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Kleinerman A, Rosenfeld A, Benrimoh D, Fratila R, Armstrong C, Mehltretter J, Shneider E, Yaniv-Rosenfeld A, Karp J, Reynolds CF, Turecki G, Kapelner A. Treatment selection using prototyping in latent-space with application to depression treatment. PLoS One 2021; 16:e0258400. [PMID: 34767577 PMCID: PMC8589171 DOI: 10.1371/journal.pone.0258400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/26/2021] [Indexed: 12/28/2022] Open
Abstract
Machine-assisted treatment selection commonly follows one of two paradigms: a fully personalized paradigm which ignores any possible clustering of patients; or a sub-grouping paradigm which ignores personal differences within the identified groups. While both paradigms have shown promising results, each of them suffers from important limitations. In this article, we propose a novel deep learning-based treatment selection approach that is shown to strike a balance between the two paradigms using latent-space prototyping. Our approach is specifically tailored for domains in which effective prototypes and sub-groups of patients are assumed to exist, but groupings relevant to the training objective are not observable in the non-latent space. In an extensive evaluation, using both synthetic and Major Depressive Disorder (MDD) real-world clinical data describing 4754 MDD patients from clinical trials for depression treatment, we show that our approach favorably compares with state-of-the-art approaches. Specifically, the model produced an 8% absolute and 23% relative improvement over random treatment allocation. This is potentially clinically significant, given the large number of patients with MDD. Therefore, the model can bring about a much desired leap forward in the way depression is treated today.
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Affiliation(s)
| | | | - David Benrimoh
- McGill University, Montreal, Canada
- Aifred Health, Montreal, Canada
| | | | | | | | | | - Amit Yaniv-Rosenfeld
- Shalvata Mental Health Center, Hod Hasharon, Israel
- Tel-Aviv University, Tel-Aviv, Israel
| | - Jordan Karp
- University of Arizona, Tucson, Arizona, United States of America
| | - Charles F. Reynolds
- University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | | | - Adam Kapelner
- Queens College, New York City, NY, United States of America
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Abstract
SummaryThe tolerability and safety of treatment with paroxetine have been assessed by analysis of a clinical trial database that extends to 4126 patients treated with paroxetine, 1954 patients on active control, and 625 placebo patients. A total of 451 patients were exposed to paroxetine for periods of 1 or more years. Paroxetine was generally better tolerated than active control and was associated with a lower frequency of manic reactions in bipolar patients and fewer seizures than active control. Paroxetine appears to offer a differential advantage in reducing suicidal thoughts; the number of suicides and attempted suicides per patient exposure year were lower for paroxetine than for other antidepressants or placebo.
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Tran BX, Ha GH, Vu GT, Nguyen LH, Latkin CA, Nathan K, McIntyre RS, Ho CS, Tam WW, Ho RC. Indices of Change, Expectations, and Popularity of Biological Treatments for Major Depressive Disorder between 1988 and 2017: A Scientometric Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2255. [PMID: 31247926 PMCID: PMC6651662 DOI: 10.3390/ijerph16132255] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Major Depressive Disorder (MDD) is the most common psychiatric disorder with high prevalence and disease burden. Biological treatments of MDD over the last several decades include a wide range of antidepressants and neurostimulation therapies. While recent meta-analyses have explored the efficacy and tolerability of antidepressants, the changing trends of biological treatments have not been evaluated. Our study measured the indices of change, expectations, and popularity of biological treatments of MDD between 1988 and 2017. METHODS We performed a scientometric analysis to identify all relevant publications related to biological treatments of MDD from 1988 to 2017. We searched the Web of Science websites for publications from 1 January 1988 to 31 December 2017. We included publications of fluoxetine, paroxetine, citalopram, sertraline, amitriptyline, fluvoxamine, escitalopram, venlafaxine, duloxetine, milnacipran, desvenlafaxine, levomilnacipran, clomipramine, nortriptyline, bupropion, trazodone, nefazodone, mirtazapine, agomelatine, vortioxetine, vilazodone, electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and transcranial direct current stimulation (tDCS). We excluded grey literature, conference proceedings, books/book chapters, and publications with low quality as well as publications not related to medicine or human health. The primary outcomes assessed were indices of change, expectations, and popularity. RESULTS Of 489,496 publications identified, we included 355,116 publications in this scientometric