Does dual antidepressant therapy as initial treatment hasten and increase remission from depression?

Items of the Montgomery-Åsberg Depression Rating Scale Associated With Response to Paroxetine Treatment in Patients With Major Depressive Disorder

OBJECTIVES

In the present study, we investigated the association between the severity of each symptom evaluated by the Montgomery-Åsberg Depression Rating Scale (MADRS) at baseline and responsiveness to treatment in patients with major depressive disorder (MDD) to identify the items that predict treatment response.

METHODS

The patients received a diagnosis of MDD if they had a score greater than 20 points on the MADRS. Following admission, 120 patients were enrolled in the study, and 89 patients completed the study. For the first week, a 20-mg/d dose of paroxetine was administered; thereafter, the dose was increased to 40 mg/d. The MADRS was applied at baseline and after 1, 2, 4, and 6 weeks. We defined responders as patients with improvements in their MADRS scores of more than 50% after 6 weeks of treatment. A multiple regression analysis of MADRS scores at 6 weeks was performed to identify patients who responded to treatment.

RESULTS

There was a significant difference between responders and nonresponders in the reported sadness (RS) score for all MADRS items. In the multiple logistic regression analysis, only the RS and concentration difficulties (C) scores showed a significant association with treatment response. Based on the results of χ tests, RS score cutoff values of 2/3 and 3/4 revealed significant differences in the responder rate. None of the cutoff values for the C score revealed significant differences.

CONCLUSIONS

The RS score was significantly associated with responsiveness to paroxetine treatment for MDD, with higher RS scores predicting poor responses to treatment.

Combination antidepressant therapy for major depressive disorder: speed and probability of remission

INTRODUCTION

Only about a third of patients with an episode of major depressive disorder remit with a given treatment and few remissions occur within the first weeks of treatment. This study tested whether combining escitalopram and bupropion as initial treatment would result in quicker remission and a higher remission rate than monotherapy with either drug.

METHOD

Two hundred forty-five outpatients aged 18-65 having non-psychotic, non-bipolar major depression were randomly assigned to double-blind treatment with bupropion or escitalopram or the combination dosed to a maximum of bupropion 450 mg/d and/or escitalopram 40 mg/d for 12 weeks. A Montgomery-Asberg Depression Rating Scale score of 22 was required for randomization, while a Hamilton Rating Scale for Depression score ≤ 7 defined remission. We hypothesized that bupropion plus escitalopram would outperform both monotherapies in both earlier onset of remission and higher rate of remission.

RESULTS

Primary analyses did not demonstrate that dual therapy outperformed both monotherapies in either timing of remission or remission rate. All three treatments were well tolerated.

DISCUSSION

These results do not support initial use of bupropion plus escitalopram to speed or enhance antidepressant response.

CLINICAL TRIALS REGISTRATION

NCT00519428.

The combination of triiodothyronine (T3) and sertraline is not superior to sertraline monotherapy in the treatment of major depressive disorder

OBJECTIVE

To determine whether the combination of triiodothyronine (T3) plus sertraline at treatment initiation confers greater antidepressant efficacy than sertraline plus placebo in patients with major depressive disorder.

METHOD

Eight-week, double blind, randomized placebo controlled clinical trial of 153 adult outpatients between 18 and 60 years of age, with DSM-IV defined major depressive disorder. Patients were treated with sertraline flexibly adjusted for tolerability and in a double blind fashion with placebo or T3 (25 μg/day in week 1 and increasing to 50 μg/day in week 2). Response was defined categorically as 50% reduction and total score less than 15 in 21-item Hamilton Rating Scale for Depression (HRSD-21) at week 8 and remission as HRSD-21 less than 8.

RESULTS

There was no difference between treatment groups at final assessment; 65% of placebo and 61.8% of T3 treated subjects achieved response and 50.6% of placebo and 40.8% of T3 treated patients achieved remission. The mean daily dose at final assessment of sertraline and T3, respectively was 144.7 mg (± 48.7 mg) and 48.2 μg (± 7 μg). Median time to response did not differ between treatment groups. Baseline thyroid function tests did not predict response to sertraline treatment or T3 augmentation.

CONCLUSIONS

These results do not support the routine use of T3 to enhance or accelerate onset of antidepressant response in patients with major depressive disorder.

Novel C-1 substituted cocaine analogs unlike cocaine or benztropine

Despite a wealth of information on cocaine-like compounds, there is no information on cocaine analogs with substitutions at C-1. Here, we report on (R)-(-)-cocaine analogs with various C-1 substituents: methyl (2), ethyl (3), n-propyl (4), n-pentyl (5), and phenyl (6). Analog 2 was equipotent to cocaine as an inhibitor of the dopamine transporter (DAT), whereas 3 and 6 were 3- and 10-fold more potent, respectively. None of the analogs, however, stimulated mouse locomotor activity, in contrast to cocaine. Pharmacokinetic assays showed compound 2 occupied mouse brain rapidly, as cocaine itself; moreover, 2 and 6 were behaviorally active in mice in the forced-swim test model of depression and the conditioned place preference test. Analog 2 was a weaker inhibitor of voltage-dependent Na+ channels than cocaine, although 6 was more potent than cocaine, highlighting the need to assay future C-1 analogs for this activity. Receptorome screening indicated few significant binding targets other than the monoamine transporters. Benztropine-like "atypical" DAT inhibitors are known to display reduced cocaine-like locomotor stimulation, presumably by their propensity to interact with an inward-facing transporter conformation. However, 2 and 6, like cocaine, but unlike benztropine, exhibited preferential interaction with an outward-facing conformation upon docking in our DAT homology model. In summary, C-1 cocaine analogs are not cocaine-like in that they are not stimulatory in vivo. However, they are not benztropine-like in binding mechanism and seem to interact with the DAT similarly to cocaine. The present data warrant further consideration of these novel cocaine analogs for antidepressant or cocaine substitution potential.

Do we need more than one antidepressant for patients with major depressive disorder?

According to currently existing treatment guidelines, when a single antidepressant medication is not working, the common next step treatment is to switch to another class of antidepressants or to add another one to the first therapeutic agent. With regard to this issue, combination therapy has been suggested to provide unexpected synergy for patients, resulting in more remission compared with switching strategies, although some debates are still ongoing. Recently, Rush and colleagues have investigated whether two antidepressant combination treatments should produce a higher remission rate in first-step acute-phase (12 weeks) and long-term (7 months) treatment compared with monotherpay. They failed to find any superiority of combination treatment over monotherapy in terms of efficacy and safety. The remission and response rates and most secondary outcomes were not different among treatment groups at 12 weeks and 7 months, while the mean number of worsening adverse events was higher for combination treatment (5.7) than for monotherapy (4.7) at 12 weeks. This article will discuss the clinical and further research implications in the context of the potential limitations and significance of this recent study.

Targeting Treatment-Resistant Depression

Only 50% of depressed patients achieve remission of symptoms after 2 trials of antidepressants. Therefore one half of patients are considered treatment resistant. Studies have shown that with each failed antidepressant, chances of remission continue to decline. Untreated depressive symptoms lead to impaired social and occupational function, decline of physical health, suicidal thoughts, and increased health care utilization. Clinicians recognize there is an urgent need to find an efficacious treatment, but it becomes more difficult to decide on an appropriate therapy once a patient has failed 2 to 3 trials of antidepressants. An evidence-based review was performed to assess the efficacy and safety of several different antidepressant strategies to help the clinician decide which may be beneficial for specific patients.