How accurate are patients in reporting their antidepressant treatment history?

Posternak MA, Zimmerman M.

Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USA. mposternak lifespan.org

BACKGROUND: A patient's report of their antidepressant treatment history is one of the most important pieces of information used in selecting an antidepressant regimen. It is currently unknown how accurate patients are in describing and characterizing their antidepressant treatment history. METHODS: Seventy-three patients receiving treatment for depression at our outpatient psychiatric practice were interviewed by an independent evaluator who was blind to each patient's treatment history. Information was obtained regarding which antidepressant and augmentation regimens patients had undergone, antidepressant doses, duration of trials, and the nature of response to each trial. The results of these interviews were then compared with patients' actual treatment history as elicited from an independent chart review. RESULTS: Patients recalled 85 of the 104 (81.7%) monotherapy trials they had undergone in the past 5 years, but only recalled 12 of 46 (26.1%) augmentation trials (P<0.001). Patients were found to be very reliable in distinguishing between those trials that were of adequate dose and duration and those that were not. Patients were also generally reliable in depicting the quality of response to past trials, though patient report of a past negative trial was significantly more reliable than a report of a past positive trial. The presence of current depressive symptomatology did not adversely affect patients' ability to recall past trials or accurately describe their responses to past regimens. LIMITATIONS: All patients were treated by a single psychiatrist, and all trials occurred within the last 5 years. CONCLUSION: Patients are able to recall the majority of monotherapy trials they have undergone, but have great difficulty remembering when two medications were taken concurrently, i.e. augmentation trials. Patient report appears to be a satisfactory method to obtain information regarding trial adequacy and response in most, but not all instances.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12798251&dopt=Abstract antidepressant




A record-based analysis of 803 patients treated for depression in psychiatric care.

Rytsala HJ, Melartin TK, Leskela US, Lestela-Mielonen PS, Sokero TP, Isometsa ET.

Department of Mental Health and Alcohol Research, National Public Health Institute, Helsinki, Finland.

BACKGROUND: New antidepressants emerged and became widely used during the 1990s. The present study investigated quality-of-care problems in the treatment of depression in a current psychiatric setting. METHOD: We investigated the treatment received for depression by all 803 inpatients or outpatients with a clinical diagnosis of ICD-10 depressive episode or recurrent depressive disorder in 1996 in the Peijas Medical Care District, which provides psychiatric services for citizens of Vantaa, a city in southern Finland. RESULTS: Most patients (84%) in the sample were found to have received antidepressants, generally in adequate, albeit low, doses. Inadequate antidepressant treatment was common only with tricyclic antidepressants. Most patients received a single antidepressant for extended periods; only 22% had 2 or more antidepressant trials. During the treatment period, disability pension was granted to 19% of those not already pensioned, two thirds (67%) of whom had received only 1 antidepressant trial prior to being granted a pension. CONCLUSION: The present study supports the emerging perception of improved quality of pharmacotherapy in psychiatric settings, with the exception of treatment with tricyclic antidepressants. Problems of quality of care now appear to be related to the suboptimal intensity and monitoring of the treatment provided. which may eventually result in considerable costs to society due to permanent disability.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11681766&dopt=Abstract antidepressant




[Inadequate pharmacotherapy in patients with obsessive-compulsive disorder]

[Article in Dutch]

Denys D, van Megen HJ, Westenberg HG.

Universitair Medisch Centrum, afd. Psychiatrie, Heidelberglaan 100, 3584 CX, Utrecht. d.a.j.p.denys azu.nl

OBJECTIVE: To determine the adequacy of drug treatment for patients with obsessive compulsive disorder (OCD). DESIGN: Retrospective. METHOD: One hundred and fifty outpatients with OCD, admitted at the University Medical Centre in Utrecht, the Netherlands, were evaluated for severity as measured with the 'Yale-Brown obsessive compulsive scale' (Y-BOCS). RESULTS: At the intake, 35% of the patients used no medication, 58% used an antidepressant, less than 1% an antipsychotic and 6% a benzodiazepine. The average active dose was taken by 12% of the patients, 5% took the maximum dosage and 41% too low a dosage. Consequently, 6 out of the 10 patients used the correct medication (antidepressant) and less than 20% used a sufficiently high dosage. Of the patients, 38% had never previously taken antidepressants, 31% had previously used one antidepressant, 17% two different antidepressants and 12% at least three different antidepressants; 13% had taken the antidepressant at the highest dosage, 18% at the average active dosage and 31% at too low (thus ineffective) a dosage. This means that from a pharmacotherapeutic viewpoint not more than 1 in 8 patients had had an adequate treatment history. CONCLUSION: The results of this study show that only 1 in 8 OCD patients were treated appropriately.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11387867&dopt=Abstract antidepressant




Antidepressant prescription for depression in general practice in The Netherlands.

van Marwijk HW, Bijl D, Ader HJ, de Haan M.