analysis. For the index of change, fluoxetine, sertraline and ECT demonstrated a positive index of change in 6 consecutive periods. Other neurostimulation therapies including rTMS, VNS, DBS and tDCS had shown a positive index of change since 1998. We calculated the index of change of popularity index (PI), which indicates that from 2013 to 2017, the number of publications on tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were reduced by 85.0% and 81.3% respectively, as compared with the period 2008-2012. For the index of expectation, fluoxetine and ECT showed the highest index of expectations in six consecutive periods and remained the highest in 2013-2017. For popularity, the three antidepressants with highest PI were fluoxetine (4.01), paroxetine (2.09), and sertraline (1.66); the three antidepressants with lowest PI were desvenlafaxine (0.08), vilazodone (0.04) and levomilnacipran (0.03). Among neurostimulation therapies, ECT has the highest PI (2.55), and tDCS the lowest PI (0.14). The PI of SSRI remained the highest among all biological treatments of MDD in 2013-2017. In contrast, the PI of ECT was reduced by approximately 50% during the period 2008 to2012 than that in the period 2013 to 2017. CONCLUSIONS This scientometric analysis represents comprehensive evidence on the popularity and change in prospects of biological treatments for MDD from 1988 to 2017. The popularity of SSRI peaked between 1998 and 2002, when their efficacy, tolerability and safety profile allowed them to replace the TCAs and MAOIs. While the newer neurostimulation therapies are gaining momentum, the popularity of ECT has sustained.
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Affiliation(s)
- Bach X Tran
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Vietnam Young Physicians' Association, Hanoi 100000, Vietnam
| | - Giang H Ha
- Institute for Global Health Innovations, Duy Tan University, Hanoi 100000, Vietnam
| | - Giang T Vu
- Center of Excellence in Evidence-Based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 70000, Vietnam
| | - Long H Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 70000, Vietnam
| | - Carl A Latkin
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Kalpana Nathan
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Roger S McIntyre
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON M5G 2C4, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON M5T 1R8, Canada
- Department of Toxicology and Pharmacology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Cyrus S Ho
- Department of Psychological Medicine, National University Health System, Singapore 119228, Singapore
| | - Wilson W Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
- Center of Excellence in Evidence-Based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 70000, Vietnam
| | - Roger C Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore.
- Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore 117599, Singapore.
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 70000, Vietnam.
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Tyuvina NA, Stolyarova AE, Smirnova VN. Bipolar affective disorder: gender differences in the course and treatment. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:162-169. [DOI: 10.17116/jnevro2019119121162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Conroy DA, Brower KJ. Alcohol, toxins, and medications as a cause of sleep dysfunction. HANDBOOK OF CLINICAL NEUROLOGY 2011; 98:587-612. [PMID: 21056213 DOI: 10.1016/b978-0-444-52006-7.00038-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Deirdre A Conroy
- University of Michigan Addiction Resarch Center, Ann Arbor, MI 48109-2700, USA
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Montgomery SA, Kasper S. Severe depression and antidepressants: focus on a pooled analysis of placebo-controlled studies on agomelatine. Int Clin Psychopharmacol 2007; 22:283-91. [PMID: 17690597 DOI: 10.1097/yic.0b013e3280c56b13] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The efficacy of agomelatine in severe depression has been examined in three positive placebo-controlled studies and in a pooled analysis of the data from the three studies in patients treated with 25-50 mg agomelatine (n=357) and placebo (n=360). Agomelatine was significantly more effective than placebo in a subgroup of patients with severe depression with a severity of 25 or more on the Hamilton Depression Rating Scale 17-item scale in each individual study (P<0.05) and in the pooled analysis (P<0.001). Analysis of the pooled data demonstrated that there was an increase in the magnitude of the agomelatine-placebo difference with increasing severity on the baseline Hamilton Depression Rating Scale. When the population was divided into subgroups using increasing cut-off Hamilton Depression Rating Scale values a significant difference between agomelatine and placebo was observed in each subgroup despite the decreasing numbers of patients with higher severity with a difference of 2.06 rising to 4.45 points on the Hamilton Depression Rating Scale. In conclusion, agomelatine is effective in treating severe depression.
