Combining antidepressants: a review of evidence

Anxiolytic-like action of 3-((4-methoxyphenyl)selanyl)-2-phenylbenzofuran (SeBZF3) in mice: A possible contribution of the serotonergic system

Anxiety disorders, characterized by high prevalence rates, cause psychiatric disabilities and are related to impairments in serotoninergic system function. Frequent anxiety recurrence, resistance, and drug adverse effects have driven searches for new therapies. We initially evaluated the anxiolytic-like activity of 3-selanyl-benzo[b]furan compounds (SeBZF1-5) (50 mg/kg, i.g.) in male Swiss mice using the light-dark test (LDT). The compound 3-((4-methoxyphenyl)selanyl)-2-phenylbenzofuran (SeBZF3) exhibited anxiolytic-like activity. SeBZF3 anxiolytic-like effects were also observed in the novelty-suppressed feeding test (NSFT) (50 mg/kg) and elevated plus-maze test (EPMT) (25 and 50 mg/kg). In the EPMT, anxiolytic-like effects of SeBZF3 (50 mg/kg) were abolished by pretreatment with p-chlorophenylalanine, a selective tryptophan hydroxylase inhibitor (100 mg/kg, i.p. for 4 days), suggesting the involvement of serotonergic mechanisms. Furthermore, we conducted experiments to investigate the synergistic effects of SeBZF3 subeffective doses (5 mg/kg, i.g.) in combination with fluoxetine (a selective serotonin reuptake inhibitor, 5 mg/kg, i.p.) or buspirone (a partial agonist of the 5-HT1A receptor, 2 mg/kg, i.p.). This coadministration resulted in pronounced synergistic effects. We also examined the effects of repeated oral treatment with SeBZF3 at doses of 1 and 5 mg/kg over 14 days and both reduced anxiety signals. In vitro and ex vivo findings revealed that SeBZF3 inhibited cerebral MAO-A activity. These findings collectively imply the potential involvement of serotonergic mechanisms in the anxiolytic-like activity of SeBZF3 in mice. These data offer contributions to the research field of organoselenium compounds and anxiolytics, encouraging the broadening of the search for new effective drugs while offering improved side effect profiles.

Potentially harmful drug-drug interactions in the therapeutic regimens of persons with spinal cord injury

OBJECTIVES

Individuals with spinal cord injury deal with multiple health complications that require them to use many medications. The purpose of this paper was to find the most common potentially harmful drug-drug interactions (DDIs) in therapeutic regimens of persons with spinal cord injury, and the risk factors associated with it. We further highlight the relevance of each of the DDIs specific to spinal cord injury population.

DESIGN

Observational design and cross-sectional analysis.

SETTING

Community; Canada.

PARTICIPANTS

Individuals with spinal cord injury (n = 108).

MAIN OUTCOME MEASURES/ANALYSIS

The main outcome was the presence of one or more potential DDIs that can lead to an adverse outcome. All the reported drugs were classified as per the World Health Organization's Anatomical Therapeutic Chemical Classification system. Twenty potential DDIs were selected for the analysis based on the most common medications prescribed to people with spinal cord injury and severity of clinical consequences. The medication lists of study participants were analyzed for selected DDIs.

RESULTS

Among the 20 potential DDIs analyzed in our sample, the top 3 prevalent DDIs were Opioids + Skeletal Muscle Relaxants, Opioids + Gabapentinoids, and Benzodiazepines + ≥ 2 other central nervous system (CNS)-active drugs. Of the total sample of 108 respondents, 31 participants (29%) were identified with having at least one potential DDI. The risk of having a potential DDI was highly associated with polypharmacy, though no associations were found between the presence of a drug interaction and age, sex, level of injury, time since injury, or cause of injury among the study sample.

CONCLUSION

Almost three out of ten individuals with spinal cord injury were at risk of having a potentially harmful drug interaction. Clinical and communication tools are needed that facilitate identification and elimination of harmful drug combinations in the therapeutic regimens of patients with spinal cord injury.

Concurrent use of polypharmacy and potentially inappropriate medications with antidepressants in older adults: A nationwide descriptive study in Denmark during 2015-2019

OBJECTIVE

Concurrent polypharmacy and potentially-inappropriate-medication (PIMs) use with antidepressants in older adults is understudied. We investigated the prevalence and associated user characteristics of concurrent polypharmacy (≥5 drugs) and PIMs with antidepressants in all older adults (≥65 years) in Denmark based on prescriptions filled at community pharmacies during 2015-2019.

