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Caldiroli A, Capuzzi E, Tagliabue I, Capellazzi M, Marcatili M, Mucci F, Colmegna F, Clerici M, Buoli M, Dakanalis A. Augmentative Pharmacological Strategies in Treatment-Resistant Major Depression: A Comprehensive Review. Int J Mol Sci 2021; 22:ijms222313070. [PMID: 34884874 PMCID: PMC8658307 DOI: 10.3390/ijms222313070] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/09/2023] Open
Abstract
Treatment resistant depression (TRD) is associated with poor outcomes, but a consensus is lacking in the literature regarding which compound represents the best pharmacological augmentation strategy to antidepressants (AD). In the present review, we identify the available literature regarding the pharmacological augmentation to AD in TRD. Research in the main psychiatric databases was performed (PubMed, ISI Web of Knowledge, PsychInfo). Only original articles in English with the main topic being pharmacological augmentation in TRD and presenting a precise definition of TRD were included. Aripiprazole and lithium were the most investigated molecules, and aripiprazole presented the strongest evidence of efficacy. Moreover, olanzapine, quetiapine, cariprazine, risperidone, and ziprasidone showed positive results but to a lesser extent. Brexpiprazole and intranasal esketamine need further study in real-world practice. Intravenous ketamine presented an evincible AD effect in the short-term. The efficacy of adjunctive ADs, antiepileptic drugs, psychostimulants, pramipexole, ropinirole, acetyl-salicylic acid, metyrapone, reserpine, testosterone, T3/T4, naltrexone, SAMe, and zinc cannot be precisely estimated in light of the limited available data. Studies on lamotrigine and pindolol reported negative results. According to our results, aripiprazole and lithium may be considered by clinicians as potential effective augmentative strategies in TRD, although the data regarding lithium are somewhat controversial. Reliable conclusions about the other molecules cannot be drawn. Further controlled comparative studies, standardized in terms of design, doses, and duration of the augmentative treatments, are needed to formulate definitive conclusions.
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Affiliation(s)
- Alice Caldiroli
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
- Correspondence: ; Tel.: +39-3495009941
| | - Enrico Capuzzi
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Ilaria Tagliabue
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Martina Capellazzi
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Matteo Marcatili
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Francesco Mucci
- Department of Medicine and Surgery, University of Milan, 20122 Milan, Italy;
| | - Fabrizia Colmegna
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Massimo Clerici
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Massimiliano Buoli
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Antonios Dakanalis
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
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Beneficial cognitive effect of lamotrigine in severe acquired brain injury: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Bennabi D, Charpeaud T, Yrondi A, Genty JB, Destouches S, Lancrenon S, Alaïli N, Bellivier F, Bougerol T, Camus V, Dorey JM, Doumy O, Haesebaert F, Holtzmann J, Lançon C, Lefebvre M, Moliere F, Nieto I, Rabu C, Richieri R, Schmitt L, Stephan F, Vaiva G, Walter M, Leboyer M, El-Hage W, Llorca PM, Courtet P, Aouizerate B, Haffen E. Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC Psychiatry 2019; 19:262. [PMID: 31455302 PMCID: PMC6712810 DOI: 10.1186/s12888-019-2237-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/12/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clear guidance for successive antidepressant pharmacological treatments for non-responders in major depression is not well established. METHOD Based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of treatment-resistant depression. The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for treatment-resistant depression. A written survey comprising 118 questions related to highly-detailed clinical presentations was completed on a risk-benefit scale ranging from 0 to 9 by 36 psychiatrist experts in the field of major depression and its treatments. Key-recommendations are provided by the scientific committee after data analysis and interpretation of the results of the survey. RESULTS The scope of these guidelines encompasses the assessment of pharmacological resistance and situations at risk of resistance, as well as the pharmacological and psychological strategies in major depression. CONCLUSION The expert consensus guidelines will contribute to facilitate treatment decisions for clinicians involved in the daily assessment and management of treatment-resistant depression across a number of common and complex clinical situations.
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Affiliation(s)
- D Bennabi
- Service de Psychiatrie clinique, Centre Expert Dépression Résistante FondaMental, Centre Investigation Clinique 1431-INSERM, EA 481 Neurosciences, Université de Bourgogne Franche Comté, Besançon, France.
- Department of Clinical Psychiatry, 25030 Besançon University Hospital, 25030, Besançon, France.
