Psychiatrists underestimate antidepressant side effects

People suffering from depression may have far more side effects than psychiatrists think they do. Mark Zimmerman from Rhode Island Hospital asked 300 people being treated for depression to fill out the Toronto Side Effects Scale. The patients rated the frequency of 31 side effects and the degree of trouble they experienced and this was compared to what the psychiatrists had documented. The average number of side effects recorded by the patients using the questionnaire was 20 times higher than the number recorded by the psychiatrists. Even when limiting the side effects to those which were 'frequently occuring' or 'very bothersome' the rate was still found to be two or three times higher than that recorded by the psychiatrists. The results are important as side effects are one of the most frequent reasons patients stop taking their medication.

You can find out more about this research at

http://www.sciencedaily.com/releases/2010/04/100419151112.htm?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+sciencedaily+%28ScienceDaily%3A+Latest+Science+News%29&utm_content=Google+Reader

Combination therapy more effective for depression

Between 50% and 75% of people show some improvement on first taking an antidepressant but only about a third completely recover after taking just one drug. Previous research has shown that a combination of drugs can have a better effect and a team of researchers led by Pierre Blier of the University of Ottawa studied the effectiveness of adding mirtazapine to various different antidepressants. Mirtazapine belongs to a different class of drugs to most other antidepressants and is classified as a noradrenergic and specific serotonergic antidepressant (NaSSA). 105 people with major depression received either fluoxetine on its own, or mirtazapine combined with fluoxetine, venlafaxine or bupropion. The recovery rates were 25% for fluoxetine, 52% for mirtazapine and fluoxetine, 58% for mirtazapine and venlafaxine and 46% for mirtazapine and bupropion. There were no extra side effects from using a combination of different drugs.

Blier, Pierre ... [et al] - Combination of antidepressant medications from treatment initiation for major depressive disorder: a double-blind randomized study American Journal of Psychiatry March 2010, 167(3), 281-288

Scopolamine might lift depression quicker

Conventional antidepressant treatment usually takes between three and four weeks to become effective so finding quicker-working drugs is of great interest both to clinicians and drug companies. The horse-anaesthetic and recreational drug ketamine has been found to lift mood quickly but researchers at the National Institutes of Health in the U.S. believe that they have found another drug that can act just as fast. Scopolamine temporarily blocks the muscarinic cholinergic receptor and was tested in a double-blind trial in which neither the researchers nor the participants knew whether those involved in the study were taking scopolamine or a placebo. Scopolamine was found to reduce symptoms of depression within three days and half of the participants experienced full symptom remission by the end of the treatment period. The effects of the scopolamine lasted for two weeks after people stopped taking it but there will need to be many more trials - including studies of scopolamine's side effects - before doctors can add scopolamine to their prescription pads as a new treatment for depression.

How effective are antidepressants?

Antidepressants could be little better than a placebo for all but the most severe depression. Researchers from the University of Pennsylvania in Philadelphia carried out a data analysis combining information from six different trials covering a total of 718 participants. They found that true advantages of antidepressants over placebos were 'non-existent to negligible' among depressed patients with mild, moderate and even severe symptoms. However, the drugs were very effective among patients with severe depression. The authors of the study pointed out that many studies used by drug companies to publicise the benefits of antidepressants only included severely-depressed people as participants.

You can find out more about this research at

http://www.sciencedaily.com/releases/2010/01/100105161538.htm?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+sciencedaily+%28ScienceDaily%3A+Latest+Science+News%29&utm_content=Google+Reader

Topping up with Omega-3 - does it work for depression?

Researchers from the Washington University School of Medicine in St Louis have been investigating the effectiveness of taking Omega-3 as well as antidepressants in a study of people with depression and heart disease. 122 people took part in the study. Half of them took sertraline and Omega-3 while the other half took sertraline and a placebo. The study found that after 10 weeks there was no difference between the group taking the Omega-3 and the group taking the placebo.

