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Abstract
This paper describes the use of cognitive behaviour therapy (CBT) with 24 chronically depressed in-patients. These individuals had previously failed to respond to all other standard antidepressant treatments and had been persistently depressed for at least two years. The clients were divided into two cohorts. The first (n=8) received a standard CBT package of 15 sessions combined with pharmacotherapy. The second cohort received a combined treatment, but the style of delivery of CBT was changed to try to take into account the special needs of the client population. At 12 weeks, 70% of the second cohort of clients showed a greater than 50% change on their pre-treatment objective and subjective depression ratings. The implications of these findings are discussed and further therapy trials in this difficult-to-treat population are encouraged.
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2
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Abstract
There seems reasonable, if depressing, agreement from studies of mixed aged subjects and elderly subjects in psychiatric settings that nonresponse or poor response to a course of an antidepressant occurs in at least one-third of depressed patients. The figure may be higher in elderly patients in general and those with poor physical health. The human cost of chronic depression is highlighted in the Medical Outcomes Study. The level of functional impairment and intereference with quality of life associated with depression was comparable with or worse than that of eight major chronic medical conditions, including diabetes, arthritis and severe coronary artery disease. The final tragedy for unremitting depression may of course be suicide.
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Abstract
The mean index episode length in 19 consecutive admissions with treatment-resistant bipolar affective disorder was 21.7 months. Four patterns of resistance were identified: rapid cycling (37%), other forms of cycling (32%), chronic depression (26%) and mixed states (6%). Female gender was significantly associated with rapid cycling. Other risk factors for treatment-resistant bipolar disorder, including a high prevalence of family history of affective disorder (72%) and electroencephalographic abnormalities (54% of recordings), were not confined to the rapid cycling group.
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Affiliation(s)
- A J Cole
- Department of Psychiatry, School of Neuroscience, University of Newcastle upon Tyne, United Kingdom
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4
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Malizia AL, Bridges PK. The management of treatment-resistant affective disorder: clinical perspectives. J Psychopharmacol 1992; 6:145-55. [PMID: 22291340 DOI: 10.1177/026988119200600201] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A L Malizia
- United Medical and Dental Schools, Guy's Campus, London
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5
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Kennedy SH, Joffe RT. Pharmacological management of refractory depression. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1989; 34:451-6. [PMID: 2670176 DOI: 10.1177/070674378903400517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Managing patients with "treatment resistant depression" offers a major challenge to clinical psychiatrists, psychopharmacologists, and others. Firstly, patient heterogeneity must be recognized in terms of symptom presentation, biological variables, co-morbidity with other psychiatric and medical disorders and associated personality disorder. Secondly, a rigorous approach to the treatment resistant patient must allow for adequate individual and combination therapies including heterocyclic agents, monoamine oxidase inhibitors, electroconvulsive therapy, and augmentation with lithium carbonate or thyroid hormone. The novel antidepressant therapies have not so far altered the relapsing course of depressive illness for many patients.
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Affiliation(s)
- S H Kennedy
- Department of Psychiatry, University of Toronto, Ontario
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6
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Affiliation(s)
- C Bass
- Academic Department of Psychological Medicine, King's College Hospital, London
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7
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Nolen WA, van de Putte JJ, Dijken WA, Kamp JS, Blansjaar BA, Kramer HJ, Haffmans J. Treatment strategy in depression. I. Non-tricyclic and selective reuptake inhibitors in resistant depression: a double-blind partial crossover study on the effects of oxaprotiline and fluvoxamine. Acta Psychiatr Scand 1988; 78:668-75. [PMID: 3146890 DOI: 10.1111/j.1600-0447.1988.tb06402.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Antidepressants are ineffective in about 30% of patients with major depression. Some authors then advise treatment of non-responders with (non-tricyclic) more selective reuptake inhibitors. In a double-blind, partial crossover study, 71 patients were selected for treatment during 4 weeks with oxaprotiline and/or fluvoxamine, two non-tricyclic antidepressants that are selective reuptake inhibitors or noradrenaline and serotonin respectively. All patients had failed to respond to earlier treatment with cyclic antidepressants during the current episode. Only 13% of the patients responded, with 27% of them responding to oxaprotiline and none to fluvoxamine. Moreover, a low response of 27% was also obtained in the crossover phase, which included all non-responders to the first treatment, oxaprotiline being effective in 39% and fluvoxamine in 10% of the patients. The results indicate that selective reuptake inhibitors are not an effective alternative for non-responders to other cyclic antidepressants and that non-responders to "noradrenergic" antidepressants do not appear to have much chance of responding to "serotonergic" antidepressants and vice versa.
