Gender differences in the clinical effects of fluvoxamine and milnacipran in Japanese major depressive patients

Outcome differences between males and females undergoing deep brain stimulation for treatment-resistant depression: systematic review and individual patient data meta-analysis

BACKGROUND

Treatment-resistant depression (TRD) occurs more commonly in women. Deep brain stimulation (DBS) is an emerging treatment for TRD, and its efficacy continues to be explored. However, differences in treatment outcomes between males and females have yet to be explored in formal analysis.

METHODS

A PRISMA-compliant systematic review of DBS for TRD studies was conducted. Patient-level data were independently extracted by two authors. Treatment response was defined as a 50 % or greater reduction in depression score. Percent change in depression scores by gender were evaluated using random-effects analyses.

RESULTS

Of 737 records, 19 studies (129 patients) met inclusion criteria. The mean reduction in depression score for females was 57.7 % (95 % CI, 64.33 %-51.13 %), whereas for males it was 35.2 % (95 % CI, 45.12 %-25.23 %) (p < 0.0001). Females were more likely to respond to DBS for TRD when compared to males (OR = 2.44, 95 % CI 1.06, 1.95). These differences varied in significance when stratified by DBS anatomical target, age, and timeframe for responder classification.

LIMITATIONS

Studies included were open-label trials with small sample sizes.

CONCLUSIONS

Our findings suggest that females with TRD respond at higher rates to DBS treatment than males. Further research is needed to elucidate the implications of these results, which may include connectomic sexual dimorphism, depression phenotype variations, or unrecognized symptom reporting differences. Methodological standardization of outcome scales, granular demographic data, and individual subject outcomes would allow for more robust comparisons between trials.

Sex Differences in Stress Response: Classical Mechanisms and Beyond

Neuropsychiatric disorders, which are associated with stress hormone dysregulation, occur at different rates in men and women. Moreover, nowadays, preclinical and clinical evidence demonstrates that sex and gender can lead to differences in stress responses that predispose males and females to different expressions of similar pathologies. In this curated review, we focus on what is known about sex differences in classic mechanisms of stress response, such as glucocorticoid hormones and corticotrophin-releasing factor (CRF), which are components of the hypothalamicpituitary- adrenal (HPA) axis. Then, we present sex differences in neurotransmitter levels, such as serotonin, dopamine, glutamate and GABA, as well as indices of neurodegeneration, such as amyloid β and Tau. Gonadal hormone effects, such as estrogens and testosterone, are also discussed throughout the review. We also review in detail preclinical data investigating sex differences caused by recentlyrecognized regulators of stress and disease, such as the immune system, genetic and epigenetic mechanisms, as well neurosteroids. Finally, we discuss how understanding sex differences in stress responses, as well as in pharmacology, can be leveraged into novel, more efficacious therapeutics for all. Based on the supporting evidence, it is obvious that incorporating sex as a biological variable into preclinical research is imperative for the understanding and treatment of stress-related neuropsychiatric disorders, such as depression, anxiety and Alzheimer's disease.

Sex Differences in Depression and Anxiety

Depression and anxiety disorders carry a tremendous worldwide burden and emerge as a significant cause of disability among western societies. Both disorders are known to disproportionally affect women, as they are twice more likely to be diagnosed and moreover, they are also prone to suffer from female-specific mood disorders. Importantly, the prevalence of these affective disorders has notably risen after the COVID pandemic, especially in women. In this chapter, we describe factors that are possibly contributing to the expression of such sex differences in depression and anxiety. For this, we overview the effect of transcriptomic and genetic factors, the immune system, neuroendocrine aspects, and cognition. Furthermore, we also provide evidence of sex differences in antidepressant response and their causes. Finally, we emphasize the importance to consider sex as a biological variable in preclinical and clinical research, which may facilitate the discovery and development of new and more efficacious antidepressant and anxiolytic pharmacotherapies for both women and men.

Sex differences in depressive symptoms and tolerability after treatment with selective serotonin reuptake inhibitor antidepressants: Secondary analyses of the GENPOD trial

BACKGROUND

Differences in serotonergic neurotransmission could lead to sex differences in depressive symptoms and tolerability after treatment with selective serotonin reuptake inhibitors (SSRIs).

