Meta-analysis of the reversible inhibitors of monoamine oxidase type A moclobemide and brofaromine for the treatment of depression.
The reversible inhibitors of monoamine oxidase type A (RIMAs) are a newer group of antidepressants that have had much less impact on clinical psychopharmacology than another contemporary class of medications, the selective serotonin reuptake-inhibitors (SSRIs). The RIMAs agents are distinguished from the older monoamine oxidase inhibitors (MAOIs) by their selectivity and reversibility. As a result, dietary restrictions are not required during RIMA therapy, and hypertensive crises are quite rare. In this article, we describe a series of meta-analyses of studies of the two most widely researched RIMAs, moclobemide (MOC; Aurorex) and brofaromine (BRO). Our findings confirm that both BRO and MOC are as effective as the tricyclic antidepressants, and they are better tolerated. However, BRO is not being studied at present for reasons unrelated to efficacy or side effects. MOC, which is available throughout much of the world (but not the United States), is significantly more effective than placebo and, at the least, comparable to the SSRIs in both efficacy and tolerability. For MOC, higher dosages may enhance efficacy for more severe depressions. We also found evidence that supports clinical impressions that MOC is somewhat less effective, albeit better tolerated, than older MAOIs, such as phenelzine or tranylcypromine. Little evidence has yet emerged to suggest that the RIMAs share older MAOIs' utility for treatment of depressions characterized by prominent reverse neurovegetative features. Based on available evidence, the RIMAs appear to have a limited, but useful, role in the differential therapeutics of the depressive disorders. (+info)
Individual and organizational predictors of depression in general practitioners.
BACKGROUND: High levels of stress and depression are seen in both general practitioners (GPs) and hospital doctors, and this has implications for patient care. It is therefore important to discover the individual and organizational causes of elevated symptoms so they can be tackled. AIM: To discover the relative importance of individual characteristics measured 10 years earlier compared with current organizational stressors in predicting depression in GPs. METHOD: Longitudinal questionnaire study, using data from those of the original cohort of 318 medical students who are now GPs (n = 131), considering perceptions of current stressors and comparing through regression analyses the relative strength of early personality and mood with current organizational factors of sleep, hours worked, and practice size in predicting current depression levels. RESULTS: There were 22 (17%) stressors scoring above threshold for depression. Relationships with senior doctors and patients are the main reported stressors, followed by making mistakes and conflict of career with personal life. The predictors of symptom levels varied for men and women. In men, depression and self-criticism as students, and current sleep levels; and in women, sibling rivalry and current alcohol use, were the main predictors: in men, 27% of the variance was accounted for by early dispositional factors alone compared with 14% in women. A model is suggested linking sleep loss with workplace stressors, self-critical cognitions, and depression. CONCLUSION: Interventions can be made throughout training, targeting self-criticism and recognizing early depression, while later addressing the organizational stressors, particularly work relationships and sleep patterns. (+info)
Increased serotonin receptor density and platelet GPIIb/IIIa activation among smokers.
This study sought to determine whether depressive symptoms and/or platelet serotonin receptor (5HT2A) density are associated with increased platelet activation (PA) found among smokers. Flow cytometric detection of PA was used to study 36 smokers and 16 nonsmokers, aged 18 to 48 years. Subjects were tested at baseline and after either smoking 2 cigarettes (smokers) or a similar resting interval (nonsmokers). Assessment of PA included both platelet secretion and fibrinogen receptor (GPIIb/IIIa) binding. Platelet 5HT2A receptor binding and saturation were tested using [3H]LSD, and depressive symptoms were measured using the Beck Depression Inventory. Platelet 5HT2A receptor density was increased among smokers versus nonsmokers (82.7+/-67.7 versus 40.0+/-20.2 fmol/mg protein; P<0.005), and there was a dose-dependent relationship between receptor density and packs/d among smokers. Baseline wound-induced GPIIb/IIIa binding at 1 minute and GPIIb/IIIa binding in response to collagen stimulation in vitro was increased among smokers (P<0.05); there were no changes in PA among smokers after smoking, and platelet secretion was not elevated among smokers. Depressive symptoms were associated with 5HT2A receptor density among nonsmokers (P<0.005), but no such relationship was evident among smokers; PA was unrelated to 5HT2A receptor density in either group. The findings indicate that smoking is associated with increased platelet serotonin receptor density and with increased GPIIb/IIIa receptor binding, although these 2 factors are not related to each other or to depressive symptoms among smokers. Serotonergic dysfunction may be an important factor in the development of cardiovascular disease among smokers. (+info)
The Montefiore community children's project: a controlled study of cognitive and emotional problems of homeless mothers and children.
OBJECTIVES: This study compares the prevalence of emotional, academic, and cognitive impairment in children and mothers living in the community with those living in shelters for the homeless. METHOD: In New York City, 82 homeless mothers and their 102 children, aged 6 to 11, recruited from family shelters were compared to 115 nonhomeless mothers with 176 children recruited from classmates of the homeless children. Assessments included standardized tests and interviews. RESULTS: Mothers in shelters for the homeless showed higher rates of depression and anxiety than did nonhomeless mothers. Boys in homeless shelters showed higher rates of serious emotional and behavioral problems. Both boys and girls in homeless shelters showed more academic problems than did nonhomeless children. CONCLUSION: Study findings suggest a need among homeless children for special attention to academic problems that are not attributable to intellectual deficits in either children or their mothers. Although high rates of emotional and behavioral problems characterized poor children living in both settings, boys in shelters for the homeless may be particularly in need of professional attention. (+info)
Persistence of depressive symptoms in diabetic adults.
