If a patient does not respond to a full dose of fluvoxamine for at least 12 weeks, what alternatives should be considered?
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Behavior Therapy↗
Biomedical subjects
A V Ravindran
Publications and source records attributed to A V Ravindran.
Efficacy and tolerability of venlafaxine in the treatment of primary dysthymia.
OBJECTIVE: Currently, there is no documentation of the efficacy of venlafaxine (a serotonin norepinephrine reuptake inhibitor) in the treatment of dysthymia. This open-label pilot investigation examined the efficacy and tolerability of venlafaxine in patients with primary dysthymia without concomitant major depression. METHODS: Fifteen patients were treated with venlafaxine for 12 weeks, with a dose range of 75 mg to 225 mg daily (taken orally), and symptom changes were measured using standard instruments including the Hamilton Depression Rating Scale (HAM-D). RESULTS: Significant changes from pretreatment to posttreatment were observed (p < 0.001). Using the standard criteria of a 50% reduction in HAM-D scores, 73.3% of patients were rated as responders. About two-thirds of the patients reported adverse events, which were mostly mild and brief in duration. CONCLUSION: Venlafaxine may be useful in the treatment of primary dysthymia but placebo-controlled studies are required for confirmation.
Adult↗
Neuroendocrine measures and lymphocyte subsets in depressive illness: influence of a clinical interview concerning life experiences.
The effects of a clinical interview concerning either positive or negative day-to-day events on lymphocyte subpopulations, and on plasma cortisol, ACTH and norepinephrine, were determined in depressive patients (major depressive and dysthymic) and in normal controls. Irrespective of its content, the interview provoked an elevation of circulating natural killer (NK) cells, suggesting that this effect was related to either a change in mood state (regardless of its valence) or to the stress associated with the interview procedure. Since the interview did not influence plasma cortisol, ACTH or norepinephrine, it is likely that the NK cell variations were independent of these endocrines. Although basal NK cells were elevated in the depressive group relative to controls, the extent of the NK cell increase provoked by the interview was comparable in depressive and control subjects. The failure to detect differences between these populations could not be attributed to ceiling effects precluding more pronounced alterations in the depressed subjects. Indeed, variations of circulating cell subtypes were found to be exquisitely sensitive to differences in stressor intensity. In a subset of control subjects, a more potent stressor (anticipation of an academic examination) increased the plasma endocrine levels, increased circulating NK cell number beyond that associated with the interview stress, and provoked an increase of several T cell subsets (CD3, CD4 and CD8). Evidently, while a clinical interview may be sufficiently stressful to influence circulating NK cells, the stress of such a procedure seems no greater in depressed than in control subjects. It is suggested that although depressed patients may exhibit higher basal NK levels, this effect is likely not related to increased reactivity to stressors.
Adrenocorticotropic Hormone↗
A double-blind, multicenter study in primary care comparing paroxetine and clomipramine in patients with depression and associated anxiety. Paroxetine Study Group.
BACKGROUND: 60%-90% of patients with a primary diagnosis of depression also experience symptoms of anxiety, and such patients have a poorer prognosis than those with uncomplicated depression. The serotonin selective reuptake inhibitors have demonstrated efficacy in the treatment of both depression and certain anxiety states. Furthermore, in a metaanalysis of the paroxetine clinical trial database of 2963 patients in whom depression predominated, there was a concomitant reduction in the Hamilton Rating Scale for Depression anxiety factor. The purpose of the present study was to prospectively compare the efficacy of paroxetine and clomipramine in patients specifically selected for coexisting depression and anxiety. METHOD: This was a 12-week, double-blind, parallel-group trial comparing paroxetine 20-40 mg/day with clomipramine 75-150 mg/day in 1002 patients with a Montgomery-Asberg Depression Rating Scale (MADRS) score > or = 20 and a Clinical Anxiety Score (CAS) > or = 11 after a 3-7 day placebo run-in period. RESULTS: Both paroxetine and clomipramine reduced the MADRS and CAS ratings at 2, 6, and 12 weeks and at endpoint, with no significant differences between treatment groups at any time point. CGI severity of illness and global improvement ratings were also similar throughout the trial; however, there was a statistically significant difference in the CGI efficacy index at 6 weeks and at endpoint, favoring paroxetine (p = .015 and p = .015, respectively). Paroxetine resulted in fewer treatment-emergent adverse experiences and related withdrawals than clomipramine (p = .025 and p = .008, respectively). The number of serious adverse experiences was not significantly different in the paroxetine group compared with the clomipramine group (14 [2.8%] vs. 27 [5.4%]), but did approach statistical significance (p = .056). Anticholinergic-emergent adverse experiences were reported twice as frequently by patients in the clomipramine group as in the paroxetine group (36.1% vs. 18.6%). CONCLUSION: There was no evidence of any significant difference in efficacy between paroxetine and clomipramine in patients with coexisting depression and anxiety. However, paroxetine was better tolerated as shown by total treatment-emergent adverse experiences, anticholinergic adverse experiences, and withdrawals due to adverse experiences.