METHOD

We applied a cross-sectional and cohort study design using socio-demographic and clinical data from Danish registers.

RESULTS

A total of 261,479 older adults (mean age 76 years, females 63%) redeemed at least one prescription of antidepressants during 2015-2019. The prevalence of polypharmacy was 73%, and PIMs was 56%, with over 80% using at least one other nervous system drug or cardiovascular system drug concomitantly with antidepressants. Characteristics associated with higher concurrent use of polypharmacy and PIM with antidepressants were older age, marital status as widow/widower/separated/single, place of residence predominantly in the rural regions, non-western origin, and having somatic diagnoses. Some characteristics showed opposite directions of the associations with the two outcomes, including previous antidepressant use and psychiatric diagnoses being associated with higher use of polypharmacy but lower use of PIM.

CONCLUSION

High polypharmacy and PIM use with antidepressants underline the importance of regularly reviewing pharmacological treatments in older adults with depression.

Sexual Dysfunction in Women with Nonpsychotic Disorders: A Cross-sectional Hospital-based Study

BACKGROUND

Sexual dysfunction among female psychiatric patients is zcommon and can be affected by various bio-psycho-social factors. The clinician's or patient's reluctance to actively inquire or spontaneously report these sexual difficulties creates a lacuna in our understanding of this association. This study aimed to assess the proportion of women with nonpsychotic psychiatric disorders reporting sexual dysfunction and evaluate its association with sociodemographic and clinical variables.

METHODS

This cross-sectional study conducted over six months included 113 women attending the psychiatry outpatient department of a tertiary care hospital. Sociodemographic and clinical variables, including diagnosis based on International Classification of Diseases 10th version (ICD 10) criteria, were assessed using a specially designed proforma. Sexual functioning was measured by Female Sexual Functioning Index (FSFI) and the Change in Sexual Functioning Questionnaire-Female Version (CSFQ-FV).

RESULTS

Sexual dysfunction was reported by 67.3% of patients. Among patients on psychotropics, 49% reported worsening of sexual dysfunction after treatment initiation. Sexual dysfunction was associated with increasing age (χ² = 7.86, P = 0.04), lower educational qualification (χ² =3.41, P = 0.04), skilled occupation (χ2 = 4.49, P = 0.03), lower socioeconomic status (χ² = 4.27, P = 0.03) and presence of ongoing psychosocial stressor (χ² = 4.49, P = 0.03).

CONCLUSIONS

Difficulties in different domains of sexual functioning are prevalent among women with nonpsychotic disorders. Sociodemographic and relational factors, along with treatment status, can influence sexual dysfunction in these patients. Clinicians should be vigilant of this association and should plan treatment to enhance compliance and outcome.

Treatment Patterns During Major Depressive Episodes Among Patients with Major Depressive Disorder: A Retrospective Database Analysis

BACKGROUND

Major depressive disorder, a highly prevalent mental health condition, can be challenging to treat.

OBJECTIVE

We aimed to characterize treatment patterns within and across multiple major depressive episodes in patients receiving treatment for major depressive disorder.

METHODS

Adults with newly diagnosed major depressive disorder and one or more major depressive episodes were identified using the IBM^® MarketScan^® Commercial database. Eligible patients had 12 months of continuous enrollment before and after diagnosis. Lines of therapy were periods of continuous treatment with one or more antidepressant claims. Antidepressant, atypical antipsychotic, or mood stabilizer regimens as monotherapy or adjunctive therapy were characterized by lines of therapy and major depressive episodes. Descriptive analyses were performed.

RESULTS

A total of 455,082 patients were included in the analysis. The majority of treatment regimens were monotherapy, which decreased with subsequent lines of therapy, while adjunctive treatments increased with subsequent lines of therapy. There were 1860 unique adjunctive regimens identified. Of the 40,315 patients (9%) who received adjunctive therapy, 8024 (20%; 2% of all patients) received atypical antipsychotic-adjunctive regimens. Only 19% of patients treated with atypical antipsychotic-adjunctive therapy discontinued treatment versus 42% of monotherapy-treated patients. On average, patients who received an adjunctive atypical antipsychotic received it as their third line of therapy and approximately 400 days after the initial antidepressant treatment.

