". . . and a small dose of an antidepressant might help"

A New Paradigm for Achieving a Rapid Antidepressant Response

The substantive delay (often 4-6 weeks) between the commencement of an antidepressant and any discernible improvement in depressive symptoms is an ongoing concern in the management of depressive disorders. This delay incurs the risk of cessation of medication, self-harm/suicide and ongoing 'damage' to the brain caused by the illness. Both historically and now, off-label polypharmacy has been used in clinical practice in an attempt to facilitate both immediate- and long-term relief from symptoms. While somewhat effective, this strategy was unregulated and associated with severe adverse side effects for patients. In this article we proffer an alternative paradigm to achieve a more rapid antidepressant response by conceptualising the gap in terms of windows of response. The Windows of Antidepressant Response Paradigm (WARP) frames treatment response as windows of time in which a clinical response can be expected following initiation of an antidepressant. The paradigm defines three distinct windows-the immediate-response window (1-2 days), fast-response window (up to 1 week) and slow-response window (from 1 week onwards). Newer agents such as rapid-acting antidepressants are considered to act within the immediate-response window, whereas atypical antipsychotic augmentation strategies are captured within the fast-response window. The slow-response window represents the delay experienced with conventional antidepressant monotherapy. Novel agents such as esketamine and brexpiprazole are discussed as examples to better understand the clinical utility of WARP. This framework can be used to guide research in this field and aide the development of newer, more effective antidepressant agents as well as providing a strategy to guide the prescription of multiple agents in clinical practice.

Correlates of low-dosage treatment with antidepressants by psychiatrists and general practitioners

BACKGROUND

The prescribing of low dosages of antidepressants has for many years been a matter of concern in the scientific literature. There is a little understanding of why physicians do not follow dosage recommendations and what factors influence medical decision-making.

METHOD

In a drug utilisation observation study, treatment of 692 patients was monitored who were prescribed the tricyclic antidepressant doxepin by 80 general practitioners and 85 psychiatrists.

RESULTS

The mean maximum dosage per day was 83 mg/d. One hundred and fifty milligrams per day or more were prescribed for only 6.1% of the patients. There were significant differences between dosage groups: patients older than 65 received lower dosages (68 mg/d) as younger patients (84 mg/d), male patients higher dosages (94 mg/d) than females (79 mg/d), patients who had a mild depression with a score of 1-35 on the depression symptom scale received on average 68 mg/d, while patients with 36-74 got 100 mg/d. Physician speciality was not significantly related to dosage levels. In a logistic regression analysis, gender and Clinical Global Impression (CGI) at first examination remained factors that significantly predicted dosages of >or=125 mg/d.

CONCLUSION

Low-dosage treatment with antidepressants is a rule rather than an exception. The prescribing pattern is not indiscriminate, but physicians follow an adaptive strategy and there is medical and theoretical evidence which supports their practice. Outcome research will have to be clarified in future studies as to what extent reference to such intervening variables can help to optimise individual dosage finding.

Background and rationale for the sequenced treatment alternatives to relieve depression (STAR*D) study

Sequenced Treatment Alternatives to Relieve Depression (STAR*D) attempts to fill in major clinical information gaps and to evaluate the theoretical principles and clinical beliefs that currently guide pharmacotherapy of major depressive disorder. The study is conducted in representative participant groups and settings using clinical management tools that easily can be applied in daily practice. Outcomes include clinical outcomes and health care utilization and cost estimates. Research findings should be immediately applicable to, and easily implemented in, the daily primary and specialty care practices. This article provides the overall rationale for STAR*D and details the rationale for key design, measurement, and analytic features of the study.

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.

First admissions for depression: is the 'no-treatment interval' a critical predictor of time to remission?

BACKGROUND

This study aimed to replicate findings that length of episode prior to adequate antidepressant treatment (the 'no-treatment interval') and premorbid neuroticism predict time to remission from the institution of adequate treatment for depression.

METHODS

Eighty-three inpatients meeting ICD-10 criteria for a depressive illness were entered into an 18-month prospective follow-up study of illness course. Subjects were assessed using the Schedules for Clinical Assessment in Neuropsychiatry, Maudsley Personality Inventory (MPI) and the Hamilton Rating Scale for Depression (HRSD). Remission was defined as an HRSD score of < 8 for 2 consecutive weeks.

