The efficacy of selective serotonin re-uptake inhibitors in depression: a meta-analysis of studies against tricyclic antidepressants

Participation of the Serotonergic System and Brain-Derived Neurotrophic Factor in the Antidepressant-like Effect of Flavonoids

Depressive disorders are among the most disabling diseases experienced around the world, and their incidence has significantly increased over the last few decades due to multiple environmental, social, and biological factors. The search for new pharmacological alternatives to treat depression is a global priority. In preclinical research, molecules obtained from plants, such as flavonoids, have shown promising antidepressant-like properties through several mechanisms of action that have not been fully elucidated, including crossing of the blood brain barrier (BBB). This review will focus on discussing the main findings related to the participation of the serotonergic system and brain-derived neurotrophic factor (BDNF) on the antidepressant-like effect of some flavonoids reported by behavioral, neurochemical, and molecular studies. In this sense, evidence shows that depressive individuals have low levels of serotonin and BDNF, while flavonoids can reverse it. Finally, the elucidation of the mechanism used by flavonoids to modulate serotonin and BDNF will contribute to our understanding of the neurobiological bases underlying the antidepressant-like effects produced by these natural compounds.

Rewiring of the Serotonin System in Major Depression

Serotonin is a key neurotransmitter that is implicated in a wide variety of behavioral and cognitive phenotypes. Originating in the raphe nuclei, 5-HT neurons project widely to innervate many brain regions implicated in the functions. During the development of the brain, as serotonin axons project and innervate brain regions, there is evidence that 5-HT plays key roles in wiring the developing brain, both by modulating 5-HT innervation and by influencing synaptic organization within corticolimbic structures. These actions are mediated by 14 different 5-HT receptors, with region- and cell-specific patterns of expression. More recently, the role of the 5-HT system in synaptic re-organization during adulthood has been suggested. The 5-HT neurons have the unusual capacity to regrow and reinnervate brain regions following insults such as brain injury, chronic stress, or altered development that result in disconnection of the 5-HT system and often cause depression, anxiety, and cognitive impairment. Chronic treatment with antidepressants that amplify 5-HT action, such as selective serotonin reuptake inhibitors (SSRIs), appears to accelerate the rewiring of the 5-HT system by mechanisms that may be critical to the behavioral and cognitive improvements induced in these models. In this review, we survey the possible 5-HT receptor mechanisms that could mediate 5-HT rewiring and assess the evidence that 5-HT-mediated brain rewiring is impacting recovery from mental illness. By amplifying 5-HT-induced rewiring processes using SSRIs and selective 5-HT agonists, more rapid and effective treatments for injury-induced mental illness or cognitive impairment may be achieved.

The broad spectrum of comorbid depression: implications for treatment

There is a high rate of depression in patients with medical or other psychiatric disorders. This comorbid depression is associated with an increased morbidity and mortality from medical illness, poor compliance with treatment, a worsening of somatic symptoms, and often a decrease in functional status. Several recent studies have demonstrated that comorbid depression is highly treatable and that effective treatment often enhances patients' adaptive coping with medical illness. However, when choosing antidepressant therapy, care must be taken to evaluate the patient's illness fully and to avoid potential drug-drug interactions and drug-related illness. This review investigates the use of antidepressants in depressed patients with medical and psychiatric disorders and their effect on prognosis and morbidity, and suggests that there is a place for the use of antidepressant medications in the treatment of comorbid conditions. Generally, the greater safety and tolerability of the selective serotonin reuptake inhibitors provides improved options for the treatment of depression in the medically and psychiatrically ill.

Frontiers in Electrochemical Sensors for Neurotransmitter Detection: Towards Measuring Neurotransmitters as Chemical Diagnostics for Brain Disorders

It is extremely challenging to chemically diagnose disorders of the brain. There is hence great interest in designing and optimizing tools for direct detection of chemical biomarkers implicated in neurological disorders to improve diagnosis and treatment. Tools that are capable of monitoring brain chemicals, neurotransmitters in particular, need to be biocompatible, perform with high spatiotemporal resolution, and ensure high selectivity and sensitivity. Recent advances in electrochemical methods are addressing these criteria; the resulting devices demonstrate great promise for in vivo neurotransmitter detection. None of these devices are currently used for diagnostic purposes, however these cutting-edge technologies are promising more sensitive, selective, faster, and less invasive measurements. Via this review we highlight significant technical advances and in vivo studies, performed in the last 5 years, that we believe will facilitate the development of diagnostic tools for brain disorders.

Severity and the Treatment of Depression: A Review of Two Controversies

Severity is an important consideration in treatment decision-making for depression. Two controversies in the treatment of depression are related to the issue of severity. First, are antidepressants only effective for severely depressed patients? Second, should the severity of depression be used as the basis for recommending medication or psychotherapy as first-line treatment? More specifically, should patients with severe depression preferentially be treated with medication? A related question is whether psychotherapy is beneficial for severely depressed patients. Some controversial articles sparked coverage in the popular press related to these questions and stimulated subsequent research on the impact of depression severity on treatment efficacy. The results of three recent large pooled analyses of patient level data indicate that the efficacy of antidepressants is not limited to the narrow band of patients who score highest on symptom severity scales. A meta-analysis of 132 controlled psychotherapy studies of more than 10,000 patients found that greater mean baseline symptom severity did not predict poorer response. A pooled analysis of individual patient data from 16 studies comparing antidepressants and cognitive behavior therapy found that severity was not associated with differential treatment outcome. These results are discussed in the context of recommendations in official treatment guidelines.

Management of Late-Life Depression

Depression is a common disorder in late life that is associated with poor quality of life, increased disability, and increased all-cause mortality. Rates of completed suicide are the highest in older depressed men compared with any other age group. In this age group, depression is often concurrent with medical illness and it can aggravate the course of medical illness. Cognitive impairment is frequently present and may be the result of the depression itself or may be the consequence of a neurodegenerative disorder such as Alzheimer's disease. Evidence-based psychotherapies, antidepressants, and somatic treatments such as electroconvulsive therapy are employed in the treatment of older depressed adults. Treatment may be complicated by the presence of cognitive impairment, other comorbid medical disorders, and medications used to treat these disorders. Certain safety issues such as increased bleeding risk, hyponatremia, decreased bone density and falls may be associated with antidepressant treatment, may be more common in older depressed adults, and their consequences may be more severe in late life. These risks, however, need to be weighed against the hazards of untreated depression. With appropriate care, most older depressed patients can be successfully treated and a positive outcome can have a significant effect on the patient's quality of life.

