Escitalopram: a review of its use in the management of major depressive disorder

Modulation of serotonin transporter expression by escitalopram under inflammation

Selective serotonin reuptake inhibitors (SSRIs) are widely used for depression based on the monoamine deficiency hypothesis. However, the clinical use of these agents is controversial, in part because of their variable clinical efficacy and in part because of their delayed onset of action. Because of the complexities involved in replicating human disease and clinical dosing in animal models, the scientific community has not reached a consensus on the reasons for these phenomena. In this work, we create a theoretical hippocampal model incorporating escitalopram's pharmacokinetics, pharmacodynamics (competitive and non-competitive inhibition, and serotonin transporter (SERT) internalization), inflammation, and receptor dynamics. With this model, we simulate chronic oral escitalopram in mice showing that days to weeks are needed for serotonin levels to reach steady-state. We show escitalopram's chemical efficacy is diminished under inflammation. Our model thus offers mechanisms for how chronic escitalopram affects brain serotonin, emphasizing the importance of optimized dose and time for future antidepressant discoveries.

Effect of cognitive retraining treatment in mild to moderate depressive disorders

Background

Cognitive retraining or remediation approaches dispense high levels of stimulation and new learning tasks, leading to an increased neural connections, which facilitate rapid recovery in patients with neurological as well as psychiatric conditions.

Objectives

The current study aimed to investigate the effect of cognitive retraining (CR) in depressive disorders. We assigned 40 patients with mild to moderate depression to two sample groups, with 20 participants each: CR alone and CR with medicine. A 6-week CR module was delivered, and participants’ scores on measures such as the Beck Depression Inventory-II, Metacognition Questionnaire 30, World Health Organization Quality of Life- Brief, and Global Assessment of Functioning were compared.

Results

Analysis using Stata/IC version 16 included descriptive statistics, paired and independent t-tests, analysis of covariance, and propensity score matching. Cohen's d was computed to determine the effect size. Within-group analysis revealed statistically significant differences in pre-post scores of the outcome measures (p  < .05) and large effect size (d  = 3.41; d  = 3.60) in both groups. The difference in scores of outcome measures between the groups was not significant (p  > .05) even when covariates were controlled, or nearest neighbor match analysis was carried out. CR is effective in alleviating symptoms and dysfunctional metacognitive beliefs in addition to enhancing functioning and quality of life.

Conclusions

CR-based interventions may be essential mental health services owing to growing research in psychotherapy via virtual modes such as tele- and video-conferencing. These interventions can substantiate both prevention and remedy.

Escitalopram's inflammatory effect on the mammalian macrophages and its intracellular mechanism of action

The majority of patients with depression are treated with antidepressant drugs that are in the serotonin reuptake inhibitor (SSRI) group. Different studies have been conducted on the effect of treatment with antidepressants on the level of pro-inflammatory cytokines. There have been studies on the effects of escitalopram, an SSRI group antidepressant, on the pro-inflammatory cytokine levels both in vivo and in vitro. The results of these studies do not overlap and therefore the escitalopram's effect on the immune system should be studied in more depth. In this study, we aimed to examine, in detail, the cytokine production amount by escitalopram treatment of the J774.2 macrophage cells and its intracellular mechanism of action by examining the PI3K and p38 pathways. As a result of our study, we observed that Escitalopram caused a significant increase in TNF-α, IL-6, and GM-CSF levels in mammalian macrophage cells, but did not induce IL-12p40 production. We observed that the p38 and PI3K pathways play a role in inflammation in the presence of Escitalopram.

A Review of Clinical Studies Assessing the Therapeutic Efficacy of Escitalopram: A Step Towards Development

BACKGROUND

Major depression is a debilitating, sometimes fatal disorder, deteriorating the quality of life and well-being. Escitalopram showed highly selective and dose-dependent inhibitory activity on human serotonin transport. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs to manage major depressive disorder (MDD).

OBJECTIVE

The objective of this study is to explore the therapeutic potential of escitalopram, a clinically approved drug to manage MDD and panic disorders.