AIMS

We investigated whether women have greater reductions in depressive symptoms than men after treatment with an SSRI (citalopram) compared with a noradrenaline reuptake inhibitor (reboxetine) control, and after antidepressant treatment irrespective of class. We also investigated tolerability and the influence of menopausal status.

METHODS

Secondary analyses of the GENPOD (GENetic and clinical Predictors Of treatment response in Depression) trial. Six hundred and one people with depression were recruited from UK primary care and randomized to citalopram or reboxetine. Beck Depression Inventory (BDI-II) score at 6 weeks was the primary outcome. Secondary outcomes included BDI-II score at 12 weeks, and physical symptoms and treatment discontinuation. We calculated main effects and interaction terms using linear and logistic regression models.

RESULTS

There was no evidence that women experienced greater reductions in depressive symptoms than men when treated with citalopram compared with reboxetine. We also found no evidence of sex differences at six or 12 weeks (irrespective of antidepressant class): men scored -0.31 (95% confidence interval (CI) -2.23 to 1.62) BDI-II points lower than women at six weeks and -0.44 (95% CI -2.62 to 1.74) points lower at 12 weeks. There was no evidence of sex differences in physical symptoms or treatment discontinuation and no evidence for an influence of menopausal status.

CONCLUSION

Citalopram was not more effective in women compared with men and there was no difference in tolerability. Women and men had similar prognosis after SSRI treatment and similar prognosis regardless of antidepressant class. Findings were unaltered by menopausal status.

Sexual dimorphism in pre-clinical studies of depression

Although there is a sex bias in the pathological mechanisms exhibited by brain disorders, investigation of the female brain in biomedical science has long been neglected. Use of the male model has generally been the preferred option as the female animal model exhibits both biological variability and hormonal fluctuations. Existing studies that compare behavioral and/or molecular alterations in animal models of brain diseases are generally underrepresented, and most utilize the male model. Nevertheless, in recent years there has been a trend toward the increased inclusion of females in brain studies. However, current knowledge regarding sex-based differences in depression and stress-related disorders is limited. This can be improved by reviewing preclinical studies that highlight sex differences in depression. This paper therefore presents a review of sex-based preclinical studies of depression. These shed light on the discrepancies between males and females regarding the biological mechanisms that underpin mechanistic alterations in the diseased brain. This review also highlights the conclusions drawn by preclinical studies to advance our understanding of mood disorders, encouraging researchers to promote ways of investigating and managing sexually dimorphic disorders.

Gender-specific approach in psychiatric diseases: Because sex matters

In both animals and human beings, males and females differ in their genetic background and hormonally driven behaviour and show sex-related differences in brain activity and response to internal and external stimuli. Gender-specific medicine has been a neglected dimension of medicine for long time, and only in the last three decades it is receiving the due scientific and clinical attention. Research has recently begun to identify factors that could provide a neurobiological basis for gender-based differences in health and disease and to point to gonadal hormones as important determinants of male-female differences. Animal studies have been of great help in understanding factors contributing to sex-dependent differences and sex hormones action. Here we review and discuss evidence provided by clinical and animal studies in the last two decades showing gender (in humans) and sex (in animals) differences in selected psychiatric disorders, namely eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder), schizophrenia, mood disorders (anxiety, depression, obsessive-compulsive disorder) and neurodevelopmental disorders (autism spectrum disorders, attention-deficit/hyperactivity disorder).

Androgen deficit changes the response to antidepressant drugs in tail suspension test in mice

Depressive symptoms are throughout our life, especially in the older population, the sex hormones reduction link to a high risk of depression. In this study, we investigated whether bilateral orchiectomy (ORX) modifies mice behaviors and antidepressant drugs effects through tail suspension test (TST). We evaluated behavioral changes at 1 week, 2 weeks, 1 month, and up to 2 months after ORX. The behavior responses to doxepin, fluoxetine, and venlafaxine at 1 week, 2 weeks, 1 month, and 2 months after ORX were evaluated. No apparent difference was detected among the durations of immobility of the control group, sham operation group, and ORX group in the TST at 1 week and 2 weeks after ORX. But the immobility time of ORX group was obvious longer than that of both control group and sham operation group at 1 month and 2 months after ORX. Only the antidepressant effect of venlafaxine was observed at 1 week and 2 weeks after ORX, while the antidepressant response to fluoxetine decreased 1 month and 2 months after ORX. The response to antidepressant drugs was strongly modified in ORX mice. Our results suggest that not all antidepressant drugs are suitable for depression with androgen deficiency.HighlightsMice with low androgen were more prone to depression-like behaviors.The response to antidepressants changed under the condition of low androgen in mice.Not all antidepressant drugs are appropriate for patients with low androgen.

