Cardiovascular effects of tricyclic antidepressants in depressed patients with chronic heart disease

Depression interventions for individuals with coronary artery disease - Cost-effectiveness calculations from an Irish perspective

BACKGROUND

A substantial proportion of individuals with coronary artery disease experience moderate or severe acute depression that requires treatment. We assessed the cost-effectiveness of four interventions for depression in individuals with coronary artery disease.

METHODS

We assessed effectiveness of pharmacotherapy, psychotherapy, collaborative care and exercise as remission rate after 8 and 26 weeks using estimates from a recent network meta-analysis. The cost assessment included standard doses of antidepressants, contact frequency, and staff time per contact. Unit costs were calculated as health services' purchase price for pharmaceuticals and mid-point staff salaries obtained from the Irish Health Service Executive and validated by clinical staff. Incremental cost-effectiveness ratios were calculated as the incremental costs over incremental remissions compared to usual care. High- and low-cost scenarios and sensitivity analysis were performed with changed contact frequencies, and assuming individual vs. group psychotherapy or exercise.

RESULTS

After 8 weeks, the estimated incremental cost-effectiveness ratio was lowest for group exercise (€526 per remission), followed by pharmacotherapy (€589), individual psychotherapy (€3117) and collaborative care (€4964). After 26 weeks, pharmacotherapy was more cost-effective (€591) than collaborative care (€7203) and individual psychotherapy (€9387); no 26-week assessment for exercise was possible. Sensitivity analysis showed that group psychotherapy could be most cost-effective after 8 weeks (€519) and cost-effective after 26 weeks (€1565); however no group psychotherapy trials were available investigating its effectiveness.

DISCUSSION

Large variation in incremental cost-effectiveness ratios was seen. With the current assumptions, the most cost-effective depression intervention for individuals with coronary artery disease after 8 weeks was group exercise.

Preoperative Management of Medications for Psychiatric Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement

There is a lack of guidelines for preoperative management of psychiatric medications leading to variation in care and the potential for perioperative complications and surgical procedure cancellations on the day of surgery. The Society for Perioperative Assessment and Quality Improvement identified preoperative psychiatric medication management as an area in which consensus could improve patient care. The aim of this consensus statement is to provide recommendations to clinicians regarding preoperative psychiatric medication management. Several categories of drugs were identified including antidepressants, mood stabilizers, anxiolytics, antipsychotics, and attention deficit hyperactivity disorder medications. Literature searches and review of primary and secondary data sources were performed for each medication/medication class. We used a modified Delphi process to develop consensus recommendations for preoperative management of individual medications in each of these drug categories. While most medications should be continued perioperatively to avoid risk of relapse of the psychiatric condition, adjustments may need to be made on a case-by-case basis for certain drugs.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.

MAIN RESULTS

Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I² = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I² = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I² = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I² = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I² = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I² = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.

AUTHORS' CONCLUSIONS

In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

Direct and indirect effects of psychopharmacological treatment on the cardiovascular system

Background Severe mental disorders, i.e. psychotic disorders, unipolar and bipolar disorders are associated with increased morbidity and mortality from cardiovascular and metabolic disorders. The underlying cause of this association is complex and comprises disorder specific alterations such as dysfunctions of immunological and hormonal systems, body-composition changes and health associated behaviors (smoking, sedentary lifestyle, alcohol intake and treatment compliance). Furthermore, some psychopharmacological drugs may exert unwanted side effects that impact the cardiovascular system. Methods This paper reviews studies concerning commonly used antidepressant and antipsychotics drugs with a particular focus on direct and indirect cardiovascular side effects. Results Newer antidepressant drugs have a favorable cardiovascular safety profile compared to tricyclic antidepressants. However, QTc prolongation, increased blood pressure and potentially higher risks of bleeding have been observed in some newer antidepressants. Some second generation (atypical) antipsychotics have raised concern because of indirect cardiovascular, metabolic side effects such as weight gain and disturbances in lipid and glucose metabolism. Conclusions Psychiatrists need to be aware of potential direct and indirect cardiovascular side effects and to include them in the risk/benefit assessment when choosing a specific individualized treatment.

Monitoring for antidepressant-associated adverse events in the treatment of patients with major depressive disorder: An international consensus statement

OBJECTIVES

These recommendations were designed to ensure safety for patients with major depressive disorder (MDD) and to aid monitoring and management of adverse effects during treatment with approved antidepressant medications. The recommendations aim to inform prescribers about both the risks associated with these treatments and approaches for mitigating such risks.

