Efficacy of Bupropion XR in Treatment-Resistant Elderly Patients: A Case Series Study

A Review of Therapeutics for Treatment-Resistant Depression in the Older Adult

One-third of older adults with depression meet criteria for treatment resistance, typically defined as a lack of response to two or more adequate trials of an antidepressant. Treatment resistance contributes to an unfavorable prognosis, compromised medical outcomes, heightened disability, accelerated cognitive decline, and an elevated risk of developing dementia. Despite this significant morbidity, evidence is sparse for how to proceed with treatment in this population. Non-pharmacologic therapy (e.g., diet, psychotherapy) can be utilized as adjunctive therapy, despite little published evidence of benefit, given that the risks are low. Pharmacotherapy trials in the treatment-resistant late-life depression population lack strong methods and external validity; however, the use of venlafaxine as monotherapy and add-on therapy, as well as lithium, bupropion, or aripiprazole as add-on therapy to standard antidepressant therapy, have enough evidence that a trial with appropriate monitoring is a prudent strategy. Electroconvulsive therapy remains a well-studied safe therapy, especially when used as maintenance treatment once an initial cycle is completed but is traditionally underutilized in the treatment-resistant late-life depression population. Ensuring non-pharmacologic and pharmacologic strategies are optimized and given a sufficient trial in those with treatment-resistant late-life depression is the best we can do for this vulnerable population.

Socio-demographic and clinical predictors of non-response/non-remission in treatment resistant depressed patients: A systematic review

Up to one third of patients adequately treated for Major Depressive Disorder (MDD) do not respond to multiple interventions. Many studies investigated predictors in MDD outcome, but no study focused on predictors of non-response or non-remission to antidepressants in subjects with treatment resistant depression (TRD). The present study aimed to evaluate possible socio-demographic and clinical predictors of non-response and non-remission in MDD patients who failed to benefit from at least one antidepressant trial. A total of 51 papers were included. A number of severity indicators, such as longer duration of depressive episode, moderate-high suicidal risk, anxious comorbidity, higher number of hospitalizations and higher dosage of antidepressants, were associated with non-response as well as age. Interestingly, severity of illness, as well as comorbid personality disorders and anxiety symptoms, had also a predictive value in non-remission with the addition of marital status. Considering limitations, selected studies were observational or randomized non controlled/controlled trials and different TRD definitions and outcome measures were used. Overall, predictors of outcome were similar to MDD, but specific socio-demographic and clinical factors should be considered in clinical practice to formulate a more focused treatment in TRD patients.

Socio-demographic and clinical predictors of treatment resistant depression: A prospective European multicenter study

BACKGROUND

Few studies investigated socio-demographic and clinical predictors of non response and remission in treatment resistant depression (TRD) in the case of failure of more than two adequate antidepressant (AD) trial. The primary aim of this study was to investigate socio-demographic and clinical predictors of TRD defined as the lack of response to at least three adequate AD treatments, two of which prospectively evaluated. As secondary aims, we also investigated predictors of non response and remission to: (1) at least two adequate AD treatment (one of which prospectively assessed); (2) at least one adequate and retrospectively assessed AD treatment.

METHODS

In the context of a European multicenter project, 407 major depressive disorder (MDD) patients who failed to respond to a previous AD treatment were recruited for a 2 stage trial, firstly receiving venlafaxine and then escitalopram. MINI, HRSD, MADRS, UKU, CGI-S and CGI-I were administered.

RESULTS

Ninety eight subjects (27.61%) were considered as resistant to three AD treatments. Clinical predictors were: longer duration and higher severity of the current episode (p=0.004; ES=0.24; p=0.01; RR=1.41, respectively), outpatient status (p=0.04; RR=1.58), higher suicidal risk level (p=0.02; RR=1.49), higher rate of the first/second degree psychiatric antecedents (MDD and others) (p=0.04; RR=1.31, p=0.03; RR=1.32 respectively) and side effects during treatments (p=0.002; RR=2.82). Multivariate analyses underlined the association between TRD and the severity of the current episode (p=0.04). As for secondary outcomes, predicting factors were partially overlapping.

LIMITATIONS

The limited sample size and specific drugs used limit present findings.

CONCLUSION

Subjects with a high degree of resistance to AD treatments show specific features which may guide the clinicians to the choice of more appropriate therapies at baseline.

Pharmacological approaches to manage persistent symptoms of major depressive disorder: rationale and therapeutic strategies

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.

Bupropion as an augmenting agent in patients of depression with partial response

The objective of this study is to evaluate the effects of bupropion as an add-on therapy to selective serotonin reuptake inhibitor (SSRI) on patients of major depressive disorder with partial response. This prospective, randomized, controlled and single-blind study was conducted in sixty patients suffering from major depressive disorder as per Diagnostic and Statistical Manual (DSM)-IV TR criteria, who were having Hamilton depression rating scale (HDRS) score ≥16 after 4 weeks of treatment with SSRIs. Group A received SSRI plus placebo and group B received SSRI plus bupropion. Evaluation was performed based on changes in HDRS score, Montgomery and Asberg depression rating scale (MADRS), Amritsar depressive inventory (ADI) and spontaneously reported adverse effects. There was a significant decrease in the HDRS, MADRS and ADI scores as compared to baseline in both groups. However, the mean decrease in depression score was more in group B than in group A. The percentage decrease of remitters was also significantly more in group B (60% as per HDRS score and 63% as per MADRS score), as compared to group A (24% as per HDRS score and 27% as per MADRS score) (p < 0.05), at the end of treatment. In conclusion, bupropion add-on can act as augmenting agent in patients of depression with partial response to SSRIs.