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Möller HJ. Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a systematic review. Eur Arch Psychiatry Clin Neurosci 2006; 256:329-43. [PMID: 16783501 DOI: 10.1007/s00406-006-0650-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 01/23/2006] [Indexed: 10/24/2022]
Abstract
The role of antidepressants in suicide prevention is a major public health question, given the high prevalence of both depression and depression-related suicidality. Therefore all means available should be utilised to clarify the influence of antidepressants on suicidality. This paper gives a comprehensive overview of the positive effects of antidepressants on suicidality. In the first section, principal methodological issues related to suicidology in general as well as to clinical and epidemiological studies that investigate the influence of antidepressants on suicidality are discussed. In the second section, the results of controlled clinical studies on the efficacy of antidepressants in suicidality are presented. The third section reports on the results of other types of studies, especially epidemiological studies. Altogether, there seems to be reasonable evidence from different research approaches that antidepressants are able to reduce suicidal ideation and also suicidal behaviour in depressive patients. While the evidence for the beneficial effect on suicidal ideation comes from randomised control group studies, some of which used a placebo arm, the evidence for the prophylactic effect on suicidal behaviour, especially suicide, was primarily obtained from well-designed epidemiological studies.
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Affiliation(s)
- Hans-Jürgen Möller
- Department of Psychiatry, Ludwig-Maximilians-University, Nussbaumstrasse 7, 80336, Munich, Germany.
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Katz MM, Tekell JL, Bowden CL, Brannan S, Houston JP, Berman N, Frazer A. Onset and early behavioral effects of pharmacologically different antidepressants and placebo in depression. Neuropsychopharmacology 2004; 29:566-79. [PMID: 14627997 DOI: 10.1038/sj.npp.1300341] [Citation(s) in RCA: 183] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study was aimed at resolving the time course of clinical action of antidepressants (ADs) and the type of early behavioral changes that precede recovery in treatment-responsive depressed patients. The first goal was to identify, during the first 2 weeks of treatment, the onset of clinical actions of the selective serotonin reuptake inhibitor (SSRI), paroxetine, and the selective noradrenergic reuptake inhibitor, desipramine (DMI). The second aim was to test the hypothesis that the two pharmacologic subtypes would induce different early behavioral changes in treatment-responsive patients. The design was a randomized, parallel group, placebo-controlled, double-blind study for 6 weeks of treatment following a 1-week washout period. The study utilized measures of the major behavioral components of the depressive disorder as well as overall severity. The results indicated that the onset of clinical actions of DMI ranged from 3 to 13 days, averaged 13 days for paroxetine, and was 16-42 days for placebo. Furthermore, as hypothesized, the different types of ADs initially impacted different behavioral aspects of the disorder. After 1 week of treatment, DMI produced greater reductions in motor retardation and depressed mood than did paroxetine and placebo, and this difference persisted at the second week of treatment. Early improvement in depressed mood-motor retardation differentiated patients who responded to DMI after 6 weeks of treatment from those that did not. Paroxetine initially reduced anxiety more in responders than in nonresponders, and by the second week, significantly improved depressed mood and distressed expression in responders to a greater extent. Depressed patients who responded to placebo showed no consistent early pattern of behavior improvement. Early drug-specific behavioral changes were highly predictive of ultimate clinical response to the different ADs, results that could eventually be applied directly to clinical practice.
