Do antidepressants have any potential to cause addiction?

The influence of drug class on reward in substance use disorders

In the United States, the societal costs associated with drug use surpass $500 billion annually. The rewarding and reinforcing properties that drive the use of these addictive substances are typically examined concerning the neurobiological effects responsible for their abuse potential. In this review, terms such as "abuse potential," "drug," and "addictive properties" are used due to their relevance to the methodological, theoretical, and conceptual framework for understanding the phenomenon of drug-taking behavior and the associated body of preclinical and clinical literature. The use of these terms is not intended to cast aspersions on individuals with substance use disorders (SUD). Understanding what motivates substance use has been a focus of SUD research for decades. Much of this corpus of work has focused on the shared effects of each drug class to increase dopaminergic transmission within the central reward pathways of the brain, or the "reward center." However, the precise influence of each drug class on dopamine signaling, and the extent thereof, differs considerably. Furthermore, the aforementioned substances have effects on several neurobiological targets that mediate and modulate their addictive properties. The current manuscript sought to review the influence of drug class on the rewarding effects of each of the major pharmacological classes of addictive drugs (i.e., psychostimulants, opioids, nicotine, alcohol, and cannabinoids). Our review suggests that even subtle differences in drug effects can result in significant variability in the subjective experience of the drug, altering rewarding and other reinforcing effects. Additionally, this review will argue that reward (i.e., the attractive and motivational property of a stimulus) alone is not sufficient to explain the abuse liability of these substances. Instead, abuse potential is best examined as a function of both positive and negative reinforcing drug effects (i.e., stimuli that the subject will work to attain and stimuli that the subject will work to end or avoid, respectively). Though reward is central to drug use, the factors that motivate and maintain drug taking are varied and complex, with much to be elucidated.

Optimising the prescribing of drugs that may cause dependency: An evidence and gap map of systematic reviews

OBJECTIVES

We set out to map the quantitative and qualitative systematic review evidence available to inform the optimal prescribing of drugs that can cause dependency (benzodiazepines, opioids, non-benzodiazepine hypnotics, gabapentinoids and antidepressants). We also consider how this evidence can be used to inform decision-making in the patient care pathway for each type of medication.

METHODS

Eight bibliographic databases were searched for the period 2010 to 2020. All included reviews were initially appraised using four items from the Collaboration for Environmental Evidence Synthesis Assessment Tool, with reviews that scored well on all items proceeding to full quality appraisal. Key characteristics of the reviews were tabulated, and each review was incorporated into an evidence and gap map based on a patient care pathway. The care pathway was based upon an amalgamation of existing NICE guidelines and feedback from clinical and patient stakeholders.

RESULTS

We identified 80 relevant reviews and displayed them in an evidence and gap map. The evidence included in these reviews was predominantly of low overall quality. Areas where systematic reviews have been conducted include barriers and facilitators to the deprescribing of drugs that may cause dependency, although we identified little evidence exploring the experiences or evaluations of specific interventions to promote deprescribing. All medications of interest, apart from gabapentinoids, were included in at least one review.

CONCLUSIONS

The evidence and gap map provides an interactive resource to support (i) policy developers and service commissioners to use evidence in the development and delivery of services for people receiving a prescription of drugs that may cause dependency, where withdrawal of medication may be appropriate, (ii) the clinical decision-making of prescribers and (iii) the commissioning of further research. The map can also be used to inform the commissioning of further systematic reviews. To address the concerns regarding the quality of the existing evidence based raised in this report, future reviews should be conducted according to best-practice guidelines. Systematic reviews focusing on evaluating interventions to promote deprescribing would be particularly beneficial, as would reviews focusing on addressing the paucity of evidence regarding the deprescription of gabapentinoids.

Efficacy, Tolerability, and Safety of Toludesvenlafaxine for the Treatment of Major Depressive Disorder-A Narrative Review

The estimated rate of treatment-resistant major depressive disorder (TRD) remains higher than 30%, even after the discovery of multiple classes of antidepressants in the last 7 decades. Toludesvenlafaxine (ansofaxine, LY03005, or LPM570065) is a first-in-class triple monoaminergic reuptake inhibitor (TRI) that has reached clinical use. The objective of this narrative review was to summarize clinical and preclinical evidence about the efficacy, tolerability, and safety of toludesvenlafaxine. Based on the results of 17 reports retrieved in the literature, the safety and tolerability profiles of toludesvenlafaxine were good in all clinical trials, and the pharmacokinetic parameters were well described in the phase 1 trials. The efficacy of toludesvenlafaxine was demonstrated in one phase 2 and one phase 3 trial, both on primary and secondary outcomes. In conclusion, this review highlights the favorable clinical results of toludesvenlafaxine in only two short-term trials that enrolled patients with major depressive disorder (MDD) (efficacy and tolerability were good for up to eight weeks), indicating the need for more good quality, larger-sample, and longer-term trials. Exploring new antidepressants, such as TRI, can be considered a priority for clinical research due to the high rates of TRD, but also due to the significant percentages of relapse in patients with MDD.

Estimating Risk of Antidepressant Withdrawal from a Review of Published Data

Adaptation of the brain to the presence of a drug predicts withdrawal on cessation. The outcome of adaptation is often referred to as 'physical dependence' in pharmacology, as distinct from addiction, although these terms have unfortunately become conflated in some diagnostic guides. Physical dependence to antidepressants may occur in some patients, consistent with the fact that some patients experience withdrawal effects from these medications. It is thought that longer duration of use, higher dose and specific antidepressants affect the risk of antidepressant withdrawal effects as they might cause greater adaptation of the brain. We searched PubMed for relevant systematic reviews and other relevant analyses to summarise existing data on determinants of antidepressant withdrawal incidence, severity and duration. Overall, data were limited. From survey data, increased duration of use was associated with an increased incidence and severity of withdrawal effects, consistent with some evidence from data provided by drug manufacturers. Duration of use may be related to duration of withdrawal effects but data are heterogenous and sparse. Serotonin and noradrenaline reuptake inhibitors and paroxetine are associated with higher risks than other antidepressants, though data for some antidepressants are lacking. Higher doses of antidepressant has some weak association with an increased risk of withdrawal, with some ceiling effects, perhaps reflecting receptor occupancy relationships. Past experience of withdrawal effects is known to predict future risk. Based on these data, we outline a preliminary rubric for determining the risk of withdrawal symptoms for a particular patient, which may have relevance for determining tapering rates. Given the limited scope of the current research, future research should aim to clarify prediction of antidepressant withdrawal risk, especially by examining the risk of withdrawal in long-term users of medication, as well as the severity and duration of effects, to improve the preliminary tool for predictive purposes. Further research into the precise adaptations in long-term antidepressant use may improve the ability to predict withdrawal effects for a particular patient.

