Moving from serotonin to serotonin-norepinephrine enhancement with increasing venlafaxine dose: clinical implications and strategies for a successful outcome in major depressive disorder

INTRODUCTION

Mental health disorders, especially depressive and anxiety disorders, are associated with substantial health-related burden. While the second-generation antidepressants are widely accepted as first-line pharmacological treatment for major depressive disorder (MDD), patient response to such treatment is variable, with more than half failing to achieve complete remission, and residual symptoms are frequently present.

AREAS COVERED

Here, the pharmacodynamics of venlafaxine XR are reviewed in relation to its role as both a selective serotonin reuptake inhibitor (SSRI) and a serotonin-norepinephrine-reuptake inhibitor (SNRI), and we look at how these pharmacodynamic properties can be harnessed to guide clinical practice, asking the question 'is it possible to develop a symptom-cluster-based approach to the treatment of MDD with comorbid anxiety utilizing venlafaxine XR?.' Additionally, three illustrative clinical cases provide practical examples of the utility of venlafaxine-XR in real-world clinical practice. The place of venlafaxine XR in managing fatigue/low energy, a frequent residual symptom in MDD, is explored using pooled data from clinical trials of venlafaxine XR.

EXPERT OPINION

Venlafaxine XR should be considered as a first-line treatment for MDD with or without comorbid anxiety, and there are clear pharmacodynamic signals supporting a symptom cluster-based treatment paradigm for venlafaxine XR.

PHYSICAL ACTIVITY AND SYMPTOMS OF ANXIETY AND DEPRESSION AMONG MEDICAL STUDENTS DURING A PANDEMIC

ABSTRACT Introduction: Decreased physical activity has been associated with poorer mental health and is a cause for concern during the COVID-19 pandemic. Objective: To compare groups of medical students (MS) who practiced different levels of moderate and vigorous physical activity (MVPA) during the COVID-19 pandemic, in relation to symptoms of anxiety and depression (BAI-BDI), sleep quality (PSQI), and physical activity (PA) - light, moderate, vigorous (LPA-MPA and VPA), and sedentary behavior (SB). Methods: This research is a cross-sectional study involving 218 MS. Data on the characteristics of the MS were collected through online forms: PA, SB, BAI, BDI, and PSQI. The Cohen's D (Effect Size - ES) and confidence interval (95% CI), Mann-Whitney test: Lower MVPA (Median=0 minute) and Higher MVPA (Median=390 minutes) were recorded. For the statistical analyses, we used: the Odds ratio (OR) for the presence of symptoms of high levels of anxiety and depression and poor sleep quality in the MS and MVPA. Results: We found a small ES for symptoms of depression (ES 0.26 95% CI 0.00 0.53 p=0.029), and significant differences (p<0.05) for symptoms of anxiety (ES 0.17 95% CI −0.09 0.44 p=0.037). There was also a significant tendency for sedentary behavior on weekdays (ES 0.27 95% CI 0.00 0.53 p = 0.051). The OR for MVPA and the presence of symptoms of high levels of anxiety was 0.407 (95% CI = 0.228 to 0.724). Conclusions: the MS who practiced higher MVPA presented less symptoms of anxiety and depression during the COVID-19 pandemic. Level of evidence III; Case-control study.

Reducing the stigma of mental health disorders with a focus on low- and middle-income countries

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.