| | - T Charpeaud
- Service de Psychiatrie de l'adulte B, Centre Expert Dépression Résistante FondaMental, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - A Yrondi
- Service de Psychiatrie et de Psychologie Médicale de l'adulte, Centre Expert Dépression Résistante FondaMental, CHRU de Toulouse, Hôpital Purpan, ToNIC, Toulouse NeuroImaging Center Université de Toulouse, Inserm, UPS, Toulouse, France
| | - J-B Genty
- SYLIA-STAT, 10, boulevard du Maréchal-Joffre, 92340, Bourg-la-Reine, France
| | - S Destouches
- SYLIA-STAT, 10, boulevard du Maréchal-Joffre, 92340, Bourg-la-Reine, France
| | - S Lancrenon
- SYLIA-STAT, 10, boulevard du Maréchal-Joffre, 92340, Bourg-la-Reine, France
| | - N Alaïli
- Service de Psychiatrie adulte, Centre Expert Dépression Résistante FondaMental, Hôpital Fernand-Widal, Paris, France
| | - F Bellivier
- Service de Psychiatrie adulte, Centre Expert Dépression Résistante FondaMental, Hôpital Fernand-Widal, Paris, France
| | - T Bougerol
- Service de Psychiatrie de l'adulte, CS 10217, Centre Expert Dépression Résistante FondaMental, CHU de Grenoble, Hôpital Nord, Grenoble, France
| | - V Camus
- Clinique Psychiatrique Universitaire, Centre Expert Dépression Résistante FondaMental, CHRU de Tours, Université de Tours, Inserm U1253 imaging and Brain : iBrain, Tours, France
| | - J-M Dorey
- Old Age Psychiatry Unit, pôle EST, Centre Hospitalier le Vinatier, Bron, France
- Brain Dynamics and Cognition, Lyon Neuroscience Research Center, INSERM U1028, CNRS UMR 5292, Lyon, France
- Geriatrics Unit, CM2R, Hospices civils de Lyon, Hôpital des Charpennes, Villeurbanne, France
| | - O Doumy
- Pôle de Psychiatrie Générale et Universitaire, Centre Expert Dépression Résistante FondaMental, CH Charles Perrens, UMR INRA 1286, NutriNeuro, Université de Bordeaux, Bordeaux, France
| | - F Haesebaert
- Service universitaire des pathologies psychiatriques résistantes, Centre expert FondaMental, PSYR2 Team, Lyon Neuroscience Research Center, INSERM U1028, CNRS UMR5292, Centre Hospitalier Le Vinatier, University Lyon 1, Bron, France
| | - J Holtzmann
- Service de Psychiatrie de l'adulte, CS 10217, Centre Expert Dépression Résistante FondaMental, CHU de Grenoble, Hôpital Nord, Grenoble, France
| | - C Lançon
- Pôle Psychiatrie, Centre Expert Dépression Résistante FondaMental, CHU La Conception, Marseille, France
| | - M Lefebvre
- Service universitaire des pathologies psychiatriques résistantes, Centre expert FondaMental, PSYR2 Team, Lyon Neuroscience Research Center, INSERM U1028, CNRS UMR5292, Centre Hospitalier Le Vinatier, University Lyon 1, Bron, France
| | - F Moliere
- Département des Urgences et Post-Urgences Psychiatriques, Centre Expert Dépression Résistante FondaMental, CHU Montpellier, University of Montpellier, Montpellier, France
| | - I Nieto
- Service de Psychiatrie adulte, Centre Expert Dépression Résistante FondaMental, Hôpital Fernand-Widal, Paris, France
| | - C Rabu
- DHU PePSY, Pole de psychiatrie et d'addictologie des Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Créteil, France
| | - R Richieri
- Pôle Psychiatrie, Centre Expert Dépression Résistante FondaMental, CHU La Conception, Marseille, France
| | - L Schmitt
- Service de Psychiatrie et de Psychologie Médicale de l'adulte, Centre Expert Dépression Résistante FondaMental, CHRU de Toulouse, Hôpital Purpan, ToNIC, Toulouse NeuroImaging Center Université de Toulouse, Inserm, UPS, Toulouse, France
| | - F Stephan
- Service hospitalo-universitaire de psychiatrie d'adultes et de psychiatrie de liaison - secteur 1, Centre Expert Dépression Résistante Fondamental, CHRU Brest, hôpital de Bohars, Bohars, France
| | - G Vaiva
- Service de Psychiatrie adulte, Centre Expert Dépression Résistante FondaMental, CHU de Lille, Hôpital Fontan 1, Lille, France
| | - M Walter
- Service hospitalo-universitaire de psychiatrie d'adultes et de psychiatrie de liaison - secteur 1, Centre Expert Dépression Résistante Fondamental, CHRU Brest, hôpital de Bohars, Bohars, France
| | - M Leboyer
- DHU PePSY, Pole de psychiatrie et d'addictologie des Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Créteil, France
| | - W El-Hage
- Clinique Psychiatrique Universitaire, Centre Expert Dépression Résistante FondaMental, CHRU de Tours, Université de Tours, Inserm U1253 imaging and Brain : iBrain, Tours, France
| | - P-M Llorca
- Service de Psychiatrie de l'adulte B, Centre Expert Dépression Résistante FondaMental, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - P Courtet
- Département des Urgences et Post-Urgences Psychiatriques, Centre Expert Dépression Résistante FondaMental, CHU Montpellier, University of Montpellier, Montpellier, France
| | - B Aouizerate
- Old Age Psychiatry Unit, pôle EST, Centre Hospitalier le Vinatier, Bron, France
- Brain Dynamics and Cognition, Lyon Neuroscience Research Center, INSERM U1028, CNRS UMR 5292, Lyon, France
- Geriatrics Unit, CM2R, Hospices civils de Lyon, Hôpital des Charpennes, Villeurbanne, France
| | - E Haffen
- Service de Psychiatrie clinique, Centre Expert Dépression Résistante FondaMental, Centre Investigation Clinique 1431-INSERM, EA 481 Neurosciences, Université de Bourgogne Franche Comté, Besançon, France
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Goh KK, Chen CH, Chiu YH, Lu ML. Lamotrigine augmentation in treatment-resistant unipolar depression: A comprehensive meta-analysis of efficacy and safety. J Psychopharmacol 2019; 33:700-713. [PMID: 31081449 DOI: 10.1177/0269881119844199] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Augmentation strategies are commonly applied when an individual is unresponsive to antidepressant monotherapy. Lamotrigine is currently considered at best only as second line augmentation for treatment-resistant unipolar depression while its clinical efficacy and safety profiles remain inconclusive. We intended to assess the therapeutic effects and safety profiles of lamotrigine augmentation in patients with treatment-resistant unipolar depression by conducting a meta-analysis. METHODS MEDLINE, Embase, EBSCO, Cochrane, Web of Science, Scopus, Wanfang and Ariniti databases were searched. Coprimary outcomes, including changes in severity of depression and response rate, were measured in this study. Secondary outcomes were defined as the safety profile of the intervention, including reported discontinuation rate and adverse events. RESULTS Eight double-blinded randomized controlled trials with 677 patients overall were included. Significant improvements in Hamilton Rating Scale for Depression scores and response rates were shown in lamotrigine augmentation groups compared with control groups, of which the pooled result of six Chinese studies showed positive effects of Hamilton Rating Scale for Depression improvement while the pooled result of two non-Chinese studies was statistically non-significant. Patients with more severe illness and longer duration of illness were more effectively treated with lamotrigine augmentation. The magnitude of depression improvement after lamotrigine augmentation was higher in patients treated with selective serotonin reuptake inhibitors than those treated with serotonin-norepinephrine reuptake inhibitors. Lamotrigine augmentation is well-tolerated in terms of all-cause discontinuation rate and adverse events. CONCLUSIONS Lamotrigine augmentation may serve as a possible choice for patients with treatment-resistant unipolar depression and further trials are warranted to clarify the optimal dosage of lamotrigine augmentation together with the treatment duration and safety over time.