METHODS

It emphasizes comparative and clinical trial studies with several pharmacological targets reviewed from the data available on PubMed, Science Direct, Clinicaltrails.gov, and from many reputed foundations.

RESULTS

To highlight the clinical efficacy, safety, recent development, and stable formulation of escitalopram with an increased bioavailability profile. Evidence-based on the available clinical and pharmacoeconomic data, escitalopram represents an effective first-line treatment option for MDD patients.

CONCLUSION

The present review highlights the placebo-controlled clinical studies and the recent development that can be helpful for further research perspectives.

Stercoral Perforation in the Setting of Chronic Antipsychotic Use: A Case Report

Stercoral perforation is a rare form of colonic perforation with limited reports in the literature, accounting for less than 140 documented cases. This complication occurs due to increased intraluminal pressure created by fecal impaction, ultimately causing colonic ulceration and necrosis. It is most often seen in elderly or debilitated patients with chronic constipation. The long-term use of drugs or medications with side effects of chronic constipation such as opioids, antispasmodics, tricyclic antidepressants, and calcium channel blockers have been implicated in these cases. Here we present a case of stercoral perforation in a patient with short-term opioid use following an orthopedic procedure, but more likely complicated by long-term use of antipsychotics and antidepressants.

Intermolecular C-H Aminocyanation of Indoles via Copper-iodine Cocatalyzed Tandem C-N/C-C Bond Formation

An efficient copper-iodine cocatalyzed intermolecular C-H aminocyanation of indoles with a broad substrate scope has been developed for the first time. This method enables highly step-economic access to 2-amino-3-cyanoindoles in moderate to good yields and provides a complementary strategy for the regioselective difunctionalization of carbon═carbon double bonds of interest in organic synthesis and related areas. Mechanistic studies suggest that these transformations are initiated by iodine-mediated C2-H amination with azoles, followed by copper-catalyzed C3-H cyanation with ethyl cyanoformate.

An acute dose-ranging evaluation of the antidepressant properties of Sceletium tortuosum (Zembrin®) versus escitalopram in the Flinders Sensitive Line rat

ETHNOPHARMACOLOGICAL RELEVANCE

Sceletium tortuosum (L.) N.E.Br. (ST) has been used by the Khoisan people of South Africa as a mood elevator. Its various pharmacological mechanisms of action suggest distinct potential as an antidepressant. Clinical studies in healthy individuals suggest beneficial effects on mood, cognition, and anxiety.

AIM OF THE STUDY

To obtain a chromatographic fingerprint of a standardized extract of S. tortuosum (Zembrin®), and to evaluate the acute antidepressant-like properties of Zembrin® versus the reference antidepressant, escitalopram, in the Flinders Sensitive Line (FSL) rat, a genetic rodent model of depression.

MATERIALS AND METHODS

The chemical profile of Zembrin® was determined by ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) chromatogram method using alkaloid standards. Twelve saline treated FSL and six Flinders Resistant Line (FRL) control rats were used to confirm face validity of the FSL model using the forced swim test (FST). Thereafter, FSL rats (n = 10) received either 5, 10, 25, 50 or 100 mg/kg of Zembrin®, or 5, 10 or 20 mg/kg escitalopram oxalate (ESC), both via oral gavage, and subjected to the open field test (OFT) and FST.

RESULTS

Four main ST alkaloids were identified and quantified in Zembrin® viz. mesembrenone, mesembrenol, mesembrine, and mesembranol (47.9%, 32%, 13.2%, and 6.8% of the total alkaloids, respectively). FSL rats showed significantly decreased swimming and climbing (coping) behaviours, and significantly increased immobility (despair), versus FRL controls. ESC 5 mg/kg and Zembrin® 25 mg/kg and 50 mg/kg showed significant dose-dependent reversal of immobility in FSL rats and variable effects on coping behaviours. Zembrin® 50 mg/kg was the most effective antidepressant dose, showing equivalence to ESC 5.