Drug-induced pulmonary arterial hypertension: a primer for clinicians and scientists

Drug-induced pulmonary arterial hypertension (D-PAH) is a form of World Health Organization Group 1 pulmonary hypertension (PH) defined by severe small vessel loss and obstructive vasculopathy, which leads to progressive right heart failure and death. To date, 16 different compounds have been associated with D-PAH, including anorexigens, recreational stimulants, and more recently, several Food and Drug Administration-approved medications. Although the clinical manifestation, pathology, and hemodynamic profile of D-PAH are indistinguishable from other forms of pulmonary arterial hypertension, its clinical course can be unpredictable and to some degree dependent on removal of the offending agent. Because only a subset of individuals develop D-PAH, it is probable that genetic susceptibilities play a role in the pathogenesis, but the characterization of the genetic factors responsible for these susceptibilities remains rudimentary. Besides aggressive treatment with PH-specific therapies, the major challenge in the management of D-PAH remains the early identification of compounds capable of injuring the pulmonary circulation in susceptible individuals. The implementation of pharmacovigilance, precision medicine strategies, and global warning systems will help facilitate the identification of high-risk drugs and incentivize regulatory strategies to prevent further outbreaks of D-PAH. The goal for this review is to inform clinicians and scientists of the prevalence of D-PAH and to highlight the growing number of common drugs that have been associated with the disease.

Lessons to be learnt from meta-analyses of newer versus older antidepressants

Meta-analysis is the use of statistical techniques to analyse the findings of many individual analyses (Glass, 1977). It covers all aspects of the review process involving formulating relevant research questions, searching the literature, assessing the quality of studies and choosing relevant ones, extracting and combining the data (for review see Henry & Wilson, 1992; Wilson & Henry, 1992). Meta-analysis as part of a systematic review has advantages over a narrative review but there are problems in applying it in practice (Box 1).

Mining the topography and dynamics of the 4D Nucleome to identify novel CNS drug pathways

The pharmacoepigenome can be defined as the active, noncoding province of the genome including canonical spatial and temporal regulatory mechanisms of gene regulation that respond to xenobiotic stimuli. Many psychotropic drugs that have been in clinical use for decades have ill-defined mechanisms of action that are beginning to be resolved as we understand the transcriptional hierarchy and dynamics of the nucleus. In this review, we describe spatial, temporal and biomechanical mechanisms mediated by psychotropic medications. Focus is placed on a bioinformatics pipeline that can be used both for detection of pharmacoepigenomic variants that discretize drug response and adverse events to improve pharmacogenomic testing, and for the discovery of novel CNS therapeutics. This approach integrates the functional topology and dynamics of the transcriptional hierarchy of the pharmacoepigenome, gene variant-driven identification of pharmacogenomic regulatory domains, and mesoscale mapping for the discovery of novel CNS pharmacodynamic pathways in human brain. Examples of the application of this pipeline are provided, including the discovery of valproic acid (VPA) mediated transcriptional reprogramming of neuronal cell fate following injury, and mapping of a CNS pathway glutamatergic pathway for the mood stabilizer lithium. These examples in regulatory pharmacoepigenomics illustrate how ongoing research using the 4D nucleome provides a foundation to further insight into previously unrecognized psychotropic drug pharmacodynamic pathways in the human CNS.

Antidepressant efficacy and side-effect burden: a quick guide for clinicians

Prescribing of antidepressant treatment (ADT) for major depressive disorder (MDD) has increased in quantity and popularity over the last two decades. This is likely due to the approval of safer medications, better education of clinicians and their patients, direct-to-consumer marketing practices, and less stigma associated with those taking ADT. This trend has also been met with some controversy, however, as the ongoing safety and effectiveness of these treatments have at times been called into question. This paper discusses the differing levels of evidence that support the use of ADT based on (A) Food and Drug Administration approvals, (B) data from randomized controlled trials or meta-analyses and, where these are not available, the authors discuss and apply, (C) theoretical pharmacodynamic principles to justify antidepressant choice in the treatment of MDD patients. The final section discusses standard psychopharmacology guideline approaches to better alert the reader as to which practices are commonplace compared with those which are more outside of the standard of care.

WITHDRAWN: Drugs versus placebo for dysthymia

This review has been withdrawn due to non‐compliance with Cochrane's Commercial Sponsorship Policy.

The editorial group responsible for this previously published document have withdrawn it from publication.

Disruption of running activity rhythm following restricted feeding in female mice: Preventive effects of antidepressants

Biological rhythms are critical in the etiology of mood disorders; therefore, effective mood disorder treatments should address rhythm disturbances. Among the variables synchronized with the light-dark cycle, spontaneous activity in rodents is useful for investigating circadian rhythms. However, previous studies have focused only on the increase of wheel-running activity under restricted feeding conditions, while little information is available on circadian rhythm of running activity. In this study, chronometrical analysis was used to assess whether circadian rhythms during wheel-running are altered by restricted feeding and affected by antidepressant drugs. Wheel revolutions were automatically recorded and analyzed using cosinor-rhythmometry in 8-week old ICR albino mice. When feeding was restricted to 1 h per day (21:00-22:00), wheel-running rhythms were reliably disrupted. Female mice exhibited marked alterations in the pattern and extent of wheel-running beginning on day 1. Subchronic treatment with imipramine or paroxetine, as well as tandospirone and (-)-DOI, prevented wheel-running rhythm disruption. Thus, altering the circadian activity rhythms of female mice on a 1-h feeding schedule may be useful for investigating disturbances in biological rhythms.

Modeling the dynamics of disease states in depression

Major depressive disorder (MDD) is a common and costly disorder associated with considerable morbidity, disability, and risk for suicide. The disorder is clinically and etiologically heterogeneous. Despite intense research efforts, the response rates of antidepressant treatments are relatively low and the etiology and progression of MDD remain poorly understood. Here we use computational modeling to advance our understanding of MDD. First, we propose a systematic and comprehensive definition of disease states, which is based on a type of mathematical model called a finite-state machine. Second, we propose a dynamical systems model for the progression, or dynamics, of MDD. The model is abstract and combines several major factors (mechanisms) that influence the dynamics of MDD. We study under what conditions the model can account for the occurrence and recurrence of depressive episodes and how we can model the effects of antidepressant treatments and cognitive behavioral therapy within the same dynamical systems model through changing a small subset of parameters. Our computational modeling suggests several predictions about MDD. Patients who suffer from depression can be divided into two sub-populations: a high-risk sub-population that has a high risk of developing chronic depression and a low-risk sub-population, in which patients develop depression stochastically with low probability. The success of antidepressant treatment is stochastic, leading to widely different times-to-remission in otherwise identical patients. While the specific details of our model might be subjected to criticism and revisions, our approach shows the potential power of computationally modeling depression and the need for different type of quantitative data for understanding depression.