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Affiliation(s)
- Kah Kheng Goh
- 1 Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chun-Hsin Chen
- 1 Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan.,2 Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Hang Chiu
- 1 Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Mong-Liang Lu
- 1 Department of Psychiatry, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan.,2 Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Lamotrigine Induces Hair Loss in a Patient With Treatment-Resistant Major Depressive Disorder. Am J Ther 2017; 24:e611-e612. [PMID: 28346304 DOI: 10.1097/mjt.0000000000000586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Safety of Long-term Use of Lamotrigine for the Treatment of Psychiatric Disorders. Clin Neuropharmacol 2016; 39:295-298. [PMID: 27438184 DOI: 10.1097/wnf.0000000000000174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lamotrigine (LTG) is a drug commonly used to treat epilepsy and can also be used to manage mood disorders, such as bipolar disorder. One of the most dangerous adverse effects of LTG is skin rash, which can make early cessation necessary. Here, we examine the adverse effects associated with long-term use of LTG for the treatment of mood disorders. METHODS Data were obtained from the medical records of 101 psychiatric patients who were prescribed long-term treatment with LTG. Patients were retrospectively divided into those who discontinued treatment within 6 months and those who continued for longer, and the groups were compared for adverse effects. We also compared the incidence of adverse effects in high and low doses. RESULTS Fifty-four patients continued LTG treatment for 6 months or longer; 47 discontinued within 6 months. A history of allergy was more prevalent among the patients who discontinued treatment early than in those who continued. Of the patients who continued treatment for 6 months or longer, only 2 later discontinued treatment because of adverse effects. Lamotrigine monotherapy showed no difference in the incidence of adverse effects for different doses of LTG (>200 mg = 4.8% vs >100 mg, ≤200 mg = 7.7%; P = 1, vs >50 mg, ≤100 mg = 0%; P = 1 vs ≤50 mg = 0%; P = 1). CONCLUSIONS Clinicians must be mindful of the adverse effects occurring early during the titration phase. However, long-term use of LTG was very well tolerated, even at high maintenance doses.
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Zheng H, Jia F, Guo G, Quan D, Li G, Wu H, Zhang B, Fan C, He X, Huang H. Abnormal Anterior Cingulate N-Acetylaspartate and Executive Functioning in Treatment-Resistant Depression After rTMS Therapy. Int J Neuropsychopharmacol 2015; 18:pyv059. [PMID: 26025780 PMCID: PMC4756723 DOI: 10.1093/ijnp/pyv059] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 05/19/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Cognitive impairment is a key feature of treatment-resistant depression (TRD) and can be related to the anterior cingulate cortex (ACC) function. Repetitive transcranial magnetic stimulation (rTMS) as an antidepressant intervention has increasingly been investigated in the last two decades. However, no studies to date have investigated the association between neurobiochemical changes within the anterior cingulate and executive dysfunction measured in TRD being treated with rTMS. METHODS Thirty-two young depressed patients with treatment-resistant unipolar depression were enrolled in a double-blind, randomized study [active (n=18) vs. sham (n=14)]. ACC metabolism was investigated before and after high-frequency (15 Hz) rTMS using 3-tesla proton magnetic resonance spectroscopy (1H-MRS). The results were compared with 28 age- and gender-matched healthy controls. Executive functioning was measured with the Wisconsin Card Sorting Test (WCST) among 34 subjects with TRD and 28 healthy subjects. RESULTS Significant reductions in N-acetylaspartate (NAA) and choline-containing Compound levels in the left ACC were found in subjects with TRD pre-rTMS when compared with healthy controls. After successful treatment, NAA levels increased significantly in the left ACC of subjects and were not different from those of age-matched controls. In the WCST, more perseverative errors and fewer correct numbers were observed in TRD subjects at baseline. Improvements in both perseverative errors and correct numbers occurred after active rTMS. In addition, improvement of perseverative errors was positively correlated with enhancement of NAA levels in the left ACC in the active rTMS group. CONCLUSIONS Our results suggest that the NAA concentration in the left ACC is associated with an improvement in cognitive functioning among subjects with TRD response to active rTMS.
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Affiliation(s)
- Huirong Zheng
- Guangdong Mental Health Center, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Affiliated School of Medicine of South China University of Technology, Guangzhou, Guangdong, P.R. China (Drs Zheng, Jia, Wu, Zhang, and Fan, and Mr Guo, Quan, Li, and Ms He); Department of Radiology, Guangzhou Hui-Ai Hospital, Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China (Dr Wu); Pharmacy Department of Guangdong General Hospital, Guangdong academy of medical sciences, Guangzhou, Guangdong, P.R. China (Ms Huang).
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Epstein I, Szpindel I, Katzman MA. Pharmacological approaches to manage persistent symptoms of major depressive disorder: rationale and therapeutic strategies. Psychiatry Res 2014; 220 Suppl 1:S15-33. [PMID: 25539871 DOI: 10.1016/s0165-1781(14)70003-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/11/2014] [Indexed: 01/29/2023]
Abstract
Major depressive disorder (MDD) is a highly prevalent chronic psychiatric illness associated with significant morbidity, mortality, loss of productivity, and diminished quality of life. Typically, only a minority of patients responds to treatment and meet criteria for remission as residual symptoms may persist, the result of an inadequate course of treatment and/or the presence of persistent side effects. The foremost goal of treatment should be to restore patients to full functioning and eliminate or relieve all MDD symptoms, while being virtually free of troublesome side effects. The current available pharmacological options to manage persistent depressive symptoms include augmentation or adjunctive combination strategies, both of which target selected psychobiological systems and specific mood and somatic symptoms experienced by the patient. As well, non-pharmacological interventions including psychotherapies may be used in either first-line or adjunctive approaches. However, the evidence to date with respect to available adjunct therapies is limited by few studies and those published have utilized only a small number of subjects and lack enough data to allow for a consensus of expert opinion. This underlines the need for further longer term, large population-based studies and those that include comorbid populations, all of which are seen in real world community psychiatry.