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Affiliation(s)
- W A Nolen
- Department of Biological Psychiatry, Psychiatric Centre Bloemendaal, Hague, the Netherlands
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8
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Abstract
Monoamine oxidase inhibitors (MAOI's) have been shown to be significantly superior to placebo in the treatment of some anxiety disorders, particularly agoraphobia and mixed anxiety--depressive states. There is no convincing evidence that MAOI's are effective treatment in pure anxiety states, whether or not panic is present as a major symptom, although they are effective in so-called endogenous anxiety. Many past published studies of MAOI's have yielded poor results because the drugs have been prescribed for insufficient time (less than four weeks) or at too low dosage. There are no important therapeutic differences between the MAOI's apart from the faster speed of response with the nonhydrazine compound, tranylcypromine. Treatment often has to be long-term, and some degree of pharmacological dependence may develop. A few clinical studies have compared the efficacy of MAOI's and tricyclic antidepressants in anxious disorders. There is growing evidence that MAOI's are somewhat more effective than tricyclic antidepressants in the treatment of anxiety disorders and when phobic anxiety is an important component of a depressive disorder.
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Affiliation(s)
- P Tyrer
- Mapperley Hospital, Nottingham, U.K
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9
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Mitchell P. The pharmacological treatment of tricyclic-resistant depression: review and management guidelines. Aust N Z J Psychiatry 1987; 21:442-51. [PMID: 3329512 DOI: 10.3109/00048678709158911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- P Mitchell
- School of Psychiatry, University of New South Wales
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11
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Abstract
Depression is common in Huntington's disease. It is customary to treat such patients with tricyclic antidepressants, although there is disagreement about their effectiveness. The use of monomine oxidase inhibitors for depression in HD has not previously been reported; three cases are described here. MAOIs appear to be of value in the management of depression in HD.
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Saletu B, Grünberger J, Linzmayer L. On central effects of serotonin re-uptake inhibitors: quantitative EEG and psychometric studies with sertraline and zimelidine. J Neural Transm (Vienna) 1986; 67:241-66. [PMID: 2949057 DOI: 10.1007/bf01243351] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In a double-blind placebo-controlled cross-over study the encephalotropic and psychotropic properties of sertraline--a new potent and highly selective inhibitor of synaptosomal serotonin uptake--were studied along with blood levels of the parent drug and main metabolite in ten normal healthy volunteers. They received randomized at weekly intervals oral single doses of placebo, 100, 200 and 400 mg setraline and 100 mg zimelidine as reference drug. Blood sampling, EEG recordings, psychometric tests and evaluation of pulse, blood pressure and side-effects were carried out at the hours 0, 2, 4, 6, and 8. Blood level investigations demonstrated that sertraline is slowly absorbed with dose-dependent blood concentrations peaking in the 4th to 6th hour and remaining high thereafter, while the main metabolite, CP-53261 exhibited an even slower rise in plasma concentration up to the 8th hour. Computer-assisted spectral analysis of the EEG demonstrated slight effects of 100 mg zimelidine and 100 mg sertraline on human brain function, but moderate to marked effects after 200 and 400 mg sertraline as compared with placebo. Changes after 100 mg sertraline and the reference compound resembled the pharmaco-EEG profiles of antidepressants of the desipramine type and were indicative of some vigilance-improving properties while higher doses of sertraline induced alterations reminiscent of those after antidepressants of the imipramine type, thereby reflecting vigilance changes of the dissociative type. This neurophysiological conclusion was supported by the psychometric and psychophysiological data showing partly after 100 mg sertraline and zimelidine an improvement in psychometric performance, while 200 and 400 mg sertraline induced a deterioration of noopsyche and thymopsyche of the normal volunteers. Psychophysiological variables exhibited a dose-dependent change in CNS activation and a widening of the pupillary size. Time-efficacy calculations based on pharmacodynamic changes demonstrated maximal encephalotropic effects after 100 mg zimelidine in the 2nd to 4th hour, and after setraline in the 4th to the 6th hour, which is in agreement with the blood level data. Pulse, systolic and diastolic blood pressure showed no clinically relevant findings. Side-effects were non-existent to minimal after 100 mg zimelidine and sertraline, but marked after 200 and 400 mg sertraline characterized by nausea, vomiting, diarrhea, giddiness, restlessness, tremor and trismus.