Early Detection of Prescription Drug Abuse Using Doctor Shopping Monitoring From Claims Databases: Illustration From the Experience of the French Addictovigilance Network

Opioid analgesics and maintenance treatments, benzodiazepines and z-drugs, and other sedatives and stimulants are increasingly being abused to induce psychoactive effects or alter the effects of other drugs, eventually leading to dependence. Awareness of prescription drug abuse has been increasing in the last two decades, and organizations such as the International Narcotics Control Board has predicted that, worldwide, prescription drug abuse may exceed the use of illicit drugs. Assessment of prescription drug abuse tackles an issue that is hidden by nature, which therefore requires a specific monitoring. The current best practice is to use multiple detection systems to assess prescription drug abuse by various populations in a timely, sensitive, and specific manner. In the early 2000's, we designed a method to detect and quantify doctor shopping for prescription drugs from the French National Health Data System, which is one of the world's largest claims database, and a first-class data source for pharmacoepidemiological studies. Doctor shopping is a well-known behavior that involves overlapping prescriptions from multiple prescribers for the same drug, to obtain higher doses than those prescribed by each prescriber on an individual basis. In addition, doctor shopping may play an important role in supplying the black market. The paper aims to review how doctor shopping monitoring can improve the early detection of prescription drug abuse within a multidimensional monitoring. The paper provides an in-depth overview of two decades of development and validation of the method as a complementary component of the multidimensional monitoring conducted by the French Addictovigilance Network. The process accounted for the relevant determinants of prescription drug abuse, such as pharmacological data (e.g., formulations and doses), chronological and geographical data (e.g., impact of measures and comparison between regions), and epidemiological and outcome data (e.g., profiles of patients and trajectories of care) for several pharmacological classes (e.g., opioids, benzodiazepines, antidepressants, and methylphenidate).

The Conceptual Framework of Dual Disorders and Its Flaws

When psychiatric illness and substance use disorder coexist, the clinical approach to the patient is, unsurprisingly, awkward. This fact is due to a cultural context and, more directly, to the patient's psychiatric condition and addiction behaviors-a situation that does not favor a scientific approach. In dual disorder facilities, several types of professionals work together: counselors, social workers, psychologists, and psychiatrists. Treatment approaches vary from one service to another and even within the same service. It is crucial to provide dual disorder patients with multiple treatments, comprising hospitalization, rehabilitative and residential programs, case management, and counselling. Still, when treating dual disorder (DD) heroin use disorder (HUD) patients, it is advisable to follow a hierarchical algorithm. First, we must deal with addiction: by detoxification, whenever possible. This means starting most patients on anti-craving pharmacological maintenance, though aversion therapy may be appropriate for a few of them. Opiate antagonists may be used with heroin-addicted patients as long as those patients are only mildly ill. In contrast, agonist opioid medications, i.e., buprenorphine and methadone suit moderately and severely ill patients, respectively. Achieving control of mood instability or psychotic episodes is the next step, to be followed by a prevention strategy to counteract residual cravings and dominate mood disorders or psychotic episodes through long-term pharmacological maintenance that is focused on a double target.

Off-label uses of drugs for depression

The prescription of drugs for depression is rising rapidly. One of the reasons for this trend is their many off-label uses. Up to one third of all prescriptions are for non-indicated use, which in addition to drug repurposing includes different dosing or duration than those recommended. In this review, we elaborate on what antidepressants can treat besides depression. The five classes of drugs for depression are introduced, and their mechanisms of action and serious side effects are described. The most common off-label uses of antidepressants are discussed, with a special focus on treating eating disorders, sleep problems, smoking cessation and managing chronic pain. Depression is often a comorbidity when antidepressants are chosen as therapy, but good therapeutic effects have been observed for other conditions also when depression is not involved. Finally, a new type of antidepressant developed from the hallucinogenic "party drug" ketamine is briefly introduced. This recent development suggests that antidepressants will keep playing a central role in medicine for years to come.

Antidepressants, withdrawal, and addiction; where are we now?

Controversy continues with regard to antidepressants and withdrawal. Recent debates have focused on the prevalence and length of withdrawal, and some continue to state that withdrawal from these compounds constitutes 'addiction'. In this editorial we examine the evidence underlying these recent debates. We acknowledge gaps in knowledge, and make suggestions for how the field can progress.

Recognising and managing antidepressant discontinuation symptoms

Antidepressant discontinuation symptoms occur with all classes of antidepressant. A well-described discontinuation syndrome occurs with the selective serotonin reuptake inhibitors, common symptoms including dizziness, headache, nausea and lethargy. Rare antidepressant discontinuation syndromes include extrapyramidal syndromes and mania/hypomania. All these syndromes, even isolated discontinuation symptoms, share three common features that facilitate diagnosis; abrupt onset within days of stopping the antidepressant, a short duration when untreated and rapid resolution when the antidepressant is reinstated. Clinicians need to be familiar with strategies for the prevention and management of such symptoms. Preventive strategies include warning patients about the possibility of discontinuation symptoms, encouraging good antidepressant adherence and tapering antidepressants at the end of treatment. Most symptoms are mild and short-lived. Consequently symptoms that follow planned termination of an antidepressant can often be managed by providing an explanation and reassurance. More severe symptoms should be treated symptomatically or the antidepressant restarted, in which case symptoms usually resolve within 24 h. More cautious tapering can then follow.