You can find out more about this research at

http://www.mentalhelp.net/poc/view_doc.php?type=news&id=123017&cn=5#

Depression in pregnancy

Postnatal depression is a well-known mental-health problem but now research is highlighting the issue of depression in pregnancy. Researchers from the U.S. health company Kaiser Permanente and Duke University in North Carolina studied 791 pregnant women and found that 44% of them had some symptoms of depression, nearly half of which were severe. Those women with depressive symptoms had nearly twice the risk of a premature birth - something which is the number one cause of infant mortality. It is estimated that 500,000 pregnancies in the U.S. each year involve women who have psychiatric illnesses. Pregnant women are recommended to avoid paroxetine (Paxil) which may increase the risk of birth defects and SSRIs (selective serotonin reuptake inhibitors) have also been linked to breathing and feeding problems.

You can find out more about this research at

http://www.mentalhelp.net/poc/view_doc.php?type=news&id=120671&cn=4

Augmentation, inflammation and depression

Augmentation strategies are used when people fail to respond to conventional antidepressants. They involve the use of other drugs - which are not antidepressants - alongside people's primary medication. Over the last twenty years research has suggested that inflammation and interactions between the nervous system and the immune system could play a part in the origins of depression and anti-inflammatory drugs have been suggested as possible candidates for drugs that could be used as part of an augmentation strategy. Researchers in Tehran studied the effect of using the anti-inflammatory drug celecoxib as a supplement to the antidepressant fluoxetine. They divided 40 participants into two groups. One group took fluoxetine and celecoxib while the other group took fluoxetine and a placebo. Both groups showed an improvement over the six weeks of the study but the group taking celecoxib did significantly better. There were no differences in side effects between the two groups.

Akhondzadeh, Shahin ... [et al] - Clinical trial of adjunctive celecoxib treatment in patients with major depression: a double-blind and placebo-controlled trial Depression and Anxiety July 2009, 26(7), 607-611

SSRI warnings affect depression care in U.S.

In 2003 the U.S. and European authorities sent out a series of public health warnings about the use of antidepressants in young people after clinical trials showed that they increased the risk of suicidal thoughts and behaviour in children and teenagers. In February 2005 the warnings were strengthened and in May 2007 they were extended to young adults between the ages of 18 and 24. Anne Libby and her colleagues from the University of Colorado analyzed health-insurance claims from the U.S. from July 1997 to June 2007 to see how the treatment and diagnosis of depression had changed over this period. They found steady increases in the rate of depression diagnoses between 1999 and 2004 but a sharp fall after that. Doctors diagnosed fewer cases of depression with a 44% lower rate among children and adolescents, a 37% lower rate among young adults and a 29% lower rate among other adults. There was an 8% rise in suicides among youth and teens in 2004. Doctors prescribed fewer SSRIs but did not turn to older drugs to treat depression and anxiety or offer psychotherapy as an alternative.

You can find out more about this research at

http://uk.reuters.com/article/healthNews/idUKTRE5507CO20090601?feedType=RSS&feedName=healthNews&sp=true

Dropping out of depression treatment

People who drop out of treatment for their depression are less likely to recover but why people drop out has received little study. Researchers from the University of Texas studied 179 people being treated for depression over the course of a year. 23% had dropped out after six months, 47% after a year. Beliefs about the perceived harmfulness of antidepressants predicted dropping out. Younger age and fewer side effects at baseline were associated with dropping out after six months. Younger age, better perceived physical functioning and more negative attitudes about antidepressants were associated with dropping out after a year.

Warden, Diane ... [et al] - Predictors of attrition during one year of depression treatment: a roadmap to personalized intervention Journal of Psychiatric Practice March 2009, 15(2), 113-124

SSRIs and suicide risk

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressants. They include paroxetine (brand name Paxil) and fluoxetine (Prozac). After 2003 authorities in the U.S. and Europe sent out warnings about their use following clinical trials which showed the drugs increased the risk of suicide in teenagers and children. A review of eight large studies involving more than 200,000 participants by researchers at the University of Verona has confirmed that the drugs do seriously raise the suicide risk for children. However, the study also found that SSRIs reduced the suicided risk for adults by 40% and for older adults by 50%.

