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Journal of Affective Disorders Aug 2023The choice of antidepressants for initial pharmacological treatment of depression in older adults and associated patients' characteristics are understudied. We aimed to...
Do sociodemographic and clinical factors affect the selection of initial antidepressant treatment for depression in older adults? Results from a nationwide descriptive study in Denmark.
BACKGROUND
The choice of antidepressants for initial pharmacological treatment of depression in older adults and associated patients' characteristics are understudied. We aimed to describe the first selected antidepressant (first-choice) for depression in older adults (≥65 years) and whether patients' sociodemographic and clinical characteristics influence selecting an alternative first-choice (any other antidepressant than the nationally recommended first-choice sertraline) in Denmark.
METHODS
Register-based cross-sectional study including all older adults who redeemed their first antidepressant prescription for depression at community pharmacies in Denmark in 2015-2019. We analyzed the effect of patients' characteristics on the first-choice antidepressant selection using multinomial logistic regression.
RESULTS
Among 34,337 older adults with a first antidepressant-prescription, over two-thirds filled alternative first-choice antidepressants than sertraline (28.9 %): escitalopram or citalopram (30.3 %) or mirtazapine (34.4 %). Socially disadvantaged older adults (e.g., with short educational attainment, being single, or of non-western ethnicity) and clinically vulnerable older adults (e.g., having somatic diagnoses and hospital contacts) were more likely to use alternative first-choice antidepressants.
LIMITATIONS
Information on prescribers and in-hospital medications was not included in this study.
CONCLUSIONS
Further investigation of the first antidepressant selection and its impact on depression treatment outcomes in older adults is necessary. Moreover, for older patients, national guidelines on depression treatment should be more specific.
ARTICLE SUMMARY
Antidepressant selection for initial pharmacological treatment of depression in older adults can be difficult due to comorbidity, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics. Real-world evidence/knowledge on first-choice antidepressant selection and associated user characteristics are rare. This Danish register-based cross-sectional study found over two-thirds of older adults filled alternative antidepressants (primarily escitalopram/citalopram or mirtazapine) than nationally recommended first-choice sertraline for depression treatment and identified wide-ranging sociodemographic and clinical factors influencing the first antidepressant selection.
Topics: Humans; Aged; Sertraline; Citalopram; Depression; Mirtazapine; Escitalopram; Cross-Sectional Studies; Antidepressive Agents; Denmark
PubMed: 37146907
DOI: 10.1016/j.jad.2023.04.110 -
Neurology and Therapy Apr 2023Patients with depression require thorough clinical assessment, which should include symptom profile, severity and staging, personality factors, antecedent and concurrent...
Patients with depression require thorough clinical assessment, which should include symptom profile, severity and staging, personality factors, antecedent and concurrent psychiatric comorbidity, physical comorbidity, neurocognitive function, exposure to stressors in early life (e.g. trauma) or recently (e.g. bereavement), and protective factors. The presence of anxiety symptoms in a depressed patient is associated with more severe depression, increased suicidality and worse outcomes compared with non-anxious depression. A network meta-analysis of antidepressant treatments found that agomelatine, citalopram, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine and vortioxetine were all significantly more effective than other antidepressants for the treatment of depression, and that agomelatine, citalopram, escitalopram, fluoxetine, sertraline and vortioxetine were better tolerated than other antidepressants. Agomelatine has been shown to have two major effects-relieving depressive symptoms, and supporting symptomatic and functional recovery-and these benefits have been demonstrated in patients with depression as well as in patients with generalised anxiety disorder, including those with more severe symptoms. Agomelatine has also been shown to be efficacious and well tolerated in patients with depression plus concomitant anxiety symptoms. A pooled analysis of data from six agomelatine studies of depression (three placebo-controlled and three with active comparators-fluoxetine, sertraline and venlafaxine) found that agomelatine was significantly more effective than placebo at relieving the anxiety subscore on the Hamilton Depression Rating Scale, and that the difference between agomelatine and placebo was even more marked in the subgroup of patients with severe anxiety symptoms at baseline. Irrespective of the pharmacotherapy used in patients with depression, the likelihoods of response and remission are increased when pharmacotherapy is combined with psychotherapy, with this approach being more effective than either pharmacotherapy or psychotherapy alone. Persistence with treatment is important, and clinicians should therefore encourage patients to keep trying to obtain relief.
