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Weiss F, Pacciardi B, D’Alessandro G, Caruso V, Maremmani I, Pini S, Perugi G. The Role of Vortioxetine in the Treatment of Depressive Symptoms in General Hospital Psychiatry: A Case-Series and PRISMA-Compliant Systematic Review of the Literature. J Clin Med 2024; 13:531. [PMID: 38256665 PMCID: PMC10816732 DOI: 10.3390/jcm13020531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/08/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
Depressive symptoms are a customary finding in hospitalized patients, particularly those who are undergoing long hospitalizations, underwent major surgical procedures or suffer from high levels of multimorbidity and frailty. The patients included in this case series shared high degrees of frailty-complexity and were evaluated within the ordinary consultation and liaison psychiatry service of the University Hospital in Pisa, Italy, from September 2021 to June 2023. Patients were administered at least one follow-up evaluation after a week and before discharge. To relate this case series to the extant literature, a comprehensive systematic review of vortioxetine safety and efficacy was performed. None of the six patients included developed serious safety issues, but one patient complained of mild-to-moderate nausea for some days after the vortioxetine introduction. Five out of six patients exhibited at least a slight clinical benefit as measured by the clinical global impression scale. Of the 858 entries screened via Scopus and Medline/PubMed, a total of 134 papers were included in our review. The present case series provides preliminary evidence for vortioxetine's safety in this healthcare domain. The literature reviewed in this paper seems to endorse a promising safety profile and a very peculiar efficacy niche for vortioxetine in consultation and liaison psychiatry.
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Affiliation(s)
- Francesco Weiss
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
| | - Bruno Pacciardi
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
| | - Giulia D’Alessandro
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
| | - Valerio Caruso
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
| | - Icro Maremmani
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
- G. De Lisio Institute of Behavioural Sciences, 56121 Pisa, Italy
| | - Stefano Pini
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
| | - Giulio Perugi
- Psychiatric Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (F.W.); (B.P.); (G.D.); (V.C.); (S.P.); (G.P.)
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Van den Eynde V, Gillman PK. Causality is the missing key: A comment on the history of MAOIs and RCTs. J Affect Disord 2022; 319:670-671. [PMID: 36115607 DOI: 10.1016/j.jad.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 10/14/2022]
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Abstract
Depressive disorders are more common in patients with physical illness than in those without, with up to one-third of medical in-patients reporting mild to moderate symptoms of depression (Rodin & Voshart, 1986). Some medical conditions have a stronger association with psychiatric illness than others, for example the prevalence rates of depressive illness in patients with diabetes, cardiac or neurological disease is about 25%, but not much more than the general population in those with hypertension. Medical in-patients are more likely to have depression than are out-patients. There are a number of potential factors that may contribute to this increased risk of depression in people with physical illness, as outlined in Box 1.
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Abstract
Biopsychosocial eclecticism has led, the authors believe, to a simplistic acceptance of a unitary view of MDD with little scientific solidity. The authors propose a return to careful psychopathology as the basis of all nosology, which has led to identifying four main types of depressive illness, and a method-based, existential approach to understanding depression.
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Affiliation(s)
- S Nassir Ghaemi
- Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street #1007, Boston, MA 02111, USA.
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Prukkanone B, Vos T, Bertram M, Lim S. Cost-effectiveness analysis for antidepressants and cognitive behavioral therapy for major depression in Thailand. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:S3-8. [PMID: 22265064 DOI: 10.1016/j.jval.2011.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness of fluoxetine and cognitive-behavioral therapy (CBT) for major depression in Thailand. METHODS A microsimulation model was developed to describe the variation in course of disease between individuals. Model inputs included Thai data on disease parameters and costs while impact measures were derived from a systematic review and meta-analysis of the international literature. Fluoxetine as the cheapest antidepressant drug in Thailand was analyzed for treatment of episodes plus a 6-month continuation phase and for maintenance treatment over 5 years of follow-up. CBT was analyzed for episodic treatment and for 5-year maintenance treatment. Results are presented as cost (Thai bahts) per disability-adjusted life-year (DALY) averted, compared with a "do-nothing" scenario. RESULTS The cost-effectiveness ratios of all interventions were below 1 time Thailand's gross domestic product of 110,000 bahts per capita. The uncertainty ranges around the cost-effectiveness ratios overlap: maintenance treatment with CBT 11,000 bahts per DALY (8,000-14,000); episodic treatment with CBT 23,000 bahts per DALY (10,000-36,000); episodic plus continuation drug treatment 33,000 bahts per DALY (26,000-44,000); maintenance drug treatment 38,000 bahts per DALY (30,000-48,000); and episodic drug treatment 42,000 bahts per DALY (32,000-57,000). CONCLUSIONS CBT and generic fluoxetine are cost-effective treatment options for both episodic and maintenance treatment of major depression in Thailand. Maintenance treatment has the greatest potential of health gain.