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Schrader GD, Levien HE. Response to sequential administration of clomipramine and lithium carbonate in treatment-resistant depression. Br J Psychiatry 1985; 147:573-5. [PMID: 3935196 DOI: 10.1192/bjp.147.5.573] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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14
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Abstract
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.
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Murphy S, Tyrer P. The pharmacological management of depression. INTERNATIONAL REHABILITATION MEDICINE 1984; 6:vi-viii. [PMID: 6746200 DOI: 10.3109/03790798409166755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Rapp MS, Kaplan A. Polypsychopharmacy revisited. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1981; 26:569-73. [PMID: 7317871 DOI: 10.1177/070674378102600811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Martini A, Bonollo L, Nicolis FB, Sega R, Palermo A. Effects of caroxazone, a reversible monoamine oxidase inhibitor, on the pressor response to oral tyramine in man. Br J Clin Pharmacol 1981; 11:611-5. [PMID: 7272178 PMCID: PMC1402186 DOI: 10.1111/j.1365-2125.1981.tb01178.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
1 A double-blind, placebo-controlled study was carried out in order to investigate the effects of caroxazone, a new antidepressant drug endowed with a reversible short-lasting MAO-inhibitory activity in man, on the blood pressure response to tyramine administered by the oral route. 2 The study was carried out in 9 healthy volunteers who were randomly assigned to treatment with caroxazone 200 mg three times daily (7 subjects) or with indistinguishable placebo (2 subjects). 3 The sensitivity to tyramine was assessed in each subject both before and after the 7-9 days of treatment. 4. While placebo did not modify the pressor response to tyramine, the threshold dose of tyramine which induced a rise in systolic blood pressure was lowered by about four-fold in 6 out of the 7 subjects treated with caroxazone. In the seventh subject the observed potentiation of peroral tyramine was not quantitatively evaluable. 5 Challenges performed in three subjects after discontinuation of treatment with caroxazone show that the effects of the compound are short-lasting, since the sensitivity to tyramine seems to regain the baseline value within 1-2 days. 6 Even if caroxazone potentiates peroral tyramine to a relatively low degree, a tyramine poor diet is recommended for patients during caroxazone treatment. 7 The reversibility of the MAO-inhibitory action of caroxazone is confirmed by the rapid return to normal values in the response to tyramine after discontinuation of treatment. This property of caroxazone would allow patients to return to a free diet in much less time than the safety limit of 2 weeks recommended for the currently used irreversible MAO-inhibitors.
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Abstract
The equilibrium binding constants of the interaction of tryptophan with albumin have been determined in plasma samples from both controls and patients suffering from affective disorders. The data corresponded with literature values for both the albumin concentration in plasma and the equilibrium constant for tryptophan binding to albumin. No differences in the equilibrium constants were detected between patients and controls but a small increase in the albumin concentration was noted in the depressives. It was agreed that this rise would be inadequate to lead to a significant effect on free tryptophan levels. Non-esterified fatty acid analysis indicated no differences between patient groups.
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Voineskos G, Pollock BG. Concepts and practice of prognosis in psychiatry. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 1980; 25:619-25. [PMID: 7471025 DOI: 10.1177/070674378002500802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The frequency with which prognosis is made in psychiatry is not known. This paper reports a study of the frequency and content of prognosis as recorded by staff psychiatrists and residents in a psychiatric teaching hospital. In addition, a review was carried out on the use of prognosis in ten psychiatric textbooks. The findings suggest that closer attention should be given to the teaching of prognosis. There is a clear need to consider moving away from the close dependence of prognosis on diagnosis, and from the unidimensional view of prognosis. Reasons are given for developing a prognosis, and suggestions are made regarding the organization of the prognostic statement.
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Szabadi E, Gaszner P, Bradshaw CM. The peripheral anticholinergic activity of tricyclic antidepressants: comparison of amitriptyline and desipramine in human volunteers. Br J Psychiatry 1980; 137:433-9. [PMID: 7470769 DOI: 10.1192/bjp.137.5.433] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effects of three single oral doses (25 mg, 50 mg and 100 mg) of amitriptyline and desipramine, and of placebo, were compared on a range of cholinergic functions (resting pupil diameter, pilocarpine-evoked miosis, baseline-sweating, carbachol-evoked sweating, salivation, heart rate) in eight healthy volunteers. Three measures (pilocarpine-evoked miosis, carbachol-evoked sweating and salivation) reflected the antimuscarinic property of the antidepressants; in two tests (pilocarpine-evoked miosis and salivation) amitriptyline appeared to be more potent than desipramine. Resting pupil diameter was not affected by amitriptyline, whereas desipramine caused mydriasis, indicating that pupil size is not a reliable measure of anticholinergic activity in the case of drugs which also affect adrenergic mechanisms. Baseline-sweating and heart rate were not affected by the antidepressants.
