A study of refractory cases of depressive illnesses and their response to combined antidepressant treatment

Pharmacological management of treatment-resistant depression

The management of patients with depression who have failed to respond to antidepressant medication is a common problem in general and old age psychiatry. It has been estimated that about 20–30% of patients with major depression fail to respond to treatment with a single antidepressant drug given in adequate dosage for an appropriate period of time. At the current time there are many possible ways to pursue pharmacological treatment, but few controlled trials to help us choose between the various options. In addition there are few clinical predictors to help match patients to an appropriate treatment.

The strategy of combining antidepressants in the treatment of major depression: clinical experience in spanish outpatients

Introduction. The combination of antidepressants is a useful tool in the treatment of major depression, especially in cases where there is a partial response to antidepressant monotherapy. However, the use of this strategy is a matter of controversy, and its frequency of use in clinical practice is not clear. The aim of our study is to assess the use of antidepressants combination in Spain by reviewing three databases used between 1997 and 2001. Methods. Databases pertain to patients who are study subjects of major depression treatment. These databases are a result of studies performed in Spain and in which 550 psychiatrists participated. The total studied sample was comprised of N = 2, 842 patients, aged over 18, fitting DSM-IV criteria for Major Depressive Episode. The percentage of patients who received more than one antidepressant and the types of combinations used was described. Subsequently, a comparative study between the group which received a combination of antidepressants (N = 64) and the group which received antidepressant monotherapy (N = 775) was performed. Results. 27.1% of patients were on antidepressive monotherapy treatment, and 2.2% were on combination therapy. In the comparison of patients on combination therapy and monotherapy, there were significant differences only in episode duration (P = 0.001). The most frequent combinations are SSRIs and tricyclic antidepressants. The active principle most widely combined is fluoxetine. Conclusions. The prevalence of use of antidepressant combination therapy is 2.2% of the global sample and 8.3% of treated patients. Other than duration of the depressive episode, no clinical characteristics exclusive to patients who received combination rather than monotherapy were found. Our study found that the most frequent combination is SSRIs + TCAs, also being the most studied.

Combined antidepressants: clinical experience

OBJECTIVE

To review the current literature on the use of combinations of antidepressive agents.

METHOD

Literature searches were undertaken and reviewed on the use of combinations of antidepressants.

RESULTS

Data sources included surveys, analyses of prescription records, decision algorithms, clinical reports, and studies comparing the monotherapy with combination therapy. More recent surveys recommend combining different selective serotonin reuptake inhibitors (SSRIs), an SSRI plus bupropion or dual action antidepressants plus an SSRI. Decision algorithms recommend an SSRI plus tricyclic antidepressant (TCA) and more recently bupropion plus venlafaxine or mirtazapine. Few controlled clinical trials comparing the combined therapy with monotherapy have been conducted. Beneficial effects have been reported with combinations of TCAs plus mianserin or SSRIs plus mirtazapine.

CONCLUSION

Adding or combining antidepressant medications has advantages for the speed of onset and maintaining the existing response. More rigorous clinical trials comparing combination therapy with monotherapy and for the development of rational treatment guidelines are required.

Therapy of treatment resistant depression: focus on the management of TRD with atypical antipsychotics

Treatment-resistant depression (TRD) represents a significant challenge for physicians. About one third of patients with major depressive disorder fail to experience sufficient symptom improvement despite adequate treatment. Despite this high occurrence of TRD there was no general consensus on diagnosis criteria for TRD until 1997 when researchers proposed a model of defining and staging TRD. In 1999, others defined operational criteria for the definition of TRD. Treatment of TRD is commonly separated into pharmacologic and nonpharmacologic methods. This review gives a short overview of these two methods. The nonpharmacologic methods include psychotherapy, electroconvulsive therapy, and vagus nerve stimulation. Pharmacologic methods include switching to another antidepressant monotherapy, and augmentation or combination with two or more antidepressants or other agents. This review especially focuses on the augmentation of the antidepressant therapy with atypical antipsychotics.

Fatal interaction between tranylcypromine and imipramine

This case report describes a patient on tranylcypromine who erroneously received a single dose of imipramine and subsequently developed a fatal serotonin syndrome. Both the clinical features and the pathophysiology of the serotonin syndrome are discussed.