Adolescent↗
Effective treatment of mania with olanzapine: 2 case reports.
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Adult↗
Successful treatment of steroid-induced panic disorder with fluvoxamine.
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Adult↗
Primary dysthymia: a study of several psychosocial, endocrine and immune correlates.
The relationship between primary dysthymia (chronic, low grade depression) and indices of major and minor life stresses, uplifts and coping styles was examined. Additionally, circulating lymphocyte subsets were assessed in dysthymic patients to determine their relationship to stress/coping factors or plasma levels of cortisol, ACTH or norepinephrine. Primary dysthymia was found to be associated with increased minor stressors (daily hassles), reduced uplifts, as well as particular reliance on emotion-focused rather than problem-oriented coping strategies. Interestingly, among dysthymics, the early onset group exhibited a greater degree of hassles and greater emotion-focused coping compared to the late onset subgroup. Although hassles and coping styles were correlated with depressed mood, only coping styles predicted severity of depressed affect. It seems that although dysthymia is characterized by increased hassles and reduced uplifts, these variables do not distinguish between the severity of the depressive affect, whereas the coping styles employed in the face of the increased hassles and reduced uplifts are more closely aligned with depression severity. Dysthymia was associated with elevated levels of circulating natural killer (NK) cells. Since levels of plasma cortisol, ACTH or norepinephrine were not increased in the dysthymic subjects, it is likely that the elevated NK cell number was unrelated to these neuroendorcrine measures. In control subjects circulating NK cells were inversely related to the severity of hassles recently encountered, while in dysthymic patients stress and coping factors were unrelated to NK cell numbers. Thus, it appears that the altered NK cells in dysthymic patients were not related to the increased stress perception and altered coping which characterize these patients.
Adaptation, Psychological↗
Variations of lymphocyte subsets associated with stress in depressive populations.
Major depression and dysthymia have been associated with increased perception of day-to-day stressors, greater reliance on emotion-focused coping efforts, and reduced perception of uplifting events. Moreover, it has been observed that levels of circulating natural killer (NK) cells were elevated in depressed patients. Given that mild stressors may increase circulating NK cells, it is conceivable that the elevated NK cells in depression may be secondary to the increased stress perception associated with the illness. In the present investigation a laboratory stressor, comprising a mathematical challenge, increased circulating NK cells; however, the extent of the increase was comparable in depressive, dysthymic and control subjects. Moreover, the increased NK cells induced by the stressor procedure appeared to be independent of variations of plasma cortisol, ACTH or norepinephrine. Interestingly, although the NK changes were not differentially influenced by stressors in the subject populations, in the major depressive patients correspondence existed between NK cell levels and emotion-focused coping styles. Likewise, the response to a laboratory stressor was directly related to the severity of depression and to the use of coping styles involving cognitive restructuring or problem solving.
Adaptation, Psychological↗
Stressful life events and coping styles in relation to dysthymia and major depressive disorder: variations associated with alleviation of symptoms following pharmacotherapy.
1. Both major depression and dysthymia (chronic, low grade depression) were associated with increased reports of minor stressors (daily hassles), and feelings of loneliness, reduced uplifts, as well as the use of inappropriate coping strategies (i.e., emotion-focussed rather than problem-oriented coping). 2. Although major depressive and dysthymic patients shared several features with respect to symptomatology, dysthymics tended to report a greater number of hassles than major depressives. 3. Treatment with serotonin reuptake inhibitors over an 8-week period resulted in a marked alleviation of the depressive symptoms in both patient groups, although the clinical effectiveness of the drugs appeared somewhat later in dysthymics. 4. The attenuation of the depressive symptoms was accompanied by a modest, but significant diminution in reports of minor stressors, while the perception of uplifts remained unchanged. Moreover, recovery from depression was associated with changes in coping style, such that patients relied less on inappropriate emotion-focussed coping strategies.