How addictive are gabapentin and pregabalin? A systematic review

In the last ten years, gabapentin and pregabalin have been becoming dispensed broadly and sold on black markets, thereby, exposing millions to potential side-effects. Meanwhile, several pharmacovigilance-databases have warned for potential abuse liabilities and overdose fatalities in association with both gabapentinoids. To evaluate their addiction risk in more detail, we conducted a systematic review on PubMed/Scopus and included 106 studies. We did not find convincing evidence of a vigorous addictive power of gabapentinoids which is primarily suggested from their limited rewarding properties, marginal notes on relapses, and the very few cases with gabapentinoid-related behavioral dependence symptoms (ICD-10) in patients without a prior abuse history (N=4). In support, there was no publication about people who sought treatment for the use of gabapentinoids. Pregabalin appeared to be somewhat more addictive than gabapentin regarding the magnitude of behavioral dependence symptoms, transitions from prescription to self-administration, and the durability of the self-administrations. The principal population at risk for addiction of gabapentinoids consists of patients with other current or past substance use disorders (SUD), mostly opioid and multi-drug users, who preferred pregabalin. Pure overdoses of gabapentinoids appeared to be relative safe but can become lethal (pregabalin > gabapentin) in mixture with other psychoactive drugs, especially opioids again and sedatives. Based upon these results, we compared the addiction risks of gabapentin and pregabalin with those of traditional psychoactive substances and recommend that in patients with a history of SUD, gabapentinoids should be avoided or if indispensable, administered with caution by using a strict therapeutic and prescription monitoring.

Nortriptyline Enhances Morphine-Conditioned Place Preference in Neuropathic Rats: Role of the Central Noradrenergic System

BACKGROUND

Combination drug therapy is commonly used to treat chronic pain conditions such as neuropathic pain, and antidepressant is often used together with opioid analgesics. While rewarding is an intrinsic property of opioid analgesics, it is unknown whether the use of an antidepressant would influence opioid reward, which may contribute to opioid addiction. In this study, we examined whether nortriptyline (a tricyclic antidepressant and a first-line medication for neuropathic pain) would enhance the morphine rewarding property in both naive and chronic constriction sciatic nerve injury (CCI) rats.

METHODS

The rewarding effect of these drugs was assessed using conditioned place preference (CPP). The real-time polymerase chain reaction, western blot, and enzyme-linked immunosorbent assay analysis were used to investigate the function of central noradrenergic system.

RESULTS

In naive rats, coadministration of nortriptyline with morphine did not change the acquisition of morphine-induced CPP. However, nortriptyline enhanced the acquisition, delayed the extinction, and augmented the reinstatement of morphine-induced CPP in CCI rats. In CCI rats treated with both nortriptyline and morphine, the expression of α2A-adrenergic receptors, norepinephrine transporter, and tyrosine hydroxylase was markedly decreased in the locus coeruleus, whereas the norepinephrine concentration in the nucleus accumbens was remarkably increased.

CONCLUSIONS

These results demonstrate that nortriptyline enhanced morphine reward when both drugs were used to treat neuropathic pain in rats and that this behavioral phenotype is likely to be mediated by upregulation of the central noradrenergic system. These findings may have implications in opioid therapy commonly used for chronic pain management.

Use of the Clinical Laboratory in Psychiatric Practice

In this review, the authors address the general principles of prescribing psychiatric medications and discuss how the clinical laboratory can be used to guide prescribing practices. Treatment considerations in different settings and for different medications are discussed. Because the clinical laboratory is advancing in its technology, so should the clinician's knowledge of how to use the clinical laboratory. The authors propose recommendations and a simple algorithm for how to use medication levels in blood and other fluids to guide care in medications without well-defined therapeutic windows.

Antidepressant drug development: Focus on triple monoamine reuptake inhibition

Many patients with major depressive disorder (MDD) only partially respond, and some have no clinically meaningful response, to current widely used antidepressant drugs. Due to the purported role of dopamine in the pathophysiology of depression, triple-reuptake inhibitors (TRIs) that simultaneously inhibit serotonin (5-HT), norepinephrine (NE) and dopamine reuptake could be a useful addition to the armamentarium of treatments for MDD. A TRI should more effectively activate mesolimbic dopamine-related reward-networks, restore positive mood and reduce potent 5-HT reuptake blockade associated "hypodopaminergic" adverse effects of decreased libido, weight gain and "blunting" of emotions. On the other hand, dopaminergic effects raise concern over abuse liability and TRIs may have many of the cardiovascular effects associated with NET inhibition. Several clinical development programs for potential TRI antidepressants have failed to demonstrate significantly greater efficacy than placebo or standard of care. Successful late-stage clinical development of a TRI is more likely if experimental research studies in the target population of depressed patients have demonstrated target engagement that differentially and dose-dependently improves assessments of reward-network dysfunction relative to existing antidepressants. TRI treatment could be individualized on the basis of predictive markers such as the burden of decreased positive mood symptoms and/or neuroimaging evidence of reward network dysfunction. This review focuses on how the next generation of monoamine-based treatments could be efficiently developed to address unmet medical need in MDD.

Abuse and misuse of antidepressants

BACKGROUND

Rates of prescription drug abuse have reached epidemic proportions. Large-scale epidemiologic surveys of this under-recognized clinical problem have not included antidepressants despite their contribution to morbidity and mortality. The purpose of this review is to look specifically at the misuse of antidepressants and how this behavior may fit into the growing crisis of nonmedical use of prescription drugs.

METHODS

We conducted a comprehensive search on PubMed, Medline, and PsycINFO using the search terms "antidepressant", "abuse", "misuse", "nonmedical use", "dependence", and "addiction", as well as individual antidepressant classes (eg, "SSRI") and individual antidepressants (eg, "fluoxetine") in various combinations, to identify articles of antidepressant misuse and abuse.

RESULTS

A small but growing literature on the misuse and abuse of antidepressants consists largely of case reports. Most cases of antidepressant abuse have occurred in individuals with comorbid substance use and mood disorders. The most commonly reported motivation for abuse is to achieve a psychostimulant-like effect. Antidepressants are abused at high doses and via a variety of routes of administration (eg, intranasal, intravenous). Negative consequences vary based upon antidepressant class and pharmacology, but these have included seizures, confusion, and psychotic-like symptoms.