Brain estrogen alters the effects of the antidepressant sertraline in middle-aged female and male mice

Estrogens are important in regulating mood, especially for females. However, whether tissue-specific estrogen, such as brain estrogen, contributes to the effects of antidepressant treatment has not been determined. The present study used middle-aged aromatase gene knockout (Ar^-/-) mice or overexpression (Thy1-Ar; hGFAP-Ar) mice as brain estrogen models to investigate whether brain estrogen synthesis alters the anti-depressive behaviors of sertraline treatment. Our results showed that depletion of brain estrogen increased depressive-like behavior in females, and elevated brain estrogen reduced depression-like behavior, regardless of sex. These genotype-related behaviors correlated with alterations of monoamine metabolism in the hippocampus (HPC) and the prefrontal cortex (PFC). We also demonstrated that male and female Ar^-/- mice exhibited an attenuation of sertraline-induced anti-depressive behaviors compared to wild-type (WT) mice. The present data suggest that brain estrogen alters depressive-like behaviors and changes the effectiveness of antidepressants in middle-aged mice, regardless of sex.

Functional Dyspepsia: A Narrative Review With a Focus on Sex-Gender Differences

Functional dyspepsia (FD) is among the most common gastrointestinal disorders affecting quality of life (QoL). As it frequently occurs in women than in men the comparison of various aspects including prevalence, clinical manifestations, and QoL in FD between women and men is very important for understanding the disease distribution and burden, evaluating treatment options, developing new drugs, and allocating medical resources. However, little is known about sex or gender differences among patients with FD. In spite of limited studies, consistent points are that FD occurs more often in women than in men and there are several symptom differences between men and women with FD. In addition, women with FD tend to have lower QoL than men with FD. Similarly, the pathophysiology of FD likely to vary depending on gender. Furthermore, a sex-gender-oriented approach in healthcare system could enhance understanding heterogeneous patients suffering from FD. Due to the sex-gender differences in physiological and psychological factors, treatment strategies should differ between women and men with FD. In conclusion, an individualized and multicomponent approach that considers sex and gender issues might improve FD treatment and improve patient Qol, especially for women.

Antidepressant resistance in adolescents with major depressive disorder: A nationwide longitudinal study

BACKGROUND

Studies have suggested that psychiatric comorbidities have major effects on antidepressant resistance in adult patients with major depressive disorder (MDD). However, the association between psychiatric comorbidities and antidepressant resistance remains unclear in adolescents with MDD.

METHODS

A total of 10,624 adolescents with MDD were selected from the Taiwan National Health Insurance Research Database between 2001 and 2010 and followed for one year. Treatment-resistant depression (TRD) was defined as unresponsiveness to at least two antidepressants, and treatment resistant tendency was defined as unresponsiveness to the first antidepressant. Psychiatric comorbidities, such as anxiety disorders, substance use disorders, and attention deficit hyperactivity disorder (ADHD), were assessed as confounding factors.

RESULTS

In our study, only 1.7% (n = 184) of adolescents with MDD met the TRD criteria but 23.3% (n = 2480) were classified as exhibiting treatment resistant tendency. Anxiety disorders (OR: 2.34, 95% CI: 1.73-3.16) and substance use disorders (OR: 2.41, 95% CI: 1.28-4.54) exhibited a correlation with TRD, and ADHD (OR: 1.34, 95% CI: 1.08-1.66) was associated with treatment resistant tendency.

CONCLUSIONS

Approximately one-fourth of adolescents with MDD respond poorly to the first antidepressant treatment. The psychiatric comorbidities of anxiety disorders, substance use disorders, and ADHD may increase the risk of treatment resistance in adolescents with MDD.