CONCLUSIONS

Zembrin® (25 and 50 mg/kg) and ESC (5 mg/kg) are effective antidepressants after acute treatment in the FST, as assessed in FSL rats. Moreover, Zembrin® 50 mg/kg proved equivalent to ESC 5. Further long-term bio-behavioural studies on the antidepressant properties of Zembrin® are warranted.

Dose-response effects of selective serotonin reuptake inhibitor monotherapy for the treatment of depression: systematic review of reviews and meta-narrative synthesis

Objective

To assess and clarify the relations between selective serotonin reuptake inhibitor (SSRI) dose efficacy, acceptability (early treatment discontinuation (dropouts)), and tolerability (reported adverse drug effects), and critically evaluate methods previously used to examine SSRI dose-response effects for the treatment of depression in adults.

Design

Systematic review of reviews and meta-narrative synthesis.

Data sources

Embase, Medline, PsycINFO, Scopus, and the Cochrane Collaboration library, from 1975 to December 2021. Reference lists of national depression treatment guidelines were systemically searched by hand.

Eligibility criteria for selecting studies

Reviews assessing SSRI monotherapy dose-response effects for the treatment of depression in adults (age ≥18 years) reporting efficacy, acceptability, or tolerability. Reviews meeting inclusion criteria had a high degree of heterogeneity, due to methodological diversity; therefore, a meta-narrative synthesis approach was applied. Standard daily doses were defined as 20 mg citalopram, fluoxetine, paroxetine; 50 mg sertraline; and 10 mg escitalopram. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, in line with Cochrane recommendations.

Results

The search identified 9138 records; 387 full text reports were assessed for eligibility, 42 of which matched the inclusion criteria. The majority, 83% (n=35), of reviews included data for studies with a duration of ≤12 weeks (ie, the acute phase of depression treatment). Of 39 reviews assessing efficacy, the majority (n=26) indicated that individual SSRIs and SSRI class demonstrated flat dose-response effects; standard doses were optimal for efficacy. Acceptability or tolerability were assessed in 28 reviews. Higher than standard daily doses were associated with higher dropout rates and a greater incidence of adverse drug effects (eg, nausea, sexual dysfunction, fatigue, anxiety). Despite a range of methods being reported, there was an overall consensus regarding SSRI dose related efficacy, dropouts, and adverse drug effects.

Conclusion

Standard daily doses of SSRIs for the treatment of depression in adults provide a favourable balance between efficacy, acceptability, and tolerability. Patients are encouraged to talk to their prescriber or community pharmacist if they experience adverse effects or have any concerns about their drug treatments.

Facile Preparation of Aryl Nitriles from Aryl Aldehydes in PEG-DME 250

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A facie and efficient method for one-pot transformation of aryl aldehydes to aryl nitriles using hydroxylamine hydrochloride and phosphorus tribromide in PEG-DME 250 is reported. The conversion of various aryl aldehydes to the corresponding aryl nitriles occurred smoothly in high yields under the present reaction conditions.

Characterization of gut microbiome in mice model of depression with divergent response to escitalopram treatment

Depression is a common and heterogeneous mental disorder. Although several antidepressants are available to treat the patients with depression, the factors which could affect and predict the treatment response remain unclear. Here, we characterize the longitudinal changes of microbial composition and function during escitalopram treatment in chronic unpredictable mild stress (CUMS) mice model of depression based on 16 S rRNA sequencing and metabolomics. Consequently, we found that escitalopram (ESC) administration serves to increase the alpha-diversity of the gut microbiome in ESC treatment group. The microbial signatures between responder (R) and non-responder (NR) groups were significantly different. The R group was mainly characterized by increased relative abundances of genus Prevotellaceae_UCG-003, and depleted families Ruminococcaceae and Lactobacillaceae relative to NR group. Moreover, we identified 15 serum metabolites responsible for discriminating R and NR group. Those differential metabolites were mainly involved in phospholipid metabolism. Significantly, the bacterial OTUs belonging to family Lachnospiraceae, Helicobacteraceae, and Muribaculaceae formed strong co-occurring relationships with serum metabolites, indicating alternations of gut microbiome and metabolites as potential mediators in efficiency of ESC treatment. Together, our study demonstrated that the alterations of microbial compositions and metabolic functions might be relevant to the different response to ESC, which shed new light in uncovering the mechanisms of differences in efficacy of antidepressants.

