were searched for randomized clinical trials comparing these two switch strategies. RESULTS Data from four clinical trials (n = 1496) were combined using a random-effects model. Patients randomized to switch to a non-SSRI antidepressant (bupropion, mirtazapine, venlafaxine) were more likely to experience remission than patients switched to a second SSRI (risk ratio = 1.29, p = .007). Pooled remission rates were 28% (for non-SSRIs) and 23.5% (for SSRIs). There was also a nonsignificant trend (p = .1) in the rate of discontinuation due to intolerance favoring the within-class switch strategy (risk ratio = 1.23). There was no difference in response rates between the two treatment groups. CONCLUSIONS These results suggest a modest yet statistically significant advantage in remission rates when switching patients with SSRI-resistant depression to a non-SSRI rather than an SSRI antidepressant. With the number needed to treat (NNT) statistic as one indicator of clinical significance, nearly 22 SSRI nonresponders would need to be switched to a non-SSRI rather than a second SSRI antidepressant to obtain one additional remitter. This difference falls well below the mark of NNT = 10 suggested by the United Kingdom's National Institute of Clinical Excellence but nonetheless might be of public health relevance given the large number of SSRI-resistant patients switched to an SSRI versus a non-SSRI antidepressant.
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Affiliation(s)
- George I Papakostas
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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A Randomized-Controlled Trial of Bilateral rTMS for Treatment-Resistant Depression. ACTA ACUST UNITED AC 2007. [DOI: 10.1017/s1748232107000018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Tobin M. Psychopharmacology column: why choose selegiline transdermal system for refractory depression? Issues Ment Health Nurs 2007; 28:223-8. [PMID: 17365170 DOI: 10.1080/01612840601096461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Brent DA, Birmaher B. Treatment-resistant depression in adolescents: recognition and management. Child Adolesc Psychiatr Clin N Am 2006; 15:1015-34, x. [PMID: 16952773 DOI: 10.1016/j.chc.2006.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Approximately 20% of adolescents experience at least one depressive episode by the time they enter their adult years. For most adolescents, depression, although serious, either remits spontaneously or responds to treatment. For a smaller but significant proportion of adolescents, however, depression can be long-lasting and relatively unresponsive to initial treatment. In this article the authors provide an operational definition of treatment-resistant depression, identify factors associated with treatment nonresponse, describe an approach to the management of treatment-resistant depression, and advance suggestions for promising avenues of research.
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Affiliation(s)
- David A Brent
- Department of Child and Adolescent Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, BFT 311, Pittsburgh, PA 15213-2592, USA.
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Rasmussen KG, Mueller M, Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, O'connor MK, Black JL, Sampson S, Fink M. Patterns of psychotropic medication use among patients with severe depression referred for electroconvulsive therapy: data from the Consortium for Research on Electroconvulsive Therapy. J ECT 2006; 22:116-23. [PMID: 16801827 DOI: 10.1097/00124509-200606000-00008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Most studies of trends in antidepressant pharmacotherapy have focused on relatively mildly ill, nonpyschotic outpatients. In this report, we provide detailed information on psychotropic use among patients with unipolar depression participating in a large, multisite electroconculsive therapy (ECT) study. Adequacy of antidepressant medication trials was assessed with the Antidepressant Treatment History Form. Among patients with nonpsychotic depression, 27% (60/220) had not had an adequate trial of an antidepressant before ECT, and 63% (139/220) had had at least one inadequate trial. Surprisingly, 33% (79/243) of nonpsychotic patients had been prescribed an antipsychotic. Among patients with psychotic depression, 95% (101/106) had not been given an adequate combination of an antidepressant and antipsychotic agent, mostly due to low doses of the latter class. Among all patients in the trial, 61% (213/352) had been prescribed at least one benzodiazepine, and only 7% (24/352) had been given a lithium augmentation trial. Use of hypnotic agents and anticonvulsants was common. In conclusion, patients with severe depression referred for ECT with a unipolar depressive episode have high rates of psychotropic usage, much of which is inadequate.