RESULTS

Twenty-two patients (27%) remained depressed 12 months after the onset of adequate treatment. Significantly longer times to remission were predicted by a longer no-treatment interval and higher premorbid neuroticism scores.

LIMITATIONS

Adequate antidepressant treatment was commenced prior to admission in half the cases, requiring a retrospective assessment of illness course prior to study entry. Twenty-four patients (29%) had not remitted at the time of completion of the MPI.

CONCLUSIONS

These results replicate previous findings identifying a longer time to treatment and higher neuroticism scores as predictors of chronicity in depression.

Management of resistant depression

The inadequate assessment and management of depression can lead to the erroneous diagnosis of treatment resistance. After briefly considering the definition and diagnosis of resistant depression, the authors describe the principles and methods of antidepressant therapy, emphasizing the systematic use of medication and the importance of therapeutic drug monitoring. The application of these is then discussed in a clinical context, and illustrated with examples.

Residual symptoms after partial remission: an important outcome in depression

This paper draws attention to an important adverse outcome in depression, the occurrence of residual symptoms after partial remission. Among patients with definite major depression followed every 3 months to remission and thereafter, residual symptoms reaching 8 or more on the Hamilton Depression Scale 17-item total were present in 32% (19) of the 60 who remitted below major depression by 15 months. The pattern was of mild but typical depressive symptoms. Residual symptoms were more common in subjects with more severe initial illness, but were not related to any other predictors, including longer prior illness, dysthymia, or lower dose of drug treatment during the illness episode. There were weak associations with personality that might have been consequences of symptom presence. Residual symptoms were very strong predictors of subsequent early relapse, which occurred in 76% (13/17) of those with residual symptoms and 25% (10/40) of those without.

Prescription pattern of antidepressants in out-patient psychiatric practice

The prescription pattern of antidepressants was reviewed in a large sample of psychiatric out-patients in the Region of Piedmont. Antidepressants were administered to 780 patients; most were diagnosed with mood disorders (62% of prescriptions) and anxiety disorders (34%), the rest with other diagnoses. The mean prescribed dose of antidepressants was at the lower end of, or below, the recommended range for out-patients, with the exception of amineptine and mianserin. The administered dose of tricyclic antidepressants was significantly associated with sex and diagnosis: female patients received a daily dose that was significantly lower than that for males, and patients with a diagnosis of mood disorders received significantly more medication than those with other diagnoses.

Effect of recommended dosage range on the prescribing of antidepressants

The aim of the study was to explore the role that suggested dosage range may play in suboptimal prescribing practice of tricyclic antidepressants. Clinicians practising in adult psychiatry were shown a clinical vignette of melancholia (as per DSM-III-R). One of two questionnaires on treatment practices, specifying either 75-200 mg or 75-425 mg of an unnamed tricyclic antidepressant, were randomly distributed to subjects. A highly significant (p = 0.001) difference was found: those who were given a narrow dosage range prescribed an average of 82.5 mg/day less antidepressant than those for whom the dosage range had been widened, indicating that the range within which dosages are recommended affects prescribing practices. When erroneously constrained, the range may contribute toward sub-optimal prescribing practices and as a consequence toward treatment-resistant depression.