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Affiliation(s)
- Irvin Epstein
- START Clinic for Mood and Anxiety Disorders, Toronto, ON, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Isaac Szpindel
- START Clinic for Mood and Anxiety Disorders, Toronto, ON, Canada
| | - Martin A Katzman
- START Clinic for Mood and Anxiety Disorders, Toronto, ON, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Northern Ontario School of Medicine, Thunder Bay, ON, Canada; Department of Psychology, Lakehead University, Thunder Bay, ON, Canada; Adler Graduate Professional School, Toronto, ON, Canada
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Coplan JD, Gopinath S, Abdallah CG, Berry BR. A neurobiological hypothesis of treatment-resistant depression - mechanisms for selective serotonin reuptake inhibitor non-efficacy. Front Behav Neurosci 2014; 8:189. [PMID: 24904340 PMCID: PMC4033019 DOI: 10.3389/fnbeh.2014.00189] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/07/2014] [Indexed: 12/20/2022] Open
Abstract
First-line treatment of major depression includes administration of a selective serotonin reuptake inhibitor (SSRI), yet studies suggest that remission rates following two trials of an SSRI are <50%. The authors examine the putative biological substrates underlying "treatment resistant depression (TRD)" with the goal of elucidating novel rationales to treat TRD. We look at relevant articles from the preclinical and clinical literature combined with clinical exposure to TRD patients. A major focus was to outline pathophysiological mechanisms whereby the serotonin system becomes impervious to the desired enhancement of serotonin neurotransmission by SSRIs. A complementary focus was to dissect neurotransmitter systems, which serve to inhibit the dorsal raphe. We propose, based on a body of translational studies, TRD may not represent a simple serotonin deficit state but rather an excess of midbrain peri-raphe serotonin and subsequent deficit at key fronto-limbic projection sites, with ultimate compromise in serotonin-mediated neuroplasticity. Glutamate, serotonin, noradrenaline, and histamine are activated by stress and exert an inhibitory effect on serotonin outflow, in part by "flooding" 5-HT1A autoreceptors by serotonin itself. Certain factors putatively exacerbate this scenario - presence of the short arm of the serotonin transporter gene, early-life adversity and comorbid bipolar disorder - each of which has been associated with SSRI-treatment resistance. By utilizing an incremental approach, we provide a system for treating the TRD patient based on a strategy of rescuing serotonin neurotransmission from a state of SSRI-induced dorsal raphe stasis. This calls for "stacked" interventions, with an SSRI base, targeting, if necessary, the glutamatergic, serotonergic, noradrenergic, and histaminergic systems, thereby successively eliminating the inhibitory effects each are capable of exerting on serotonin neurons. Future studies are recommended to test this biologically based approach for treatment of TRD.
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Affiliation(s)
- Jeremy D Coplan
- Division of Neuropsychopharmacology, Department of Psychiatry and Behavioral Science, State University of New York Downstate Medical Center , Brooklyn, NY , USA
| | - Srinath Gopinath
- Division of Neuropsychopharmacology, Department of Psychiatry and Behavioral Science, State University of New York Downstate Medical Center , Brooklyn, NY , USA
| | - Chadi G Abdallah
- Department of Psychiatry, Yale School of Medicine , New Haven, CT , USA ; Clinical Neuroscience Division, National Center for PTSD , West Haven, CT , USA
| | - Benjamin R Berry
- State University of New York Downstate College of Medicine , Brooklyn, NY , USA
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Zavodnick AD, Ali R. Lamotrigine in the treatment of unipolar depression with and without comorbidities: a literature review. Psychiatr Q 2012; 83:371-83. [PMID: 22322995 DOI: 10.1007/s11126-012-9208-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To review the available data behind the use of lamotrigine in unipolar depression and common comorbid conditions. A PubMed based literature review was conducted using keywords related to lamotrigine, depression, anxiety, post traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and personality disorders. A large number of trials using lamotrigine for unipolar depression and various comorbid conditions were reviewed. A major limitation behind the majority of studies was a limited course of the treatment phase. The most robust data was found among studies that followed patients for over 8 weeks, and used higher dosages. Patients with comorbid anxiety states appeared to benefit. Patients with borderline personality disorder also appeared to benefit. The benefits of lamotrigine in unipolar depression have been inconsistently noted in a number of studies. This is due in part to short treatment phases, atypical domains of benefit and different patient populations across studies. Patients with more treatment-resistance, comorbid anxiety and borderline personality disorder may be more able to benefit from lamotrigine.
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Affiliation(s)
- Adam Daniel Zavodnick
- Department of Psychiatry and Behavioral Medicine, Carilion Clinic-Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.