Transition-metal-free direct C-3 cyanation of quinoxalin-2(1H)-ones with ammonium thiocyanate as the “CN” source

A practical protocol for TBHP-mediated oxidative C–H cyanation of quinoxalin-2(1H)-ones utilizing ammonium thiocyanate as the cyanide source has been developed under metal free conditions.

Palladium-catalyzed cyanation of aryl halides with in situ generated CN− from ClCF2H and NaNH2

An efficient Pd-catalyzed cyanation of aryl halides with in situ generated CN⁻ anions is described.

A combined experimental and computational study of NHC-promoted desulfonylation of tosylated aldimines

NHC-catalyzed mild desulfonylation of tosylated aldimines provides efficient access to aryl nitriles with broad substrate scope. DFT calculations demonstrate that the reaction undergoes multiple stepwise processes.

Minocycline alters behavior, microglia and the gut microbiome in a trait-anxiety-dependent manner

Major depressive disorder is the main cause of disability worldwide with imperfect treatment options. However, novel therapeutic approaches are currently discussed, from augmentation strategies to novel treatments targeting the immune system or the microbiome-gut-brain axis. Therefore, we examined the potential beneficial effects of minocycline, a tetracycline antibiotic with pleiotropic, immunomodulatory action, alone or as augmentation of escitalopram on behavior, prefrontal microglial density, and the gut microbiome in rats selectively bred for high anxiety-like behavior (HAB). We show that concomitant with their high innate anxiety and depression, HABs have lower microglial numbers in the infralimbic and prelimbic prefrontal cortex and an altered gut microbiota composition compared with controls. Three weeks of minocycline treatment alleviated the depressive-like phenotype, further reduced microglial density, exclusively in male HAB rats, and reduced plasma concentrations of pro-inflammatory cytokines. However, coadministration of escitalopram, which had no effect alone, prevented these minocycline-induced effects. Moreover, minocycline led to a robust shift in cecal microbial composition in both HABs and rats non-selected for anxiety-like behavior. Minocycline markedly increased relative abundance of Lachnospiraceae and Clostridiales Family XIII, families known for their butyrate production, with a corresponding increase and positive correlation in plasma 3-OH-butyrate levels in a trait-dependent manner. Thus, our data suggest that the antidepressant effect of minocycline is sex- and trait-dependent, associated with a reduced microglial number in the prefrontal cortex, and with changes in microbial composition and their metabolites. These results further support the microbiome-gut-brain axis as potential target in the treatment of depression.

Botulinum Toxin a Valuable Prophylactic Agent for Migraines and a Possible Future Option for the Prevention of Hormonal Variations-Triggered Migraines

BACKGROUND

In 1989, Botulinum toxin (BoNT) was accepted by the FDA for the management of some ophthalmic disorders. Although it was initially considered a lethal toxin, in recent times, Botulinum toxin A (BoNT-A), which is the more used serotype, has expanded to cover different clinical conditions, primarily characterized by neuropathic pain, including migraines and headaches. Evidence suggests that migraines are influenced by hormonal factors, particularly by estrogen levels, but very few studies have investigated the prevalence and management strategies for migraines according to the hormonal status. The effects of several therapeutic regimens on migraines have been investigated, but the medications used varied widely in proven efficacies and mechanisms of action. BoNT-A is increasingly used in the management of migraine and several placebo-controlled trials of episodic and chronic migraine are currently underway. This paper is a review of the recently published data concerning the administration of BoNT-A in the prevention of chronic migraines. Considering the lack of population-based studies about the effectiveness of BoNT-A in the alleviation of premenstrual and perimenopausal migraines, this study proposes a new perspective of the therapeutic approach of migraine syndrome associated with menopausal transition and the premenstrual period.