CONCLUSION

The majority of individuals prescribed antidepressants do not misuse the medication. However, certain classes of antidepressants do carry abuse potential. Vulnerable patient populations include those with a history of substance abuse and those in controlled environments. Warning signs include the presence of aberrant behaviors. Physicians should include antidepressants when screening for risky prescription medication use. When antidepressant misuse is detected, a thoughtful treatment plan, including referral to an addiction specialist, should be developed and implemented.

Patient barriers to and enablers of deprescribing: a systematic review

BACKGROUND

Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process.

OBJECTIVES

The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication.

DATA SOURCES

A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised.

STUDY ELIGIBILITY CRITERIA

Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased.

STUDY APPRAISAL AND SYNTHESIS METHODS

Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results.

RESULTS

Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.

Gabapentin for Substance Use Disorders: Is it Safe and Appropriate?

Gabapentin is effective for the treatment of alcohol dependence and can be used for treating anxiety, insomnia, headaches, and/or pain in patients who have comorbid substance use disorders (SUDs) or who are at high risk of substance abuse. Deaths from unintentional drug overdoses are increasing, are the leading cause of injury death in the United States, and are mostly attributable to prescription drugs, in particular opioid agents. Compared to other psychotropic drugs, gabapentin is not especially harmful or lethal. Gabapentin misuse is possible, similar to other medications not typically considered drugs of abuse, but it should be considered safe and appropriate for use in patients with all types of SUDs, including patients who take opioid drugs.

Increased alcohol consumption in rats after subchronic antidepressant treatment

The use of antidepressants for alcoholism in humans has been a matter of controversy in recent years. Despite the existence of an important co-morbidity for depression and alcoholism, some studies suggest that the use of antidepressants could worsen the prognosis of alcoholism. However, there is a lack of studies in animal models exploring this phenomenon. In the present study, we show how the 15-d treatment with fluoxetine (10 mg/kg) or venlafaxine (50 mg/kg) affected alcohol deprivation effect (ADE) and subsequent alcohol consumption. Initially, fluoxetine reduced ADE and venlafaxine did not affect it. However, in the following days, both antidepressants increased alcohol consumption, an effect that was found to last at least 5 wk. Fluoxetine treatment was shown to cause a locomotor sensitized response to a challenge dose of amphetamine (0.5 mg/kg), indicating the presence of a supersensitive dopaminergic transmission. In summary, antidepressant treatment may increase alcohol consumption in rats after a period of alcohol deprivation and this could be related to alterations in the reward circuitry. This finding confirms in an animal model previous reports in humans that may limit the use of antidepressants for alcoholism.

Experiences from consumer reports on psychiatric adverse drug reactions with antidepressant medication: a qualitative study of reports to a consumer association

BACKGROUND

The new European pharmacovigilance legislation has been suggested as marking the beginning of a new chapter in drug safety, making patients an important part of pharmacovigilance. In Sweden since 2008 it has been possible for consumers to report adverse drug reactions (ADRs) to the Medical Products Agency (MPA), and these reports are now understood as an increasingly valuable contribution in the monitoring of safety aspects in medicines. Already in 2002 it was possible to report experiences with medicines to the non-profit and independent organization Consumer Association for Medicines and Health (KILEN) through a web-based report form with an opportunity to describe ADR experiences in free text comments. The aim of this study was to qualitatively analyze the free text comments appended to consumer reports on antidepressant medication.

METHODS

All reports of suspected adverse reactions regarding antidepressant medications submitted from January 2002 to April 2009 to KILEN's Internet-based reporting system in Sweden were analyzed according to reported narrative experience(s). Content analysis was used to interpret the content of 181 reports with free text comments.

RESULTS

Three main categories emerged from the analyzed data material: (1) Experiences of drug treatment with subcategories (a) Severe psychiatric adverse reactions, and (b) Discontinuation symptoms; (2) Lack of communication and (3) Trust and distrust. A majority of the reports to KILEN were from patients experiencing symptoms of mental disturbances (sometimes severe) affecting them in many different ways, especially during discontinuation. Several report included narratives of patients not receiving information of potential ADRs from their doctor, but also that there were no follow-ups of the treatment. Trust was highlighted as especially important and some patients reported losing confidence in their doctor when they were not believed about the suspected ADRs they experienced, making them attempt to discontinue their antidepressant treatment on their own.

CONCLUSIONS

The present study indicates that free text comments as often contained in case reports directly submitted by patients can be of value in pharmacovigilance and provide important information on how a drug may affect the person using it and influence his or her personal life.

Combination treatment with benzodiazepines and SSRIs for comorbid anxiety and depression: a review

OBJECTIVE

To review the literature on the co-occurrence of anxiety with depressive disorders and the rationale for and use of combination treatment with benzodiazepines and selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) for treating comorbid anxiety and depression.

DATA SOURCES

PubMed and PsycINFO were searched using terms identified as relevant based on existing practice guidelines. The primary search terms were anxiety, anxiety disorders, depression, depressive disorders, comorbidity, epidemiology, benzodiazepines, antidepressants, pharmacology, clinical trials, and pharmacotherapy. Reference lists of identified articles were also reviewed to ensure capture of relevant literature.

STUDY SELECTION

Publications were selected for inclusion in the review if they applied to adult populations and specifically addressed the comorbidity of anxiety and depression, their epidemiology, or their management. Case reports and case series were not considered for inclusion.

DATA EXTRACTION

Each author assessed the publications independently for content related to the review topics. Findings considered relevant to the clinical understanding and management of comorbid anxiety and depression were incorporated into the review.

DATA SYNTHESIS

Comorbidity is very common among patients with anxiety and depressive disorders, and, even when full criteria for 2 separate disorders are not met, subsyndromal symptoms are often present. Little controlled research has explored how benzodiazepines and SSRIs/SNRIs may be usefully combined, yet their combination is frequently employed in clinical practice. Patients with comorbidities are likely to have poorer treatment outcomes and have greater utilization of health care resources. Currently SSRIs/SNRIs are considered first-line therapy and are effective in both anxiety and depressive states. Nevertheless, many patients have only a partial response or have difficulty tolerating efficacious doses of antidepressant monotherapy. Benzodiazepines appear to improve treatment outcomes when an anxiety disorder co-occurs with depression or for depression characterized by anxious features. Specifically, they may provide benefits both in terms of speed of response and overall response.

