Use of Endocrine Hormones for Treating Depression

Finding intestinal fortitude: Integrating the microbiome into a holistic view of depression mechanisms, treatment, and resilience

Depression affects at least 322 million people globally, or approximately 4.4% of the world's population. While the earnestness of researchers and clinicians to understand and treat depression is not waning, the number of individuals suffering from depression continues to increase over and above the rate of global population growth. There is a sincere need for a paradigm shift. Research in the past decade is beginning to take a more holistic approach to understanding depression etiology and treatment, integrating multiple body systems into whole-body conceptualizations of this mental health affliction. Evidence supports the hypothesis that the gut microbiome, or the collective trillions of microbes inhabiting the gastrointestinal tract, is an important factor determining both the risk of development of depression and persistence of depressive symptoms. This review discusses recent advances in both rodent and human research that explore bidirectional communication between the gut microbiome and the immune, endocrine, and central nervous systems implicated in the etiology and pathophysiology of depression. Through interactions with circulating inflammatory markers and hormones, afferent and efferent neural systems, and other, more niche, pathways, the gut microbiome can affect behavior to facilitate the development of depression, exacerbate current symptoms, or contribute to treatment and resilience. While the challenge of depression may be the direst mental health crisis of our age, new discoveries in the gut microbiome, when integrated into a holistic perspective, hold great promise for the future of positive mental health.

Pharmacological approaches to the challenge of treatment-resistant depression

Although monoaminergic antidepressants revolutionized the treatment of Major Depressive Disorder (MDD) over a half-century ago, approximately one third of depressed patients experience treatment-resistant depression (TRD). Such patients account for a disproportionately large burden of disease, as evidenced by increased disability, cost, human suffering, and suicide. This review addresses the definition, causes, evaluation, and treatment of unipolar TRD, as well as the major treatment strategies, including optimization, augmentation, combination, and switch therapies. Evidence for these options, as outlined in this review, is mainly focused on large-scale trials or meta-analyses. Finally, we briefly review emerging targets for antidepressant drug discovery and the novel effects of rapidly acting antidepressants, with a focus on ketamine.

Generic switching and non-persistence among medicine users: a combined population-based questionnaire and register study

BACKGROUND

Generic substitution means that one medicinal product is replaced by another product containing the same active substance. It is strictly regulated with respect to its bioequivalence, and all products must have undergone appropriate studies. Although generic substitution is widely implemented, it still remains to be answered how generic switch influences persistence to long-term treatment, and if it is modified by patients' concerns about medicine and views on generic medicine. This study focuses on users of antidepressants and antiepileptics, and their experience of generic switching.

METHODS

The study was an observational cohort study. By use of a prescription database, we identified patients who had redeemed prescriptions on generically substitutable drugs, and a questionnaire was mailed to them. We analyzed predictors of discontinuation in relation to generic switch and patients' attitudes towards generic medicines and concerns about their medicine.

RESULTS

Patients who experience their first-time switch of a specific drug were at higher risk of non-persistence, Hazard Ratio 2.98, 95% CI (1.81;4.89) versus those who have never switched, and 35.7% became non-persistent during the first year of follow-up. Generic switching did not influence persistence considerably in those having previous experience with generic switching of the specific drug. Stratified analyses on users of antidepressants and antiepileptics underpin the results, showing higher risk of non-persistence for first-time switchers for both drug categories.

CONCLUSION

In conclusion, patients who are first-time switchers of a specific drug were at higher risk of non-persistence compared to never switchers and those having experienced previous generic switching.

Meta-review of depressive subtyping models

BACKGROUND

Increasing dissatisfaction with the non-specificity of major depression has led many to propose more specific depressive subtyping models. The present meta-review seeks to map dominant depressive subtype models, and highlight definitions and overlaps.

METHODS

A database search in Medline and EMBASE of proposed depressive subtypes, and limited to reviews published between 2000 and 2011, was undertaken. Of the more than four thousand reviews, 754 were judged as potentially relevant and provided the base for the present selective meta-review.

RESULTS

Fifteen subtype models were identified. The subtypes could be divided into five molar categories of (1) symptom-based subtypes, such as melancholia, psychotic depression, atypical depression and anxious depression, (2) aetiologically-based subtypes, exemplified by adjustment disorders, early trauma depression, reproductive depression, perinatal depression, organic depression and drug-induced depression, (3) time of onset-based subtypes, as illustrated by early and late onset depression, as well as seasonal affective disorder, (4) gender-based (e.g. female) depression, and (5) treatment resistant depression. An overview considering definition, bio-psycho-social correlates and the evidence base of treatment options for each subtype is provided.

LIMITATIONS

Despite the large data base, this meta-review is nevertheless narrative focused.

CONCLUSIONS

Subtyping depression is a promising attempt to overcome the non-specificity of many diagnostic constructs such as major depression, both in relation to their intrinsic non-specificity and failure to provide treatment-specific information. If a subtyping model is to be advanced it would need, however, to demonstrate differential impacts of causes and treatments.

[Organic and comorbid causes of depression: a first step]

The primary objective of this review is to obtain a clinical orientation as to evidence-supported common «other» causes of depressive symptomatology, which predominantly are: medical issues; life events; vitamin, mineral and diet-related deficiencies; and hormones. A secondary goal was to reflect those more frequent "other" causes in a checklist for clinical use, comprising also the preferred treatment (medical/dietary, antidepressants, or psychological) resulting from the available evidence. Medline, Cochrane and main related databases were searched from 4(th) October 2010 to 27(th) April 2011, no language limits, with keywords: depression; organic; comorbid; medication; life events; hormones; vitamin; mineral; diet; disease; as well as further searches into each upcoming possibly related issue. Total studies contemplated: 3.211; total studies reviewed: 301, with criteria of relevancy; date of study or review; size and type; journal status. Data were abstracted based upon probable clinical relevancy and use. The main results obtained were evidence-supported indications as to these other causes of depressive symptomatology, that warrant early screening, attention and treatment, possibly before antidepressant or psychological therapy is started. PRELIMINARY CONCLUSION: There appears to be a clinical rationale for early checking of a number of evidence-based causes of depressive symptoms for which first-line testing is readily available. In several cases clinical treatment may be simple, and improvements in depressive symptoms rapidly obtainable. Using a pre-treatment protocol, both patients and health systems could benefit from biological and comorbid causes of depressive symptoms being established early. An enhanced response to low-cost corrective measures can decrease the risk of suicide.

When Is a "Generic" Medication not Really a Generic?

The distinction between pharmaceutical equivalent and pharmaceutical alternative drug products can lead to considerable confusion, especially with the proliferation of various branded, alternative, and generic medications that contain the same active ingredient. To illustrate this problem, four examples of medication products containing the active ingredients paroxetine, venlafaxine, bupropion, and valproate will be described. Understanding these differences is important for nurses providing patient care. Only generic drugs can be freely substituted for a brand-name product. Switching to a pharmaceutical alternative requires a change in prescription. Finally, the use, labeling, and cost of branded, alternative, and generic medications may be different.