Venlafaxine in the treatment of dysthymia: an open-label study

Evaluation of venlafaxine on glucose homeostasis and oxidative stress in diabetic mice

Depression occurs frequently with diabetes affecting the quality of life. All major classes of antidepressants have been shown to have a direct pharmacologic effect on metabolic function, which further worsens glycemic control. There were no reports on the effects of venlafaxine on glucose levels and oxidative stress in diabetic animals. The present study evaluated the effects of venlafaxine (8 and 16 mg/kg per d) on glucose homeostasis along with oxidative stress in brain in diabetic mice (streptozotocin (STZ), 40 mg/kg per d for 5 days). We observed that 21 days of administration of venlafaxine (8 and 16 mg/kg per d) in diabetic mice significantly enhanced swimming in normal and STZ-treated mice with a corresponding reduction in immobility. No significant difference in blood glucose levels was observed in diabetic and normal mice following venlafaxine treatment. Venlafaxine (16 mg/kg) reversed STZ-induced elevated thiobarbituric acid reactive substance (TBARS) levels and also restored the glutathione (GSH) levels in diabetic mice. Venlafaxine (8 and 16 mg/kg) per se does not produce any significant effect in normal animals. The results indicate a dose-dependent antidepressant action of venlafaxine in diabetes-induced depressive mice. Furthermore, the blood glucose levels were not significantly altered in normal and diabetic mice. In addition, venlafaxine exhibited a decrease in TBARS and elevation in GSH levels in mice brain. Venlafaxine drug treatment appears to be safer for depression associated with diabetes.

Dysthymia and apathy: diagnosis and treatment

Dysthymia is a depressive mood disorder characterized by chronic and persistent but mild depression. It is often difficult to be distinguished from major depression, specifically in its partially remitted state because "loss of interest" or "apathy" tends to prevail both in dysthymia, and remitted depression. Apathy may also occur in various psychiatric and neurological disorders, including schizophrenia, stroke, Parkinson's disease, progressive supranuclear palsy, Huntington's disease, and dementias such as Alzheimer's disease, vascular dementia, and frontotemporal dementia. It is symptomatologically important that apathy is related to, but different from, major depression from the viewpoint of its causes and treatment. Antidepressants, especially noradrenergic agents, are useful for depression-related apathy. However, selective serotonin reuptake inhibitors (SSRIs) may be less effective for apathy in depressed elderly patients and have even been reported to worsen apathy. Dopaminergic agonists seem to be effective for apathy. Acetylcholine esterase inhibitors, methylphenidate, atypical antipsychotics, nicergoline, and cilostazol are another choice. Medication choice should be determined according to the background and underlying etiology of the targeting disease.

Venlafaxine reverses chronic fatigue-induced behavioral, biochemical and neurochemical alterations in mice

A state of chronic fatigue was produced in mice by subjecting them to forced swim inside a rectangular jar of specific dimensions everyday for a 6 min session for 15 days. Immobility period was recorded on alternate days. The effect of venlafaxine, a dual reuptake inhibitor of serotonin and norepinephrine was evaluated in this murine model of chronic fatigue. Venlafaxine was administered daily and on the days of testing, it was injected 30 min before forced swim session. On the 16th day i.e. 24 h after the last dose of venlafaxine, various behavioral, biochemical and neurotransmitter estimations in the brain were carried out. There was a significant increase in immobility period in vehicle treated mice on successive days, the maximum immobility score reaching on the 7th day and sustained till 15th day. Behavioral parameters revealed hyperlocomotion, anxiety response, muscle incoordination, hyperalgesia and memory deficit. Biochemical analysis showed a significant increase in lipid peroxidation, nitrite and myeloperoxidase levels and a decrease in the reduced glutathione (GSH) levels in brain homogenates. Further, there was a decrease in adrenal ascorbic acid following chronic forced swim. The neurotransmitter estimations in the brain samples revealed a decrease in norepinephrine, serotonin and dopamine levels on chronic exposure to forced swim for 15 days. Daily treatment with venlafaxine (8 and 16 mg/kg, i.p.) for 15 days produced a significant reduction in immobility period and reversed various behavioral, biochemical and neurotransmitter alterations induced by chronic fatigue. Venlafaxine could be of therapeutic potential in the treatment of chronic fatigue.