METHODS

We selected the reviewed papers from CrossRef, PubMed, Medline, and GoogleScholar, and a total of 21 studies met our inclusion criteria.

RESULTS

To date, no specific preventive measures have been recommended for menopausal women with migraines. BoNT-A often reduces the frequency and intensity of migraine attacks per month; the treatment is well tolerated and does not exhibit a significantly higher rate of treatment-related side effects. No population-based studies were conducted in order to highlight the role of BoNT-A in menopause-related migraines, neither in menstrual migraines.

CONCLUSION

There is a need for further research in order to quantify the real burden of menstrual and perimenopausal migraines and to clarify if BoNT-A could be used in the treatment of refractory postmenopausal and premenstrual migraines.

Socioeconomic determinants affecting the access and utilization of depression care services in immigrants: A population-based study

BACKGROUND

It is imperative to address the health problems faced by immigrants in their destination countries in light of the current magnitude of migration processes worldwide. We aimed to evaluate the socioeconomic determinants of healthcare utilization in immigrants with depression.

METHOD

A population-based cohort comprising all immigrants who were eligible for National Health Insurance coverage (permanent residents, marriage immigrants, and naturalized citizens) using the National Health Insurance Claims Database in 2011-2013 was established. Cases were defined as immigrants with new-onset depression. Controls were new-onset Korean patients with depression matched by age, sex, and Charlson comorbidity index in a 1:2 ratio. Appropriateness of care (AOC) was defined as visiting a clinic for depression management at least 3 times in the first 12 weeks and 4 times thereafter until 12 months post-cohort entry.

RESULTS

A total of 2,378 immigrants and 4,756 matched Korean patients were identified. Of the immigrants, 30.0% achieved AOC, in contrast to 38.7% of Koreans (p < .0001). Adjusting for possible covariates, AOC was less likely for immigrants (adjusted OR (aOR), 0.760; 95% CI: 0.670-0.863). Medical Aid (aOR, 2.309; 95% CI, 1.479-3.610), rural residence (aOR, 1.536; 95% CI, 1.054-2.237), the presence of a psychiatric comorbidity (aOR, 1.912; 95% CI, 1.484-2.463), and visiting a psychiatrist (aOR, 2.387; 95% CI, 1.821-3.125) were associated with an increased likelihood of AOC in immigrants.

CONCLUSION

Socioeconomic determinants included insurance type (Medical Aid and National Health Insurance), place of residence, psychiatric comorbid status, doctor specialty, easy access to medical services (clinic-based), and a SSRI-based treatment regimen. Those predictors should be taken into account when developing healthcare strategies for immigrants.

Quantitation of escitalopram and its metabolites by liquid chromatography-tandem mass spectrometry in psychiatric patients: New metabolic ratio establishment

Therapeutic drug monitoring (TDM) is used to determine the concentration of drug in plasma/serum to adjust the dose of the therapeutic drug. Selective and sensitive analytical methods are used to determine drug and metabolite levels for the successful application of TDM. The aim of the study was to develop and validate using LC-MS/MS to analyse quantitative assay of escitalopram (S-CT) and metabolites in human plasma samples. In order to provide a convenient and safe treatment dose, it was aimed to determine the levels of S-CT and its metabolites in the patients' plasma. A new method with short sample preparation and analysis time was developed and validated using LC-MS/MS to analyse quantitative assay of S-CT and its metabolites in plasma. Also, plasma samples of 30 patients using 20 mg S-CT between the ages of 18 and 65 years were analysed by the validated method. The mean values of S-CT, demethyl escitalopram and didemethyl escitalopram in plasma of patients were 27.59, 85.52 and 44.30 ng/mL, respectively. At the end of the analysis, the metabolic ratio of S-CT and metabolites was calculated. It is considered that the method for the quantitative analysis of S-CT and its metabolites in human plasma samples may contribute to the literature on account of its sensitive and easy application. Additionally, the use of our data by physicians will contribute to the effective drug treatment for their patients who take S-CT.