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Bipolarity and inadequate response to antidepressant drugs: clinical and psychopharmacological perspective. J Affect Disord 2012; 136:e13-e19. [PMID: 21621266 DOI: 10.1016/j.jad.2011.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 04/28/2011] [Accepted: 05/08/2011] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The reason why depression may respond poorly to treatment with antidepressant drugs may be connected with the features of bipolarity. Evidence to this effect has accumulated in recent studies of various kinds of depression in mood disorders. Additional evidence for such a connection may be the efficacy of mood-stabilizing drugs in the augmentation of antidepressants in treatment-resistant depression. METHODS This review is based on clinical and psychopharmacological research performed over the past five years. The clinical investigation was based on the response to antidepressants of bipolar depression or to symptoms of hypomania, assessed mainly by the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32). The psychopharmacological research tested the efficacy of augmentation of antidepressants in treatment-resistant depression by mood-stabilizing drugs of the 1st and 2nd generations. RESULTS A number of studies have pointed to an association between bipolar depression, or symptoms of hypomania and an inadequate response to antidepressants. Such a connection was also found in the Polish TRES-DEP study which included 1051 depressed patients. Pharmacological studies have demonstrated the efficacy of first generation mood-stabilizing drugs (lithium, carbamazepine) and second generation drugs (quetiapine, olanzapine, risperidone, ziprasidone, lamotrigine) for augmentation of antidepressants in treatment-resistant depression. Some evidence has been presented that mixed depressive episodes may also belong to this category. CONCLUSIONS The results of these clinical and psychopharmacological studies appear to confirm an association between bipolarity and a poor response of depression to treatment with antidepressant drugs.
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Abstract
The phenomenon of treatment-resistant depression (TRD), described as the occurrence of an inadequate response after an adequate treatment with antidepressant agents (in terms of dose, duration, and adherence), is very common in clinical practice. It has been broadly defined in the context of unipolar major depression, but alternative definitions for bipolar depression have also been suggested. In both cases, there is a remarkable lack of consensus amongst professionals concerning its operative definition. A relatively wide variety of treatment options for unipolar TRD are available, whilst the evidence is very scanty for bipolar TRD. TRD is associated to poor clinical, functional, and social outcomes. Several novel therapeutic options are currently being investigated as promising alternatives, targeting the neurotransmitter system outside of the standard monoamine hypothesis. Augmentation or combination with lithium or atypical antipsychotics appears as a valid option for both conditions, and the same occurs with electroconvulsive therapy. Other non-pharmacological strategies such as deep brain stimulation may be promising alternatives for the future. The use of cognitive behaviour therapy is recommended for unipolar TRD, but there is no evidence supporting its use in bipolar TRD.
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Affiliation(s)
- Eduard Vieta
- Bipolar Disorders Program, Hospital Clinic, University of Barcelona , Catalonia, Spain.
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13
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Yüksel C, Öngür D. Magnetic resonance spectroscopy studies of glutamate-related abnormalities in mood disorders. Biol Psychiatry 2010; 68:785-94. [PMID: 20728076 PMCID: PMC2955841 DOI: 10.1016/j.biopsych.2010.06.016] [Citation(s) in RCA: 349] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 06/08/2010] [Accepted: 06/09/2010] [Indexed: 12/13/2022]
Abstract
In mood disorders, there is growing evidence for glutamatergic abnormalities derived from peripheral measures of glutamatergic metabolites in patients, postmortem studies on glutamate-related markers, and animal studies on the mechanism of action of available treatments. Magnetic resonance spectroscopy (MRS) has the potential to corroborate and extend these findings with the advantage of in vivo assessment of glutamate-related metabolites in different disease states, in response to treatment, and in relation with functional imaging data. In this article, we first review the biological significance of glutamate, glutamine, and Glx (composed mainly of glutamate and glutamine). Next, we review the MRS literature in mood disorders, examining these glutamate-related metabolites. Here, we find a highly consistent pattern of Glx-level reductions in major depressive disorder and elevations in bipolar disorder. In addition, studies of depression, regardless of diagnosis, provide suggestive evidence for reduced glutamine/glutamate ratio and in mania for elevated glutamine/glutamate ratio. These patterns suggest that the glutamate-related metabolite pool (not all of it necessarily relevant to neurotransmission) is constricted in major depressive disorder and expanded in bipolar disorder. Depressive and manic episodes may be characterized by modulation of the glutamine/glutamate ratio in opposite directions, possibly suggesting reduced versus elevated glutamate conversion to glutamine by glial cells, respectively. We discuss the implications of these results for the pathophysiology of mood disorders and suggest future directions for MRS studies.
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Affiliation(s)
- Cagri Yüksel
- Istanbul University, Istanbul Medical School, Istanbul, Turkey
- McLean Hospital, Belmont, MA
| | - Dost Öngür
- McLean Hospital, Belmont, MA
- Harvard Medical School, Boston, MA
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Thomas SP, Nandhra HS, Jayaraman A. Systematic review of lamotrigine augmentation of treatment resistant unipolar depression (TRD). J Ment Health 2010; 19:168-75. [DOI: 10.3109/09638230903469269] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Philip NS, Carpenter LL, Tyrka AR, Price LH. Pharmacologic approaches to treatment resistant depression: a re-examination for the modern era. Expert Opin Pharmacother 2010; 11:709-22. [PMID: 20151847 PMCID: PMC2835848 DOI: 10.1517/14656561003614781] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE OF THE FIELD Treatment-resistant depression (TRD) is common and debilitating. Initial treatment is often insufficient to achieve full remission in a given depressive episode, resulting in more frequent episodes, worsened severity, and major disability. AREAS COVERED IN THIS REVIEW This review surveys literature on the diagnosis and pharmacological management of TRD in light of recent developments. Evidence regarding commonly used treatment options is critically examined and key recommendations are offered. The review ends by considering drugs acting on the melatonin, acetylcholine, and glutamate systems that hold promise as future options for TRD. WHAT THE READER WILL GAIN Recent trends and research findings have impacted how the evidence supporting different approaches to TRD should be evaluated. For example, many earlier TRD studies employed tricyclics as the primary antidepressant, but tricyclics have now been superseded by selective serotonin reuptake inhibitors (SSRIs) in routine clinical practice. This deficiency has been addressed by the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, the largest effectiveness study of TRD ever conducted. However, design characteristics of the STAR*D study preclude simple comparisons with earlier studies. TAKE HOME MESSAGE A shortcoming of most treatment recommendations for TRD is their reliance on older studies that do not reflect the current preeminence of SSRIs in clinical practice. This has distorted the prioritization of pharmacological strategies for TRD. Efforts to correct this distortion with effectiveness research, designed to better reflect current practice trends, require critical consideration of the strengths and limitations of this approach.