PubMed: 37115460
DOI: 10.1007/s40120-023-00470-z -
NPJ Digital Medicine Apr 2023Antidepressant selection is largely a trial-and-error process. We used electronic health record (EHR) data and artificial intelligence (AI) to predict response to four...
Antidepressant selection is largely a trial-and-error process. We used electronic health record (EHR) data and artificial intelligence (AI) to predict response to four antidepressants classes (SSRI, SNRI, bupropion, and mirtazapine) 4 to 12 weeks after antidepressant initiation. The final data set comprised 17,556 patients. Predictors were derived from both structured and unstructured EHR data and models accounted for features predictive of treatment selection to minimize confounding by indication. Outcome labels were derived through expert chart review and AI-automated imputation. Regularized generalized linear model (GLM), random forest, gradient boosting machine (GBM), and deep neural network (DNN) models were trained and their performance compared. Predictor importance scores were derived using SHapley Additive exPlanations (SHAP). All models demonstrated similarly good prediction performance (AUROCs ≥ 0.70, AUPRCs ≥ 0.68). The models can estimate differential treatment response probabilities both between patients and between antidepressant classes for the same patient. In addition, patient-specific factors driving response probabilities for each antidepressant class can be generated. We show that antidepressant response can be accurately predicted from real-world EHR data with AI modeling, and our approach could inform further development of clinical decision support systems for more effective treatment selection.
PubMed: 37100858
DOI: 10.1038/s41746-023-00817-8 -
Epilepsia Open Jun 2023We searched for, from the FDA (Food and Drug Administration-USA)-approved drugs, inhibitors of FKBP5 with tolerable adverse effect profiles (eg, mild headache, sedation,...
OBJECTIVE
We searched for, from the FDA (Food and Drug Administration-USA)-approved drugs, inhibitors of FKBP5 with tolerable adverse effect profiles (eg, mild headache, sedation, etc.) and with the ability to cross the blood brain barrier (BBB), using bio-informatics tools (in-silico). This may pave the road for designing clinical trials of such drugs in patients with functional seizures (FS) and other stress-associated disorders.
METHODS
Several databases were used to find all the approved drugs that potentially have interactions with FKBP51 protein [ie, CTD gene-chemical interaction section of FKBP51 protein of Harmonizome of Mayaanlab, DrugCenteral database, PDID (Protein Drug Interaction Database), DGIdb (the Drug Gene Interaction database)]. Other databases were also searched [eg, clinicaltrials.gov; DRUGBANK (the FASTA format of the FKBP51 protein was imported to the target sequencing section of the database to find the associated drugs), and the STITCH database (to find the related chemical interaction molecules)].
RESULTS
After a comprehensive search of the designated databases, 28 unique and approved drugs were identified. Fluticasone propionate and Mifepristone and Ponatinib, Mirtazapine, Clozapine, Enzalutamide, Sertraline, Prednisolone, Fluoxetine, Dexamethasone, Clomipramine, Duloxetine, Citalopram, Chlorpromazine, Nefazodone, and Escitalopram are inhibitors of FKBP5 and have BBB permeability.
SIGNIFICANCE
While the current in-silico repurposing study could identify potential drugs (that are already approved and are widely available) for designing clinical trials in patients with stress-associated disorders (eg, FS), any future clinical trial should consider the pharmacological profile of the desired drug and also the characteristics and comorbidities of the patients in order to foster a success.
Topics: United States; Humans; Sertraline; Fluoxetine; Citalopram; Clomipramine; Duloxetine Hydrochloride
PubMed: 37078238
DOI: 10.1002/epi4.12749 -
Neuropsychiatric Disease and Treatment 2023This survey aims to explore the current medical treatment of major depressive disorder (MDD) in China and match its degree with Canadian Network for Mood and Anxiety...