Selective serotonin reuptake inhibitor use in primary care: a 5-year naturalistic study

OBJECTIVE

To investigate prescribing trends of selective serotonin reuptake inhibitors (SSRIs) during the course of the Defeat Depression Campaign (1992 to 1996).

METHODS

This study utilised cross-sectional data on the prescribing of SSRIs for the treatment of depression from a large primary care database for the 5 consecutive years of the Defeat Depression Campaign, producing the largest study of SSRI use to date.

RESULTS

A total of 93 600 prescriptions were issued for fluoxetine, paroxetine and sertraline, in 27 210 treatment episodes. Over the 5-year period, there was a five-fold increase in the number of prescriptions issued, and a four-fold increase in the number of patients treated, reflecting a trend for longer periods of treatment. Patients initiating treatment with fluoxetine were most likely and those initiating treatment with sertraline were least likely to complete 60, 90 and 120 consecutive days of treatment. Differences in dose patterns also emerged and were consistent throughout the study. Fluoxetine-treated patients were most likely to remain on the starting dose of 20mg daily, while large numbers of sertraline-treated patients received doses above the recommended dose of 50mg daily. These differences were not apparent from clinical trials, and this may be an artefact of trial design.

CONCLUSION

Differences in the doses prescribed may explain why sertraline-treated patients are less likely to complete an adequate course of antidepressant therapy. Longitudinal studies are required to evaluate fully the clinical significance of these findings.

A comparative survey of antidepressant drug prescribing habits of general practitioners and psychiatrists

OBJECTIVE

Clinical experience suggests important differences in prescriptions from general practitioners and specialists. This study investigated these differences and their determinants for antidepressant drug prescribing intentions by general practitioners and psychiatrists in France.

STUDY PARTICIPANTS

In May 1995, a mail questionnaire was sent to a representative panel of 300 general practitioners and 100 psychiatrists from the Midi-Pyrenees area (South West France). Two types of questions were asked: the first concerned the type of antidepressants prescribed according to the characteristics of depression ('severe', with insomnia, anxiety, etc.) and the second, the factors influencing prescriptions (personal experience, adverse effects, clinical trials, cost, etc.).

RESULTS

151 general practitioners (51%) and 63 psychiatrists (63%) answered the questionnaire. The analysis showed large differences between the two groups of physicians. Serotoninergic antidepressants were reported to be the most common first-line drugs of choice in both groups of practitioners. General practitioners claimed to prescribe serotoninergic antidepressants more frequently than psychiatrists (74 vs 59%, p < 0.05). Psychiatrists were reported to prescribe higher dosages of antidepressants than general practitioners in 'severe' depression (109.7 vs 85.6mg daily, p < 0.001). General practitioners were reported to prescribe anxiolytic agents more frequently than psychiatrists (73 vs 54%, p < 0.05), and neuroleptic agents less frequently (1 vs 11%, p < 0.001). The factors reported to influence antidepressant prescription differed in the two groups of physicians. Postuniversity teaching, hospital specialist information and registered indication were considered more important by general practitioners than psychiatrists, who reported to be more influenced by patients' and colleagues' opinions.

CONCLUSION

These results demonstrated that the differences in intention in prescribing between psychiatrists and general practitioners can be explained by a different approach to prescription since psychiatrists place more importance on human and clinical factors (patients' and colleagues' opinions) than general practitioners, who referred more to 'official' data (university, hospital and registered indications).

Nortriptyline versus fluoxetine in the treatment of major depressive disorder: a six-month, double-blind clinical trial

BACKGROUND

Depression is a common psychiatric disorder worldwide, including in Iran, and is estimated to affect 10%-15% of the population. Antidepressant drugs can have multiple side effects, so a good choice of drug is important for successful treatment. This study compared the efficacy of nortriptyline with that of fluoxetine in the treatment of patients with major depressive disorder and assessed related factors, including age, gender, and level of education.

METHODS

The study was a double-blind, randomized clinical trial with a six-month follow-up period. Participants were 120 patients aged 15-60 years with a diagnosis of major depressive disorder based on a psychiatry interview and the Beck depression rating scale, which were performed at the beginning, middle, and end of the study. The patients were treated with nortriptyline or fluoxetine. The paired t-test, independent t-test, and the k chi-square test were used to analyze the data.

RESULTS

Twenty-three patients dropped out and 97 remained in the trial. Before intervention, the mean depression score was 32.85 ± 6.23 in the nortriptyline group and 33.12 ± 6.50 in the fluoxetine group. The results of the independent t-test showed a significant difference between depression score means before and after treatment in both groups. Changes at the end of the trial compared with baseline scores were 13.4 ± 4.68 and 16.96 ± 4.96 for nortriptyline and fluoxetine, respectively. Paired t-testing showed a significant difference in the mean depression score for both the nortriptyline and fluoxetine groups. Age, gender, and level of education had no significant effects on the outcome of treatment in the two groups.

CONCLUSION

The present study suggests that both nortriptyline and fluoxetine were effective in the treatment of depression, but that fluoxetine was more effective than nortriptyline after 3 and 6 months of treatment.

Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy

BACKGROUND

Antidepressant drugs are widely used in the treatment of depression in people with chronic physical health problems.

AIMS

To examine evidence related to efficacy, tolerability and safety of antidepressants for people with depression and with chronic physical health problems.

METHOD

Meta-analyses of randomised controlled efficacy trials of antidepressants in depression in chronic physical health conditions. Systematic review of safety studies.

RESULTS

Sixty-three studies met inclusion criteria (5794 participants). In placebo-controlled studies, antidepressants showed a significant advantage in respect to remission and/or response: selective serotonin reuptake inhibitors (SSRIs) risk ratio (RR) = 0.81 (95% CI 0.73-0.91) for remission, RR = 0.83 (95% CI 0.71-0.97) for response; tricyclics RR = 0.70 (95% CI 0.40-1.25 (not significant)) for remission, RR = 0.55 (95% 0.43-0.70) for response. Both groups of drugs were less well tolerated than placebo (leaving study early due to adverse effects) for SSRIs RR = 1.80 (95% CI 1.16-2.78), for tricyclics RR = 2.00 (95% CI 0.99-3.57). Only SSRIs were shown to improve quality of life. Direct comparisons of SSRIs and tricyclics revealed no advantage for either group for remission, response, effect size or tolerability. Effectiveness studies suggest a neutral or beneficial effect on mortality for antidepressants in participants with recent myocardial infarction.