Non-pharmacological treatment of psychiatrists in addition to the prescribing of an antidepressant drug

BACKGROUND

Guidelines for the treatment of depression regularly emphasize that pharmacotherapy of depression should be accompanied by supportive counseling and other psychotherapeutic interventions. It is unknown which role psychiatrists in routine care give to such verbal therapies.

METHODS

In a drug utilization study of venlafaxine, psychiatrists in private practice and in hospitals were asked to tell what non-pharmacological therapies they saw as an important part of the treatment of the present depressive episode. Additionally patient characteristics, treatment variables, setting characteristics and physician characteristics were assessed.

RESULTS

Psychiatrists reported some kind of verbal therapies in 19.0% of outpatients and 36.8% of inpatients. Verbal therapies were reported more often for younger patients, who got more double diagnoses and were more severely ill. Patients with verbal therapies got more psychotropic medication. In the inpatient setting verbal therapies were related to generally more treatment overall and a higher rate of treatment response. In both treatment settings verbal therapies were related to lower rates of discontinuation of the antidepressant.

CONCLUSION

Verbal interactions are part of any patient-physician encounter and should be theory guided as part of the therapeutic process in the treatment of depressive disorders. Under this assumption the rate of patients for which psychiatrists reported some kind of verbal therapy as explicit part of their treatment could be higher. More research is needed on patient guidance, counseling and supportive psychotherapy in psychiatry.

N-Benzyl-N-(tetrahydro-2H-pyran-4-yl)pyrrolidin-3-amines as selective dual serotonin/noradrenaline reuptake inhibitors

A series of N-benzyl-N-(tetrahydro-2H-pyran-4-yl)pyrrolidin-3-amine monoamine reuptake inhibitors are described. Selective dual 5-HT and NA reuptake inhibition was achieved, and analogues with weak CYP2D6 inhibition, good human in vitro metabolic stability and wide ligand selectivity, such as 12b, were identified.

A double-blind, randomised, controlled clinical trial of acetyl-L-carnitine vs. amisulpride in the treatment of dysthymia

AIM

Evaluation of the effect of acetyl-L-carnitine (ALCAR) vs. amisulpride measured by total Hamilton Depression Rating Scale score (HAM-D(21)) in patients with pure dysthymia (DSM IV). Two hundred and four patients were randomised and treated with ALCAR 500 mg b.i.d. or amisulpride 50 mg u.i.d. in a double-blind study, for 12 weeks.

RESULTS

A solid improvement of HAM-D(21) was observed in both treatment groups throughout the study. The results did not disclose statistically significant differences between treatments, although the confidence interval for the non-inferiority of the primary end-point exceeded the pre-established limit of 2 by 0.46 points. According to a non-inferiority margin of 3 (considered acceptable by recent published data) the primary end-point could have been fully satisfied. CDRS, MADRS and CGI, employed to further measure the clinical outcome, reported similar results in both treatment groups. The greater tolerability of ALCAR is of clinical relevance considering the chronicity of dysthymia, which often requires prolonged treatment.

Citalopram in the treatment of dysthymic disorder

This study aimed to provide preliminary data on the tolerability and effectiveness of citalopram for patients with dysthymic disorder. Twenty-one adult subjects meeting DSM-IV criteria for dysthymic disorder were enrolled in this 12-week open-label study, of whom 15 had pure dysthymia (e.g. no major depression in the past 2 years). Citalopram was initiated at 20 mg/day, and increased to a maximum of 60 mg/day. Response was defined as 50% or greater drop in score on the Hamilton Depression Rating Scale (HDRS) and a Clinical Global Impressions-I score of 1 ('very much improved') or 2 ('much improved'). Of these 15 pure dysthymic disorder subjects, all completed the trial, and 11 (73.3%) were treatment responders. All paired sample t-tests were highly significant, demonstrating significant average improvement on all measures of symptomatology and functioning. Scores on the 24-item HDRS decreased from 22.3+/-4.3 at baseline to 9.1+/-7.8 at week 12 [t(14)=6.1, P<0.001]. In addition, improvement was noted in self-reported measures of temperament and social functioning. The average final dose of citalopram was 39 mg/day. Side-effects were reported by nine of 15 subjects (60%), most frequently gastrointestinal symptoms (n=5), dry mouth (n=5) and sexual side-effects (n=3). These findings suggest the effectiveness and tolerability of citalopram in treating dysthymic disorder. Double-blind prospective studies are needed comparing citalopram both to placebo and to other medications, assessing both initial and sustained response to treatment.