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Affiliation(s)
- Keith G Rasmussen
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
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Abstract
Treatment-resistant depression represents a common problem, with the vast majority of depressed patients showing incomplete response to antidepressant trials. Augmentation and combination strategies are commonly employed to address this problem, but there are few randomized, controlled studies to guide treatment choice. Indeed, some of the most common augmentation strategies in depression are those with the least controlled evidence. The popularity of bupropion, psychostimulants and atypical antipsychotics as augmentors may not be warranted by existing controlled studies, whereas two less commonly used augmentors-lithium and thyroid hormone- have substantial controlled evidence to support their use. This paper summarizes the state of the evidence for commonly used augmenting strategies and explores preliminary findings for more investigational approaches.
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Affiliation(s)
- Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Stanford, CA 94305, USA.
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Millan MJ. Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application. Pharmacol Ther 2006; 110:135-370. [PMID: 16522330 DOI: 10.1016/j.pharmthera.2005.11.006] [Citation(s) in RCA: 388] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Accepted: 11/28/2005] [Indexed: 12/20/2022]
Abstract
Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.
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Affiliation(s)
- Mark J Millan
- Institut de Recherches Servier, Centre de Recherches de Croissy, Psychopharmacology Department, 125, Chemin de Ronde, 78290-Croissy/Seine, France.
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Thase ME, Fava M, DeBattista C, Arora S, Hughes RJ. Modafinil augmentation of SSRI therapy in patients with major depressive disorder and excessive sleepiness and fatigue: a 12-week, open-label, extension study. CNS Spectr 2006; 11:93-102. [PMID: 16520686 DOI: 10.1017/s1092852900010622] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Many patients with major depressive disorder (MDD) treated with selective serotonin reuptake inhibitors have residual symptoms (eg, persistent fatigue, excessive sleepiness) despite an overall antidepressant response. Placebo-controlled studies indicate that modafinil, a wake-promoting agent, may relieve residual symptoms. METHODS This 12-week, open-label, dose titration, extension study followed an 8-week placebo-controlled study of modafinil augmentation in patients with MDD. The dose was 100-400 mg/day. The median stable dose was 300 mg/day. Assessments were the Epworth Sleepiness Scale, Brief Fatigue Inventory, Clinical Global Impression of Improvement scale, 17-item Hamilton Rating Scale for Depression, and Montgomery-Asberg Depression Rating Scale. RESULTS Of the 245 patients treated, 194 completed the study; 70% reported Clinical Global Impression of Improvement scale responses of "much improved" or "very much improved" between open-label baseline and final visit (previous randomized modafinil group: 74%; placebo group: 66%). When data were analyzed for four subsets of patients (former modafinil responders, placebo responders, modafinil nonresponders, and placebo nonresponders), improvements in scores on all outcome measures were at least twice as great among former modafinil and placebo nonresponders compared with responders. Most common adverse events were headache (18%), nausea (9%), and dizziness (7%); all were generally mild to moderate in severity. CONCLUSION Twelve weeks of modafinil augmentation relieved excessive sleepiness, reduced fatigue, and improved patients' overall clinical condition, including mood.
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Affiliation(s)
- Michael E Thase
- Division of Adult Academic Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Seidman SN, Miyazaki M, Roose SP. Intramuscular testosterone supplementation to selective serotonin reuptake inhibitor in treatment-resistant depressed men: randomized placebo-controlled clinical trial. J Clin Psychopharmacol 2005; 25:584-8. [PMID: 16282843 DOI: 10.1097/01.jcp.0000185424.23515.e5] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treatment-resistant depression is a persistent clinical problem. Exogenous testosterone therapy has psychotropic effects and has been proposed as an antidepressant supplement, although this strategy has received limited systematic study. OBJECTIVE The aim of the study was to examine the mood effects of testosterone supplementation to a serotonergic antidepressant in men with treatment-resistant depression. METHOD Twenty-six healthy adult men with major depressive disorder, partial or nonresponse to 2 adequate antidepressant trials during the current episode, and currently using a selective serotonin reuptake inhibitor were randomized under double-blind conditions to receive intramuscular injections of escalating doses of testosterone or placebo, in addition to their existing selective serotonin reuptake inhibitor regimen, for 6 weeks. The main outcome measure was the Hamilton Rating Scale for Depression score. RESULTS The mean age was 46.4 +/- 10.8 years; mean total testosterone level, 417.5 +/- 197 ng/dL; mean baseline Hamilton Rating Scale for Depression score, 22.2 +/- 5.2; and median duration of the current depressive episode, 6.3 +/- 10.6 years. Hamilton Rating Scale for Depression scores decreased significantly in both testosterone (8.4) and placebo (7.4) groups. Antidepressant response, defined as a 50% decline in Hamilton Rating Scale for Depression score, was achieved by 53.8% (7/13) in the testosterone group and 23.1% (3/13) in the placebo group (P = 0.226). CONCLUSION Both injectable testosterone and placebo supplementation to selective serotonin reuptake inhibitor were associated with improvement in mood; group differences were not distinguishable in this small sample of predominantly eugonadal men with treatment-resistant depression.