Strategies for Treatment Refractory Depression

Ten to thirty percent of patients do not respond adequately to antidepressant therapy. Absolute treatment refractory depression occurs in up to 10% of patients with depression. To date, few studies have addressed this issue. Several treatment options are available for refractory depression, including increasing the dose, extending the treatment period, switching and augmentation strategies, and electroconvulsive therapy. This paper will review some strategies available for treatment refractory depression.

The serotonin syndrome and its treatment

Serotonin syndrome is caused by drug induced excess of intrasynaptic 5-hydroxytryptamine. The clinical manifestations are mediated by the action of 5-hydroxytryptamine on various subtypes of serotonin receptors. There is no effective drug treatment established. The history of the treatment of serotonin syndrome with 5-hydroxytryptamine blocking drugs is reviewed. A literature search was undertaken using both Medline and a manual search of the older literature. Reports of cases treated with the 5-HT2 blockers cyproheptadine and chlorpromazine were identified and analysed. There is some evidence suggesting the efficacy of chlorpromazine and cyproheptadine in the treatment of serotonin syndrome. The evidence for cyproheptadine is less substantial, perhaps because the dose of cyproheptadine necessary to ensure blockade of brain 5-HT2 receptors is 20-30 mg, which is higher than that used in the cases reported to date (4-16 mg).

Novel strategies for treatment-resistant depression

This article describes a highly selective constellation of the more unique strategies for managing the treatment-resistant patient. In light of the often-devastating toll that treatment-resistant depression takes on an individual's life, it behooves us to continue the search for more effective strategies for those patients that fail more traditional interventions. As each successive move down the treatment algorithm flowchart becomes necessary, the risk/benefit ratio may shift toward less well-substantiated, but still biologically informed, strategies. Although some of the more unusual treatments described in this article represent minimally charted territories, the more promising techniques are deserving of further careful exploration.

Efficacy of combined antidepressant therapy in resistant neurotic disorder

A 35-year-old woman with persistent affective and phobic symptoms responded dramatically to a combination of isocarboxazid and amitriptyline, and this improvement was maintained over the next three-and-a-half years. Isocarboxazid was replaced by placebo, using double-blind procedure. The change to placebo was accompanied by a marked increase in anxiety and depressive symptoms, which resolved when active isocarboxazid was reintroduced. It is suggested that combined antidepressant therapy still has a place in the treatment of resistant neurotic disorder.

Monoamine oxidase inhibitors: rehabilitation from recent research?

For a long time, monoamine oxidase inhibitors (MAOIs) have been the Cinderella drugs of psycho-pharmacy. Although they were introduced just before the tricyclic antidepressants (TCAs), they rapidly became second-line treatments. Several factors contributed to this, in particular the dietary restrictions, the scattered reports of death from overdose and/or toxic interactions, and the unfavourable reports on the efficacy of phenelzine in depression from, among others, the Medical Research Council trial (1965). For a number of years afterwards, prescription of these drugs was limited to a few enthusiasts. More recently, however, their popularity has increased owing firstly to a re-evaluation of their effectiveness in tricyclic-resistant depression and in anxiety disorders, and secondly to growing awareness of the exaggerated claims made about their dangerousness (Pare, 1985).

Treatment resistant depression: a clinical perspective

One hundred and fourteen patients with a diagnosis of "treatment resistant depression" (TRD) were assessed and treated at a Mood Disorders Clinic. Diagnostically, 52 (45.6%) subjects met criteria for bipolar disorder, 49 (42.9%) for recurrent depression, and 13 (11.4%) patients did not fulfill diagnostic criteria for affective disorder which explained their treatment resistance. With appropriate, individualized treatment, 59 of 98 (60.2%) patients had complete symptom remission based on clinical and psychometric ratings (initial Ham-D 26.7, final Ham-D 5.9). Eighteen of 98 patients had partial remission (final Ham-D 15.9) with vigorous pharmacological interventions, and 8 subjects exhibited "absolute" TRD (final Ham-D 23.4). The results suggest the value of specialized mood disorder services. The partial and absolute TRD's were more likely to be older, received more Axis II diagnoses, and had previous histories of drug or alcohol abuse.