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Affiliation(s)
- Benjamas Prukkanone
- Department of Mental Health, Galaya Rajanagarindra Institute, Ministry of Public Health, Bangkok, Thailand.
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6
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¿Fármacos en la depresión menor? Med Clin (Barc) 2009; 132:142-3. [DOI: 10.1016/j.medcli.2008.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 06/09/2008] [Indexed: 11/23/2022]
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Waring DR. The antidepressant debate and the balanced placebo trial design: an ethical analysis. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2008; 31:453-462. [PMID: 18954907 DOI: 10.1016/j.ijlp.2008.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
There is ongoing debate about whether randomized, placebo-controlled trials under a double-blind have reliably established the pharmacological efficacy of antidepressants. Numerous meta-analyses of antidepressant efficacy trials, e.g., Kirsch et al. [Kirsch, I., Moore, T. J., Scoboria, A., & Nicholls, S. (2002). The emperor's new drugs: An analysis of antidepressant medication data submitted to the U.S. food and drug administration. Prevention and Treatment, 5, Article 23. (Retrieved July 19, 2007 from http://journals.apa.org/prevention/volume5)], have shown a modest drug-placebo difference but methodological problems with standard trial design preclude a definitive conclusion that this difference results from specific biological effects of antidepressants or the nonspecific factors that have not been adequately excluded. Standard trial design assumes the additivity thesis of pharmacological efficacy, being the assumption that the specific or "true" magnitude of the pharmacological effect is limited to the difference between the drug and placebo responses in a standard trial. If the drug effects are as small as these meta-analyses suggest, then their clinical effectiveness is questionable. If the drug effects are actually larger but masked by placebo effects, then the additivity thesis is not valid and we risk false negative results with standard trial design. Kirsch et al. propose an alternative, four arm balanced placebo trial design (BPTD) that can accurately test the additivity thesis. The BPTD uses antidepressants, active placebos and the intentional deception of research subjects. My focal question is whether the BPTD is ethically defensible. I will explore two objections that can be raised against it: 1) lying to BPTD research subjects violates their autonomy and exploits their illness and 2) the BPTD may not enable us to test the additivity thesis with accuracy, i.e., it may contribute to the masking of drug effects that it aims to avoid. I argue that these objections support the conclusion that the BPTD is ethically indefensible.
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Affiliation(s)
- Duff R Waring
- York University, 4700 Keele Street, Toronto, Ontario, Canada.
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Zinc deficiency induces enhanced depression-like behaviour and altered limbic activation reversed by antidepressant treatment in mice. Amino Acids 2008; 36:147-58. [DOI: 10.1007/s00726-008-0195-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Accepted: 07/15/2008] [Indexed: 12/28/2022]
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Abstract
The aim of the present study was to critically appraise current conceptual approaches; demographic, neurobiological and clinical correlates; and management strategies of treatment-resistant depression (TRD), especially in light of recent research findings. To this end, a review of the relevant English-language literature was undertaken using Medline, Embase and Psychinfo. TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of aetiology made. It is likely that a range of sociodemographic (such as higher socioeconomic status), genetic (such as variation in functional monoamine polymorphisms) and clinical variables (such as signal hyperintensities seen on structural neuroimaging scans) are responsible for non-response in individuals. There is insufficient evidence to suggest that TRD is associated with specific subtypes of depression, physical comorbidity, personality or chronicity. The large-scale Sequenced Treatment Alternatives to Relieve Depression (STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behaviour therapy may be as effective as medication in initial drug non-responders. Also conventional alternatives such as the use of older antidepressant classes, pharmacological augmentation or electroconvulsive therapy in established cases of TRD are not as effective as traditionally thought. There is insufficient preliminary evidence to make formal recommendations about the use of novel brain stimulation techniques in TRD. TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies. Treatment resistance may be more usefully conceived within the context of well-defined cohorts such as patients with specific subtypes of depression. Although neurobiological markers such as gene polymorphisms, which are potentially predictive of medication tolerance and efficacy, may be used in the future, it is likely that sociocultural variables such as beliefs about depression, and evidence-based treatments for it, will also determine treatment resistance.