CONCLUSIONS

Long-term management plans for anxiety disorder with or without comorbid depression should include strategies for acute or short-term care, long-term maintenance, and episodic or breakthrough symptoms. Combination therapy with benzodiazepines and antide-pressants in appropriate clinical settings may improve outcomes over monotherapy in some patients.

The association between non-medical prescription drug use, depressive symptoms, and suicidality among college students

PURPOSE

Studies have substantiated a relationship between drug use, depression, and suicidality. However, little research has examined this relationship with prescription drugs. Given the prevalence of non-medical prescription drug use (NMPDU) among college students, this study explored the association between general and specific NMPDU, depressive symptoms, and suicidality.

METHODS

Data from the Fall 2008 National College Health Assessment (NCHA) was utilized (N=22,783). Five separate logistic regression models were employed, with the first combining any NMPDU (antidepressants, painkillers, sedatives, and stimulants) followed by four additional regressions for each drug, and then separated by gender. Models were estimated before and after control for key covariates.

RESULTS

Approximately 13% of participants reported NMPDU. After covariate adjustment, those who reported feeling hopeless, sad, depressed, or considered suicide were 1.22-1.31 times more likely to report NMPDU (p<.05). Those who reported feeling hopeless, sad, or depressed were 1.18-1.43 times more likely to report opioid painkiller use; those who reported feeling sad, depressed, or considered suicide were 1.22-1.38 times more likely to report stimulant use; those who reported being depressed were 1.36 times more likely to report sedative use; and those who reported feeling hopeless or depressed were 1.44 and 1.91 times more likely to report antidepressant use (p<.05). When the adjusted models were repeated separately by gender, results were more pronounced for females, especially for females who reported painkiller use.

CONCLUSIONS

Depressive symptoms and suicidality were significantly associated with greater odds of any NMPDU, with painkiller use (especially for females) representing the greatest correlate among college students. Results suggest that students may be inappropriately self-medicating psychological distress with prescription medications.

Noradrenergic antidepressants increase cortical dopamine: potential use in augmentation strategies

Most antidepressant treatments, based on serotonin (5-HT) and/or norepinephrine (NE) transporter blockade, show limited efficacy and slow onset of action, requiring the use of augmentation strategies. Here we report on a novel antidepressant strategy to selectively increase DA function in prefrontal cortex (PFC) without the potential tolerance problems associated to DA transporter blockade. This approach is based on previous observations indicating that extracellular DA in rat medial PFC (mPFC) - but not in nucleus accumbens (NAc) - arises from noradrenergic terminals and is sensitive to noradrenergic drugs. A low dose of reboxetine (3 mg/kg i.p.; NE reuptake inhibitor) non-significantly increased extracellular DA in mPFC. Interestingly, its combined administration with 5 mg/kg s.c. mirtazapine (non-selective α₂-adrenoceptor antagonist) increased extracellular DA in mPFC (264 ± 28%), but not in NAc. Extracellular NE (but not 5-HT) in mPFC was also enhanced by the combined treatment (472 ± 70%). Repeated (×3) reboxetine + mirtazapine administration produced a moderate additional increase in mPFC DA and markedly reduced the immobility time (-51%) in the forced-swim test. Neurochemical and behavioral effects of the reboxetine + mirtazapine combination persisted in rats pretreated with citalopram (3 mg/kg, s.c.), suggesting its potential usefulness to augment SSRI effects. In situ hybridization c-fos studies were performed to examine the brain areas involved in the above antidepressant-like effects, showing changes in c-fos expression in hippocampal and cortical areas. BDNF expression was also increased in the hippocampal formation. Overall, these results indicate a synergistic effect of the reboxetine + mirtazapine combination to increase DA and NE function in mPFC and to evoke robust antidepressant-like responses.

Conditioned place preference studies with atomoxetine in an animal model of ADHD: effects of previous atomoxetine treatment

To investigate the putative rewarding effects of atomoxetine, a non-stimulant medication for Attention-deficit/hyperactivity disorder (ADHD), we conducted conditioned place preference (CPP) tests in an animal model of ADHD, the spontaneously hypertensive rat (SHR). The effects of drug pre-exposure were also evaluated, thus, parallel experiments were done in rats which have undergone 14 days of atomoxetine treatment. The responses of SHR were compared with the rat strain representing the "normal" heterogeneous population, the Wistar rats. Neither rat strain showed significant CPP to atomoxetine. However, previous atomoxetine treatment produced place preference responses in rats, more profoundly in Wistar rats conditioned with the low and moderate atomoxetine doses. In conclusion, acute exposure to atomoxetine does not have any rewarding effect, however, drug pretreatment produces responses characteristic of reward or psychological dependence, more specifically in the "normal" vs. the ADHD animal model. The present findings call for more studies with atomoxetine, especially those that investigate the effects of long-term or chronic drug treatment.

Uncontrolled self-medication with venlafaxine in a patient with major depressive disorder

Antidepressants are known to have no significant ability to cause addiction. However, a recent study showed many individuals with mood disorders self-medicated with antidepressants to relieve symptoms. We report here a male physician, diagnosed five years ago with major depressive disorder, with insomnia, anxiousness, and chest heaviness. He began self-medicating with 150 mg of venlafaxine daily, without any monitoring. During his most recent severe depressive episode, he was taking up to 1,500 mg of venlafaxine daily. Without this medication, he experienced discontinuation syndrome, which included severe anxiety, chest heaviness, and breathing difficulty, and which he judged as indicating a more severely depressed state. He also experienced overdose symptoms, such as hypertension and tachycardia. He attempted suicide with drugs that he possessed. In conclusion, careful monitoring is needed when treating patients with venlafaxine, because its discontinuation syndrome is similar to symptoms of major depressive disorder, and suicidality may result from an overdose.

From descartes to desipramine: psychopharmacology and the self

Despite the remarkably widespread use of the new generation of antidepressants, almost everything we know about their effects comes from animal studies and clinical trials in which the sole parameter of interest is depressive symptomatology. Almost nothing is known about the effects that antidepressants have on cognition, affect, or motivation when used over a period of months or years. Nor do we understand what effects, if any, antidepressants have on what we think of as the self. In this article, we argue that neither psychiatry nor philosophy, in their current state, are well equipped to think about these issues. In order to explore this idea, we consider the neurobiology of romantic love and its relation to antidepressant neurochemistry. This case study, we suggest, supports the view that antidepressants are very likely to have significant effects on personhood as well as the suggestion that we are in need of new ways of thinking about the self and its pathologies.