You can find out more about this research at

http://uk.reuters.com/article/healthNews/idUKTRE5115YF20090202?feedType=RSS&feedName=healthNews&sp=true

Antidepressants much of a muchness

A review of more than 200 studies into the effectiveness of second-generation antidepressants has concluded that they are all equally effective although they do have different side effects. The review was carried out by the American College of Physicians which recommended that physicians make treatment decisions based on side effects, cost and patient preferences and make changes if the patient's response is not sufficient after 6-8 weeks. The guidelines issued by the college also recommend continuing treatment for four to nine months after a satisfactory response to an antidepressant in patients with a first episode of major depression. Those people who have had two or more episodes of depression should have a longer course of treatment aimed at preventing a recurrence or relapse.

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St John's Wort and depression

St John's Wort has long been used in folk medicine to treat depression and sleep disorders. The plant produces a number of different substances that may have anti-depressant properties although it is thought that the whole extract is more effective than its individual constituents. A review of 29 different studies, covering 5,489 participants, whose depression was assesse using the same methodology found that it was superior to placebos and as effective as standard antidepressants with fewer side effects. However, the researchers stressed that people should still see their doctor in the first instance as St John's Wort can interfere with the effectiveness of other medication and not all preparations of St John's Wort are equally effective.

You can find out more about this research at

http://psychcentral.com/news/2008/10/08/st-johns-wort-can-help-with-depression/3089.html

STAR*D study of persistent depression

Non-response to antidepressants is one of the major problems in mental health (see post below). Only about half of adult patients respond to the first antidepressant they try, with only a third achieving remission. Patients can either switch to a new drug altogether or augment the first drug with another one although it is not clear which of these strategies is the more effective. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study is the largest study into this issue ever undertaken and has found that both options are equally effective. The study also found that with persistent trial and error 7 out of 10 adult patients will eventually find a treatment that works.

You can find out more about this research at

http://psychcentral.com/news/2008/08/08/quest-for-a-better-antidepressant/2718.html

What happens when the (first) drugs don't work?

Major depression is usually very hard to treat. Studies have shown that only 11-30% of patients reach remission with initial treatment, even after 8-12 months. Most patients require a 'second-step' treatment but there is little information about the relative effectiveness of different drugs as a second step and prescribing tends to be done on a 'trial-and-error' basis. A U.S. study of 727 patients, between the ages of 18 and 75 looked at which factors were associated with a remission in patients being treated with 'second-step' medication. The researchers found that remission was more likely among participants who were White, employed, cohabiting or married and who had made no prior suicide attempts. Remission was less likely among patients who were also suffering from anxiety, obsessive-compulsiv disorder, panic disorder, post-traumatic stress disorder and social phobia. People with substance abuse problems were also less likely to improve when treated with a 'second-step' drug.

Rush, John A. ... [et al] - Selecting among second-step antidepressant medication monotherapies: predictive value of clinical, demographic, or first-step treatment features Archives of General Psychiatry August 2008, 65(8), 870-881

Medication adherence and antidepressants

Major depression is a pervasive and debilitating mental disorder that affects families and individuals throughout their lives. The prevalence of major depression is 2.9% in Western societies with 12.6% of people suffering from minor depression. Antidepressants can be highly effective but it is important that patients keep taking them for four-to-six months with those people most at risk taking them for at least a year. However, patients with major depression do not always stick to their medication regimes which can drastically reduce the effectiveness of the drugs. A Taiwanese study of 181 patients looked at their compliance with their medication. About 50% of the patients reported good medication adherence. The predictors of adherence to medication were a higher income (even though patients do not pay for these drugs in Taiwan), a feeling that the antidepressants were effective and an understanding of the importance of continuing to take the drugs.