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Abstract
Isocarboxazide has been used as long-term treatment for a selected group of 20 depressive patients, of whom some 90% (17/19) were non-responders to treatment with tricyclic antidepressants. At the follow-up the median duration of illness was 162 months, and the median duration of treatment was 42 months. Side-effects and interactions were moderate thus legitimating a treatment procedure on which all the patients of the material responded better than on any other antidepressive treatment. Treatment with monoamine-oxidase-inhibitors, like isocarboxazide, should not be left untried in the case of therapy-resistant depression.
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Shopsin B, Waters B. The pharmacotherapy of major depressive syndrome. Part 1: treatment of acute depression. PSYCHOSOMATICS 1980; 21:542-56. [PMID: 7403417 DOI: 10.1016/s0033-3182(80)73642-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Tyrer P, Gardner M, Lambourn J, Whitford M. Clinical and pharmacokinetic factors affecting response to phenelzine. Br J Psychiatry 1980; 136:359-65. [PMID: 6992903 DOI: 10.1192/bjp.136.4.359] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sixty patients, 30 with depressive neurosis, 15 with anxiety neurosis and 15 with phobic anxiety states, were treated with the monoamine oxidase inhibitor, phenelzine, in two different dosage schedules for four weeks. All patients received an initial dose of 15 mg daily, increasing to 30 mg daily between the third and seventh day, but subsequently, using double-blind procedure, one group tooke the commonly prescribed dose of 45 mg daily and the other took 90 mg daily. Acetylator status was independently determined before the start of treatment. Each diagnostic group showed a similar response to treatment, but patients taking the higher dose improved significantly more than those taking normal dosage, and the rate of improvement, measured by weekly self-ratings, was also more rapid with higher dosage. Acetylator status did not affect clinical response. The results suggest that dosage is more important in determining clinical response to phenelzine in neurotic disorder than specific diagnosis or acetylator status.
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Tantam D. Primary Mental Health Care in the United Kingdom. INTERNATIONAL JOURNAL OF MENTAL HEALTH 1979. [DOI: 10.1080/00207411.1979.11448836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Marco EJ, Meek JL. The effects of antidepressants on serotonin turnover in discrete regions of rat brain. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 1979; 306:75-9. [PMID: 311440 DOI: 10.1007/bf00515596] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Serotonin (5-HT) turnover was measured in hypothalamus, hippocampus, cortex, septum and nucleus caudatus of rats after acute or chronic treatment with antidepressants. Acute chlorimipramine (1.8 -- 16.2 mg/kg i.p.) decreased 5-HT turnover in all the areas tested as measured by the rate of accumulation of 5-hydroxyindoleacetic acid after probenecid, or the rate of accumulation of 5-hydroxytryptophan after decarboxylase inhibition. However, chlorimipramine failed to reduce the rate of 5-HT accumulation after monoamine oxidase inhibition. Chronic chlorimipramine treatment (3 times daily for 2 weeks) did not change the 5-HT turnover. Fluoxetine, which like chlorimipramine specifically blocks 5-HT uptake also decreased 5-HT synthesis. In contrast, no change in 5-HT turnover was observed after desmethylimipramine, amitriptyline, iprindole or amphetamine which affect the catecholaminergic, but not serotoninergic systems.
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Checkley SA. A new distinction between the euphoric and the anti-depressant effects of methylamphetamine. Br J Psychiatry 1978; 133:416-23. [PMID: 728690 DOI: 10.1192/bjp.133.5.416] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The psychological effects of an injection of methylamphetamine have been measured in 22 drug-free patients with endogenous depressive illness and in 9 patients with other psychiatric illness. A new distinction between the time course of the euphoric and anti-depressant effects is described. The euphoric effects were seen in the first hour after the injection, but the anti-depressant effects were delayed for 1--3 hours and then lasted for as long as 36 hours. These findings are at variance with the noradrenaline depletion hypothesis of depressive illness which (in its simplest form) predicts an immediate alleviation of depression as a result of an immediate rise in the concentration of noradrenaline at central receptor sites.
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