Is quetiapine a drug of abuse? Reexamining the issue of addiction

BACKGROUND

The abuse and diversion of pharmacological agents with CNS mechanisms of action is an important concern from governmental, regulatory, public health and safety perspectives. In recent years, there have been an increased number of reports concerning the abuse and diversion of quetiapine in forensic population and in individuals with histories of substance abuse.

OBJECTIVE

To better understand this surging pattern the available body of evidence was critically examined.

METHODS

A literature search from January 1991 to July 2008 restricting papers to English and using PUBMED and PsychInfo was performed.

RESULTS

Nine papers were identified. The content of these papers is discussed in light of recent research on drug abuse.

Venlafaxine dependence in a patient with a history of alcohol and amineptine misuse

BACKGROUND

Venlafaxine is an inhibitor of neuronal serotonin and noradrenaline re-uptake and a weak inhibitor of dopamine re-uptake. There was no indication of problems of abuse/dependence during the clinical trials.

CASE DESCRIPTION

A 53-year-old client with a history of alcohol and amineptine misuse and a long history of recurrent depression, for which he was prescribed venlafaxine tablets. Over time, he increased the dosage to 50 tablets daily (3750 mg). Large venlafaxine dosages produced amphetamine-like effects, due possibly to the related increase in dopamine turnover. Once hospitalized for detoxification, the patient had a symptomatology which was consistent with a serotonergic discontinuation syndrome.

CONCLUSIONS

Physicians should be aware that patients with a history of drug and alcohol abuse might develop venlafaxine dependence.

Mésusage des médicaments du sommeil et de la vigilance

Sleep disorders, mainly insomnia and daytime somnolence, can arise from very different causes. For example insomnia may be related to anxiety-depression or occur in response to a stressful lifestyle or as an element of restless leg syndrome. Subjects with hypersomnia may present episodes of sleep apnea, drug-related depression or narcolepsia. Specific management is required for each etiology. Misuse of sleep drugs generally results from an insufficient etiological diagnosis and a misunderstanding of their proper use. These drugs can be used as necessary expedients but cannot replace correct management or treatment of the cause or causes of the sleep disorder. We present here a review of the undesirable effects, particularly among the elderly population, and of the risk of addiction to the different drugs used to induce sleep in order to propose prescription guidelines.

Is it possible to be dependent to Tianeptine, an antidepressant? A case report

Tianeptine, an atypical tricyclic antidepressant, is one of the first chemical agents, like tricyclic antidepressants and selective serotonin re-uptake inhibitors (SSRIs), which are employed for the treatment of anxiety and depressive disorders. It is believed that tianeptine, unlike the SSRIs, is enhancing serotonin re-uptake the velocity of the cortical neurons in the lymbic system and hippocampal neurons. In literature, there are more examples of dependence cases of antidepressants, which have amphetaminergic effects, such as amineptine and tranylcipromine, than amitriptyline, fluoxetine and tianeptine. Contrary to the reports about using high dosages of tianeptine, case reports about misuse and dependence have revealed that the most common reason of dependence is the psychostimulant effect. In these cases, tolerance to tianeptine and the symptoms of depreviation in absence of the drug have been seen, and the history of dependence or abuse of any drug or alcohol, treatment for mood and/or personality disorders are mentioned as possible risks for the dependence to tianeptine. This report discusses the diagnosis and treatment of a tianeptine dependence case. The 34 year-old patient, who is in conflict with her own family members, does not have the history of dependence or abuse of any substances, except for smoking, had been using excessive doses of 750 mg/day of tianeptine for a year.

On the effects of psychostimulants, antidepressants, and the antiparkinsonian drug levodopa on dopamine neurons

The dopaminergic system constitutes the principal target of many psychostimulants, antidepressant, and antiparkinsonian drugs. The effects caused by these compounds are partly associated with an increased dopamine (DA) levels within the terminal areas of DA neurons and in the ventral midbrain. Therefore, several substances of abuse, antidepressants, and endogenous compounds (levodopa and trace amines [TAs]) regulate the activity of DA cells by activating D2 autoreceptors located on the terminals, soma, and dendrites. Considering our past and recent experimental studies on this issue, here we will briefly reexamine the mechanisms of action of several psychoactive drugs on DA neurons. In particular, we propose three different modalities by which the mesencephalic DA neurons can be regulated by drugs: amphetamine/TAs-like, cocaine-like, and levodopa-like. We, therefore, discuss the potential therapeutic and addictive properties of the psychoactive substances.

Estimating the relative reinforcing strength of (+/-)-3,4-methylenedioxymethamphetamine (MDMA) and its isomers in rhesus monkeys: comparison to (+)-methamphetamine

RATIONALE

(+/-)3,4-Methylenedioxymethamphetamine (MDMA) is an analog of methamphetamine (MA) and a drug of abuse. MA, MDMA, and its isomers release monoamine neurotransmitters with varying selectivities and would, therefore, be predicted to vary in their relative strength as reinforcers.

OBJECTIVES

This study compared self-administration of MA, MDMA, and its isomers using a progressive-ratio schedule in rhesus monkeys.

METHODS

Rhesus monkeys [n = 6, MA and MDMA; n = 5, (+)-MDMA and (-)-MDMA] were prepared with chronic i.v. catheters and allowed to self-administer cocaine or saline in daily baseline sessions. When responding was stable, MA (0.006-0.1 mg/kg per injection), MDMA (0.025-0.8 mg/kg injection), (+)-MDMA (0.025-0.8 mg/kg per injection), or (-)-MDMA (0.05-0.8 mg/kg per injection) was made available in test sessions.

RESULTS

MA, MDMA, and (+)-MDMA functioned as positive reinforcers in all monkeys with a potency relationship of MA > (+)-MDMA > (+/-)-MDMA. Two of five monkeys took (-)-MDMA above saline levels. Dose-response relationships were biphasic for MA and (+/-)-MDMA, and asymptotic for (+)-MDMA. In terms of maximum number of injection per session, a measure of relative reinforcing strength, the order was MA > (+)-MDMA = (+/-)-MDMA > (-)-MDMA.