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Affiliation(s)
- Noah S. Philip
- Mood Disorders Research Program, Butler Hospital, Providence RI
| | | | - Audrey R. Tyrka
- Mood Disorders Research Program, Butler Hospital, Providence RI
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16
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Kagawa S, Nemoto K, Suzuki T, Nagai G, Nakamura A, Mihara K, Kondo T. Lamotrigine augmentation for the treatment-resistant mood disorder. ACTA ACUST UNITED AC 2010. [DOI: 10.5234/cnpt.1.35] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Vigo DV, Baldessarini RJ. Anticonvulsants in the treatment of major depressive disorder: an overview. Harv Rev Psychiatry 2009; 17:231-41. [PMID: 19637072 DOI: 10.1080/10673220903129814] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Major depressive disorder (MDD) is highly prevalent, potentially disabling, and sometimes fatal. Antidepressants (ADs) have improved its treatment, but incomplete response, sustained morbidity, recurrences, agitation, substance abuse, excess medical mortality, and suicide remain unsolved problems among mood disorder patients. AD treatment itself sometimes induces adverse behavioral responses. Several anticonvulsants (ACs) used to treat bipolar disorder (BPD) might also be of value for MDD. Accordingly, we reviewed published reports on ACs for MDD, identifying studies by computerized searches. We excluded reports dealing only with BPD patients or with sedatives, classified trials by design quality, and evaluated treatment of acute episodes and recurrences of adult MDD. We found 36 reports involving 41 relevant trials of carbamazepine (12 trials), valproate (11), lamotrigine (9), gabapentin (3), topiramate (3), phenytoin (2), and tiagabine (1). They include 9 blinded, controlled trials (of 28-70 days), involving carbamazepine (3 trials), lamotrigine (3), phenytoin (2), or topiramate (1) as primary treatments (5) or AD adjuncts (4). Some of these trials, as well as 7 of lesser quality, suggest benefits of carbamazepine, lamotrigine, and valproate, mainly as adjuncts to ADs. Another 20 anecdotes or small trials further suggest that these ACs might be useful as AD adjuncts-specifically to treat irritability or agitation in MDD. Overall, these reports provide suggestive evidence of beneficial effects of carbamazepine, lamotrigine, and valproate that require further study, especially for long-term adjunctive use, particularly in patients with recurring MDD with prominent irritability or agitation.
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Affiliation(s)
- Daniel V Vigo
- Department of Psychiatry, Harvard Medical School, MA, USA.
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18
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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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19
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Abstract
PURPOSE OF REVIEW The majority of patients with depression fail to remit on one or more antidepressant trials. These patients have treatment-resistant depression (TRD) with high relapsing rates. Augmentation pharmacotherapy refers to the addition of drugs that are not standard antidepressants in order to enhance the effect of a classical antidepressant drug. This review highlights the current status and future research directions of augmentation treatments for TRD with a special focus on research data published within the past year. RECENT FINDINGS Atypical antipsychotics, stimulants, pindolol, lithium, lamotrigine and mecamylamine were tested for efficacy in clinical trials. Most of the trials were not controlled or had limited sample size. Recent data now support the use of some atypical antipsychotics to augment depression resistant to the newer, more selective, antidepressants. SUMMARY Lithium and triiodothyronin (T3) augmentation of tricyclic agents remains the best studied strategy. Data converge to demonstrate the efficacy of some atypical antipsychotics as augmenting agents to selective serotonin reuptake inhibitors. Further adequately powered controlled trials on augmentation pharmacotherapy of TRD are necessary.
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20
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Abstract
Anticonvulsant drugs are widely used in psychiatric indications. These include mainly alcohol and benzodiazepine withdrawal syndromes, panic and anxiety disorders, dementia, schizophrenia, affective disorders, bipolar affective disorders in particular, and, to some extent, personality disorders, A further area in which neurology and psychiatry overlap is pain conditions, in which some anticonvulsants, and also typical psychiatric medications such as antidepressants, are helpful. From the beginning of their psychiatric use, anticonvulsants have also been used to ameliorate specific symptoms of psychiatric disorders independently of their causality and underlying illness, eg, aggression, and, more recently, cognitive impairment, as seen in affective disorders and schizophrenia. With new anticonvulsants currently under development, it is likely that their use in psychiatry will further increase, and that psychiatrists need to learn about their differential efficacy and safety profiles to the same extent as do neurologists.
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Affiliation(s)
- Heinz C R Grunze
- University of Newcastle School of Neurology, Neurobiology and Psychiatry, Leazes Wing, Royal Victoria Infirmary, Queen Victoria Rd., Newcastle upon Tyne NE14LP, United Kingdom.
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21
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Tsai SJ. Sipatrigine could have therapeutic potential for major depression and bipolar depression through antagonism of the two-pore-domain K+ channel TREK-1. Med Hypotheses 2008; 70:548-50. [PMID: 17703894 DOI: 10.1016/j.mehy.2007.06.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2007] [Accepted: 06/26/2007] [Indexed: 11/24/2022]
Abstract
Major depressive disorder (MDD) is a chronic, recurring and potentially life-threatening mental illness. Current treatments are inadequate - many depression medications, although safe and effective, generally have a slow onset of clinical benefit and around half of the MDD patients do not show full remission with optimized treatment. Therefore, there is still a need for the development of faster-acting and more effective medication for MDD. Recent studies have demonstrated that the TREK-1 protein, one of the 17 members of the two-pore domain K+ (K2P) potassium channel family, is inhibited by the antidepressant fluoxetine. Deletion of TREK-1 in mice caused a substantially reduced elevation of corticosterone levels under stress, and produced behaviour similar to that of naive animals treated with fluoxetine in various behavioural tests. These findings suggested that the blocker of the TREK-1 channel might potentially be a new type of antidepressant. Sipatrigine (BW619C89), a neuroprotective agent, has been found to be a potent antagonist of TREK-1. Its related compound, lamotrigine, has been approved for the treatment of bipolar depression and is used to supplement antidepressant medication in patients with treatment-resistant depression. Furthermore, in addition to its antagonistic effect on TREK-1, sipatrigine is also a glutamate release inhibitor. Excessive glutamatergic neurotransmission is associated with depressive-like behaviours and inhibiting glutamate neurotransmission may be implicated in antidepressant therapeutic mechanisms. From the above findings of the effects of sipatrigine on TREK-1 and glutamate neurotransmission, it is hypothesised that sipatrigine could have potential therapeutic effects for MDD or bipolar depression. Further evaluation of its antidepressant therapeutic and toxic effects in animal models is needed before clinical application.