CONCLUSIONS

Antidepressants are efficacious and safe in the treatment of depression occurring in the context of chronic physical health problems. The SSRIs are probably the antidepressants of first choice given their demonstrable effect on quality of life and their apparent safety in cardiovascular disease.

Psychopharmacology: a house divided

BACKGROUND

Psychopharmacology and psychiatry during the past 50 years have focused on the specificity model in which it is assumed that psychiatric disorders are specific entities which should respond to drugs with specific mechanisms of action. However, the validity of this model has been challenged by the approval of multiple drugs for the same disorder, as well as the approval of single agents for a variety of disorders which have little in common. As an example of this unacknowledged paradigm shift, I will examine the foundation for using antipsychotics in the treatment of depression.

METHODS

An extensive literature search of studies investigating various mechanisms of actions of antipsychotics and antidepressants with the goal of identifying neurochemical processes common to both.

RESULTS

The neurochemical differences in these classes of drugs appear to be profound, although several processes are common in both, including some degree of neuroprotection and changes in the epigenome. Whether these common features have any effect on clinical outcome remains in doubt.

CONCLUSIONS

While psychopharmacology and psychiatry remain largely committed to the specificity model, it appears that clinicians are prescribing on a dimensional model wherein symptoms are being treated with a variety of drugs, regardless of the diagnosis.

The noradrenergic action in antidepressant treatments: pharmacological and clinical aspects

Even though noradrenaline has been recognized as one of the key neurotransmitters in the pathophysiology of major depression (MD), noradrenergic compounds have been less extensively utilized in clinical practice, compared to selective serotonin reuptake inhibitors (SSRIs). The development of the first selective noradrenergic reuptake inhibitor (NRI), Reboxetine, has not substantially changed the state of the art. In addition, Atomoxetine, a relatively pure NRI used for the treatment of ADHD, has shown mixed results when administered in augmentation to depressed subjects. Through a Medline search from 2000 to 2010, the present article provides an updated overview of the main pharmacological and clinical aspects of antidepressant classes that, partially or selectively, act on the noradrenergic systems. The noradrenergic action plays an important clinical effect in different antidepressant classes, as confirmed by the efficacy of dual action antidepressants such as the serotonin noradrenaline reuptake inhibitors (SNRIs), the noradrenergic and dopaminergic reuptake inhibitor (NDRI) Bupropion, and other compounds (e.g., Mianserin, Mirtazapine), which enhance the noradrenergic transmission. In addition, many tricyclics, such as Desipramine and Nortriptyline, have prevalent noradrenergic effect. Monoamine oxidase inhibitors (MAOIs), moreover, block the breakdown of serotonin, noradrenaline, dopamine and increase the availability of these monoamines. A novel class of antidepressants--the triple reuptake inhibitors--is under development to selectively act on serotonin, noradrenaline, and dopamine. Finally, the antidepressant effect of the atypical antipsychotic Quetiapine, indicated for the treatment of bipolar depression, is likely to be related to the noradrenergic action of its metabolite Norquetiapine. Even though a pure noradrenergic action might not be sufficient to obtain a full antidepressant effect, a pronoradrenergic action represents an important element for increasing the efficacy of mixed action antidepressants. In particular, the noradrenergic action seemed to be related to the motor activity, attention, and arousal.

Desvenlafaxine in major depressive disorder: an evidence-based review of its place in therapy

INTRODUCTION

Desvenlafaxine, the active metabolite of venlafaxine, is a serotonin norepinephrine reuptake inhibitor (SNRI) recently approved for the treatment of major depressive disorder. It is one of only three medications in this class available in the United States.

AIMS

The objective of this article is to review the published evidence for the safety and efficacy of desvenlafaxine, and to compare it to other antidepressants to delineate its role in the treatment of depression.

EVIDENCE REVIEW

At the recommended dose of 50 mg per day the rate of response and remission was similar to other SNRIs, as was the adverse effect profile. The rate of discontinuation was no greater than placebo, and a discontinuation syndrome was not observed at this dose. Higher doses were not associated with greater efficacy, but they did lead to more side effects, and the use of a taper prior to discontinuation. The most common side effects reported were insomnia, somnolence, dizziness, and nausea. Some subjects experienced clinically significant blood pressure elevation.

PLACE IN THERAPY

Like duloxetine, desvenlafaxine inhibits the reuptake of both norepinephrine and serotonin at the starting dose. Dual reuptake inhibitors have been shown to have small but statistically significantly greater rates of response and remission compared to selective serotonin reuptake inhibitors, and they have also shown early promise in the treatment of neuropathic pain. Desvenlafaxine may prove to be a valuable treatment option by expanding the limited number of available dual reuptake inhibitors.

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.

Comparison of antidepressant effects of azafan, tianeptine, and paroxetine

Antidepressant activity of Russian product Azafen (pipofezine) and foreign products Paroxetine and Tianepine was compared using behavioral despair test (Porsolt test) and forced swimming test in a container with wheels (Nomura). Azafen significantly shortened the duration of depressive state in both tests. The results suggest that Azafen exhibits pronounced antidepressant activity, superior to that of the reference drugs.

A study of intensity dependence of the auditory evoked potential (IDAEP) in medicated melancholic and non-melancholic depression

BACKGROUND

Major Depressive Disorder is widely recognised to be a heterogeneous syndrome with numerous depressive phenotypes, one of which is melancholic depression. Patients with melancholic depression exhibit treatment responses and outcomes that differ from patients with non-melancholic depression. The current study aimed to assess whether differences existed between melancholic and non-melancholic subtypes of depression, as measured by the event related potential, intensity dependence of the auditory evoked potential (IDAEP).

METHODS

IDAEP was assessed in 14 melancholic and 13 non-melancholic depressed subjects and 14 controls.

RESULTS

The melancholic patients had a significantly shallower IDAEP slope than the non-melancholic patients not explained by depression severity or age.

LIMITATIONS

Antidepressants were taken by all patients in this study and the effect of continual use of these drugs on the IDAEP slopes has yet to be confirmed.