CONCLUSIONS

MDMA and (+)-MDMA were consistent positive reinforcers, but weaker than MA, whereas (-)-MDMA was, at best, a weak reinforcer in some monkeys. The reinforcing strength of MDMA appears to derive primarily from (+)-MDMA. Because MDMA and its isomers have been shown to have relatively higher serotonin to dopamine releasing potency, these data support the hypothesis that increasing 5-HT releasing potency relative to DA is associated with weaker reinforcing effects.

Antidepressant-like effect of D(2/3) receptor-, but not D(4) receptor-activation in the rat forced swim test

Dopamine plays a role in the pathophysiology of depression and therapeutic effects of antidepressants but the contribution of individual D(2)-like receptor subtypes (D(2), D(3), D(4)) to depression is not known. We present evidence that activation of D(2)/D(3), but not D(4) receptors, can affect the outcome in the rat forced swim test (FST). Nomifensine, a dopamine uptake inhibitor (7, 14, and 28 micromol/kg); quinpirole, a D(2)-like receptor and agonist (0.4, 1.0, and 2.0 micromol/kg); PD 12,8907, a preferential D(3) receptor agonist (0.17, 0.35, and 0.7 micromol/kg); PD 168077 (0.1, 0.3, and 1.0 micromol/kg) and CP 226269 (0.3, 1.0, and 3.0 micromol/kg), both selective D(4) receptor agonists, were administered s.c. 24, 5, and 0.5/1 h before testing. Nomifensine, quinpirole at all doses and PD 128907 at the highest dose decreased immobility time in FST. PD 168077 and CP 226269 had no effect on the model. To further clarify what type of dopamine receptors were involved in the anti-immobility effect of quinpirole, we tested different antagonists. Haloperidol, a D(2)-like receptor antagonist (0.27 micromol/kg), completely blocked the effect of quinpirole; A-437203 (LU-201640), a selective D(3) receptor antagonist (17.46 micromol/kg), showed a nonsignificant trend to attenuate the effect of the low dose of quinpirole, and L-745,870, a selective D(4) receptor antagonist (1.15 micromol/kg), had no effect. The pharmacological selectivity of the compounds tested suggests that the antidepressant-like effects of quinpirole are most likely mediated mainly by D(2) and to a lesser extent by D(3) but not D(4) receptors.

Evaluation of the reinforcing effects of monoamine reuptake inhibitors under a concurrent schedule of food and i.v. drug delivery in rhesus monkeys

Most medications prescribed for attention-deficit-hyperactivity disorder are psychomotor stimulants with reinforcing effects in laboratory animals (eg methylphenidate). The present studies were conducted to evaluate the reinforcing effects of the recently approved medication atomoxetine in monkeys trained to 'choose' between automated deliveries of either an i.v. injection or food. Rhesus monkeys were trained to lever-press under concurrent schedules of reinforcement; responses on one lever resulted in an injection of either saline or drug, and responses on the alternative lever resulted in food delivery. Data were collected on four measures: response rates, percentage of total responses occurring on the injection-lever (% ILR), number of injections earned, and number of food pellets earned. Dose-effect functions were determined for cocaine (0.003-0.3 mg/kg/inj), methylphenidate (0.003-0.1 mg/kg/inj), amphetamine (0.003-0.1 mg/kg/inj), atomoxetine (0.01-0.3 mg/kg/inj), and desipramine (0.03-1.0 mg/kg/inj) using a double alternation schedule of saline and drug availability. Results indicate that the distribution of behavior changed according to the drug and dose available for self-injection. Saline availability was typically associated with high rates of food-maintained responding. The % ILR increased from 3+/-1% when saline was available to >90% when >0.03 mg/kg/inj of cocaine, methylphenidate or d-amphetamine was available. However, no dose of atomoxetine or desipramine maintained self-administration behavior on the injection-lever. The number of food pellets earned per session decreased as the dose of each drug increased, indicative of behavioral activity with all five drugs. The reinforcing effects of cocaine, methylphenidate, and d-amphetamine in these studies are consistent with previous findings in nonhuman primates and with their documented abuse liability. The absence of reinforcing effects of atomoxetine support the view that, like desipramine, it has no evident abuse potential.

Psychoactive substance consumption in eating disorders

Research investigating the comorbidity between eating disorders and substance-use disorders have reported positive but contrasting results. The aim of this study was to further explore this association by studying patterns of consumption of the entire range of psychoactive substances (alcohol, specific drugs, prescribed psychotropics) in a large sample (N=271) of eating-disorder DSM-IV subtypes. Results show that subjects suffering from anorexia of the restrictive type show significantly less drug-consumption behaviors and alcohol abuse and/or dependence disorders than purging anorexic and bulimic subjects. No difference was found in the total consumption of psychotropics among the four groups of eating disorders. However, more than half of eating-disorder subjects are regular consumers of psychotropics. Among these regular consumers, bulimics self-prescribe and increase their doses of psychotropics significantly more than anorexics. Features of impulsivity that are associated with purging and bulimic behaviors could play a specific role in these patterns of comorbidity and account for such differences.

What do medical outpatients attending a neurology clinic think about antidepressants?

OBJECTIVE

To determine how medical outpatients attending a neurology clinic view antidepressant medication and whether those who present with medically unexplained symptoms have different views than those whose symptoms are explained by neurological disease.

METHODS

A total of 89 consecutive outpatients attending a medical neurology clinic were interviewed.

RESULTS

Those who believed that antidepressants were addictive comprised 74% and those who thought that they could cause physical harm comprised 47%. Only 49% were aware that antidepressants could be used to treat symptoms other than depression. The views of patients whose symptoms were rated by the doctor as being 'not at all' only 'somewhat' unexplained by neurological disease (37% of the total) were neither substantially nor statistically different those whose symptoms were rated as 'largely' or 'completely' explained by neurological disease.

CONCLUSION

The majority of medical patients attending a neurology clinic, and not just those with medically unexplained symptoms, have largely negative beliefs about antidepressant drugs. The implications for patient adherence to these agents and for medical practice are discussed.