Dysthymic disorder: treatment with citalopram

We studied 15 patients with dysthymic disorder with open-label citalopram. The purpose of this study was to determine the dose range and safety of citalopram necessary for treatment of patients with dysthymic disorder and to attempt to increase doses in order to enhance remission of patients with dysthymic disorder when treated. Citalopram was well tolerated. The mean dose used in this 10-week study was 37.3 mg and the majority of patients responded to treatment. Various criteria for response and remission were employed. These findings are intended to give guidelines for a subsequent treatment study of dysthymic patients with citalopram using a double-blind placebo-controlled strategy.

Dysthymic disorder: integrating research findings into clinical treatment

Dysthymic disorder, a form of chronic depression, has been studied over the past two decades. A variety of forms of research, from epidemiological research to psychopharmacology and psychotherapy outcome studies, has provided data that may help clinicians who treat patients with dysthymic disorder. This article reviews clinically relevant research studies and applies their findings to the clinical setting. Epidemiological research and prospective follow-up studies can define the risks of untreated and under-treated chronic depression. Studies on the phenomenology of dysthymic disorder can help the clinician assess target symptoms. Psychopharmacology and psychotherapy research can help guide treatment choices. The emerging literature on combining medication and psychotherapy can clarify goals for different phases of treatment. Thus the clinician has a significantly greater chance of helping patients with dysthymic disorder now than only 20 years ago.

Antidepressant efficacy of venlafaxine

Venlafaxine is a unique antidepressant medication with well documented efficacy and safety in the acute treatment of major depressive disorder. Reports suggest that it may also be effective in the treatment of dysthymic disorder and bipolar II depression, but the available data for these conditions are more limited compared to major depressive disorder. Several studies suggest that there may be a more rapid onset of action for venlafaxine in the treatment of major depression compared to other antidepressant pharmacotherapies, but this has not been fully established. Venlafaxine is also effective in the important long term continuation and maintenance phases of the treatment of depression.

Bupropion sustained-release for the treatment of dysthymic disorder: an open-label study

Many studies of antidepressants in the treatment of dysthymic disorder (DD) have been conducted, but none has included bupropion sustained-release (SR). The aim of this study was to provide preliminary data on the tolerability and effectiveness of bupropion SR for patients with DD. Twenty-one adult subjects meeting DSM-IV criteria for DD were enrolled in this 8-week open-label study. Bupropion SR was initiated at 150 mg/day and was increased to a maximum of 200 mg, twice daily. Response was defined as a 50% or greater decrease in score on the Hamilton Rating Scale for Depression (HAM-D). Of these 21 subjects, 15 (71.4%) responded to treatment. All paired sample t-tests were highly significant, demonstrating average improvement on all measures of symptomatology and functioning. Subject scores on the HAM-D decreased from 21.7 +/- 5.6 at baseline to 5.9 +/- 3.6 at week 8 (t[19] = 12.74, p < 0.001). The average final dosage was 364 mg/day. None of the subjects dropped out during the trial. Patients with a history of alcohol or chemical abuse were significantly less likely to respond to bupropion. Side effects were reported by eight subjects (38.1%), and the most frequently reported effects were headache, decreased appetite, insomnia, gastrointestinal problems, restlessness, and tremulousness. These findings suggest the effectiveness and high tolerability of bupropion SR for the treatment of DD. Double-blind prospective studies are needed for the comparison of bupropion SR to both placebo and other medications, assessing both initial and sustained responses to treatment.