Sex differences in the pharmacology of itch therapies-a narrative review

BACKGROUND

Chronic itch is the most common skin-related condition, associated with a high psychosocial and economic burden. In recent years, increasing evidence of sex differences in the perception, clinical presentation and treatment requirements of itch points towards potential benefits when using sex-adapted therapies. It is well-known that body composition, absorption, metabolism, elimination and adverse drug reactions (ADRs) differ between sexes, but only little is known about the impact of sex in the pharmacology of itch treatments, which could help to rationalise sex-adapted treatment strategies.

AIM

To evaluate and review sex effects in the pharmacokinetics and /-dynamics of drugs used to treat itch.

METHODS

In this narrative review we performed a PubMed and MEDLINE (Ovid) search using the terms (itch OR pruritus) AND (gender OR sex) AND (drug OR medication OR pharmacokinetics OR pharmacodynamics). Additional searches were performed for the topical and systemic drugs recommended by the European Guideline on Chronic Pruritus.

RESULTS

We found numerous reports with variable levels of evidence of sex effects with respect to the pharmacokinetics and/or pharmacodynamics of 14 drug classes used for the treatment of itch, including a total of 19 systemic and 3 topical drugs. Women seem to present higher plasma levels of several drugs used in itch treatment, including tri- and tetracyclic antidepressants (e.g. doxepin, amitriptyline, mirtazapine), serotonin reuptake inhibitors (e.g. paroxetine, sertraline, fluoxetine), immunosuppressive drugs (e.g. cyclosporine, mycophenolate mofetil), serotonin receptor antagonists (e.g. ondansetron) and betablockers (e.g. propranolol). Adverse drug reactions (ADRs) were generally more common in women. Being female was reported to be an independent risk factor for QTc-prolongation associated with antihistamines and tetracyclic antidepressants. Additionally, women seem to be more prone to sedative effects of antihistamines, and to suffer from a higher frequency as well as severity of side effects with systemic calcineurin inhibitors, opioid agonists, and opioid antagonists. Women were also sensitised more often to topically applied drugs. Of note, apart from only one experimental study with capsaicin, none of these reports were designed specifically to assess the effect of sex (and gender) in the treatment of itch.

DISCUSSION/CONCLUSION

Our review supports previous reports that sex is of importance in the pharmacokinetics and /-dynamics of several drugs used to treat itch although those drugs were mostly evaluated for non-itch indications. However, the results are limited by methodological limitations evident in most studies such as underrepresentation of women in clinical trials. This emphasises the need to study the impact of sex (and gender) in future itch trials to yield better outcomes and prevent ADRs in both sexes.

Sex differences in depression: Insights from clinical and preclinical studies

Depression represents a global mental health concern, and disproportionally affects women as they are twice more likely to be diagnosed than men. In this review, we provide a summary of evidence to support the notion that differences in depression between men and women span multiple facets of the disease, including epidemiology, symptomology, treatment, and pathophysiology. Through a lens of biological sex, we overview depression-related transcriptional patterns, changes in neuroanatomy and neuroplasticity, and immune signatures. We acknowledge the unique physiological and behavioral demands of pregnancy and motherhood by devoting special attention to depression occurring in the peripartum period. Specifically, we discuss issues surrounding the presentation, time course, treatment, and neurobiology of peripartum depression. We write this review with the intention of highlighting the encouraging advancements in our understanding of sex differences in depression, while underscoring the gaps that remain. A more systematic consideration of biological sex as a variable in depression research will be critical in the discovery and development of pharmacotherapies that are efficacious for both men and women.

