[The treatment of depressions with antidepressive agents].
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The response to tricyclic antidepressants of eight obsessive-compulsive patients was assessed at pretreatment and at 4, 8, and 12 weeks of treatment, with the aim of delineating differential rates of improvement, or desynchrony, between the various symptoms. Change in obsessive-compulsive symptoms paralleled change in depression and anxiety, suggesting a global beneficial effect of the drugs. The analysis of individual data also revealed this synchronous pattern of change, with significant improvement, in responders, occurring within the first 4 weeks of treatment. Furthermore, responders had higher initial Hamilton depression ratings compared to nonresponders. These results do not lend support to the claim that tricyclics possess specific antiobsessional effect which is independent of their antidepressant effect. The limitations of a purely symptomatic approach in exploring the mode of action of antidepressants in obsessive-compulsive disorder is briefly discussed.
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Series of new antidepressants appeared in the treatment of central nervous system disorders in the last years. Into this group belong: 1. antidepressants of the 3rd generation which selectively inhibit serotonine reuptake; 2. thymoleptics--a group of compounds which have no anticholinergic effects and act as noradrenaline reuptake inhibitors or noradrenaline and serotonine reuptake inhibitors; 3. antipsychotics from the group of selective serotonine and dopamine antagonists. All they have less undesirable side-effects than classical tricyclic antidepressants of the first generation and thymoleptics of the second generation. Thus they are nowadays more often used as the drugs of the first choice and are therefore met more often in the biological material analyzed in toxicological laboratories. This contribution deals with the detection and identification of paroxetine, sertraline, venlafaxine, mirtazapine, tianeptine, risperidone and quetiapine in urine by thin layer chromatography.
In 1994, the risk/benefit ratio when using antidepressant drugs for the treatment of mood disorders has become very difficult to assess. From the medical standpoint, frequent nosographical modifications generated new clinical entities (brief recurrent depression, subsyndromal depression, mixed anxiety and depression according to the ICD 10, dysthymia). Within these entities, mood appears modified in duration and severity and belongs to extremely different structures. The obvious link between antidepressants and typical depression has to be thoroughly assessed for these new forms of illness. But the evolution of medical and economical assessment techniques progressively turns the attributed risk into a global index based on group results far from the dual patient-physician relationship in which the risk/benefit ratio is assessed according to idiosyncratic criteria. The development of a dimensional clinical field could, if misused, be reduced to an addition of "target treatments". Finally, some antidepressants are no longer presented for their main antidepressive effects (for which their use is authorized) but for peripheral properties: treatment strategies (particularly duration) remain unclear for these latter effects. From a sociological point of view, consequences of consumerism, social and economical crisis and modifications of the image of the psychiatry, play a role in the evaluation of this risk/benefit ratio.
Antidepressants, in particular tricyclic ones (TCA), and inhibitors of monoaminooxidase (IMAO) exert a number of undesirable cardiovascular effects. TCA and IMAO frequently cause postural hypotension (PH). IMAO administration is associated with the risk of hypertensive crisis. TCA raises the heart rate and can cause abnormalities in the conduction of the cardiac excitation. TCA are contraindicated after myocardial infarction and are the cause of death after overdosage. When PH is undesirable, in hypertension and cardiac insufficiency the following safe antidepressants are recommended: nortriptyline, mianserine, trazodone and viloxazine. In abnormalities of conduction of the cardiac excitation and after myocardial infarction only mianserine, trazodione and viloxazine are recommended. With regard to cardiovascular toxicity, antidepressants from the series of selective inhibitors of serotonin reabsorption are very promising: fluvoxamine, fluoxetine, citalopram, paroxetine and sertraline. The same applies also to the reversible IMAO type A moclobemide.
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OBJECTIVES: Involving patients in treatment decisions may reduce premature antidepressant treatment terminations and improve clinical and health economic outcomes. However, a first step is to determine what information to provide to patients to facilitate their decision making. The authors therefore identified, valued, and ranked factors of antidepressant treatment selection that are relevant to patients and compared them with the opinions of general practitioners. METHODS: Matching surveys were developed for patients and physicians with feedback from focus groups. In the patient group, participation was requested from consecutive patients at four family practice sites in Nova Scotia, Canada. Surveys were mailed to 247 randomly selected general practitioners. RESULTS: Surveys were completed by 127 patients and 110 physicians, representing return rates of 70% and 46%, respectively. The most valued of the 12 differentiating factors when selecting an antidepressant, ranked first by both patients and physicians, was common side effects. Also ranked highly by both groups were precautions with antidepressant use, physician antidepressant experience, and discontinuation problems. Groups differed in their ranking of uncommon serious side effects, time since antidepressants were marketed, cost, and dosing schedule. The ranking distributions were significantly different for six of 12 factors between patients and general practitioners (Wilcoxon ranked-sum test). Patient experience with antidepressants did not influence factor value. CONCLUSIONS: The data demonstrate moderate disagreement between patients and general practitioners regarding the relative value of antidepressant selection factors. The effect of this disagreement on treatment adherence and other outcomes requires further investigation, as improving patient-physician concordance regarding antidepressant choices may lead to improved treatment acceptance.