OBJECTIVE: To determine the level and pattern of persistent depressive symptoms among adults with diabetes and identify factors associated with increased risk of being persistently depressed. RESEARCH DESIGN AND METHODS: A self-report depression symptom inventory was administered to 245 patients at two initial time points--the beginning and end of a comprehensive outpatient diabetes education program--and at 6-month follow-up. RESULTS: Only 13% of subjects were persistently depressed (i.e., exceeded the criterion for depression symptoms at all three time points). The rate of being depressed at follow-up was 10% for those negative for depression symptoms at either of the initial time points, 36% for those positive at one initial time point, and 73% for those positive at both initial time points (P < 0.0001). Those at increased risk for being persistently depressed were those who did not graduate from high school, had more than two complications of diabetes, and were not treated with insulin. CONCLUSIONS: Persistent depressive symptomatology is present in a substantial number of diabetic adults and can be effectively predicted using simple screening instruments during initial contacts. Risk factors for being persistently depressed only partly overlap those for transient depressive symptoms and represent a possible biological dimension. (+info)
A cost-effective approach to the use of selective serotonin reuptake inhibitors in a Veterans Affairs Medical Center.
In light of the tremendous expansion in the number of selective serotonin reuptake inhibitors available to the clinician, the Pharmacy and Therapeutics Committee of the Denver Veterans Affairs Medical Center considered the advantages and disadvantages of fluoxethine, paroxetine, and sertraline, to determine which agent or agents would be carried on the formulary. The committed recommended sertraline as the preferred agent for the treatment of depression, panic disorders, and obsessive-compulsive disorders. The purpose of this retrospective study was to assess the economic outcome of that decision. The study population consisted of patients at the medical center who were receiving selective serotonin reuptake inhibitors during January through March of 1994 and those were receiving these agents between September 1995 and January 1996. The expanded collection period in 1995-96 was due to a relatively new medical center policy to offer 90-day fills on medication to reduce costs. The extended collection period assured a 100% sample of patients receiving these agents. The 1994 fluoxetine to sertraline dosage equivalency ratio was 20 mg:55.6 mg, based on average daily doses of fluoxetine and sertraline of 32.7 and 90.9 mg, respectively. The cost to the medical center for an average daily dose of fluoxetine was $1.86; sertraline cost $1.22 per day. The 1996 fluoxetine to sertraline dosage equivalency ratio (20 mg:51.3 mg) had not changed significantly since 1994, indicating that the dose of 20 mg of fluoxetine remained very close to a 50-mg dose of sertraline. The average daily doses of fluoxetine and sertraline (34.9 mg and 89.7 mg, respectively) were not significantly different than the 1994 doses. Only 33 patients had been prescribed paroxetine (average daily dose, 32.4 mg). On the basis of these values, the average daily cost of fluoxetine to the medical center was $2.01, compared with $1.18 for sertraline and $1.24 for paroxetine. This $0.83 per patient per day drug acquisition cost difference between fluoxetine and sertraline results in a drug cost reduction of $302,674 per year. (+info)
Alternative insurance arrangements and the treatment of depression: what are the facts?
Using insurance claims data from nine large self-insured employers offering 26 alternative health benefit plans, we examine empirically how the composition and utilization for the treatment of depression vary under alternative organizational forms of insurance (indemnity, preferred provider organization networks, and mental health carve-outs), and variations in patient cost-sharing (copayments for psychotherapy and for prescription drugs). Although total outpatient mental health and substance abuse expenditures per treated individual do not vary significantly across insurance forms, the depressed outpatient is more likely to receive anti-depressant drug medications is preferred provider organizations and carve-outs than when covered by indemnity insurance. Those individuals facing higher copayments for psychotherapy are more likely to receive anti-depressant drug medications. For those receiving treatment, increases in prescription drug copayments tend to increase the share of anti-depressant drug medication costs accounted for by the newest (and more costly) generation of drugs, the selective serotonin reuptake inhibitors. (+info)
Effectiveness and economic impact of antidepressant medications: a review.
This article reviews the existing literature on the pharmacoeconomics and effectiveness of antidepressant medications. Although selective serotonin reuptake inhibitors (SSRIs) have not proved to be more efficacious than the older tricyclics, and their prescription costs are significantly higher, they provide superior effectiveness; ie, patients are less likely to discontinue taking them or switch antidepressants. Pharmacoeconomic studies consistently demonstrate a relationship between this superior effectiveness and reductions in overall treatment costs, often through decreased utilization of medical and hospital services. The most conservative study found a cost offset that more than negated the extra cost of drugs, although the cost savings were not statistically significant. Other studies found statistically significant lowering of utilization costs by using SSRIs rather than tricyclics. Studies comparing SSRIs with each other present conflicting findings, although fluoxetine appears to have an edge over sertraline and paroxetine with regards to effectiveness and pharmacoeconomics. More studies employing a prospective outcome design and naturalistic study setting need to be conducted with SSRIs and other new antidepressants. (+info)