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Affiliation(s)
- Chanaka Wijeratne
- School of Psychiatry, University of New South Wales, Kensington, New South Wales, Australia.
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Singewald N, Sinner C, Hetzenauer A, Sartori SB, Murck H. Magnesium-deficient diet alters depression- and anxiety-related behavior in mice—influence of desipramine and Hypericum perforatum extract. Neuropharmacology 2004; 47:1189-97. [PMID: 15567428 DOI: 10.1016/j.neuropharm.2004.08.010] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Revised: 07/21/2004] [Accepted: 08/17/2004] [Indexed: 11/19/2022]
Abstract
A relation between magnesium (Mg) status and mood disorders has been suggested, but evidence remains inconsistent. Therefore, we examined in mice whether Mg-depletion would alter behavior evaluated in established animal models of depression and anxiety and whether these effects would be sensitive to antidepressants. Compared to control mice fed with normal diet, mice receiving a low Mg diet (10% of daily requirement) for several weeks displayed increased immobility time in the forced swim test, indicating enhanced depression-like behavior. In addition, the partial Mg-depletion increased anxiety-related behavior in the light/dark and open field test, while locomotor activity or motor coordination was not influenced. Chronic oral administration of desipramine (30 mg/kg/day), or Hypericum extract LI160 (Hyp, 380 mg/kg/day) prevented the "pro-depression-like" forced swim behavior in Mg-depleted mice. Furthermore, the increase in anxiety-related behavior of Mg-depleted mice was abolished in both the open field and light dark test by Hyp. Taken together, we report that Mg-depletion leads to enhanced depression- and anxiety-related behavior in mice, which was further validated by the reversibility of the behavioral changes by known antidepressant and anxiolytic substances. Further, the utility of Mg-depletion as a new screening model for clinically active antidepressant and anxiolytic drugs is suggested.
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Affiliation(s)
- Nicolas Singewald
- Department of Pharmacology and Toxicology, Institute of Pharmacy and CMBI, Leopold-Franzens-University of Innsbruck, Peter-Mayr-Str. 1, A-6020 Innsbruck, Austria.
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Abstract
BACKGROUND The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Ministry of Health. METHOD The CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted meta-analyses of outcome research. TREATMENT RECOMMENDATIONS Establish an effective therapeutic relationship; provide the patient with information about the condition, the rationale for treatment, the likelihood of a positive response and the expected timeframe; consider the patient's strengths, life stresses and supports. Treatment choice depends on the clinician's skills and the patient's circumstances and preferences, and should be guided but not determined by these guidelines. In moderately severe depression, all recognized antidepressants, cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are equally effective; clinicians should consider treatment burdens as well as benefits, including side-effects and toxicity. In severe depression, antidepressant treatment should precede psychological therapy. For depression with psychosis, electroconvulsive therapy (ECT) or a tricyclic combined with an antipsychotic are equally helpful. Treatments for other subtypes are discussed. Caution is necessary in people on other medication or with medical conditions. If response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. Second opinions are useful. Depression has a high rate of recurrence and efforts to reduce this are crucial.
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Affiliation(s)
- Peter Ellis
- Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand.
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Abstract
OBJECTIVE To detail limitations to level I evidence derived from randomised controlled trials of antidepressant treatments and which is held to be fundamental to the development and validity of treatment guidelines. METHOD Recent efficacy studies and meta-analyses of treatments of major depression are considered. RESULTS The largest database in psychiatry--demonstrating that all principal treatments are of similar efficacy, and that antidepressant drugs are not distinctly superior to placebo treatment--is unlikely to be valid. CONCLUSION Excessive belief in and weighting of the evidence emerging from randomised controlled trials deserves to be criticized. An argument is put for adopting alternative approaches to evaluating the likely effectiveness of any antidepressant treatment.
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Affiliation(s)
- Gordon Parker
- School of Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick, Australia.