CONCLUSIONS

In this study, many patients continued monotherapy major depressive disorder regimens and experienced multiple treatment changes. Few patients were treated with adjunctive therapy. These results suggest underutilization of potentially effective treatments, which represents an opportunity to optimize the treatment of patients with major depressive disorder.

Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review

Depression is the most prevalent psychiatric disorder in the world, affecting 4.4% of the global population. Despite an array of treatment modalities, depressive disorders remain difficult to manage due to many factors. Beginning with the introduction of fluoxetine to the United States in 1988, selective serotonin reuptake inhibitors (SSRIs) quickly became a mainstay of treatment for a variety of psychiatric disorders. The primary mechanism of action of SSRIs is to inhibit presynaptic reuptake of serotonin at the serotonin transporter, subsequently increasing serotonin at the postsynaptic membrane in the serotonergic synapse. The six major SSRIs that are marketed in the USA today, fluoxetine, citalopram, escitalopram, paroxetine, sertraline, and fluvoxamine, are a group of structurally unrelated molecules that share a similar mechanism of action. While their primary mechanism of action is similar, each SSRI has unique pharmacokinetics, pharmacodynamics, and side effect profile. One of the more controversial adverse effects of SSRIs is the black box warning for increased risk of suicidality in children and young adults aged 18–24. There is a lack of understanding of the complexities and interactions between SSRIs in the developing brain of a young person with depression. Adults, who do not have certain risk factors, which could be confounding factors, do not seem to carry this increased risk of suicidality. Ultimately, when prescribing SSRIs to any patient, a risk–benefit analysis must factor in the potential treatment effects, adverse effects, and dangers of the illness to be treated. The aim of this review is to educate clinicians on potential adverse effects of SSRIs.

A narrative review of the importance of pharmacokinetics and drug-drug interactions of preventive therapies in migraine management

Objective

To review the pharmacokinetics of major classes of migraine preventives and the clinical implications of drug–drug interactions (DDIs) with the use of these therapies in migraine management.

Background

Preventive treatments for migraine are recommended for a large proportion of patients with frequent migraine attacks. These patients often exhibit a number of comorbidities, which may lead to the introduction of multiple concomitant therapies. Potential DDIs must be considered when using polytherapy to avoid increased risk of adverse events (AEs) or inadequate treatment of comorbid conditions.

Methods

A literature search was performed to identify pharmacokinetic properties and potential DDIs of beta‐blockers, antiepileptic drugs, antidepressants, calcium channel blockers, gepants, and monoclonal antibody therapies targeting the calcitonin gene‐related peptide pathway with medications that may be used for comorbid conditions.

Results

Most DDIs occur through alterations in cytochrome P450 isoenzyme activity and may be complicated by genetic polymorphism for metabolic enzymes. Additionally, drug metabolism may be altered by grapefruit juice ingestion and smoking. The use of migraine preventive therapies may exacerbate symptoms of comorbid conditions or increase the risk of AEs associated with comorbid conditions as a result of DDIs.

Conclusions

DDIs are important to consider in patients with migraine who use multiple medications. The development of migraine‐specific evidence‐based preventive treatments allows for tailored clinical management that reduces the risk of DDIs and associated AEs in patients with comorbidities.

Trade‐offs between male fertility reduction and selected growth factors or the klotho response in a lipopolysaccharide-dependent mouse model

The increasing number of depression cases leads to a greater need for new antidepressant treatment development. It is postulated that antidepressants may harm male fertility, but the cellular mechanism is still poorly understood. The role of growth factors and klotho protein in maintaining normal male reproductive function is well documented. Hence, the study aimed to investigate the effect of the antidepressant drug – imipramine (tricyclic AD), and other substances with antidepressant potential (ALS), administered in combination or in combination with LPS (an animal model of depression) on gene expression and protein synthesis of IGF-2 (insulin-like growth factor 2), TGF-β1 (transforming growth factor β1), NGF (nerve growth factor), KGF (keratinocyte growth factor) and protein synthesis of VEGF-A (vascular endothelial growth factor A), IGF-IR (insulin-like growth factor receptor 1), EGFR (epidermal growth factor receptor) and klotho in the testis of mice. Mice were injected intraperitoneally with selected ALS and LPS or 10% DMSO (controls) (n = 7/group) once a day for 14 days. Animals were decapitated and testes collected for RNA and protein purification. PCR and western blot methods were employed for the evaluation of growth factors and klotho expression. The results obtained indicated a decreased level of most of the analyzed genes and proteins, except KGF; its expression increased after treatment with MTEP and IMI administrated individually and after NS-398, and IMI in combination with LPS. Our results may suggest that the tested ALS and LPS can contribute to a reduction of male fertility, but NS-398, IMI, and IMI+NS-398 may also act as stimulants after LPS.