Women's Psychiatry

Brain disorders and mental diseases, in particular, are common and considered as a top global health challenge for the twenty-first century. Interestingly, women suffer more frequently from mental disorders than men. Moreover, women may respond to psychotropic drugs differently than men, and, through their lifespan, they endure sex-orientated social stressors. In this chapter, we present how women may differ in the development and manifestation of mental health issues and how they differ from men in pharmacokinetics and pharmacodynamics. We discuss issues in clinical trials regarding women participation, issues in the use of psychotropic medications in pregnancy, and challenges that psychiatry faces as a result of the wider use of contraceptives, of childbearing at older age, and of menopause. Such issues, among others, demand further women-oriented psychiatric research that can improve the care for women during the course of their lives. Indeed, despite all these known sex differences, psychiatry for both men and women patients uses the same approach. Thereby, a modified paradigm for women's psychiatry, which takes into account all these differences, emerges as a necessity, and psychiatric research should take more vigorously into account sex differences.

Study of Sex Differences in Duloxetine Efficacy for Depression in Transgenic Mouse Models

Clinical evidences show sex differences in risk of developing depressive disorders as well as effect of antidepressants in depression treatment. However, whether such a sex-dependent risk of depression and efficacy of antidepressants is dependent on endogenous estrogen level remain elusive. The aim of this study is to explore the molecular mechanisms of sex differences in antidepressant duloxetine. In the present study, we used genetic knockout or overexpression estrogen-synthesizing enzyme aromatase (Ar) gene as models for endogenous estrogen deficiency and elevation endogenous estrogen, respectively, to examine the anti-depressive efficacy of duloxetine in males and females by force swimming test (FST). We also measured the sex-specific effect of duloxetine on dopamine and serotonin (5-HT) metabolisms in frontal cortex and hippocampus (HPC). Elevation of brain endogenous estrogen in male and female mice showed a reduction of immobility time in FST compared to control mice. Estrogen deficiency in females showed poor response to duloxetine treatment compared to sex-matched wildtype (WT) or aromatase transgenic mice. In contrast, male mice with estrogen deficiency showed same anti-depressive response to duloxetine treatments as aromatase transgenic mice. Our data showed that the sex different effect of endogenous estrogen on duloxetine-induced anti-depressive behavioral change is associated with brain region-specific changes of dopamine (DA) and 5-HT system. Endogenous estrogen exerts antidepressant effects in both males and females. Lacking of endogenous estrogen reduced antidepressive effect of duloxetine in females only. The endogenous estrogen level alters 5-HT system in female mainly, while both DA and 5-HT metabolisms were regulated by endogenous estrogen levels after duloxetine administration.

Sex differences in the psychopharmacological treatment of depression

Although a number of studies have observed that females respond better to serotonergic antidepressants than males and that postmenopausal females have a diminished response to antidepressants compared with younger females, there are also studies that conflict with both of these findings, making any generalizations regarding sex differences difficult to make. Sex variance in antidepressant efficacy and pharmacokinetics profiles have been attributed to sex-based physiological differences, behavioral differences, related disorders, and sex-specific conditions, including pregnancy and menopause. This paper will review the history and current research on sex effects of antidepressant treatment.

Ovariectomy changes the response to antidepressant drugs in tail suspension test in mice

Depressive symptoms are very frequent over a lifetime, especially for women. Menopause is a period of higher depressive vulnerability. There are suggestive data that estrogen deficiency may increase the susceptibility for depression. We studied whether a bilateral ovariectomy (OVX) modifies mice behaviors and antidepressant drug effects through tail suspension test (TST). We evaluated behavioral changes at 1 week, 2 weeks, and up to 2 months after OVX. The behavior responses to doxepin, paroxetine, and venlafaxine at 1 week, 2 weeks, and 2 months after OVX were evaluated. No obvious difference was detected on the duration of immobility among control group, sham group, and OVX group in the TST at 1 week and 2 weeks after OVX. But the duration of immobility of OVX group was distinctly longer than that of both control group and sham operation group at 2 months after OVX. At 1 and 2 weeks after OVX, only the antidepressant response to venlafaxine was observed, while response to paroxetine increased 2 months after OVX. Response to antidepressant drugs was strongly modified in OVX mice. The present results suggest that not all antidepressant drugs are appropriate for depression with estrogen deficiency.