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Hajós M, Fleishaker JC, Filipiak-Reisner JK, Brown MT, Wong EHF. The selective norepinephrine reuptake inhibitor antidepressant reboxetine: pharmacological and clinical profile. CNS DRUG REVIEWS 2004; 10:23-44. [PMID: 14978512 PMCID: PMC6741733 DOI: 10.1111/j.1527-3458.2004.tb00002.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Reboxetine is the first commercially available norepinephrine reuptake inhibitor developed specifically as a first line therapy for major depressive disorder. In vitro and in vivo pharmacological studies indicated that reboxetine methanesulphonate has high affinity and selectivity for the human norepinephrine transporter over the serotonin and dopamine transporters. Pharmacological specificity is further demonstrated by the absence of affinity for 45 transmitter receptors and CNS targets. Pharmacokinetic studies demonstrated that reboxetine is suitable for twice daily administration (8-10 mg/day) and that it exhibits minimal drug-drug interactions. The starting dose of reboxetine should be reduced in the elderly, in patients with renal or hepatic impairment, or in patients receiving potent CYP3A inhibitors. A total of 20 phase II/III clinical studies comprising placebo-controlled, active comparator-controlled and open-label uncontrolled studies in both short-term and long-term treatment of major depression have been conducted. In the treatment of major depression, reboxetine was superior to placebo in 5 of 12 short- or long-term placebo-controlled studies and was comparable in efficacy to active comparators in 3 out of 3 active-controlled studies. Unlike conventional tricyclic antidepressants (TCAs), reboxetine had only minimal sedative and cardiovascular liabilities, probably due to increased pharmacological specificity of reboxetine as compared with TCAs. Unlike serotonin reuptake inhibitors, this selective and specific norepinephrine reuptake inhibitor demonstrated a distinct side-effect profile with diminishing sexual dysfunction and GI side effects. The availability of this agent has afforded patients suffering from major depressive disorder a new class of agents to combat the debilitating consequence of this psychiatric disease. The demonstrated pharmacological specificity of this compound has provided the psychopharmacology community with a tool to elucidate the role of norepinephrine in brain functions. Testing this agent in different animal models has enabled the exploration of the role of modulation of norepinephrine tone in the therapy of CNS disorders beyond depression.
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Affiliation(s)
- Mihály Hajós
- Department of Neuroscience, CNS Discovery, Pfizer Inc., Eastern Point Road, Groton, CT 06340, USA.
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Akhondzadeh S, Faraji H, Sadeghi M, Afkham K, Fakhrzadeh H, Kamalipour A. Double-blind comparison of fluoxetine and nortriptyline in the treatment of moderate to severe major depression. J Clin Pharm Ther 2004; 28:379-84. [PMID: 14632962 DOI: 10.1046/j.0269-4727.2003.00505.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Depression is an international public health problem. Impairment in social and occupational functioning, increased comorbidity with other psychiatric and medical conditions, and an increased risk of mortality are a few of its consequences. Some psychiatrists have the impression that selective serotonin re-uptake inhibitors may not work as well as tricyclic anti-depressants in severe depression and/or melancholia. On the contrary, there is a general belief that selective serotonin re-uptake inhibitors are superior to the tricyclic anti-depressants in having fewer side-effects, particularly cardiovascular effects. The objective of this double-blind study was to compare the efficacy and safety of fluoxetine and nortriptyline in patients with moderate to severe major depression. METHODS A total of 48 adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), forth edition for major depression, based on the structured clinical interview for DSM IV participated in the trial. Patients had a baseline Hamilton Rating Scale for Depression score of at least 20. In this double-blind, single-center trial, patients were randomly assigned to receive nortriptyline 150 mg/day (group 1) or fluoxetine 60 mg/day (group 2) for 6-weeks. The outcome of the two groups was assessed using Hamilton Depression Rating Scale, a side-effect checklist and a regular ECG assessment. RESULTS The results suggest that the efficacy of nortriptyline is superior to fluoxetine in this group of major depressed patients. No significant differences were observed between dropout rates in the two groups but anti-cholinergic side-effects were significantly more frequent with nortriptyline than with fluoxetine but there was no significant difference in cardiovascular effects in particular QTc prolongation. CONCLUSION The results of the current study suggest that nortriptyline was more effective than fluoxetine in the treatment of moderate to severe depression. A larger study is warranted.