CONCLUSIONS

These results provide support for neurobiological differences between melancholic and non-melancholic depressive subtypes. Melancholic depression may be characterized by ongoing over function of the serotonin system in spite of medication treatment.

Recent advances in the biological treatment of mood disorders

Welcome to the first module in our Continuing Professional Development Section (CPD). CPD is now a key element in the clinical activity of all health professionals and a cornerstone of good clinical governance throughout mental health services. This section of the Irish Journal of Psychological Medicine will provide CPD modules dedicated to key topics in mental health care. In order to assist learning and self-assessment, multiple choice questions will be provided at the end of each module. This module and its multiple choice questions are available online on the website of the Irish Journal of Psychological Medicine (www.ijpm.org). The CPD policy of the College of Psychiatry of Ireland indicates that psychiatrists who participate in suitable online learning which fits the criteria for CPD may claim CPD points under the Personal CPD category (up to a maximum of 5 points per year). We are confident that this CPD Section of the Irish Journal of Psychological Medicine will prove to be a valuable resource for consultant psychiatrists, psychiatric trainees and all journal readers. We welcome feedback from readers and, especially, any suggestions for topics to be covered in future CPD modules. Suggestions should be emailed to: psychological@medmedia.ie.

Mind, brain and psychotherapy

There is long-standing debate about superiority of mind over brain, in other words about superiority of mind over matter. And outcome of this debate is going to decide future of psychiatry. The psychiatrists believing in materialism may say that brain is all and by changing neurotransmitters level with new molecules of drugs would cure all illnesses. On the other hand, antipsychiatry activists and some psychotherapists oppose all types of treatment despite of convincing evidence that drug therapy is effective (although sometimes it is not as effective as it claims to be). However, truth lies somewhere in between. Pharmacotherapy and psychotherapy are like two legs of psychiatry and psychiatry cannot walk into a future on one leg. The studies have shown that judicious use of pharmacotherapy along with psychotherapy gives better outcome than any one of them used alone. We must heal dichotomy between mind and brain before we heal the patients.

Comprehensive analysis of remission (COMPARE) with venlafaxine versus SSRIs

BACKGROUND

To compare venlafaxine and selective serotonin reuptake inhibitors (SSRIs; fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram) in the treatment of depression.

METHODS AND MATERIALS

Meta-analysis of 34 randomized, double-blind studies identified by a worldwide search of all research sponsored by Wyeth Pharmaceuticals through January 2007. Patients were treated with venlafaxine (n = 4191; mean dose 151 mg/day) or SSRIs (n = 3621); nine studies also included a placebo control group (n = 932). The primary outcome measure was intent-to-treat (ITT) remission rates (Hamilton Rating Scale for Depression </=7) at week 8.

RESULTS

The overall difference in ITT remission rates was 5.9% favoring venlafaxine (95% confidence interval [CI]: .038-.081; p < .001). Based on this difference, the number needed to treat (NNT) to benefit is 17 (95% CI: 12-26). In the nine placebo controlled studies, the drug-placebo differences were 6% (.02-.09) for the SSRIs and 13% (.09-.16) for venlafaxine. For the specific SSRIs, the difference versus fluoxetine (mean dose = 37 mg/day; 20 studies) was significant (6.6% [95% CI: .030-.095]); smaller differences versus paroxetine (mean dose = 25 mg/day; eight studies; 5%), sertraline (mean dose = 127 mg/day; three studies; 3%), and citalopram (mean dose = 38 mg/day; two studies; 4%) were not significant. Attrition rates due to adverse events were higher with venlafaxine than with SSRI therapy, 11% and 9% respectively (p = .0011).

CONCLUSIONS

These results indicate that venlafaxine therapy is statistically superior to SSRIs as a class, but only to fluoxetine individually. The clinical significance of this modest advantage seems limited for the broad grouping of major depressive disorder. Nonetheless, an NNT of 17 may be of public health relevance given the large number of patients treated for depression and the significant burden of illness associated with this disorder.

Restoring melancholia in the classification of mood disorders

The present DSM criteria for major depression poorly identify samples for treatment selection, prognosis, and assessments of pathophysiology. Melancholia, in contrast, is a disorder with definable clinical signs that can be verified by laboratory tests and treatment response. It identifies more specific populations than the present system and deserves individual identification in psychiatric classification. Its re-introduction will refine diagnosis, prognosis, treatment selection, and studies of pathophysiology of a large segment of the psychiatrically ill.

Depressive Störungen

Das Spektrum depressiver Erkrankungen macht den Hauptteil affektiver Störungen aus und gehört mit einer Inzidenz von ca. 8–20% zu den häufigsten psychischen Erkrankungen. Depressionen werden nach wie vor zu selten einer adäquaten Therapie (Antidepressiva, störungsspezifische Psychotherapie wie z. B. kognitive Verhaltenstherapie) zugeführt.

Which antidepressants have demonstrated superior efficacy? A review of the evidence

A review of published evidence of superior efficacy of a particular antidepressant in major depressive disorder may assist clinicians in making considered treatment choices. To identify such candidates, an international group of experts met to assess published evidence (identified through searches in Medline and Embase databases and discussions with experts in the field) from randomized, controlled trials and meta-analyses comparing two antidepressants under conditions of fair comparison. Criteria were defined to judge the strength of evidence. Two pivotal studies in moderate-to-severe major depressive disorder that demonstrate superiority on the primary efficacy measure, or alternatively one pivotal study supported by consistent results from meta-analyses, was considered to constitute evidence for definite superiority. Three antidepressants met these criteria: clomipramine, venlafaxine, and escitalopram. Three antidepressants were found to have probable superiority: milnacipran, duloxetine, and mirtazapine. Only escitalopram was found to have definite superiority in the treatment of severe depression; probable superiority was identified for venlafaxine and possible superiority for milnacipran and clomipramine. This review of published data found evidence that only a very few antidepressants are shown to be more effective than others.

Sequential treatment of depression in primary care

BACKGROUND

In the past decade, in clinical psychiatry several investigations suggested the usefulness of a sequential way of integrating pharmacotherapy and psychotherapy in mood disorders. The aim of this paper was to illustrate the practical implications of sequential treatment strategy for depression in primary care, with particular reference to the increasingly common problem of recurrent depression.

METHODS

The Authors tried to integrate the evidence which derives from meta-analyses and comprehensive general reviews with the insights which derive from controlled studies concerned with specific populations.