Sex differences in the pharmacokinetics of antidepressants: influence of female sex hormones and oral contraceptives

Women are twice as likely to develop depression as men. Moreover, the symptoms they experience also show sex differences: women tend to develop depression at an earlier age and show more severe symptoms than men. Likewise, the response to antidepressant pharmacotherapy appears to have sex differences. These differences can partially be explained by differences in pharmacokinetic properties (i.e., absorption, distribution, metabolism, and excretion) of drugs in males and females. More recent research has shown that sex hormones may influence all these previously named pharmacokinetic processes. As concentrations of sex hormones vary throughout the female lifespan, these hormonal variations can have effects on therapeutic responses to antidepressants as well as the occurrence of adverse events. The purpose of this paper is therefore to review the literature reporting on the effects of female sex hormones on the pharmacokinetics of antidepressants and to discuss and evaluate the implications of changes in levels of sex hormones throughout life for the treatment of depression.

The impact of gender on antidepressants

There is a large body of literature debating whether and how gender affects the metabolism, side-effect profile, and efficacy of antidepressants. Gender differences in antidepressant pharmacokinetics and efficacy profiles have been attributed to not only anatomic and physiological differences between the sexes, but also behavioral factors, comorbid disorders, and gender-specific conditions, such as pregnancy and menopause. Despite the large body of research on this topic, few definitive conclusions regarding effects of gender on antidepressant treatment exist, and much of this research is incomplete, contradictory, or not fully used to optimize the administration of antidepressants and the response to treatment. This chapter will review the latest research on gender-specific effects of antidepressant treatment, focusing on the overall, gender-related differences in efficacy, metabolism, and side-effect profile of antidepressants, and how these differences can be used to better optimize treatment of depression in a clinical setting.

Sex differences in the pharmacokinetics and pharmacodynamics of antidepressants: an updated review

BACKGROUND

An increasing number of studies have reported differences in the pharmacokinetics and/or pharmacodynamics of antidepressants between women and men.

OBJECTIVES

This article updates previously published literature describing sex differences in the pharmacokinetics and pharmacodynamics of antidepressants, and examines specific issues that face women with psychiatric illness.

METHODS

An English-language literature search was performed with the PubMed database (March 2003-December 2008) using combinations of the search terms sex, gender, and antidepressants. In addition, each antidepressant was identified in the 63rd edition of the Physicians' Desk Reference.

RESULTS

The current data suggest that the pharmacokinetics of antidepressants can be substantially different between women and men. Likewise, the response to antidepressants can be quite variable, including sex differences in adverse effects and time to response.

CONCLUSIONS

Despite the many sex differences reported, there is still little published work systematically evaluating potential sex differences in antidepressant pharmacokinetics and pharmacodynamics. More research is needed to guide the treatment of depression and other mental illnesses.

Fluvoxamine versus other anti-depressive agents for depression

BACKGROUND

Fluvoxamine, one of the oldest selective serotonin reuptake inhibitors (SSRIs), is prescribed to patients with major depression in many countries. Several studies have previously reviewed the efficacy and tolerability of fluvoxamine for the treatment of major depression. However, these reviews are now outdated.

OBJECTIVES

Our objective is to evaluate the effectiveness, tolerability and side effect profile of fluvoxamine for major depression in comparison with other anti-depressive agents, including tricyclics (TCAs), heterocyclics, other SSRIs, SNRIs, other newer agents and other conventional psychotropic drugs.

SEARCH STRATEGY

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register. Trial databases and ongoing trial registers in North America, Europe, Japan and Australia, were handsearched for randomised controlled trials. We checked reference lists of the articles included in the review, previous systematic reviews and major textbooks of affective disorder for published reports and citations of unpublished research. The date of last search was 31 August 2008.

SELECTION CRITERIA

We included all randomised controlled trials, published in any language, that compared fluvoxamine with any other active antidepressants in the acute phase treatment of major depression.

DATA COLLECTION AND ANALYSIS

Two independent review authors inspected citations and abstracts, obtained papers, extracted data and assessed the risk of bias of included studies. We analysed dichotomous data using odds ratios (ORs) and continuous data using the standardised mean difference (SMD). A random effects model was used to combine studies.