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Affiliation(s)
- Stuart N Seidman
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA.
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Thase ME. Pharmacologic Strategies for Treatment-resistant Depression: An Update on the State of the Evidence. Psychiatr Ann 2005. [DOI: 10.3928/00485713-20051201-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zajecka J, Goldstein C. Combining and Augmenting: Choosing the Right Therapies for Treatment-resistant Depression. Psychiatr Ann 2005. [DOI: 10.3928/00485713-20051201-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Most patients in acute depression trials fail to achieve remission with antidepressant monotherapy. Many patients seem to require more than one medication to achieve remission or adequate response. Augmentation strategies are commonly used in clinical practice, but most have been poorly studied. In addition, better-studied strategies, such as the use of lithium and thyroid augmentation, have not been well investigated in combination with newer antidepressants. Various novel strategies are being investigated as augmenting agents, including selective dopamine agonists, sex steroids, norepinephrine reuptake inhibitors, glucocorticoid-specific agents, and newer anticonvulsants. We review the status of augmentation strategies in the treatment of depression.
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Affiliation(s)
- Charles DeBattista
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
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Gutierrez RL, McKercher RM, Galea J, Jamison KL. Lamotrigine augmentation strategy for patients with treatment-resistant depression. CNS Spectr 2005; 10:800-5. [PMID: 16400242 DOI: 10.1017/s1092852900010324] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate if lamotrigine added to an antidepressant regimen reduces the symptoms of major depression in treatment-resistant patients. INTRODUCTION Charts were retrospectively reviewed for 34 patients (36-63 years of age) with major depressive disorder who received lamotrigine augmentation to the antidepressant regimen for treatment-resistant depression (TRD). Data collection occurred at baseline and at an average of 30 (Time 2), 78 (Time 3), 167 (Time 6), and 356 days (Time 12), thereafter, using a "Medication Visit by MD" scale for collection of target symptom data at each timepoint. RESULTS Following the addition of lamotrigine to the antidepressant regimen (mean dose of 43, 63, and 113 mg/day for Time 3, Time 6, and Time 12, respectively), a statistically significant reduction of scores was shown as early as Time 2 for target symptoms of depressed mood, loss of interest, anxiety, irritability, (low) energy, and cognitive impairment. The difference from baseline remained statistically significant at Time 3, Time 6, and Time 12 (with the exception of irritability, which was not statistically significant at Time 6). "Patient's response" also reflected statistically significant improvement at each time period compared with baseline. The most common side effect reported and reason for discontinuation was tiredness. DISCUSSION Because TRD is a clinical condition that can present with severe and disabling symptoms, many clinicians are faced with an urgent need to find relief for their patients. Trying to achieve symptom improvement in a timely manner during a medication change can be challenging and difficult. This can be managed by an augmentation strategy using a psychotropic add-on to an existing medication regimen. Our results show the benefits of lamotrigine augmentation to an antidepressant regimen. Prospective, controlled clinical trials with larger sample size are needed to confirm our results. CONCLUSION In this retrospective chart review, augmentation with lamotrigine was a tolerable and efficacious strategy for treating patients with TRD.
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