Copper-catalyzed cyanation of heterocycle C–H bonds with ethyl(ethoxymethylene)cyanoacetate as a cyanating agent and its mechanism

A method for copper-catalyzed cyanation of heterocycles with ethyl(ethoxymethylene)cyanoacetate as a nontoxic and easily available cyanating agent via C–H bond activation has been developed.

The Effects of Fluvoxamine on the Steady-State Plasma Concentrations of Escitalopram and Desmethylescitalopram in Depressed Japanese Patients

BACKGROUND

The aim of this study was to determine the impact of fluvoxamine, an inhibitor of Cytochrome P450 (CYP) 2C19 (CYP2C19), on the pharmacokinetics of escitalopram, a substrate of CYP2C19.

METHODS

Thirteen depressed patients initially received a 20-mg/d dose of escitalopram alone. Subsequently, a 50-mg/d dose of fluvoxamine was administered because of the insufficient efficacy of escitalopram. Plasma concentrations of escitalopram and desmethylescitalopram were quantified using high-performance liquid chromatography before and after fluvoxamine coadministration. The QT and corrected QT (QTc) intervals were measured before and after fluvoxamine coadministration.

RESULTS

Fluvoxamine significantly increased the plasma concentrations of escitalopram (72.3 ± 36.9 ng/mL versus 135.2 ± 79.7 ng/mL, P < 0.01) but not those of desmethylescitalopram (21.5 ± 7.0 ng/mL versus 24.9 ± 12.0 ng/mL, no significance [ns]). The ratios of desmethylescitalopram to escitalopram were significantly decreased during fluvoxamine coadministration (0.37 ± 0.21 versus 0.21 ± 0.10, P < 0.01). The CYP2C19 genotype did not fully explain the degree of the change. Fluvoxamine coadministration did not change the QT or QTc intervals.

CONCLUSIONS

The results of this study suggest that adjunctive treatment with fluvoxamine increases the concentration of escitalopram. The QTc interval did not change in this condition.

R- and S-citalopram concentrations have differential effects on neuropsychiatric scores in elders with dementia and agitation

AIMS

The aim was to determine the relationship between (R) and (S)-citalopram enantiomer exposure (AUC(0,24 h)) and therapeutic response in agitated individuals greater than 60 years old with Alzheimer's dementia (AD).

METHODS

Citalopram enantiomer exposures (AUC(0,24 h)) derived from an established population pharmacokinetic analysis were utilized to explore the relationship between (R)- and (S)-citalopram area under the curve (AUC(0,24 )) and Mini-Mental State Examination (MMSE), Neurobehavioural Rating Scale-Agitation Subscale (NBRS-A), modified Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC) and Neuropsychiatric Inventory Agitation subscale (NPIA) scores. Time dependent changes in these scores (disease progression) were accounted for prior to exploring the exposure effect relationship for each enantiomer. These relationships were evaluated using a non-linear-mixed effects modelling approach as implemented in nonmem v7.3.

RESULTS

(S)-AUC(0,24 h) and (R)-AUC(0,24 h) each contributed to improvement in NBRS-A scores (k3(R) -0.502; k4(S) -0.712) as did time in treatment. However, increasing (R)-AUC(0,24 h) decreased the probability of patient response (maximum Δ -0.182%/AUC(0,24 h)) based on the CGIC while (S)-AUC(0,24 h) improved the probability of response (maximum Δ 0.112%/AUC(0,24 h)). (R)-AUC(0,24 h) was also associated with worsening in MMSE scores (-0.5 points).

CONCLUSIONS

Our results suggest that citalopram enantiomers contributed differentially to treatment outcomes. (R)-citalopram accounted for a greater proportion of the adverse consequences associated with racemic citalopram treatment in patients with AD including a decreased probability of treatment response as measured by the CGIC and a reduction in MMSE scores. The S-enantiomer was associated with increased probability of response based on the CGIC.