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Affiliation(s)
- S Akhondzadeh
- Psychiatric Research Center, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Abstract
OBJECTIVE To review critically alternative models of depression. METHOD Contrasting historical models are noted and some results of a study overviewing a temperament-based model for the non-melancholic disorders are presented. RESULTS Limitations to all models are considered. CONCLUSION As depression can present as a mood state, a syndrome, a disorder and as a disease, it is unwise to assume that a single model will suffice. A pure temperament diathesis model of non-melancholic depression is unlikely to be sufficient and would benefit from testing of additional personality constructs.
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Affiliation(s)
- G Parker
- School of Psychiatry, University of New South Wales, Sidney, Australia
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Parker G, Anderson IM, Haddad P. Clinical trials of antidepressant medications are producing meaningless results. Br J Psychiatry 2003; 183:102-4. [PMID: 12893662 DOI: 10.1192/bjp.183.2.102] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A recent alert from the UK Committee on Safety of Medicines stated that the dangers of treatment of depression with paroxetine outweigh the benefits in those under 18. Such a warning should focus our minds on the evidence on which clinical practice is based. Antidepressant treatment of depression in the under-18s has been thought to be justified because clinical trials show that it works so well in over-18s. But is that a reasonable assessment of the evidence? Kirsch et al (2002) use the analogy of ‘The Emperor's New Clothes' to describe the findings from their meta-analysis of randomised placebo-controlled trials of antidepressants. They conclude that antidepressant medication appears to have only a small effect on outcome over and above placebo. In this analogy psychiatry is the emperor, drug trials are the fraudsters and the deception is being revealed by a growing body of critical opinion proposing that, once methodological problems with clinical trials are taken into account, antidepressants either do not work at all or have an effect that is so small as to be clinically unimportant (Andrews, 2001; Moncrieff, 2002). A large number of randomised placebo-controlled trials of antidepressants have been carried out over the past decades, mostly funded by the pharmaceutical industry, and it is now recognised that about 50% of negative trials go unpublished (Thase, 1999). Meanwhile, unipolar depression has jumped into the top five of the world's total burden of disease, and there is an imperative need for effective and safe treatments. Do we need more randomised controlled trials (RCTs) of antidepressant medications, or has that research paradigm outlived its usefulness? In this month's debate, Professor Gordon Parker, University of New South Wales and Black Dog Institute, Australia, and Drs Ian Anderson and Peter Haddad from the University of Manchester discuss whether clinical trials for antidepressant medication produce meaningless results.
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Affiliation(s)
- Gordon Parker
- School of Psychiatry, University of New South Wales, Australia
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Abstract
BACKGROUND Despite the availability of effective antidepressants, recurrence and relapse rates for depression are high (up to 80%), treatment failures are common (40% to 60%), and as many as 20% of patients remain inadequately treated. Depression treatment guidelines are often not followed, and rates of nonadherence to treatment are high, with 28% of patients discontinuing antidepressant treatment within the first month and 44% discontinuing within 3 months of initiating therapy. OBJECTIVE The aim of this article was to summarize research on antidepressant therapy nonadherence and examine the limitations of strategies used to minimize adverse events (AEs) and improve treatment duration. METHODS A thorough search of the published literature from 1990 to the present was performed on MEDLINE and other search engines. The following search terms were used: tolerability, antidepressants, patient compliance, adherence, therapy, SSRIs, tricyclics, and other related terms focusing on specific agents. RESULTS Physician-specific issues represent some of the most important obstacles to adequate antidepressant therapy. Inadequate patient education, prescription of inappropriate medications or inadequate dosages, and lack of follow-up care are all issues the physician can control to improve patient adherence. Patient-specific issues include poor motivation (due to symptoms of depression) to continue therapy, failure to perceive a benefit, and concerns about cost of therapy. Medication-specific issues such as treatment-related AEs, delayed onset of action, complicated dosing or titration schedule, and subtherapeutic dosing also contribute to treatment discontinuation. Therapy with >/=I antidepressant and/or atypical antipsychotic may improve symptom control, but little evidence exists regarding efficacy and safety. Dosage reduction has been attempted to reduce events that may lead to patient discontinuation, but this may increase the risk of recurrent depressive episodes. CONCLUSIONS To maximize patient adherence to antidepressant therapy, it is necessary to combine adequate treatment duration, realistic patient expectations, and the right dose of an agent capable of treating the full range of symptoms while controlling for AEs.