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Affiliation(s)
- Martin M Katz
- Department of Psychiatry, The University of Texas Health Science Center, San Antonio, TX, USA
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Waintraub L, Septien L, Azoulay P. Efficacy and safety of tianeptine in major depression: evidence from a 3-month controlled clinical trial versus paroxetine. CNS Drugs 2002; 16:65-75. [PMID: 11772119 DOI: 10.2165/00023210-200216010-00005] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE This study was performed to compare the efficacy and safety of tianeptine and paroxetine in the treatment of major depression. Anxiolytic drug use was systematically reported to provide an indirect evaluation of the anxiolytic activity of both treatments. Zopiclone use was assessed to provide an indirect evaluation of the possible hypnotic activity of both treatments. DESIGN AND SETTING This was a 3-month controlled, randomised, double-blind clinical trial which involved 82 centres in France. PATIENTS 277 outpatients who met DSM-IV criteria for major depression. INTERVENTIONS Patients were treated with either tianeptine (12.5mg three times daily) or paroxetine (20mg once daily plus two placebo capsules). The drug dosages could be doubled after 3 weeks if required by the patient's medical state. MAIN OUTCOME MEASURES AND RESULTS There was a significant decrease in the Montgomery-Asberg Depression Rating Scale score in both groups (from 28.9 at baseline to 11 at endpoint in the tianeptine group, and from 29.6 to 11.6 in the paroxetine group) after 3 months of treatment. No significant difference was evident between the groups. Secondary criteria confirmed the antidepressant efficacy of both medications, with no difference between tianeptine and paroxetine (Hamilton Depression Rating Scale global score at endpoint, Clinical Global Impression final scores, number of responders, delay-to-response, rate of dosage doubling at day 21). The anxiolytic and hypnotic consumption rates decreased in both groups, with no significant difference between the groups. There was no significant difference in clinical safety parameters. CONCLUSION Tianeptine appears to be as effective and as safe as paroxetine for the ambulatory treatment of major depression.
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Affiliation(s)
- Lionel Waintraub
- Service de Psychiatrie du Pr. J.D. Guelfi, Centre Hospitalier Paul Brousse, Villejuif, France.
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Heffern WA. Psychopharmacological and electroconvulsive treatment of anxiety and depression in the elderly. J Psychiatr Ment Health Nurs 2000; 7:199-204. [PMID: 11249312 DOI: 10.1046/j.1365-2850.2000.00284.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The pharmacotherapeutics of antianxiety and antidepressant medication in the elderly is reviewed, and the benefits and risks of electroconvulsive therapy (ECT) are discussed. Physiological changes in normal ageing are described, and the pharmacodynamic and pharmacokinetic implications are addressed. Finally, the role of the advanced practice nurse (mental health/psychiatry) is discussed in terms of accountability, collaboration, and the development of empirical knowledge to enhance quality patient care.
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Affiliation(s)
- W A Heffern
- Faculty of Nursing, University of Alberta, 3-134 Clinical Sciences Building, Edmonton, Alberta, Canada, T6G 2G3
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Montgomery SA, Lecrubier Y. Is severe depression a separate indication? ECNP Consensus Meeting September 20, 1996, Amsterdam. European College of Neuropsychopharmacology. Eur Neuropsychopharmacol 1999; 9:259-64. [PMID: 10208298 DOI: 10.1016/s0924-977x(98)00048-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
There is not an accepted definition of severe depression, but using cut-off scores on rating scales severe depression is considered to lie at one extreme of a continuum of severity. The evidence from epidemiological, biological, and clinical efficacy studies does not support severe depression as a separate illness category. A good response to antidepressants is seen in both moderate and severe depression. The available evidence supports the view that in most cases an effective antidepressant in moderate depression is likely to have efficacy in severe depression. Few studies have found differences between antidepressants in their efficacy in treating severe depression. Most evidence of differential efficacy derives from studies of clomipramine, which is perceived as a particularly potent antidepressant by many clinicians. Other tricyclic antidepressants do not appear to have an advantage in severe depression. Separate studies to demonstrate efficacy in severe depression are not necessary for the registration of a new antidepressant. However if efficacy in severe depression is demonstrated in separate studies this information could be included in the summary of product characteristics to provide guidance to clinicians.