Transcriptome composition of the preoptic area in mid-age and escitalopram treatment in male mice

The decrease in serotonergic neurotransmission during aging can increase the risk of neuropsychiatric diseases such as depression in elderly population and decline the reproductive system. Therefore, it is important to understand the age-associated molecular mechanisms of brain aging. In this study, the effect of aging and chronic escitalopram (antidepressant) treatment to admit mice was investigated by comparing transcriptomes in the preoptic area (POA) which is a key nucleus for reproduction. In the mid-aged brain, the immune system-related genes were increased and hormone response-related genes were decreased. In the escitalopram treated brains, transcription-, granule cell proliferation- and vasoconstriction-related genes were increased and olfactory receptors were decreased. Since homeostasis and neuroprotection-related genes were altered in both of mid-age and escitalopram treatment, these genes could be important for serotonin related physiologies in the POA.

Palladium-Catalyzed Synthesis of α-Iminonitriles from Aryl Halides via Isocyanide Double Insertion Reaction

An efficient one-pot synthesis of α-iminonitriles from readily available aryl halides via palladium-catalyzed double isocyanide insertion and elimination has been developed, without using various hypertoxic cyanides and excess oxidants. Furthermore, the utility of this reaction was demonstrated by the rapid total synthesis of quinoxaline and the reaction of functional groups exchanged with aryl halides.

Pharmacokinetics of antidepressants in patients with hepatic impairment

Appropriate use of antidepressant in patients with hepatic impairment requires careful consideration of how the hepatic illness may affect pharmacokinetics. This review aims to analyze pharmacokinetic profile, plasma level variations so as the metabolism of several antidepressants relating to their use in patients with an hepatic impairment. Due to the lack of data regarding hepatic impairment itself, the review is focused mainly on studies investigating pharmacokinetics in hepatic cirrhosis or alcohol-related conditions. More data on reduced hepatic metabolism can be extrapolated by drug studies conducted in elderly populations. Dose adjustment of antidepressants in these patients is important as most of these drugs are predominantly metabolized by the liver and many of them are associated with dose-dependent adverse reactions. As no surrogate parameter is available to predict hepatic metabolism of drugs, dose adjustment according to pharmacokinetic properties of the drugs is proposed. There is a need for a more balanced assessment of the benefits and risks associated with antidepressants use in patients with hepatic impairment, particularly considering pharmacokinetic profile of the drugs to ensure that patients, who would truly benefit from these agents, are not denied appropriate treatment. In conclusion, kinetic studies for centrally acting drugs including antidepressants with predominant hepatic metabolism should be carried out in patients with liver disease to allow precise dose recommendations for enhanced patient safety.

[Evidence-based choice and antidepressants treatment in psychiatry]

Depression is a severe and usually recurrent mental disorder which leads to a prominent impairment of physical and social functioning, a reduced quality of life of the patients, implies as well an increased morbidity and mortality. Reducing the social-economic depression burden is possible in the optimization of decision-making process of antidepressant choice (including SSRIs and SNRIs) based on the evidence-based risk/benefit ratio and resource saving potential treatment involving target psychosocial interventions and monitoring of long-term treatment adherence.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

Sodium channel blockade with QRS widening after an escitalopram overdose

INTRODUCTION

Escitalopram is rarely associated with prolongation of the QTc interval; however, there are no reported cases of QRS complex widening associated with escitalopram overdose. We report a case of a patient who presented with both QRS complex widening and QTc interval prolongation after an escitalopram overdose.

CASE

A 16-year-old girl presented to the emergency department after ingestion of escitalopram, tramadol/acetaminophen, and hydrocodone/acetaminophen. Laboratory results were significant for 4-hour acetaminophen 21.1 μg/mL. Serum electrolytes including potassium, magnesium, and calcium were all normal. Initial electrocardiogram (ECG) revealed a widened QRS with an incomplete right bundle branch pattern. After administration of 100-mEq sodium bicarbonate, a repeat ECG revealed narrowing of the QRS complex and a prolonged QTc interval. Magnesium sulfate 2 g intravenous and sodium bicarbonate drip were initiated. A repeat ECG, 1 hour after the second, revealed normalization of the QRS complex and QTc interval.