MAIN RESULTS

A total of 54 randomised controlled trials (n = 5122) were included. No strong evidence was found to indicate that fluvoxamine was either superior or inferior to other antidepressants regarding response, remission and tolerability. However, differing side effect profiles were evident, especially with regard to gastrointestinal side effects of fluvoxamine when compared to other antidepressants. For example, fluvoxamine was generally associated with a higher incidence of vomiting/nausea (versus imipramine, OR 2.23, CI 1.59 to 3.14; versus clomipramine, OR 2.13, CI 1.06 to 4.27; versus amitriptyline, OR 2.86, CI 1.31 to 2.63).

AUTHORS' CONCLUSIONS

We found no strong evidence that fluvoxamine was either superior or inferior to any other antidepressants in terms of efficacy and tolerability in the acute phase treatment of depression. However, differing side effect profiles were evident. Based on these findings, we conclude that clinicians should focus on practical or clinically relevant considerations, including these differences in side effect profiles.

Are there differences between serotonergic, noradrenergic and dual acting antidepressants in the treatment of depressed women?

BACKGROUND

This study aims to investigate if there is a differential outcome of serotonergic and noradrenergic antidepressant treatment and if menopausal status has an impact on antidepressant response in depressed women.

METHODS

Data of the 111 depressed women who were included and completed the previous four open-label studies where patients were evaluated six times during a 10-week period, were pooled in the current study. Each of the reboxetine, sertraline and venlafaxine groups consisted of 37 depressed women. Patients were also divided into two subgroups of age, determining the 44 years as the cut-off point representing the menopausal status.

RESULTS

No significant difference was observed in the percent change of Hamilton Depression Rating Scale-17 (HDRS) and remission rates among treatment groups. Percent changes in Clinical Global Impression-Severity of Illness scale (CGI-S) and response rates were in favour of venlafaxine group at week 10. Individual HDRS items 2, 3, 4, 5 and 6 demonstrated significant improvement in the sertraline group, whereas HDRS item 7 demonstrated significant improvement in the venlafaxine group. An early reduction in anxiety subscale was observed in the venlafaxine group. Menopausal status had no impact on the outcome measures.

CONCLUSIONS

These results suggest that noradrenergic and serotonergic activity do not differ from each other in treating depressed women. However, serotonergic activity appears to be more prominent in some particular symptoms such as feelings of guilt, suicidal ideation and sleep. Also, menopause does not appear to affect antidepressants' benefit in depressed women.

Milnacipran versus other antidepressive agents for depression

BACKGROUND

Although pharmacological and psychological interventions are both effective for major depression, antidepressant drugs are frequently used as first-line treatment in primary and secondary care settings. Milnacipran, a dual serotonin-norepinephrine reuptake inhibitor (SNRI), is one of the antidepressant drugs that clinicians use for routine depression care.

OBJECTIVES

To assess the evidence for the efficacy, acceptability and tolerability of milnacipran in comparison with tricyclic antidepressants (TCAs), heterocyclics, SSRIs and other newer antidepressive agents in the acute-phase treatment of major depression.

SEARCH STRATEGY

The Cochrane Collaboration Depression, Anxiety & Neurosis review group Controlled Trials Register (CCDANCTR-Studies and CCDANCTR-References) were electronically searched in August 2008. References of relevant trials and other reviews were also checked. Trial databases of the drug-approving agencies and ongoing clinical trial registers for all published and unpublished trials were hand-searched in 2007. All relevant authors were contacted for supplemental data. No language restriction was applied.

SELECTION CRITERIA

Randomised controlled trials comparing milnacipran with any other active antidepressive agents (including non-conventional agents such as herbal products like hypericum) as monotherapy in the acute phase of major depression were selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently checked eligibility, assessed methodological quality and extracted data from the eligible trials using a standardised data extraction form. The number of participants who responded to treatment or those who achieved remission were calculated on an intention-to-treat basis. Random-effects meta-analyses were conducted, combining data from the included trials.

MAIN RESULTS

A total of 16 randomised controlled trials (n=2277) were included in the meta-analysis.Despite the size of this sample, the pooled 95% confidence intervals were rather wide and there were no statistically significant differences in efficacy, acceptability and tolerability when comparing milnacipran with other antidepressive agents. However, compared with TCAs, patients taking milnacipran were associated with fewer dropouts due to adverse events (OR 0.55; 95%CI 0.35 to 0.85). There was also some weak evidence to suggest that patients taking milnacipran experienced fewer adverse events of sleepiness/ drowsiness, dry mouth or constipation compared with TCAs.