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Affiliation(s)
- Prakash S Masand
- Program for Continuing Medical Education, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Hildebrandt MG, Stage KB, Kragh-Soerensen P. Gender differences in severity, symptomatology and distribution of melancholia in major depression. Psychopathology 2003; 36:204-12. [PMID: 14504455 DOI: 10.1159/000072791] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2002] [Accepted: 03/28/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies of gender differences in the clinical presentation of depression have provided divergent results. This study aimed at analyzing gender differences in severity, symptomatology and distribution of melancholia in major depression. SAMPLING AND METHODS The study comprised 930 in- and out-patients (652 women, 278 men) from 6 randomized controlled trials. All patients fulfilled DSM-III or DSM-III-R criteria for major depression. The 17-item Hamilton Depression Scale (HDS) was applied to all patients. A multi-axial evaluation was completed using the Newcastle 1 Depression Rating Scale from 1965 for melancholia (N1) in a subsample of patients (n = 439). A factor analysis on the HDS was performed. Non-parametric statistical tests were used and only gender differences greater than 20% were considered clinically relevant. RESULTS The median on the HDS total score was 22 and the median number of symptoms was 13 for both men and women. Presentation of specific symptoms was similar for men and women. The factor analysis revealed no gender differences, and neither did analyses on symptoms of Axes II and IV. According to the N1, 80% of the men and 66% of the women suffered from melancholic depression (p = 0.004). CONCLUSIONS In a large and broad sample of in- and out-patients with major depression, the severity and symptomatology of depression were similar for men and women. Melancholic depression was significantly more frequent among male than female patients. Inclusion and exclusion criteria in the randomized controlled trials provided a selected group of patients, which limited the generalisability of the results to an exclusive subgroup of patients treated for depression in routine clinical practice.
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Affiliation(s)
- Malene Grubbe Hildebrandt
- Department of Psychiatry, Centre for Depression Research, University of Southern Denmark, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark.
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Bech P. The Bech-Rafaelsen Melancholia Scale (MES) in clinical trials of therapies in depressive disorders: a 20-year review of its use as outcome measure. Acta Psychiatr Scand 2002; 106:252-64. [PMID: 12225492 DOI: 10.1034/j.1600-0447.2002.01404.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the psychometric properties of the Bech-Rafaelsen Melancholia Scale (MES) by reviewing clinical trials in which it has been used as outcome measure. METHOD The psychometric analysis included internal validity (total scores being a sufficient statistic), interobserver reliability, and external validity (responsiveness in short-term trials and relapse prevention in long-term trials). RESULTS The results showed that the MES is a unidimensional scale, indicating that the total score is a sufficient statistic. The interobserver reliability of the MES has been found adequate both in unipolar and bipolar depression. External validity including both relapse, response and recurrence indicated that the MES has a high responsiveness and sensitivity. CONCLUSION The MES has been found a valid and reliable scale for the measurement of changes in depressive states during short-term as well as long-term treatment.
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Affiliation(s)
- P Bech
- Psychiatric Research, Unit WHO Collaborating Centre for Mental Health, Frederiksborg General Hospital, Denmark.
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Parker G. Differential effectiveness of newer and older antidepressants appears mediated by an age effect on the phenotypic expression of depression. Acta Psychiatr Scand 2002; 106:168-70. [PMID: 12197852 DOI: 10.1034/j.1600-0447.2002.02432.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A possible mechanism whereby the serotonin reuptake inhibitor (SSRI) antidepressants may not (overall) be as effective as the tricyclic (TCA) antidepressants is explored. METHOD Clinical psychiatrists rated the effectiveness of past antidepressant medications in a clinical panel study of patients with a major depressive disorder, with 200 having previously received a TCA and 219 an SSRI. RESULTS Analyses indicated decreased SSRI effectiveness with age in those with the melancholic subtype. TCA effectiveness appeared uninfluenced by age and depressive subtype. CONCLUSION Findings suggest why the broader-based TCAs may be more effective than the SSRIs in implicating age and depressive subtype influences.
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Affiliation(s)
- G Parker
- School of Psychiatry, University of New South Wales, and Mood Disorders Unit, Prince of Wales Hospital, Sydney, Australia.
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