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Kasper S, Zivkov M, Roes KC, Pols AG. Pharmacological treatment of severely depressed patients: a meta-analysis comparing efficacy of mirtazapine and amitriptyline. Eur Neuropsychopharmacol 1997; 7:115-24. [PMID: 9169299 DOI: 10.1016/s0924-977x(96)00394-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Efficacy data were available from 405 severely depressed patients (baseline 17-item Hamilton Rating Scale for Depression-HAMD scores > or = 25) participating in randomized, double-blind, amitriptyline-controlled studies of mirtazapine. Main efficacy variable were changes from baseline in the group mean 17-item HAMD scores and responder rates. Secondary efficacy variables were changes in depressed mood item on the HAMD and in factors derived from the 17-item HAMD scale. Treatment with either mirtazapine or amitriptyline resulted in robust reductions of baseline HAMD scores and in similar and high percentages of responders. Both drugs produced favourable effects on depressed mood and on symptoms commonly associated with depression, such as anxiety, sleep and vegetative disturbances. There were neither statistically significant nor clinically relevant differences between mirtazapine and amitriptyline at any assessment point nor at endpoint. The results demonstrate that the new antidepressant mirtazapine and the tricyclic antidepressant amitriptyline are equally effective in the treatment of severely depressed patients.
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Affiliation(s)
- S Kasper
- Department of General Psychiatry, University of Vienna, Austria
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Skerritt U, Evans R, Montgomery SA. Selective serotonin reuptake inhibitors in older patients. A tolerability perspective. Drugs Aging 1997; 10:209-18. [PMID: 9108894 DOI: 10.2165/00002512-199710030-00005] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Depression is a serious illness that is common in the elderly but which is frequently overlooked. Management is complicated by physiological changes associated with aging, the presence of comorbid physical illness, and compliance problems; these factors must be taken into account when selecting an appropriate antidepressant. The well known problems associated with the tricyclic antidepressants (TCAs) [i.e. their unwanted anticholinergic, adrenergic and histaminergic effects], which are troublesome in younger patients, can have serious consequences for elderly depressed patients. The TCAs can cause symptoms that worsen concomitant physical illness, which is frequently present in the elderly, and their cardiotoxicity in overdose is of concern in both younger and older patients. The selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors have been shown to be as efficacious as the TCAs in the general depressed population, but to lack the anticholinergic adverse effects and cardiotoxicity associated with those drugs. Their increased safety and tolerability makes them a preferred treatment for depressed elderly patients.
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Affiliation(s)
- U Skerritt
- Imperial College of Science Technology, St Mary's Hospital Medical School, London, England
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Geretsegger C, Stuppaeck CH, Mair M, Platz T, Fartacek R, Heim M. Multicenter double blind study of paroxetine and amitriptyline in elderly depressed inpatients. Psychopharmacology (Berl) 1995; 119:277-81. [PMID: 7675961 DOI: 10.1007/bf02246291] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Paroxetine is a phenylpiperidine compound which is a selective serotonin reuptake inhibitor (SSRI). Ninety-one hospitalised patients with a major depression (DSM-III) aged 65 and over from six Austrian and one German center were entered into the study, which compared the efficacy and tolerability of paroxetine versus amitriptyline. After 6 weeks both groups showed similarly good therapeutic results. In the paroxetine group, 64.3% of the patients had a 50% or more reduction of the HAMD total score compared to 58.1% in the amitriptyline group. Side effects were distributed similarly in both groups. Patients in the paroxetine group showed a higher incidence of anxiety and agitation; anticholinergic side effects were registered more often in the amitriptyline group.
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Affiliation(s)
- C Geretsegger
- Salzburg State Hospital, Department of Psychiatry, Austria
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Abstract
One of the most important recent developments in the management of depression is the recognition of the need for long-term treatment. Treatment of an episode of depression must continue after apparent response in order to consolidate response and prevent relapse. A continuation treatment period of at least four months after response of the acute episode is required in all patients with depression. Most depression is recurrent, and prophylactic treatment with antidepressants reduces the risk of new episodes. This treatment needs to be continued over very long periods, because the risk of new episodes does not appear to diminish with time. In selecting an antidepressant for long-term treatment efficacy, safety and tolerability in the long term should be taken into account since not all antidepressants have been adequately tested, and some do not appear to be effective. The most thoroughly tested antidepressants are the tricyclic imipramine and the new selective serotonin reuptake inhibitors.