AUTHORS' CONCLUSIONS

Currently, there is inadequate evidence to conclude whether milnacipran is superior, inferior or the same as other antidepressive agents in terms of efficacy, acceptability and tolerability in the acute phase treatment of major depression. However, there is some evidence in favour of milnacipran over TCAs in terms of dropouts due to adverse events (acceptability) and the rates of experiencing adverse events (tolerability). Information about other clinically meaningful outcomes such as cost-effectiveness and social functioning, including the ability to return to work, is lacking. Further study is needed to answer whether milnacipran would be the better choice of antidepressant for acute major depression.

Differential clinical effects of fluvoxamine by the effect of age in Japanese female major depressive patients

The effects of gender differences and age on the treatment response to fluvoxamine were investigated in major depressive Japanese patients. A total of 100 Japanese patients participated in this study. The daily dose of fluvoxamine was fixed to 100, 150 or 200 mg in the fourth week. This fixed dose was maintained until the end of the 6-week study. The patients were divided into 3 groups: younger females, older females, and males. Depressive symptoms were evaluated using the Montgomery and Asberg Depression Rating Scale (MADRS) at pretreatment and at 1, 2, 4, and 6 weeks after the commencement of the study. Seven of the 100 patients were excluded, and the remaining 93 patients constituted the subjects (50 females, 43 males). The number of intent-to-treat responders and non-responders was 55 and 38, respectively. There was a significant difference in the changes in the time course of the MADRS score and changes in the MADRS scores at each evaluation point between the younger and older females. Younger females demonstrated a significantly better response than older females. The results suggest that fluvoxamine is more effective in younger female patients than in older female patients.

Association study of a brain-derived neurotrophic-factor polymorphism and short-term antidepressant response in major depressive disorders

Major depressive disorder (MDD) is one of the most common mental disorders worldwide. Single nucleotide polymorphisms (SNPs) can be used in clinical association studies to determine the contribution of genes to drug efficacy. A common SNP in the brain-derived neurotrophic factor (BDNF) gene, a methionine (Met) substitution for valine (Val) at codon 66 (Val66Met), is a candidate SNP for influencing antidepressant treatment outcome. In this study, our goal was to determine the relationship between the Val66Met polymorphism in the BDNF gene and the rapid antidepressant response to venlafaxine in a Taiwanese population with MDD. Overall, the BDNF Val66Met polymorphism was found not to be associated with short-term venlafaxine treatment outcome. However, the BDNF Val66Met polymorphism showed a trend to be associated with rapid venlafaxine treatment response in female patients. Future research with independent replication in large sample sizes is needed to confirm the role of the BDNF Val66Met polymorphism identified in this study.

Pharmacogenomics with antidepressants in the STAR*D study

Major depressive disorder is one of the most common psychiatric disorders worldwide. No single antidepressant has been shown to be more effective than any other in lifting depression, and the effectiveness of any particular antidepressant in an individual is difficult to predict; therefore, doctors must prescribe antidepressants based on educated guesses. SNPs can be used in clinical association studies to determine the contribution of genes to drug efficacy. Evidence is accumulating to suggest that the efficacy of antidepressants results from the combined effects of a number of genetic variants, such as SNPs. Although there are not enough data currently available to prove this hypothesis, an increasing number of genetic variants associated with antidepressant response are being discovered. In this article, we review the pharmacogenomics of the drug efficacy of antidepressants in major depressive disorder. First, we survey the SNPs and genes identified as genetic markers that are correlated and associated with the drug efficacy of antidepressants in the Sequenced Treatment Alternatives for Depression (STAR*D) study. Second, we investigate candidate genes that have been suggested as contributing to treatment-emergent suicidal ideation during the course of antidepressant treatment in the STAR*D study. Third, we briefly describe the pharmacokinetic genes examined in the STAR*D study, and finally, we summarize the limitations with respect to the pharmacogenomics studies in the STAR*D study. Future research with independent replication in large sample sizes is needed to confirm the role of the candidate genes identified in the STAR*D study in antidepressant treatment response.