Department of General Practice and Department of Clinical Epidemiology and Biostatics, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. HWJ.van_Marwijk.GPNH med.vu.nl

OBJECTIVE: To evaluate diagnoses and the prescription of antidepressants drugs for depression, based on data from 1993 to 1998 related to consultations for depression in general practice in the Netherlands. METHOD: An exploratory analysis of data provided by IMS Health. Consecutive annual representative samples of 640 GPs regularly registered data on morbidity and (drug) treatment for specific medical problems in special booklets for a period of one week. The data refer to consultations for depression. The diagnoses were initially based on ICD-9 criteria and later ICD-10 criteria for depression. MAIN OUTCOME MEASURES: Number of diagnoses of depression and number of prescriptions for antidepressants. RESULTS: The number of first consultations for depression rose gradually, from 909 in 1993 (95% CI: 774 to 1043), to 1,482 (CI: 1292 to 1672) in 1998: an increase of 63%. For an individual GP, this represents an increase from 18 to 30 in first consultations for depression. The number of prescriptions for antidepressants also increased, mainly during repeat consultations: a 278% increase, from 3,708 in 1993 to 14,024 in 1998 (CIs: 3,504 to 3,912 and 13,252 to 14,796). Antidepressants were prescribed during the first consultation 564 times in 1993 compared with 1,080 times in 1998. The first contact with a GP for depression led to an antidepressant prescription in 62% of cases in 1993 and 73% in 1998. Although the guidelines issued by the Dutch College of General Practitioners in 1994 recommended tricyclic antidepressants (TCAs) for the treatment of depression, paroxetin, fluoxetin, and mirtazapin (SSRIs) accounted for 56% of the prescribed antidepressants. CONCLUSION: Between 1993 and 1998, GPs in the Netherlands prescribed increasingly more antidepressants, and they prescribed more SSRIs than TCAs. Furthermore, GPs diagnose depression more frequently and the number of repeat consultations has increased.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11411443&dopt=Abstract antidepressant




[Chronic pain treatment with antidepressants--metaanalysis]

[Article in German]

Feuerstein TJ.

Sektion Klinische Neuropharmakologie der Neurologischen Universitatsklinik, Neurozentrum, Freiburg.

Both preclinical and clinical evidence support the usefulness of antidepressants in chronic pain treatment. Monoamine uptake inhibitors influence the neurotransmissions of noradrenaline (NA) and/or serotonin (5-HT); their effect on nociception is thought to take place predominantly within the spinal cord. Antidepressant drugs seem to differ in their properties as analgesics and as thymoleptics. The present work is aimed at correlating the special mechanism of action of antidepressants in diminishing nocicepetion with the pharmacological profile of these drugs in clinical pain treatment. From a preclinical, experimental point of view, it can be expected, that mixed type uptake blockers should be superior to selective NA or 5-HT uptake inhibitors. The analgesic profile of antidepressants was established by a metaanalysis of clinical trials on the effect of these drugs, given alone or in combination with other analgetics, in chronic pain syndromes. 57 Clinical trials were separated into 5 groups according to their scientific quality: [1] placebo-controlled double-blind studies with high power; [2] placebo-controlled double-blind studies with low power; [3-4] open controlled studies or studies with historical controls; [5] case reports. A study was positive if the tested antidepressant was more effective than placebo or the compared drug or seemed beneficial with respect to the interval of its previous absence. The most effective antidepressants in chronic pain treatment only included unselective monoamine reuptake inhibitors in the following rank order: amitriptyline > clomipramine > or = desipramine > or = imipramine > or = doxepin. A statement about the appropriate dosage of these drugs in chronic pain treatment, however, must wait for properly conducted dose finding studies which include the measurement of plasma concentrations.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12799822&dopt=Abstract antidepressant




Antidepressant use and the risk of breast cancer: a non-association.

Wang PS, Walker AM, Tsuang MT, Orav EJ, Levin R, Avorn J.

Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA. pwang rics.bwh.harvard.edu

OBJECTIVE: Animal studies have suggested that some antidepressant medications may act as breast tumor promoters and recent epidemiologic studies of antidepressant use and breast cancer outcomes in humans have also reported such associations. DESIGN: Retrospective cohort study. STUDY POPULATION: 38,273 women who filled a prescription for any of a number of antidepressants and 32,949 who filled a prescription for any other medication during 1989-1991; all were > or =20, enrolled in Medicare, Medicaid or the Pharmaceutical Assistance to the Aged and Disabled (PAAD) programs of New Jersey, and free of evidence of breast cancer. DATA COLLECTION: Antidepressant use was assessed over a period lasting up to 24 months. Subjects were followed for a maximum of 7.5 years; those who had a first diagnosis of breast cancer in the New Jersey Cancer Registry at least 3 months after their index date were considered incident breast cancer cases. Other covariates, including demographic, clinical, and health care utilization variables were also assessed. MAIN OUTCOME OF INTEREST: Adjusted hazard ratio (HR) of developing breast cancer, based on multivariable proportional hazards models. RESULTS: Use of antidepressants was unrelated to the development of breast cancer (adjusted HR = 1.04; 95% CI 0.87-1.25). No elevated risks were found for specific antidepressants, including agents found to be breast tumor promoters in animal studies, as well as drugs thought to be associated with breast cancer in prior epidemiologic studies. There was no suggestion that breast cancer risks were increased with more intensive use of antidepressants or that antidepressant use is associated with a more severe stage of cancer at diagnosis. CONCLUSIONS: Despite recent reports from much smaller epidemiologic studies or laboratory animals, these results provide reassurance that antidepressant use is not associated with the development of breast cancer.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11438414&dopt=Abstract antidepressant




Antidepressant drugs in dermatology.

Gupta MA, Gupta AK.

Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.

Antidepressant drugs can be an important component of the dermatologists' therapeutic armamentarium. When considering the use of psychotropic agents in dermatology two major factors should be considered: (1) the accurate diagnosis of the comorbid psychiatric disorder, and (2) the presence of proper indications for the use of antidepressant agents. Antidepressant drugs are used in the management of the psychiatric syndromes, which are most frequently comorbid with dermatologic disorders, i.e., Major Depressive Disorder, Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, Post-traumatic Stress Disorder and Social Phobia. The antihistaminic and analgesic properties of some antidepressants such as doxepin and amitriptyline, are also of benefit in the treatment of some pruritic and neuralgic states. The specific guidelines, side effect profile, drug-drug interactions, and the most current indications should always be obtained for any particular antidepressant agent before it is prescribed.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11438813&dopt=Abstract antidepressant




Retrospective analysis of serum valproate levels and need for an antidepressant drug.

Stoner SC, Worrel JA, Vlach D, Jones MT, Ramlatchman LV.

Pharmacy Practice Division, University of Missouri-Kansas City School of Pharmacy, 64108-2792, USA.

We sought to determine whether patients receiving valproate plus an antidepressant had significantly lower serum valproate levels before initiation of the antidepressant than those patients receiving valproate without an antidepressant. We further sought to identify the prevalence of antidepressant-induced mania and to determine if valproate provided a protective effect against antidepressant-induced mania. A computer database search from January 1, 1990-June 30, 1998, identified patients with bipolar or schizoaffective disorder treated with valproate. Patients receiving an antidepressant during valproate therapy were identified as the treatment group (9 patients), and the remaining patients served as the control group (17 patients). Serum valproate levels were recorded just before starting the antidepressant for the treatment group and monthly during a comparable period for the control group. The mean time to antidepressant initiation was 15 +/- 8 weeks. The mean serum valproate level just before antidepressant initiation was significantly lower for the treatment group compared with the mean serum valproate level averaged over 16 +/- 6 weeks for the control group (54 +/- 24 vs 73 +/- 13 microg/ml, p<0.05). Four patients (44%) developed antidepressant-induced mania. Three required discontinuation of the antidepressant; their serum valproate levels were 54, 60, and 71 microg/ml. Patients requiring the addition of an antidepressant had significantly lower valproate serum levels than those who did not require an antidepressant. Further study is necessary to determine whether higher serum valproate levels are needed for prevention of depressive symptoms in bipolar and schizoaffective disorders.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11444581&dopt=Abstract antidepressant