OBJECTIVE
This survey aims to explore the current medical treatment of major depressive disorder (MDD) in China and match its degree with Canadian Network for Mood and Anxiety Treatments (CANMAT).
METHODS
A total of 3275 patients were recruited from 16 mental health centers and 16 general hospitals in China. Descriptive statistics presented the total number and percentage of drugs, as well as all kinds of treatments.
RESULTS
Selective serotonin reuptake inhibitors (SSRIs) accounted for the largest proportion (57.2%), followed by serotonin-noradrenaline reuptake inhibitors (SNRIs) (22.8%) and mirtazapine (7.0%) in the first therapy, while that of SNRIs (53.9%) followed by SSRIs (39.2%) and mirtazapine (9.8%) in the follow-up therapy. An average of 1.85 medications was administered to each MDD patient.
CONCLUSION
SSRIs were the first choice in the first therapy, while the proportion of those drugs decreased during the follow-up therapy and were replaced by SNRIs. Plenty of combined pharmacotherapies were directly selected as the first trial of patients, which was inconsistent with guideline recommendations.
PubMed: 37077710
DOI: 10.2147/NDT.S401359 -
Psychiatria Polska Oct 2022The emerging SARS-CoV-2 pandemic is known to take a toll on both physical and mental health. We present a case of a patient with a first episode of severe depression...
The emerging SARS-CoV-2 pandemic is known to take a toll on both physical and mental health. We present a case of a patient with a first episode of severe depression with COVID-19-related psychotic features. A patient with no history of mental disorders was admitted to the Psychiatric Unit due to the symptoms of severe depressive episode with psychotic features. Progressive deterioration of his mental health, behavior and activity was observed in March of 2020. He was not infected nor exposed to infectious agents but presented delusions about being infected with SARS-CoV-2 and being a source of transmission to other people. He suffered from Hashimoto disease and recently diagnosed lymphoma which further diagnosis was postponed. He was administrated venlafaxine 150 mg and mirtazapine 45 mg with addition of olanzapine up to 20 mg and risperidone up to 6 mg per day. No side effects were reported. The patient reached a full recovery with the exception of slightly blunted ability to feel pleasure, minor problems with concentration and occasional pessimistic thoughts. Discussion: The social distancing recommendations put a psychological strain related to alienation and negative emotions which can favor development of depressive symptoms. Analysis of psychological mechanisms related to the pandemic and restrictions is significant for limiting negative influence of global crisis on individual mental well-being. Conclusions: In this case the impact of global anxiety and its integration into the developing psychopathological symptoms is especially significant. The circumstances surrounding an episode of affective disorder may shape its course and thought content.
Topics: Humans; Pandemics; Depression; COVID-19; SARS-CoV-2; Psychotic Disorders
PubMed: 37074848
DOI: 10.12740/PP/141830 -
Gastroenterology and Hepatology From... 2023In the current clinical trial study, the potency of mirtazapine and nortriptyline was compared in patients with Functional Dyspepsia (FD) who had anxiety or depression.
AIM
In the current clinical trial study, the potency of mirtazapine and nortriptyline was compared in patients with Functional Dyspepsia (FD) who had anxiety or depression.
BACKGROUND
FD usually accompanies other psychosocial disorders. According to previous studies, among these disorders, anxiety and depression have the most correlation.
METHODS
This randomized clinical trial was organized in Taleghani hospital (Tehran, Iran). In two parallel groups, 42 patients were treated for 12 weeks, with 22 patients receiving 7.5 mg of mirtazapine and 20 patients receiving 25 mg of nortriptyline per day. To gain robust results, the patients with a positive history of antidepressant therapy, organic diseases, alcohol abuse, pregnancy, and major psychiatric disorders were excluded from the study. The subjects were examined by three questionnaires, including Nepean and Hamilton questionnaires. The patients were asked to answer the questions three times during the study: once before the onset of the treatment, second during the treatment, and third at the end of the treatment.