Impact of Drug-Gene-Interaction, Drug-Drug-Interaction, and Drug-Drug-Gene-Interaction on (es)Citalopram Therapy: The PharmLines Initiative

We explored the association between CYP2C19/3A4 mediated drug-gene-interaction (DGI), drug-drug-interaction (DDI) and drug-drug-gene-interaction (DDGI) and (es)citalopram dispensing course. A cohort study was conducted among adult Caucasians from the Lifelines cohort (167,729 participants) and linked dispensing data from the IADB.nl database as part of the PharmLines Initiative. Exposure groups were categorized into (es)citalopram starters with DGI, DDI and DDGI. The primary outcome was drug switching and/or dose adjustment, and the secondary was early discontinuation after the start of (es)citalopram. Logistic regression modeling was applied to estimate adjusted odd ratios with their confidence interval. We identified 316 (es)citalopram starters with complete CYP2C19/3A4 genetic information. The CYP2C19 IM/PM and CYP3A4 NM combination increased risks of switching and/or dose reduction (OR: 2.75, 95% CI: 1.03–7.29). The higher effect size was achieved by the CYP2C19 IM/PM and CYP3A4 IM combination (OR: 4.38, 95% CI: 1.22–15.69). CYP2C19/3A4 mediated DDIs and DDGIs showed trends towards increased risks of switching and/or dose reduction. In conclusion, a DGI involving predicted decreased CYP2C19 function increases the need for (es)citalopram switching and/or dose reduction which might be enhanced by co-presence of predicted decreased CYP3A4 function. For DDI and DDGI, no conclusions can be drawn from the results.

Management of severe arterial hypertension associated with serotonin syndrome: a case report analysis based on systematic review techniques

Serotonin syndrome is thought to arise from serotonin excess. In many cases, symptoms are mild and self-limiting. But serotonin syndrome can become life threatening, when neuromuscular hyperexcitability spins out of control. Uncontainable neuromuscular hyperexcitability may lead to cardiovascular complications, linked to extreme changes in blood pressure. Currently, there is little guidance on how to control blood pressure in hyperserotonergic states. We report a case with treatment-resistant arterial hypertension, followed by a clinical review (using systematic review principles and techniques) of the available evidence from case reports published between 2004 and 2016 to identify measures to control arterial hypertension associated with serotonin syndrome. We conclude that classic antihypertensives may not be effective for the treatment of severe hypertension associated with serotonin syndrome. Benzodiazepines may lower blood pressure. Patients with severe hypertension not responding to benzodiazepines may benefit from cyproheptadine, propofol or both. In severe cases, higher cyproheptadine doses than currently recommended may be necessary.

Managing inadequate antidepressant response in depressive illness

INTRODUCTION OR BACKGROUND

Depression frequently fails to respond to initial treatment.

SOURCES OF DATA

Predominantly meta-analyses and RCTs but supplemented where necessary by additional data and the authors' clinical experience.

AREAS OF AGREEMENT

A systematic assessment to identify remedial causes of poor response should be followed by planned sequential treatment trials. Joint decision making by the patient and clinician is essential. Strategies with the strongest support are antidepressant augmentation with lithium or second generation antipsychotics and adding cognitive behavioural treatment. Electroconvulsive therapy is highly effective in resistant depression but there is a high relapse rate when treatment ends.

AREAS OF CONTROVERSY

Some pharmacological strategies have inconsistent data (e.g. antidepressant combinations, T3 augmentation) or limited preliminary data (e.g. ketamine, antidepressant augmentation with pramipexole). The efficacy of vagus nerve stimulation, deep brain stimulation and repetitive transcranial magnetic stimulation is unclear.

GROWING POINTS

A greater understanding of the causes of depression may assist the development of more effective treatments.

AREAS TIMELY FOR DEVELOPING RESEARCH

Role of glutamate antagonists and psychological treatments, other than cognitive behavioural therapy, as adjunctive treatments.