Death and dependence: current controversies over the selective serotonin reuptake inhibitors

Recent years have seen a considerable media interest in the adverse effects of the selective serotonin reuptake inhibitors (SSRIs). This has led to claims that these antidepressants may lead to suicide and homicide and that they cause dependence or even addiction. Such claims have caused great concerns to many patients and have confused doctors in both primary care and psychiatric practice. In this article I review the basis of these claims and show that many seem to emerge from the misinterpretation of evidence and the use of imprecise definitions. Although the SSRIs are not free of problems they compare very favourably with other antidepressants and other classes of psychotropic drugs. There is no evidence they are addictive in the formal sense of leading to a drug dependence syndrome. Some suggestions on the way these issues can be more precisely defined and studied in future are given.

Dependence potential of antidepressants compared to benzodiazepines

The aim of the present study was to compare the possible dependence potential of antidepressants (ADs) to benzodiazepines (BZDs). The Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ) and the Symptom Checklist-90 (SCL-90) were administered to 70 psychiatric outpatient BZD users and 54 psychiatric outpatient AD users. Significantly more Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM-III-R) as well as International Classification of Diseases, Tenth Edition (ICD-10) past year (PY) and lifetime (LT) dependence diagnoses were made in the BZD group than in the AD group. Bendep-SRQ scale scores for Problematic Use, Preoccupation and Lack of Compliance were significantly higher in the BZD group than in the AD group. The BZD group also had a higher rating on the Withdrawal scale, but this difference was not statistically significant. According to DSM-III-R and ICD-10 criteria ADs do have some dependence liability in psychiatric outpatients, but clearly to a lesser extent than BZDs. Further research is needed to differentiate the dependence potential among the various classes of ADs.

Dopaminergic augmentation of sleep deprivation effects in bipolar depression

Total sleep deprivation (TSD) has been used in association with lithium salts and with serotonergic and noradrenergic antidepressants, leading to sustained improvements in patients affected by major depression. Current theories on the neurobiological mechanism of action of TSD propose a major role for enhanced dopamine activity. To test the clinical relevance of dopaminergic enhancement in TSD, we treated a homogeneous sample of 28 bipolar depressed patients with three cycles of TSD combined with placebo or with the dopaminergic antidepressant amineptine. Changes in mood over time were rated with self-administered visual analogue scales and with the Montgomery-Asberg Depression Rating Scale. Patients showed improved mean daily-mood scores after TSD, an effect that was highest at the first cycle and decreased with treatment repetition. Amineptine enhanced the effects of TSD on perceived mood during the first two TSD cycles, but patients in the placebo and amineptine groups showed comparable results at the end of the treatment. Despite its theoretical importance, the clinical usefulness of combining TSD with a dopaminergic agent must be questioned.

Nicotine as an Addictive Substance: A Critical Examination of the Basic Concepts and Empirical Evidence

The present review is a critical analysis of the concepts behind and the empirical data supporting the view that tobacco use represents an addiction to nicotine. It deals with general aspects of the notion of addiction, while concentrating on specific problems associated with incorporating nicotine into current frameworks. The notion of addiction suffers from unprecedented definitional difficulties. The definitions offered by various authorities are very different, even contradictory. Definitions that reasonably include nicotine are so broad and vague that they allow many trivial things, such as salt, sugar, and watching television, to be considered addictive. Definitions that exclude the trivia also exclude nicotine. The addiction hypothesis, in general, is strongly shaped by views that certain drugs bring about a molecular level subversion of rationality. The main human evidence for this is verbal reports of smokers who say that they can't quit. On the other hand, the existence of many millions of successful quitters suggests that most people can quit. Some smokers don't quit, but whether they can't is another matter. The addiction hypothesis would be greatly strengthened by the demonstration that any drug of abuse produces special changes in the brain. It has yet to be shown that any drug produces changes in the brain different from those produced by many innocuous substances and events. The effects of nicotine on the brain are similar to those of sugar, salt, exercise, and other harmless substances and events. Apart from numerous conceptual and definitional inadequacies with the addiction concept in general, the notion that nicotine is addictive lacks reasonable empirical support. Nicotine does not have the properties of reference drugs of abuse. There are so many findings that conflict so starkly with the view that nicotine is addictive that it increasingly appears that adhering to the nicotine addiction thesis is only defensible on extra-scientific grounds.

Antidepressant Discontinuation Syndromes

Discontinuation symptoms are recognised with tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors (SSRIs) and miscellaneous antidepressants. A wide variety of symptoms have been described, differing somewhat between antidepressant classes, and several symptom clusters or discontinuation syndromes appear to exist. A common feature is onset within a few days of stopping the antidepressant or, less commonly, reducing the dosage. Discontinuation syndromes are clinically relevant as they are common, can cause significant morbidity, can be misdiagnosed leading to inappropriate treatment and can adversely effect future antidepressant compliance. Preventative strategies include tapering antidepressants prior to stoppage and educating patients and healthcare professionals to ensure that antidepressants are taken consistently and not stopped abruptly. Most reactions are mild and short-lived and require no treatment other than patient reassurance. Severe cases can be treated symptomatically or the antidepressant can be reinstated before being gradually withdrawn. Reinstatement usually leads to symptom resolution within 24 hours. Some individuals require very conservative tapering schedules to prevent the re-emergence of symptoms. With SSRIs and venlafaxine another strategy to consider is switching to fluoxetine, which may suppress the discontinuation symptoms, but which has little tendency to cause such symptoms itself. Neonatal discontinuation symptoms can follow maternal use of antidepressants during pregnancy and possibly breast feeding. The patient and doctor must take this into consideration when making prescribing decisions. Discontinuation symptoms have received little systematic study with the result that most of the recommendations made here are based on anecdotal data or expert opinion. Research is needed to provide a firm evidence base for future recommendations.

Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. British Association for Psychopharmacology

A revision of the British Association for Psychopharmacology guidelines for treating depressive disorders with antidepressants was undertaken in order to specify the scope and target of the guidelines and to update the recommendations based explicitly on the available evidence. A consensus meeting, involving experts in depressive disorders and their treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is given which identifies the quality of evidence followed by recommendations, the strength of which are based on the level of evidence. The guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing, management when initial treatment fails, continuation treatment, maintenance treatment to prevent recurrence and stopping treatment.