Combined MAO-inhibitor and tri- (tetra) cyclic antidepressant treatment in therapy resistant depression

1. One aspect of using MAO-inhibitors - combining them with tricyclic antidepressants in the treatment of therapy resistant depression - has always been controversely discussed in regard to its unusual toxicity and efficacy. 2. To obtain detailled information about safety and efficacy of such a combined treatment, the charts of 94 inpatients treated with a tranylcypromine - tri- (tetra) cyclic antidepressant combination were reviewed. 3. Within a mean treatment period of 21.9 days, 68% of the patients demonstrated a very good or good improvement to combined treatment, the most effective combination being tranylcypromine + amitriptyline. 4. The incidence of side effects among the patients on the combined regimen was slightly, but not significantly lower as compared to the patients on single tri- (tetra) cyclic antidepressant treatment. 5. Our retrospective study supports the general safety and efficacy of combined MAOI-TCA treatment and suggests that combined treatment, if properly administered, leads to neither serious complications nor an inordinate number of side effects.

The pharmacological treatment of tricyclic-resistant depression: review and management guidelines

Despite the introduction of a wide range of antidepressant drugs since the late 1950s, approximately 30-50% of depressed subjects do not respond to these agents. Various treatment strategies, both pharmacological and non-pharmacological, have been proposed for treatment-resistant depression. This paper critically reviews the studies of single and combined pharmacological treatments for tricyclic-resistant patients, with a particular discussion of lithium augmentation. The major inadequacies of these studies have been the frequent lack of definitions of treatment resistance, the heterogeneity of the depressed samples, and the infrequent use of double-blind, placebo-controlled designs. Two central issues, definition of treatment resistance and clinical predictors of response to pharmacological treatments, are discussed in detail. Finally, a suggested guideline for the management of tricyclic-resistant depression is proposed.

Clomipramine, tryptophan and lithium in combination for resistant endogenous depression: seven case studies

Seven patients suffering from severe endogenous depression who had proven resistant to lengthy trials of treatment with tricyclic and other antidepressants are described. Their successful treatment with a combination of clomipramine, L-tryptophan and lithium is discussed in the context of other strategies for the treatment of resistant depression.

The present status of monoamine oxidase inhibitors

The present status of monoamine oxidase inhibitors in the treatment of depression is reviewed. With adequate doses they are effective antidepressants, but dosages have in the past been too low. Provided proper dietary precautions are taken, the incidence of fatality from dietary interactions is very small and should not deter doctors from using these drugs, especially in those depressed patients who do not respond to tricyclic-type antidepressants. The present status of combining monoamine oxidase inhibitors with tricyclics is discussed, as are the newer specific inhibitors particularly clorgyline and deprenyl.

Interactions of a non-selective monoamine oxidase inhibitor, phenelzine, with inhibitors of 5-hydroxytryptamine, dopamine or noradrenaline re-uptake

Interactions of combined antidepressants which occur in man were reproduced in rats pretreated with phenelzine, features elicited including myoclonic phenomena, an augmented lower limb flexor reflex, muscle fasiculation and fatalities, particularly with combinations incorporating 5-hydroxytryptamine (5-HT) re-uptake inhibitors. Combinations of antidepressants included phenelzine with 5-HT re-uptake inhibitors (paroxetine, fluoxetine, clomipramine); with "mixed" re-uptake inhibitors affecting 5-HT and noradrenaline (imipramine, amitriptyline); with noradrenaline re-uptake inhibitors (desipramine, maprotiline, nisoxetine) and with dopamine re-uptake inhibitors (benztropine, nomifensine). Myoclonic phenomena such as forelimb flexor-extensor movements, head and body twitches, occurred in phenelzine pretreated rats after paroxetine, fluoxetine, clomipramine, imipramine, amitriptyline and desipramine. Wet dog shakes, the most intense phenomenon, were obtained only after paroxetine, fluoxetine, clomipramine and imipramine. Myoclonic features were prevented when pretreatment included p-chlorophenylalanine but were unaffected when this incorporated alpha-methyl-p-tyyrosine; there were attenuated by methysergide, cyproheptadine, clozapine or pimozide. The myoclonic phenomena were reproduced by combination of 5-hydroxytryptophan but not L-3,4-dihydroxyphenylalanine with clomipramine. Electrocortical changes observed included 2-4 Hz, 5-8 Hz, large amplitude potentials unrelated to the myoclonic incidents and unaffected by sensory stimulation. Following phenelzine, brain monoamine oxidase (MAO) A inhibition was 99% and that of MAO B, 88%; 5-HT concentration was significantly elevated in the cortex and hypothalamus, as was hypothalamic noradrenaline. Peak and basal tensions of a lower-limb flexor reflex were elevated in phenelzine pretreated spinal rats by fluoxetine, paroxetine, clomipramine and imipramine, effects attenuated by cyproheptadine. Forelimb flexor-extensor movements and body twitches were elicited by fluoxetine and paroxetine in phenelzine pretreated spinal rats in the presence of electrical stimulation of the central stump of a divided posterior tibial nerve. Pressor responses were observed in phenelzine pretreated spinal rats given 5-HT re-uptake inhibitors, "mixed" re-uptake inhibitors and those affecting noradrenaline re-uptake; ECG anomalies occurred in such rats given clomipramine.