Adaptation, Psychological↗
A comparison of placebo responders and nonresponders in subgroups of depressive disorder.
The objective of this study was to determine if the placebo treatment response varied in subgroups of depressed patients (single episode, recurrent, and double depression). Data from placebo-treated patients from seven placebo-controlled clinical trials were pooled and analyzed retrospectively. The placebo response rate was highest for females with a single episode of depression (66.7%) and lowest for females with recurrent depressive episodes (13.3%). Among patients experiencing their first episode, placebo responders had lower Hamilton Rating Scale for Depression (HAMD) total scores at baseline and lower ratings of pschomotor retardation than nonresponders. For patients having a recurrence of an episode, placebo responders had lower baseline ratings of somatic anxiety. The major finding was that patients suffering from their first depressive episode differed from patients with recurrent depressive episodes in the rate of placebo response, effect of gender, and the clinical symptoms that were associated with a positive placebo response.
Antidepressive Agents↗
Primary early onset dysthymia, biochemical correlates of the therapeutic response to fluoxetine: I. Platelet monoamine oxidase and the dexamethasone suppression test.
A subgroup of primary dysthymic patients have been reported to respond to traditional antidepressants and, more recently, to the newer serotonergic agents. Two putative biological markers of affective illness, platelet monoamine oxidase (MAO) activity and plasma cortisol levels following dexamethasone administration, were explored for their diagnostic and predictive potential in dysthymia. Compared to controls, patients had significantly lower platelet MAO activity. Among patients, those that responded to treatment with the serotonergic agent, fluoxetine, had lower pretreatment MAO activity than nonresponders. Higher pretreatment plasma cortisol levels following dexamethasone were also associated with a positive treatment response to this medication. These findings support the view that there is a biological substrate for some subgroups of dysthymics. This biological component may involve the hypothalamic pituitary adrenal axis and serotonergic system(s).
Adult↗
Primary early onset dysthymia, biochemical correlates of the therapeutic response to fluoxetine: II. Urinary metabolites of serotonin, norepinephrine, epinephrine and melatonin.
The present study investigated pre- and post-treatment 24-h urinary metabolites of monoamines and melatonin as a function of response to treatment in primary early onset dysthymic patients. The main finding was that treatment responders had lower urinary 5-hydroxyindoleacetic acid (5-HIAA) levels prior to treatment. Following treatment, urinary 5-HIAA tended to be decreased in nonresponders and increased in responders. As well, metanephrine levels were lower and 6-sulphatoxymelatonin levels were higher in responders prior to treatment. These data support the view that there is a biological substrate for certain subgroups of dysthymia, part of which may involve serotonergic systems.
Adult↗
Platelet serotonin measures in primary dysthymia.
Serotonergic function in 22 patients with primary dysthymia and 22 normal volunteers was evaluated by measuring [3H]serotonin uptake and [3H]paroxetine binding in platelets. A significantly lower maximum rate of serotonin uptake was noted in the dysthymic patients than in the normal subjects, indicating a possible serotonergic dysfunction in dysthymia. However, the values for parameters of paroxetine binding were similar in the two groups.
Adult↗
Therapeutic efficacy of specific serotonin reuptake inhibitors (SSRIs) in dysthymia.
Pharmacological treatment of dysthymia is a contentious issue mainly because of the traditional view that this disorder has characterological origins and responds to psychotherapy. However, Akiskal's subtyping of primary dysthymia, which was based in part on its response to older antidepressants, can assist in the prediction of responses to antidepressants. Specific serotonin reuptake inhibitors (SSRIs) have equal efficacy but fewer adverse effects and greater tolerability than older antidepressants. Therefore, SSRIs appear to be a viable treatment option for these patients although there are few documented systematic studies of the use of these agents in primary dysthymia. An open study was conducted to determine the efficacy of fluoxetine in primary dysthymia (DSM-III-R and Akiskal's criteria). A good response was observed in the subaffective subtype but not in the character spectrum group. Overall, the antidepressant was tolerated well, with significant adverse effects reported and responders showing reductions in both depressive and anxious symptoms. These initial findings indicate a potential role for SSRIs in the pharmacotherapy of dysthymia.