DISCUSSION

Prolongation of the QTc interval is an expected effect of escitalopram. Both escitalopram and citalopram are metabolized to the cardiotoxic metabolite S-didesmethylcitalopram and didesmethylcitalopram, respectively, which have been implicated in numerous cardiac abnormalities including widening of the QRS complex. Although never previously described with escitalopram, this mechanism provides a reasonable explanation for the QRS complex widening and incomplete right bundle branch block that occurred in our patient.

CONCLUSIONS

Both QRS complex widening and QTc interval prolongation should be monitored in cases of escitalopram and citalopram overdoses.

Combining a dopamine agonist and selective serotonin reuptake inhibitor for the treatment of depression: a double-blind, randomized pilot study

BACKGROUND

Antidepressants that act on two or more amine neurotransmitters may confer higher remission rates when first-line agents affecting a single neurotransmitter have failed. Pramipexole, a dopamine agonist, has antidepressant effects in patients with major depressive disorder (MDD). This pilot study examined the efficacy and safety of combination therapy with pramipexole and the selective serotonin reuptake inhibitor (SSRI) escitalopram in MDD.

METHODS

In this double-blind, controlled, pilot study, 39 patients with DSM-IV MDD who had failed to respond to a standard antidepressant treatment trial were randomized to receive pramipexole (n=13), escitalopram (n=13), or their combination (n=13) for six weeks. Pramipexole was started at 0.375 mg/day and titrated weekly up to 2.25 mg/day; escitalopram dosage remained at 10 mg/day. The primary outcome measure was the Montgomery-Asberg Depression Rating Scale (MADRS).

RESULTS

Subjects receiving pramipexole monotherapy had significantly lower MADRS scores than the combination group (p=0.01); no other primary drug comparisons were significant. The combination group had a substantially higher dropout rate than the escitalopram and pramipexole groups (69%, 15%, 15%, respectively). Only 15% of patients in the combination group tolerated regularly scheduled increases of pramipexole throughout the study, compared with 46% of patients in the pramipexole group.

LIMITATIONS

Group size was small and the treatment phase lasted for only six weeks.

CONCLUSIONS

The combination of an SSRI and a dopamine agonist was not more effective than either agent alone, nor did it produce a more rapid onset of antidepressant action. Combination therapy with escitalopram and pramipexole may not be well-tolerated.

Rapid improvement of depression and quality of life with escitalopram treatment in outpatients with breast cancer: a 12-week, open-label prospective trial

BACKGROUND

Among patients with cancer, the management of depression is very important to improve quality of life as well as distress. Because the efficacy of escitalopram, a potent serotonin reuptake inhibitor, has not been well evaluated in cancer patients, we investigated its effects on depression and quality of life in outpatients with breast cancer.

METHODS

A 12-week, open-label, prospective study with escitalopram (5-20mg/day) was performed in 79 breast cancer outpatients with depression. The primary outcome was measured using the Hamilton Depression Rating Scale (HAMD), which was administered at baseline, 1, 2, 4, 8, and 12 weeks after treatment. The Functional Assessment of Cancer Therapy-Breast (FACT-B), MD Anderson Symptoms Inventory (MDASI), Clinical Global Impression-Severity of Illness (CGI-S), and Distress Thermometer (DT) were also used to measure improvement in symptoms, distress, and quality of life.

RESULTS

Compared to baseline, HAMD, DT, and CGI-S scores were significantly decreased at week 1 and onwards, and FACT-B and MDSAI were improved at week 2 and onwards. At the end point (week 12), all FACT-B subscales including the physical, emotional, social/family, functional well-being, and the breast cancer subscales were improved. Improvement in distress and quality of life was associated with a reduction in depressive symptoms. Of all participants, 45.1% met the response criterion (at least a 50% decrease in HAMD total score), and 30.6% met the remission criterion (HAMD total score ≤ 7) at week 12.

CONCLUSIONS

In the present study, escitalopram improved quality of life and reduced depression in breast cancer patients. Symptoms rapidly improved within 1 week, influencing quality of life. Escitalopram may be an effective treatment of depressive symptoms in breast cancer patients.