CONCLUSIONS

The sequential treatment of mood disorders is an intensive, two-stage approach, which derives from the awareness that one course of treatment with a specific tool (whether pharmacotherapy or psychotherapy) is unlikely to entail solution to the affective disturbances of patients, both in research and in clinical practice settings. The aim of the sequential approach is to add therapeutic ingredients as long as they are needed. In this sense, it introduces a conceptual shift in clinical practice.

Severe depression and antidepressants: focus on a pooled analysis of placebo-controlled studies on agomelatine

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.

Drug treatment of depression in the 2000s: An overview of achievements in the last 10 years and future possibilities

During the past 10 years our knowledge about the pharmacotherapy of depression has been consolidated, and a variety of very interesting new compounds launched onto the market. The pipeline of the pharmaceutical industry is still filled with an assortment of new developments and very promising new approaches towards the pharmacotherapy of depressive disorders. Future pharmacological treatments of depression will not only enhance serotonergic and noradrenergic neurotransmission: other systems, such as the melatonergic receptor system and the hypothalamus-pituitary-adrenal axis, are also the targets of newly developed and upcoming substances with putative antidepressant effects. The main advantages of the currently available newer pharmacotherapeutic options are the broadening of the spectrum of possible antidepressant treatments, which is of particular importance for the growing number of patients suffering from difficult-to-treat depression, and a far better tolerability profile in comparison to older compounds such as tricyclic antidepressants. Unresolved issues are the unacceptably high rate of non-responsiveness during antidepressant treatment, a latency of sometimes several weeks until clinical improvement and remission can be achieved, and a variety of possible side effects also present during treatment with modern compounds. This review mainly presents the development of antidepressant pharmacotherapies during the past 10 years, together with pharmacokinetic and pharmacodynamic information and a comparison of different pharmacological treatment principles evaluated in randomized controlled clinical trials. In addition, new pharmacological strategies that are not yet available on the market and strategies currently under development are reviewed in detail. The study of new treatment options is of major importance to provide better strategies for the clinical management of depression in the future, and is thus also of great socio-economic importance.

Efficacy and tolerability of reboxetine compared with citalopram: a double-blind study in patients with major depressive disorder

The objective of this study was to compare efficacy and tolerability of the selective noradrenaline reuptake inhibitor reboxetine with the selective serotonin reuptake inhibitor citalopram, in the treatment of major depressive disorder (MDD). In total, 357 outpatients with MDD were randomized to treatment with reboxetine 8-10 mg or citalopram 20-40 mg per day during 24 weeks. Primary end-point was change from baseline in the Hamilton Depression Rating Scale (HAM-D, 21 items). Sexual function/dysfunction was measured by the Sexual Function scale (SF). Observed case analysis showed that both treatments yielded a gradual reduction of HAM-D scores: reboxetine with -21.4 and citalopram with -22.1 points (NS). LOCF analysis showed a greater reduction of the HAM-D scores with citalopram compared with reboxetine (-19.6 vs. -17.8; P = 0.034). The response rate was 90.3% for reboxetine and 92.7% for citalopram (NS). The most common side effect in the reboxetine group was dry mouth, and in the citalopram group sexual dysfunction. At week 24, anorgasmia was reported by 5.9% of the sexually active women in the reboxetine group vs 39% in the citalopram group. The dropout number was 91 in the reboxetine group, and 54 in the citalopram group. To summarize, both treatments gave a satisfactory antidepressant effect. The side effect profile differed between the groups, with a notably high prevalence of sexual dysfunctions in the citalopram group. The high number of dropouts in the reboxetine group, is considered as a result of the non-titration starting dose of 8 mg reboxetine per day, which gave a high incidence of early side-effects.

Managing depressive and anxiety disorders with escitalopram

This article reviews escitalopram, the S-stereoisomer of the racemic compound citalopram, and a highly selective and potent member of the selective serotonin re-uptake inhibitor class of antidepressants. Escitalopram has a straightforward pharmacokinetic profile, little effect on hepatic metabolism, and is relatively safe in overdose. Similar to other members of the selective serotonin re-uptake inhibitor class, escitalopram (10-20 mg/day) is a well-tolerated and effective treatment of major depressive disorder. Although relatively few head-to-head comparative studies with other antidepressants have been published, pooled analyses of studies using citalopram as the active comparator suggest a modest advantage for the stereoisomer. This advantage, which is more apparent among patients with greater symptom levels, may be attributable to a greater than predicted potency compared with citalopram, presumably as a result of the greater effect of escitalopram at the allosteric binding site of the serotonin transporter. Results of two published studies versus venlafaxine also suggest better tolerability in the context of comparable efficacy. Escitalopram is also approved for the treatment of generalised anxiety disorder (in the US) and social anxiety disorder and panic disorder (in the EU). Pharmacoeconomic models suggest that the greater drug acquisition cost of this patent-protected compound may be offset by greater efficacy (relative to generic citalopram) and tolerability (compared with extended release venlafaxine).

Serotonin noradrenaline reuptake inhibitors: Logical evolution of antidepressant development

Although considerable progress has been made in improving the tolerability of antidepressant drugs, the classical tricyclic antidepressants (TCA) are still a standard for efficacy. The selective serotonin reuptake inhibitors (SSRI) are much better tolerated than the TCAs, but their antidepressant efficacy is, at best, equivalent and probably inferior to the TCA, clomipramine, in many situations. The introduction of the SSRIs naturally focussed both fundamental and clinical research effort on the role of serotonin (5-HT) in the pharmacogenesis and pharmacotherapy of depression. More recently the probable role of noradrenaline (NA) has been "rediscovered" and increasingly both 5-HT and NA dysfunctions are seen as fundamental to depressive illness. The therapeutic importance of this has been underlined by studies showing the increased antidepressant efficacy obtained when selective serotonergic drugs have been used in conjunction with selective noradrenergic drugs. The development of the new class of serotonin and noradrenaline reuptake inhibitors (SNRI) was a logical extension of these ideas. Compounds of this class, which currently comprises venlafaxine, milnacipran and duloxetine, act to inhibit the reuptake of both monoamines with no direct actions at postsynaptic receptors. Although, by definition all three SNRIs have actions on both 5-HT and NA neurotransmission, they do not all have equal potency for both transmitters. Venlafaxine has a 30-fold higher affinity for 5-HT than NA while duloxetine has a 10-fold selectivity for 5-HT. Only milnacipran is balanced between the two neurotransmitters with an approximately equal potency for the inhibition of reuptake of 5-HT and NA both in vitro and in vivo. At high doses venlafaxine and duloxetine appear to be superior to SSRIs but not at lower doses. Duloxetine is, however, not licensed in the EU at these higher doses. Milnacipran at usual doses appears more effective than SSRIs with efficacy which is similar to TCAs but with a lower side effect burden.