RESULTS
Based on Gastrointestinal (GI) manifestations, mirtazapine, in comparison to nortriptyline could significantly suppress the signs and symptoms of FD, including epigastric pains (P=0.02), belching (P=0.004), and bloating (P=0.01). Although the results from the use of mirtazapine compared to the use of nortriptyline (P=0.002) showed a lower mean depression score on the Hamilton questionnaire, no significant differences were found between the effects of these drugs on the anxiety scale of patients (P=0.091).
CONCLUSION
Mirtazapine is more effective for GI symptoms related to gastric emptying. Considering the level of anxiety, mirtazapine, compared to nortriptyline, revealed better outcomes in FD patients suffering from depression.
PubMed: 37070114
DOI: 10.22037/ghfbb.v16i1.2513 -
Psychiatria Danubina 2023
Topics: Humans; Mirtazapine; Hyponatremia; Mastocytosis, Systemic; Anxiety Disorders; Antidepressive Agents, Tricyclic; Mianserin
PubMed: 37060606
DOI: 10.24869/psyd.2023.126 -
Case Reports in Psychiatry 2023. Sleep disturbance and insomnia are some of the most frequent complaints in patients suffering from depression. Some common antidepressant with excitatory effects may...
. Sleep disturbance and insomnia are some of the most frequent complaints in patients suffering from depression. Some common antidepressant with excitatory effects may worsen sleep qualities, whereas others (like mirtazapine), thanks to their antihistaminergic action, are associated with sedative properties and can quickly improve sleep quality. In the case of mirtazapine, even if its mechanisms of action on sleep remain controversial, beneficial changes in sleep pattern may be observable since the first dose and are associated with a faster onset of the antidepressive action. . Despite these documented beneficial effects, we reported five cases of elderly patients (age ranging from 69 to 79) with various diagnoses and comorbidities (severe or recurrent depression, general anxiety disorder, borderline personality disorder, and Parkinson's disease) assessed during clinical daily routine for whom the use of mirtazapine was linked to the onset of nightmares so impressive and dramatic that made it necessary to interrupt the treatment. . This peculiar side effect is still scarcely documented, and the literature on this topic remains conflicting; however, considering that the cases were collected in a short range of time, the exacerbation of nightmares caused by mirtazapine may be more frequent than previously believed. Furthermore, some common features shared by all the cases reported have been highlighted such as the onset of the nightmares being chronologically associated with the initiation of the therapy with mirtazapine, the disappearance with the interruption, the similar age range of all, and the occurrence of the episodes described during fall season.
PubMed: 37057036
DOI: 10.1155/2023/8843206 -
Journal of Medical Case Reports Apr 2023Mirtazapine is a frequently prescribed psychotropic drug for depression in older age. It is considered safe and has a side-effect profile uniquely favorable to an older...
BACKGROUND
Mirtazapine is a frequently prescribed psychotropic drug for depression in older age. It is considered safe and has a side-effect profile uniquely favorable to an older person affected by reduced appetite, difficulty maintaining body weight, or insomnia. However, it is largely unknown that mirtazapine can cause a dangerous decline in neutrophil count.
CASE PRESENTATION
We present a case of mirtazapine-induced severe neutropenia in a 91-year-old white British woman requiring drug withdrawal and granulocyte-colony stimulating factor administration.
CONCLUSION
This case is of significance because mirtazapine is regarded as a safe, and often preferable, antidepressant in older age. However, this case demonstrates a rare, life-threatening side effect of mirtazapine and calls for greater pharmacovigilance when prescribing it. There is no previous report of mirtazapine-induced neutropenia requiring drug withdrawal and granulocyte-colony stimulating factor administration in an older person.
Topics: Female; Humans; Aged; Aged, 80 and over; Mirtazapine; Antidepressive Agents; Neutropenia; Sepsis; Colony-Stimulating Factors
PubMed: 37055872
DOI: 10.1186/s13256-023-03881-6