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Affiliation(s)
- Shih-Jen Tsai
- Department of Psychiatry, Taipei Veterans General Hospital, Taiwan.
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22
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Augmentation strategies in the treatment of major depressive disorder. Recent findings and current status of augmentation strategies. CNS Spectr 2007; 12:6-9. [PMID: 18396508 DOI: 10.1017/s1092852900016011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Augmentation strategies have become popular in patients with a partial response or residual symptoms. In a survey conducted by the American Society of Consultant Pharmacists, 65% of 169 psychiatrists indicated that they would augment treatment as the next step in a partial responder in contrast to non-responders in whom they would switch to another drug (J.C. Nelson, unpublished data). This decision is based on common sense and practicality rather than empirical evidence. Many clinicians and patients think that if a patient achieves at least a partial response to a medication, it makes sense to continue that drug and add a second. To some extent, the patient preferences for treatment shown in the Systematic Treatment Alternatives to Relieve Depression (STAR*D) study reflect this approach. This discussion will update clinicians on the use of augmentation agents for the treatment of major depressive disorder (MDD).Lithium augmentation has been used since it was first described by de Montigny and colleagues in 1981. This strategy is based on a rational neurochemical hypothesis that lithium has a synergistic effect when added to a tricyclic antidepressant (TCA). Lithium increases serotonin turnover and the TCA increases postsynaptic serotonin receptor sensitivity. Recent debates have focused on whether lithium is as effective combined with selective serotonin reuptake inhibitors (SSRIs) as it is combined with a TCA. The rapid effects sometimes observed with lithium augmentation of TCAs does not seem to occur with SSRIs, conceivably because SSRIs do not increase postsynaptic serotonin receptor sensitivity.
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23
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Abstract
Major depression is a chronic disorder with a high morbidity and mortality. Approved treatment for major depression at present includes monotherapy with antidepressants of different pharmacologic classes. There is increasingly widespread use of two other options: augmentation, the addition to an antidepressant of a second compound that is not an antidepressant when used alone; and combination, which is the use of two antidepressants concurrently to enhance or accelerate response. This review focuses on the data available to support these various augmentation and combination treatments.
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Affiliation(s)
- Russell T Joffe
- New Jersey Medical School, Department of Psychiatry, Maplewood, NJ 07040, USA.
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24
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Schindler F, Anghelescu IG. Lithium versus lamotrigine augmentation in treatment resistant unipolar depression: a randomized, open-label study. Int Clin Psychopharmacol 2007; 22:179-82. [PMID: 17414745 DOI: 10.1097/yic.0b013e328014823d] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment-resistant depression affects up to 70% of patients. In our 8-week, randomized, open-label, prospective study of 34 treatment-resistant depression patients lamotrigine-add-on was compared with lithium-augmentation. Both treatments resulted in clinically significant reduction in Hamilton rating scale for depression score: mean Hamilton rating scale for depression-score declined from 22.7 (SD 3.9) to 11.7 (SD 4.2) in the lamotrigine group and from 21.5 (SD 3.8) to 13.3 (SD 5.7) in the lithium (Li) group. No significant differences were seen in Hamilton rating scale for depression scores between treatment groups at baseline (P=0.82) and after 8 weeks (P=0.11). Twenty-three percent of the lamotrigine group (n=4) and 18% (n=3) of the Li group achieved remission, 53% of the lamotrigine group (n=9) responded to treatment vs. 41% in the Li group (n=7) and 47% of the lamotrigine group (n=8) vs. 35% of the Li group (n=6) showed at least a partial response. Lamotrigine-augmentation was well tolerated. In conclusion, this study demonstrated that the add-on of lamotrigine to antidepressive medication revealed comparable results in most outcome measures as a lithium augmentation. Owing to small sample size no conclusions regarding similar efficacy can be drawn from our data. Larger trials that should include a placebo arm are needed to further investigate lamotriginés role in treatment-resistant depression.
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Affiliation(s)
- Frank Schindler
- Charite Campus Benjamin Franklin, Department of Psychiatry, Unit for Affective Disorders, Berlin, Germany.