Duloxetine: A balanced and selective norepinephrine- and serotonin-reuptake inhibitor

PURPOSE

The pharmacology, pharmacokinetics, efficacy, safety, drug interactions, dosage and administration, cost, and place in therapy of duloxetine for major depression, pain from diabetic peripheral neuropathy, and stress urinary incontinence are reviewed.

SUMMARY

Duloxetine is a balanced selective serotonin and norepinephrine-reuptake inhibitor available in the United States for the treatment of major depressive disorder (MDD) and diabetic peripheral neuropathic pain (DPNP). Duloxetine has also been used for the treatment of stress urinary incontinence (SUI). Absorption of duloxetine begins two hours after oral administration, reaching a maximum plasma concentration in six hours. Half-life and volume of distribution are 12 hours and 1640 L, respectively. The recommended dosage of duloxetine is 40-80 mg daily, depending on the indication, preferably split into two doses per day. For the treatment of major depression, duloxetine has achieved remission rates similar to that of existing selective serotonin-reuptake inhibitors (SSRIs). For SUI and pain associated with diabetic peripheral neuropathy, duloxetine has not demonstrated equivalence or superiority to existing therapies. The adverse effects of duloxetine are similar to those of traditional SSRIs. Nausea is common and has been cited as the primary reason for discontinuation of duloxetine in trials. Increases in blood pressure have been mild, but caution should be used in patients with hypertension. Patients with a creatinine clearance of <30 mL/min and patients with hepatic impairment should avoid duloxetine. Duloxetine should not be recommended as first-line therapy for SUI or DPNP. For MDD, duloxetine may be a useful alternative for patients who do not benefit from or are unable to tolerate other antidepressant therapy.

CONCLUSION

Duloxetine has been approved for the treatment of MDD and pain associated with diabetic peripheral neuropathy in adults.

SNRIs: their pharmacology, clinical efficacy, and tolerability in comparison with other classes of antidepressants

The class of serotonin and norepinephrine reuptake inhibitors (SNRIs) now comprises three medications: venlafaxine, milnacipran, and duloxetine. These drugs block the reuptake of both serotonin (5-HT) and norepinephrine with differing selectivity. Whereas milnacipran blocks 5-HT and norepinephrine reuptake with equal affinity, duloxetine has a 10-fold selectivity for 5-HT and venlafaxine a 30-fold selectivity for 5-HT. All three SNRIs are efficacious in treating a variety of anxiety disorders. There is no evidence for major differences between SNRIs and SSRIs in their efficacy in treating anxiety disorders. In contrast to SSRIs, which are generally ineffective in treating chronic pain, all three SNRIs seem to be helpful in relieving chronic pain associated with and independent of depression. Tolerability of an SNRI at therapeutic doses varies within the class. Although no direct comparative data are available, venlafaxine seems to be the least well-tolerated, combining serotonergic adverse effects (nausea, sexual dysfunction, withdrawal problems) with a dose-dependent cardiovascular phenomenon, principally hypertension. Duloxetine and milnacipran appear better tolerated and essentially devoid of cardiovascular toxicity.

Management of depression in primary care: a survey of general practitioners in Spain

OBJECTIVE

The objective of this study was to analyze the current situation of health care for depression in Spain according to general practitioners' (GPs') opinion and how it has evolved over the last 20 years on the basis of comparisons with the results of two previous social-health studies (published in 1997 and 1982).

METHOD

Throughout 2002, we recorded the opinions of 238 GPs after asking them to fill up structured questionnaires in which they rated care, clinical, therapeutic and care quality aspects.

RESULTS

Only 40% of patients with depression visit a doctor, implying a very high level of "concealed epidemiology." The diagnostic instruments most commonly used are assessment of symptoms and patient interview. Pharmacological treatment is the option GPs most commonly choose once a depression diagnosis is established (80% vs. 50% in 1997; P<.001). Selective serotonin reuptake inhibitors (SSRIs), together with anxiolytics, are the drugs most commonly used in the treatment of depression. SSRIs are the first choice drugs, being preferred to tricyclic antidepressants and anxiolytics, which were the most popular options for GPs in the 1997 survey. Areas where there is a need for improvement are time devoted to consultation, coordination between GPs and psychiatrists and waiting lists.

CONCLUSIONS

The quality of health care for depression has improved in recent years, thanks to changes in the attitudes of GPs and the evolution of pharmacological treatment.

Strategies for producing faster acting antidepressants

Existing antidepressant treatments exhibit limited efficacy and a slow onset of action. Several neurobiological adaptive mechanisms might delay the clinical effects of antidepressants, whose therapeutic action is primarily triggered by an increase of serotonergic and noradrenergic neurotransmission. Here, we review several potential mechanisms that could be useful to increase the speed of current antidepressant drugs, such as additional blockade of aminergic autoreceptors or antagonism of certain postsynaptic (5-HT2A, 5-HT2C) receptors. The potential use of strategies not based on monoaminergic transmission, such as CRF and NK1 receptor antagonists, or more novel strategies, based on glutamatergic or GABAergic transmission or on intracellular messengers, are also reviewed.

Comparing the effects of antidepressants: consensus guidelines for evaluating quantitative reviews of antidepressant efficacy

With increasing numbers of treatment options available for patients with major depression over the last decade and the growing body of evidence describing their efficacy and safety, clinicians often find it difficult to determine the best and most appropriate evidence-based treatment for each patient. Systematic reviews utilizing statistical methods that synthesize and evaluate data from a number of studies have become increasingly more available over the past decade. We review major findings and lessons learned from salient examples of quantitative analyses of antidepressant research and provide recommendations for meta-analysts, journal and grant reviewers, and research 'consumers' (ie, clinicians) for conducting, reporting, and evaluating such analyses.

Duloxetine 60 mg once-daily in the treatment of painful physical symptoms in patients with major depressive disorder

BACKGROUND

While emotional symptoms such as depressed mood and loss of interest have traditionally been considered to constitute the core symptoms of major depressive disorder (MDD), the prevalence and importance of painful physical symptoms such as back pain, abdominal pain, and musculoskeletal pain is becoming increasingly appreciated. Antidepressants possessing dual serotonin/norepinephrine (5-HT/NE) reuptake inhibition may demonstrate greater efficacy in the alleviation of pain. The efficacy of duloxetine, a balanced and potent dual reuptake inhibitor of 5-HT and NE, was evaluated within a cohort of depressed patients with associated painful physical symptoms.