Yeh, Mei-Yu ... [et al] - Predictors of adherence to an antidepressant medication regimen among patients diagnosed with depression in Taiwan Issues in Mental Health Nursing 29(7), 701-717

Drugs, genes and depression

Antidepressants are the most prescribed medicine in the U.S. with about 10% of adults taking prescription medication for depression. However, studies show that less than 50% of people treated for depression experience complete remission of their symptoms. Pharmacogenetics is the study of how people's genes interact with their medication and a U.S. study of 1,914 people looked into how people's genetic make-up affected the effectiveness of the antidepressant citalopram. The researchers found that White patients with a variation in the serotonin transporter gene SLC6A4 were more likely to see a remission of their symptoms after treatment with citalopram; but there was no difference for Black and Hispanic patients.

You can find out more about this research at

http://psychcentral.com/news/2008/07/16/genes-influence-antidepressant-effectiveness/2614.html

Antipsychotics for depression

Studies have found that a large percentage of depressed patients may have limited response and remission rates when treated with traditional antidepressants. There is increasing evidence in favour of the use of atypical antipsychotics in the treatment of depression and a review of the literature has found that olanzapine and risperidone have several controlled clinical trials indicating their effectiveness at doses lower than those used in treating psychoses. The review concluded that aripiprazole, olanzapine and risperidone are reasonable choices to add to anti-depressants in cases of treatment-resistant depression.

Philip, Noah S. ... [et al] - Augmentation of anti-depressants with atypical antipsychotics: a review of the current literature Journal of Psychiatric Practice January 2008, 14(1), 34-44

Risperidone for depression in older adults

Mood disorders are a significant health care issue in the elderly and are associated with suffering, functional decline, compromised quality of life, care-giver burden and increased rates of suicide and service utilization. Persistent depression worsens the outcome of other illnesses and increases non-suicide mortality. Only a third of depressed older adults achieve remission with another 20% showing a partial improvement. Adding an atypical antipsychotic to an antidepressant is one of the alternatives available for people who have failed to respond to drug therapy and a U.S. study of 93 people compared the effectiveness of risperidone to a placebo in terms of delaying relapse and preventing it altogether. The group taking risperidone were just as likely to suffer a relapse as those taking a placebo but they did go over twice as long before becoming ill again as the placebo group.

Alexopoulos, George S. ... [et al] - Placebo-controlled study of relapse prevention with risperidone augmentation in older patients with resistant depression American Journal of Geriatric Psychiatry January 2008, 16(1), 21-30

Disappointing results for escitalopram in older depressed people

A study into the effectiveness of escitalopram in treating depression in people over 60 has yielded disappointing results. The 12-week trial divided 264 patients into two groups one receiving escitalopram and the other a placebo. Escitalopram was no more effective at treating depression than a placebo and 11% of the people taking the drug discontinued it due to side effects of headache, nausea, diaorrhea and a dry mouth.

Bose, Anjana, Dayong, Li and Gandhi, Chetan - Escitalopram in the acute treatment of depressed patients aged 60 years or older American Journal of Geriatric Psychiatry January 2008, 16(1), 14-20

Antipsychotics for depression and anxiety

Major depression often goes hand-in-hand with anxiety. 85% of adults with major depression exhibit significant symptoms of anxiety and 58% of them have a diagnosable anxiety disorder in their lifetime. Anxiety on top of depression leads to more severe symptoms, decreased psychosocial functioning, a higher risk of suicide and longer-lasting depression. Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine are the first-line treatments for depression and anxiety but in some cases only a partial cure is achieved meaning that symptoms can flare up again later. In these cases other medication is used - not always successfully. Antipsychotic drugs have been used for people with hard-to-treat depression and for people with bipolar disorder and anxiety and a recent Canadian trial on 58 patients has shown that these drugs can also be effective in patients with major depression and anxiety. Quetiapine worked quickly, produced a significant reduction in depression compared to a placebo and reduced feelings of guilt, suicide and tension. The most common side effect was an increase in sleepiness and lethargy. The researchers called for further, larger-scale studies of the drug in people with depression and anxiety.

McIntyre, Alexander, Gendron, Alain and McIntyre, Amanda - Quetiapine adjunct to selective serotonin reuptake inhibitors or venlafaxine in patients with major depression, comorbid anxiety, and residual depressive symptoms : a randomized, placebo-controlled pilot study Depression and Anxiety 24(7), 484-494