Clinical and experimental aspects of interactions between amine oxidase inhibitors and amine re-uptake inhibitors

Dangerous and even fatal interactions can occur in man following combinations of antidepressants which include non-selective MAO inhibitors. To ascertain the causation, interactions reproducing the clinical phenomena have been elicited in animals with these combinations, and the mechanisms involved have been explored by various pharmacological strategies; 5-HT re-uptake inhibitors proved especially hazardous in combination. Interactions could, however, be avoided even with the 5-HT re-uptake inhibitors, by combination with relatively selective MAO A or B inhibitors, an approach with potential clinical value.

Effects of LM 5008, a selective inhibitor of 5-hydroxytryptamine uptake, on blood pressure and responses to sympathomimetic amines

LM 5008 (4-[2-(3-indolyl)ethyl]piperidine) (10, 20 and 50 mg kg-1) had no significant effect on pressor responses to noradrenaline or tyramine in rats anaesthetized with urethane. Desmethylimipramine (1 mg kg-1) blocked the response to tyramine but chlorimipramine (5 mg kg-1) had no significant effect on responses to noradrenaline or tyramine. In the rabbit, anaesthetized with chloralose, LM 5008 (5 mg kg-1) had no effect on pressor responses to noradrenaline, tyramine or angiotensin II, while desmethylimipramine (0.25 mg kg-1) inhibited responses to tyramine and potentiated those to noradrenaline. LM 5008 (10 mg kg-1) had no effect on resting blood pressure of conscious normotensive or DOCA-saline hypertensive rats. Tranylcypromine (5 mg kg-1) produced a fall in blood pressure in conscious normotensive and in DOCA hypertensive rats. Treatment with a combination of LM 5008 (10 mg kg-1) and tranylcypromine (5 mg kg-1) resulted in the appearance of a behavioural hyperactivity syndrome, but blood pressure was not different from that of animals treated with tranylcypromine alone. These results further demonstrate the selectivity of LM 5008 for 5-hydroxytryptamine as opposed to catecholamine uptake.

Polypsychopharmacy revisited

In this paper, polypsychopharmacy is defined, noting variations of definition in the medical literature. We show that the high incidence rates are bot dependent only on the physician's behaviour. Much of the medical literature is hostile to the use in psychiatry of two-drug combinations, and this hostility is based on three assumptions about drug use. We find little evidence to support these assumptions. Attempts to reduce the incidence of polypsychopharmacy may be simply irrelevant. We list several two-drug combinations which are of value in psychiatry, and then return to two questions: 1) Why is there so little research into two-drug combinations, considering their high incidence of use? 2) Why does this high incidence persist in the absence of good supportive evidence of its value? We offer tentative responses to these questions, and conclude that since multiple drug use is as likely to be of value in psychiatry as in any other branch of medicine, research into specific drug-combinations is overdue.

Towards rational therapy with monoamine oxidase inhibitors

A rational approach to the use of monoamine oxidase inhibitors (MAOIs) is outlined. Patients suitable for treatment cannot be classified adequately using conventional diagnostic labels. They include those with primary symptoms of hypochondriasis, agoraphobia and social phobias, irritability, somatic anxiety and anergia; those with primary depressed mood, guilt, ideas of reference and personality disorders seldom respond. There is great variation in the interval between the first administration of these drugs and clinical response, and this may account for the inconsistencies in published trials. The type of drug and its dose may affect rate of response, as may biochemical factors, including acetylator and monoamine oxidase status. To obtain maximum benefit, a course of therapy with MAOIs should last for several months.