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25
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Kaufman KR. Anticonvulsants in sports: ethical considerations. Epilepsy Behav 2007; 10:268-71. [PMID: 17258507 DOI: 10.1016/j.yebeh.2006.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Revised: 12/04/2006] [Accepted: 12/08/2006] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Antidoping codes in sport are intended to deter and sanction athletes using performance-enhancing agents while promoting an even playing field for all competitors. Although the World Anti-Doping Code (WADC) permits anticonvulsants in general, harmonization of antidoping permits an international sport federation (IF) to prohibit specific medications within that IF. The anticonvulsants levetiracetam, tiagabine, and lamotrigine may pose ethical dilemmas and could be considered violations of antidoping codes. METHOD This study is a literature review with analysis. RESULTS Lamotrigine, with antiglutamatergic and sodium channel properties, is FDA-approved for maintenance treatment of bipolar disorder, in addition to its use in the treatment of major depression, anxiety disorders, and schizophrenia. Tiagabine, a selective GABA reuptake inhibitor, has mood-stabilizing and anxiolytic properties. Levetiracetam, whose unique mechanism involves the modulators beta-carboline and zinc, has anxiolytic and mood-stabilizing properties. Anxiolytics, antidepressants, and antipsychotics are banned in archery; under strict liability, all three anticonvulsants violate WADC/IF for that specific sport and could result in disqualification unless therapeutic use exemptions (TUEs) are obtained. Ethical issues regarding the use of anticonvulsants by athletes and the need to obtain TUEs are addressed. CONCLUSION The WADC with harmonized IF policies are meant to prevent doping by athletes, but not appropriate medical treatment. When anticonvulsants have other psychotropic properties, ethical issues arise. Athletes should list all medications taken with diagnoses, obtain TUEs as indicated, and contact the appropriate IF or Olympic organization to determine the status of the proposed medication (banned, restricted, nonbanned). Further, clinicians should be knowledgeable regarding these issues when treating athletes.
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Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, UMDNJ--Robert Wood Johnson Medical School, 125 Paterson Street, Suite 2200, New Brunswick, NJ 08901, USA.
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26
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Abstract
Recurrent brief depression is a well-recognized subtype of depressive illness with brief episodes of depression alternating with periods of euthymia. The symptoms are often severe, with frequent association to suicidal ideation. Literature suggests frequent nonresponse to first-line antidepressants. Lamotrigine is an anticonvulsant with antidepressant properties, and reported effectiveness in bipolar depression. We report on two patients with recurrent brief depression, nonresponsive to selective serotonin reuptake inhibitors and venlafaxine, and who responded to therapeutic doses of lamotrigine.
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Affiliation(s)
- Lakshmi N Ravindran
- University of Toronto, Department of Psychiatry, University Health Network, Toronto, Ontario Canada
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27
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Ettinger AB, Kustra RP, Hammer AE. Effect of lamotrigine on depressive symptoms in adult patients with epilepsy. Epilepsy Behav 2007; 10:148-54. [PMID: 17071141 DOI: 10.1016/j.yebeh.2006.09.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Revised: 09/07/2006] [Accepted: 09/13/2006] [Indexed: 11/21/2022]
Abstract
In this investigation, the effects of lamotrigine versus placebo on depressive symptoms in patients with epilepsy were prospectively assessed. This investigation was a secondary analysis of a randomized, double-blind, placebo-controlled, parallel-group study in which adult patients received adjunctive lamotrigine (n=32) or placebo (n=38) for a 7-week dose escalation phase, followed by a 12-week maintenance phase, for primary generalized tonic-clonic (PGTC) seizures. Mood symptoms were assessed with the Beck Depression Inventory, second edition (BDI-II), the Profile of Mood States (POMS), and the Cornell Dysthymia Rating Scale-Self-Report (CDRS). Mean (SD) BDI-II scores at screening reflected mild depressive symptoms and were similar between groups (lamotrigine 18.3 (12.1), placebo 16.8 (12.0)). At the end of the maintenance phase, mean (SD) improvement from baseline was greater with lamotrigine than placebo with respect to BDI-II score (lamotrigine 8.9 (7.6), placebo 1.7 (8.5), P=0.01) and POMS total score (lamotrigine 32.0 (30.4), placebo 6.5 (32.3), P=0.03) and numerically greater with lamotrigine than placebo for CDRS score (lamotrigine 7.3 (7.8), placebo 4.1 (13.9), P=0.50). Among the subset of patients with at least mild depression (BDI-II score10), mean improvement from baseline was numerically, but not statistically significantly, greater with lamotrigine (11.5, n=13) than placebo (3.1, n=18) (P=0.054). Median percentage reductions in seizure frequency were significantly greater with lamotrigine than placebo during the escalation phase, the maintenance phase, and the escalation and maintenance phases combined for PGTC seizures and all generalized seizures. However, improvement in seizure frequency was not correlated with improvement in mood (r=0.1, P=ns). Compared with placebo, lamotrigine improved mood symptoms independently of seizure reduction in patients with generalized seizures. Lamotrigine may be useful in treating patients with epilepsy and comorbid depressive symptoms.
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Affiliation(s)
- Alan B Ettinger
- North Shore-LIJ Comprehensive Epilepsy Centers, Long Island Jewish Medical Center, EEG Lab, 270-05 76th Avenue, New Hyde Park, NY, USA.
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28
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Fakhoury TA, Barry JJ, Mitchell Miller J, Hammer AE, Vuong A. Lamotrigine in patients with epilepsy and comorbid depressive symptoms. Epilepsy Behav 2007; 10:155-62. [PMID: 17166775 DOI: 10.1016/j.yebeh.2006.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 11/03/2006] [Accepted: 11/05/2006] [Indexed: 11/25/2022]
Abstract
PURPOSE This open-label study evaluated the antidepressant qualities of lamotrigine (LTG) in people with epilepsy. METHODS Eligible patients exhibited low to moderate depressive symptoms and required a change in antiepileptic drug (AED) therapy, but were excluded if they had a major depressive disorder (MDD). Lamotrigine was added onto a stable AED regimen, and self-report instruments were administered to evaluate changes in mood states. Evaluations were conducted at baseline, at the end of 19 weeks of adjunctive treatment, and 36 weeks following conversion to monotherapy. RESULTS One hundred and fifty-eight patients with epilepsy participated; 96 patients completed adjunctive treatment, and 66 patients completed monotherapy. Intent-to-treat analyses for all instruments showed improvement in depression scores after adjunctive LTG treatment. Improvement was maintained for those converted to monotherapy. CONCLUSIONS These data suggest that LTG may have antidepressant activity for patients with epilepsy and comorbid low to moderate depressive symptoms, and warrant a randomized controlled trial for validation.
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Affiliation(s)
- Toufic A Fakhoury
- Department of Neurology, University of Kentucky, Lexington, KY, USA.
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