METHODS

In this multicenter, double-blind, placebo-controlled study, patients meeting DSM-IV criteria for MDD were randomized to receive placebo (N=141) or duloxetine 60 mg QD (N=141). Patients were required to have a 17-item Hamilton Rating Scale for Depression (HAMD17) total score 15, a Clinical Global Impression of Severity (CGI-S) score 4, and a Brief Pain Inventory (BPI) Average Pain score 2 at baseline. The primary efficacy measure was the BPI Average Pain score, while secondary measures included other BPI items, the HAMD17 total score, CGI-S, the Patient Global Impression of Improvement (PGI-I) scale, Visual Analog Scales (VAS) for pain, and the Symptom Questionnaire, Somatic Subscale (SQSS). Safety was evaluated by recording treatment-emergent adverse events (spontaneously reported), vital signs, and laboratory analytes.

RESULTS

Mean changes in BPI Average Pain for duloxetine- and placebo-treated patients differed significantly at most visits, but only approached significance at endpoint p=0.066. For the main effect of treatment (pooling all visits), significant advantages for duloxetine-treated patients were found in 10 of 11 assessed BPI pain severity and pain interference items, in addition to VAS overall pain and back pain. Mean changes in pain measures for duloxetine-treated patients corresponded to improvements of 25-50%, compared with 19-39% for placebo. Mean changes at endpoint in depression rating scales (HAMD17, CGI-S, PGI-I) did not differ significantly between duloxetine and placebo treatment groups due to unusually high placebo response. The magnitude of placebo treatment effects (as measured by HAMD17 total score and Maier subscale) was significantly smaller in patients with 1 previous depressive episode, compared to those patients with no previous episodes. In patients with 1 previous depressive episode the advantage of duloxetine over placebo was similar to previous studies. Rates of discontinuation due to adverse events were 14.2% vs. 2.1% for duloxetine and placebo, respectively p<0.001. Treatment-emergent adverse events reported at a significantly higher rate by duloxetine-treated patients included nausea, dry mouth, fatigue, and decreased appetite.

CONCLUSIONS

In this study, duloxetine (60 mg QD) was shown to be an effective treatment for the painful physical symptoms which are frequently associated with depression. Improvements in pain severity occurred independently of changes in depressive symptom severity.

Mental health policy and psychotropic drugs

The pace of innovation in psychotropic drugs has been rapid over the past 15 years. There also have been unprecedented increases in spending on prescription drugs generally and psychotropic medications specifically. Psychotropic medications are playing a more central role in treatment. They also are receiving close scrutiny from health insurers, state budget makers, and ordinary citizens. Public policy actions regarding prescription drugs have the potential to significantly affect clinical care for mental disorders, the costs of this care to individuals and society at large, and the prospects for future scientific advances. This article outlines the policy issues related to psychotropic drugs with respect to their role in determining access to mental health treatment and the cost and quality of mental health care.

A comparative study of milnacipran and paroxetine in outpatients with major depression

BACKGROUND

Milnacipran is a dual-action antidepressant which inhibits both serotonin and noradrenaline reuptake with no affinity for any neurotransmitter receptor studied.

METHODS

A 6-week double-blind multicentre study compared milnacipran (100 mg/day) with paroxetine (20 mg/day) in 300 outpatients with major depression. Efficacy was evaluated using HAMD17, MADRS and CGI for severity of illness and global improvement. Data were analysed on an intention to treat, last observation carried forward, basis.

RESULTS

Milnacipran and paroxetine were both effective and well tolerated with no significant difference in their effects. After treatment discontinuation, milnacipran was associated with significantly less emergent symptoms. Responders, at endpoint, to milnacipran had significantly greater levels of psychomotor retardation at baseline than non-responders.

LIMITATIONS

The study did not include a placebo group so that it is impossible to determine absolute levels of efficacy.

CONCLUSIONS

Both milnacipran and paroxetine were effective and well tolerated by outpatients with major depression treated for 6 weeks. After treatment discontinuation milnacipran was associated with less emergent symptoms. Psychomotor retardation at baseline may be a predictive factor of a favourable response to milnacipran.

Understanding pain in depression

A dysfunction of the serotonergic and noradrenergic pathways is commonly accepted as playing a major role in the aetiology of depression. Serotonergic cell bodies, located in the raphe nucleus, send projections to various parts of the brain where they are involved in the control of mood, movement, emotions such as anxiety and regulate behaviours such as eating, sexual activity and the feeling of pleasure. Similarly, the noradrenergic neurons, located in the locus coeruleus, project to the same regions where they regulate, in addition, attention and cognition. A further projection to the cerebellum regulates motor control. A dysfunction at the level of the monoamine neurons thus results in the classical symptoms of depression. In addition to these ascending pathways, however, the neurons in the raphe nucleus and the locus ceruleus also project to the spinal cord. These descending pathways serve to inhibit input from the intestines, the skeletal muscles and other sensory inputs. Under normal conditions, these inhibitory effects are modest, but in times of stress, in the interests of the survival of the individual, they can completely inhibit the input from painful stimuli. A dysfunction at the level of the serotonergic and noradrenergic neurons can thus affect both the ascending and descending pathways resulting in the psychological and somatic symptoms of depression but also in physical painful symptoms.

Antidepressant-like effect of nicotinamide adenine dinucleotide in the forced swim test in rats

Nicotinamide adenine dinucleotide (NADH), a cosubstrate for energy transfer in the oxidative phosphorylation, has supposedly beneficial effects on central nervous system (CNS)-related diseases, e.g., shown in an open study with depressive patients. To our knowledge there are no data concerning the efficacy of NADH in animal tests. Acute effects of NADH and the precursor nicotinamide, compared to controls and the antidepressants desipramine and fluoxetine, were examined in the forced swim test (FST) in Wistar rats. NADH, but not nicotinamide, reduced immobility and increased swimming behaviour in the FST, with a minimum effective dose of 5 mg/kg. NADH-induced behavioural profile was similar to fluoxetine, but different from desipramine. Since NADH did not induce hyperlocomotion but even decreased motor activity in the open field test, the antidepressant-like effect cannot be attributed to an increase in motor activity. These data support an antidepressant potential of NADH.