Adult↗
Semi-structured depression scale sensitive to change with treatment for use in the elderly.
The construction of a semi-structured interview depression scale that is sensitive to change for use in the elderly is described. Depression items from a well validated diagnostic instrument, the Geriatric Mental State Schedule (GMSS), were used as the core items in the development of the instrument. Improvement in depression in 80 elderly patients was independently assessed with two standard rating scales for depression, the Hamilton Rating Scale for Depression and the Beck Depression Inventory, and by an independent clinician's judgement before and after standard antidepressant treatment. Depression items that were sensitive to change were retained from the core items to form the new instrument. Results indicate that this scale is reliable and valid, shows better correlation with both the clinician's and the patient's judgement of improvement than the standard instruments, and is sparing of the rater's time.
Aged↗
Characterization of histogranin receptors in human peripheral blood lymphocytes.
Histogranin (HN), a peptide recently isolated from bovine adrenal medulla, is also present in the spleen. In present studies, specific high affinity binding sites for HN were characterized on membrane preparations of human lymphocytes by radioligand binding. [125I]-[Ser1]HN binding was found to be dependent on time and protein concentration and to be sensitive to trypsin treatment. The binding displayed high affinity (Kd = 1.1 +/- 0.3 nM) and saturability (Bmax = 40.2 +/- 5.0 fmol/mg protein), and it was reversed upon addition of unlabelled [Ser1]HN and closely related peptides. The relative potency of various fragments in displacing [125I][Ser1]HN binding indicated that the active core of the molecule resides inside the C-terminal fragment, HN-(6-15). Interestingly, depressed patients displayed a marked decrease in the binding activity (from 15.4 to 8.55 fmol/mg protein at 0.5 nM of [125I][Ser1]HN). The presence of high affinity HN binding sites on lymphocytes provides evidence for a modulatory role for HN in the regulation of lymphocyte functions.
Adult↗
Platelet alpha 2-adrenoreceptor binding in elderly depressed patients.
Specific binding of 3H-clonidine to platelet membranes was measured in depressed elderly patients and in an elderly control group. Maximum specific binding was significantly higher in depressed patients than in the control group, whereas the binding affinity was not significantly different.
Age Factors↗
Circulating lymphocyte subsets in obsessive compulsive disorder, major depression and normal controls.
BACKGROUND: Obsessive compulsive disorder (OCD) shares several features with depressive illness (e.g., comorbidity, early escape from dexamethasone suppression, effectiveness of serotonergic pharmacotherapy). It was of interest to establish whether OCD, like major depression, was also associated with immune alterations, notably elevations of circulating natural killer (NK) cells. METHOD: Circulating lymphocytes were determined from morning blood samples taken from OCD and major depressive patients, as well as from age- and sex-matched controls. Stress perception and coping styles were evaluated in order to assess whether such variables accompanied the NK alterations. Finally, in a subset of patients, symptoms of the illness, stress/coping, and circulating lymphocytes, were also evaluated following 12 weeks of antidepressant medication (serotonergic reuptake inhibitor). RESULTS: The major depressive and OCD patients reported increased perception of day-to-day stresses, coupled with reliance on emotion focused coping styles. Moreover, circulating NK cells were elevated among male OCD and major depressive patients, whereas only a modest increase of NK cells was seen in female major depressives. Twelve weeks of medication alleviated depressive and OCD symptoms, and resulted in normalization of NK cells in the major depressives. However, in OCD patients the reduction of symptoms was not accompanied by significant variations of circulating NK cells. CONCLUSIONS: Although major depression and OCD are both accompanied by elevated circulating NK cells, at least in males, normalization of NK cells following treatment was only evident in depression. The persistent elevations of NK cells among male OCD patients may reflect either a trait characteristic of the illness, or symptom reduction and not true remission. LIMITATIONS: Although elevations of lymphocyte subsets in major depressive and OCD patients were observed, conclusions concerning immune status in OCD ought to be held in abeyance pending assessment of other indices of immune and cytokine functioning.
Adaptation, Psychological↗