Treatment approaches to therapy-resistant depression

Resistance to antidepressant treatment is a controversial field and therapy resistance has received a wide range of definitions. The field has suffered from a lack of consensus on how to classify treatment resistance and from the related failure to standardise clinical criteria in trials of new therapeutic approaches. A significant proportion of tricyclic antidepressant (TCA)-resistant depression results from the failure to sustain an adequate course of therapy. This can be due to either inadequate prescribing or the poor tolerability of TCAs. The majority of cases of treatment resistance, however, involve antidepressant therapy at a dose and duration that would normally be expected to be effective. In these cases, therapy may fail for many reasons. Refractory depression may occur in patients with medical conditions such as subclinical hypothyroidism, stroke and closed head injuries. Patients with alcoholism may prove refractory to treatment, as may those receiving certain medications, notably calcium channel blockers. Certain subtypes of depression, such as rapid-cycling disorder and delusional depression, also appear to be more refractory to treatment. A variety of therapeutic approaches have been applied to treatment-resistant depression but, for most of these, placebo-controlled clinical trials with substantial numbers of patients have not been conducted. Selective serotonin re-uptake inhibitors (SSRIs) may have a role to play in TCA-resistant patients as a result of their superior tolerability; monoamine oxidase inhibitors (MAOIs) also have a significant therapeutic role. ECT has an important role to play in patients who failed to respond to successive drug therapies. Of the various add-on therapies, thyroid augmentation (triiodothyronine) of antidepressant treatment has shown promise, and definite benefits have been established for lithium augmentation. Evidence has emerged to show that lithium is not only effective as an adjunct to TCA therapy, but also to the better tolerated SSRIs. However, further trials will be necessary to determine the optimal dosage and treatment duration for lithium augmentation.

Psychosurgery: stereotactic subcaudate tractomy. An indispensable treatment

BACKGROUND

Stereotactic subcaudate tractotomy (SST) is the only type of psychosurgery performed at the Geoffrey Knight Unit, London, where nearly 1300 operations have been done since 1961. Statistically reliable data are not available to prove the effectiveness of SST. A detailed statement about contemporary psychosurgery is given.

METHOD

Relevant publications from the Unit and via Medline are discussed. The outcome figures are reviewed. The outcome is assessed at the Unit in global and clinical terms, associated with results of self-completed questionnaires.

RESULTS

SST allows 40-60% of patients to live normal or near-normal lives, perhaps with continuation of medication. A reduction in suicide rate to 1% post-operatively, from 15% in cases of uncontrolled affective disorders is seen.

CONCLUSION

As a treatment of last resort, no controlled trial against a comparable treatment is possible. It appears reasonable to offer SST to patients with suicidal and deluded depression or with frequently swinging moods, not responding to other treatments.

Patterns of antidepressant use in community practice

Computerized pharmacy records from a large staff-model health maintenance organization were used to examine patterns of antidepressant use by primary care physicians and psychiatrists. Based on timing of prescription refills, patients treated by psychiatrists were more likely than those treated in primary care to continue medication for more than 30 days (35% vs 25%, p < 0.00001) and more likely to reach a prescribed daily dose of 100 mg of imipramine or the equivalent (48% vs 40%, p < 0.00001). Patients treated with newer antidepressants were significantly more likely to continue treatment past 30 days (range from 75% for fluoxetine to 54% for doxepin, p < 0.00001) and to reach an adequate daily dose (range from 51% for fluoxetine to 26% for doxepin, p < 0.00001). Psychiatrists more often prescribed newer antidepressants, and much of the difference between specialties could be explained by drug selection. These findings suggest more intensive antidepressant treatment than in earlier reports, especially in primary care. More intensive treatment with newer antidepressants may reflect more tolerable side effects, but these observational data are liable to selection bias. Any potential advantages of newer antidepressant medications must be balanced against significantly higher costs.

Can we predict the persistence of depression?

Fifty-five patients with primary major depression were followed up prospectively from time of onset of the index illness episode until recovery. The course of depression in hospital-treated patients was protracted, with a median length of episode of one year. Two factors significantly predicted persistence of symptoms: interval between onset and receipt of treatment, and premorbid neuroticism, which accounted for 55% of the variance in length of episode.

The safety of antidepressants

It is no exaggeration to say that, in the 30 years since antidepressants were introduced, they have revolutionised the management of depression, thus fulfilling, at least for depressive illness, Paracelsus' prophetic wish. We now have a group of drugs which can induce remission in a disease which is disabling and not infrequently fatal. Despite intensive research, however, our understanding of the mechanism of action of these drugs is still largely hypothetical. Even our methods of evaluation are sufficient only to enable one to decide whether an antidepressant drug is effective or ineffective; there is no experimental method which can rank them in an overall order of potency, and perhaps this should not be the aim, since there must be subgroups of depressed patients who will respond differently to any one agent.