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Affiliation(s)
- S A Montgomery
- Department of Psychiatry, St. Mary's Hospital Medical School, London, England
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Kasper S, Lepine JP, Mendlewicz J, Montgomery SA, Rush AJ. Efficacy, safety, and indications for tricyclic and newer antidepressants. ACTA ACUST UNITED AC 1994. [DOI: 10.1002/depr.3050020304] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Montgomery DB, Roberts A, Green M, Bullock T, Baldwin D, Montgomery SA. Lack of efficacy of fluoxetine in recurrent brief depression and suicidal attempts. Eur Arch Psychiatry Clin Neurosci 1994; 244:211-5. [PMID: 7888419 DOI: 10.1007/bf02190400] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recurrent brief depression (RBD) fulfills DSM-III-R symptom criteria for major depression but the episodes are of shorter duration than the 2 weeks required by DSM-III-R. The clinical importance of the disorder has been observed in prophylactic studies of suicidal behavior. The possibility that antidepressants with selective action on the reuptake of serotonin might be effective in preventing recurrences of brief depression has been investigated. Fluoxetine in a dose of 120 mg a week, administered biweekly, had no effect on the recurrence rate, which was maintained at approximately the same rate on fluoxetine (1 every 18.7 days) as with placebo (1 every 17.6 days). In a group of patients with two or more prior episodes of suicidal behavior, there were 18 attempted suicides in the 54 patients treated with fluoxetine and the same number in the 53 patients treated with placebo. Fluoxetine neither raised nor lowered the suicide attempt rate as compared with placebo, providing no evidence to support the drug's role in either suicide provocation or prevention. Since fluoxetine is clearly effective with recurrent major depression, it would appear that recurrent brief depression has a different pharmacology.
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Affiliation(s)
- D B Montgomery
- Department of Psychiatry, St Mary's Hospital Medical School, London, England
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Anderson IM, Tomenson BM. The efficacy of selective serotonin re-uptake inhibitors in depression: a meta-analysis of studies against tricyclic antidepressants. J Psychopharmacol 1994; 8:238-49. [PMID: 22298630 DOI: 10.1177/026988119400800407] [Citation(s) in RCA: 179] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A meta-analysis of the efficacy of five selective serotonin re-uptake inhibitors (SSRIs) against non-selective and noradrenergic re-uptake inhibitors (mainly tricyclic antidepressants, TCAs) is presented. Fifty five double- blind studies were identified after excluding those multiply reported or with methodological problems likely to bias the outcome in favour of SSRIs. Standardised effect sizes and 95% confidence intervals were calculated based on the difference in the reduction in mean Hamilton depression rating scale (HDRS) scores for the two antidepressants. For studies not reporting standard deviations, the pooled variance from complete studies was used and a variance-weighted mean effect size calculated. There were no differences in efficacy between SSRIs and comparator antidepressants for SSRIs taken together or individually. If studies were classified into high and low depression scores based on a median split of initial HDRS scores, there was a slight advantage to TCAs in the high HDRS group. In addition, SSRIs were slightly less effective than TCAs in in-patients and against combined serotonin and noradrenaline re-uptake inhibitors (clomipramine and amitriptyline). These findings were accounted for by a clinically significant lower efficacy of paroxetine in these subgroups. In contrast, SSRIs as a group were marginally more effective than noradrenergic antidepressants, a finding accounted for by two studies with sertraline. Fluvoxamine was the only SSRI to have been tested adequately in in-patients, where it displayed equal efficacy to TCAs. This meta-analysis confirms that SSRIs and TCAs are in general equally effective, but suggests that paroxetine's efficacy in in-patients and against clomipramine and amitriptyline is not proven.
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Affiliation(s)
- I M Anderson
- University of Manchester Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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