Methodology of measuring the efficacy of antidepressants

Evaluation of the efficacy of antidepressant agents needs to take into account factors which increase the "effect size", such as dosage, treatment duration, the use of two-phase trials, and pattern analysis of responders. Although many patients are thought to receive inadequate doses of antidepressants, relatively few dose-response studies have been performed. However, trials of both tricyclic antidepressants and phenelzine have shown that statistically significant improvements in outcome result from the use of higher dosages; the length of treatment may also affect results. In some studies, the proportion of patients showing a clear-cut response increased significantly among patients treated with active drug instead of placebo when the treatment period was extended from 4 to 6 weeks, independent of the dose used. There may thus be a distinct advantage in extending trials of antidepressants for a minimum of 6 weeks. Two-phase drug trials can be used to extend the trial period still further in responding patients, to emphasize the contrast between treatment and placebo effects and to eliminate type-2 errors. Twelve-week trials might increase the statistical power of the evaluation by 10-20%, in studies where the drug effect size is small. Pattern analysis of the timing and duration of patients' responses has been shown to aid the distinction of true responses from non-specific or placebo effects, and may be useful for evaluating data from studies of antidepressant agents which yield ambiguous results.

The prevention of suicide in patients with recurrent mood disorder

Recurrent mood disorder carries a risk of suicide of ∼ 15%. Patients who do commit suicide have often received inadequate antidepressant or prophylactic lithium treatment. Long-term treatment with lithium normalizes the excess mortality associated with recurrent mood disorders, including that from suicide. A reduced availability of the most lethal methods of suicide may contribute epidemiologically to a reduced rate of suicide, and therefore the differences in overdose toxicity between antidepressants may be pertinent. Education of mental health workers regarding the effective treatment of mood disorders can help to reduce the rate of suicide. Patient education and psychological support can lead to improved compliance with prophylactic medication and early detection of relapse, but more formal psychotherapy does not appear to be helpful. Specialized mood disorder clinics lead to better patient care than is possible in a routine psychiatric out-patient clinic.

Antidepressant drug treatment in relation to the use of ECT

The adequacy of antidepressant treatment by psychiatrists prior to ECT was examined in a group of 95 patients. ECT was considered inevitable in 16 cases. Of the remainder, 41 patients had not been given adequate antidepressant treatment prior to ECT. Alternative drug strategies were seldom pursued after one drug had failed. Most patients were continued on a variety of psychotropic drugs during ECT. Subsequent outcome was poor, which may reflect difficulty in identifying an appropriate drug for continuation treatment after ECT.

A comparison of electroconvulsive therapy with a combined lithium and tricyclic combination among depressed tricyclic nonresponders

Thirty severely depressed patients who were resistant to tricyclic antidepressant therapy were randomly allocated to treatment either with electroconvulsive therapy (ECT) or addition of lithium (Li) to the tricyclic. Twenty-one of the 30 patients significantly improved at the end of 3 weeks of treatment. There were no differences in improvement rates between the two groups. However, the patients treated with a Li/tricyclic combination improved more rapidly, showing significant alterations in mental state by day 7. It is suggested that in otherwise physically healthy patients who are tricyclic nonresponders, the addition of Li may be a more rapid treatment than the use of ECT.

Prescribing for the long-term mentally ill. A study of treatment practices

A survey of the drug treatment of long-term mentally ill users of a district psychiatric service is described. The appropriateness of prescriptions was assessed against standard criteria after a detailed clinical review of each patient. Overprescribing, particularly of sedative/hypnotic and of anticholinergic and antipsychotic drugs, was common. Junior psychiatrists and general practitioners are in need of improved training in the management of chronic psychiatric illness: a review of treatment practices might be an appropriate medium for this training.

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.

An outpatient survey of antidepressant prescription habits

A review of case notes of patients attending a general hospital psychiatric outpatient clinic revealed that 75% of patients with depressive disorders and 38% of patients with neurotic disorders were prescribed antidepressants. Antidepressants were often prescribed for long periods in low doses and in combination with benzodiazepines. There was less polypharmacy, however, with more sedating antidepressants. The results indicate that clinical prescription habits for antidepressants may still be at some variance with recommendations from the literature.