METHODS

Expert contributors were sought internationally by contacting representatives of key stakeholder professional societies in the treatment of MDD (ASBDD, CANMAT, WFSBP and ISAD). The manuscript was drafted through iterative editing to ensure consensus.

RESULTS

Adequate risk assessment prior to commencing pharmacotherapy, and safety monitoring during pharmacotherapy are essential to mitigate adverse events, optimise the benefits of treatment, and detect and assess adverse events when they occur. Risk factors for pharmacotherapy vary with individual patient characteristics and medication regimens. Risk factors for each patient need to be carefully assessed prior to initiating pharmacotherapy, and appropriate individualised treatment choices need to be selected. Some antidepressants are associated with specific safety concerns which were addressed.

CONCLUSIONS

Risks of adverse outcomes with antidepressant treatment can be managed through appropriate assessment and monitoring to improve the risk benefit ratio and improve clinical outcomes.

Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale

Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Tricyclic Antidepressants in the Intensive Care Unit

Tricyclic antidepressants (TCAs) are one of the most commonly prescribed classes of antidepressant medica tions, and they may account for more than 25% of all serious drug overdoses for persons admitted to adult intensive care units (ICUs). TCA overdose is the most common life-threatening drug ingestion in the United States, with an in-hospital mortality ranging from 0.6 to 15%. Manifestations of a significant overdose include anticholinergic effects (fever, mydriasis, tachycardia, and urinary retention), central nervous system toxicity (confusion, agitation, coma, hallucinations, and grand mal seizures), respiratory depression, and cardiovascu lar toxicity (ventricular tachycardia or fibrillation, hypotension, and conduction defects). The principal cardiovascular findings associated with therapeutic doses of TCAs are discussed and grouped into three categories: (1) electrocardiographic changes—sinus tachycardia, repolarization abnormalities, conduction disturbances, and ventricular arrhythmias; (2) mild depression of myocardial contractility; and (3) sudden cardiac death. The therapeutic feasibility and selection of a TCA for patients with preexisting cardiovascular disease is discussed, and current recommendations on the diagnosis and management of TCA overdoses are reviewed.

Treatment of affective disorders in cardiac disease

Patients with cardiovascular disease (CVD) commonly have syndromal major depression, and depression has been associated with an increased risk of morbidity and mortality. Prevalence of depression is between 17% and 47% in CVD patients. Pharmacologic and psychotherapeutic interventions have long been studied, and in general are safe and somewhat efficacious in decreasing depressive symptoms in patients with CVD. The impact on cardiac outcomes remains unclear. The evidence from randomized controlled clinical trials indicates that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe, and likely to be effective in the treatment of depression in patients with CVD. This review describes the prevalence of depression in patients with CVD, the physiological links between depression and CVD, the treatment options for affective disorders, and the clinical trials that demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population. Great progress has been made in understanding potential mediators between major depressive disorder and CVD—both health behaviors and shared biological risks such as inflammation.

Psychiatric agents and implications for perioperative analgesia

The use of antidepressants, anxiolytics, mood stabilizers, anticonvulsants, and major tranquilizers introduces neurochemical, behavioral, cognitive, and emotional factors that increase the complexity of medical and surgical tasks. Increasingly, various classes of psychotropic medications are being prescribed in the perioperative setting for their analgesic properties in patients with or without a psychiatric diagnosis. In many cases, the precise mechanisms of action and dose-response relationships by which these agents mediate analgesia are largely unclear. An appreciation of the side effects and adverse-effect profiles of such medications and familiarity with the clinically relevant drug interactions that may occur in the perioperative setting are imperative to ensure the best possible outcome in dealing with patients on these medications. This review focuses on various classes of psychotropic agents, which are addressed individually, with particular focus on their analgesic properties. The latest published research is summarized, deficiencies in our current collective knowledge are discussed, and evidence-based recommendations are made for clinical practice.

Treatment of depression in cardiovascular disease

BACKGROUND AND OBJECTIVES

Depression in patients with Cardiovascular Disease (CVD) is extremely common, with a prevalence of 17-47%, and is associated with increased risk of morbidity and mortality. Treatment of depression has been hypothesized to reduce cardiac mortality. Pharmacologic and psychotherapeutic interventions have been studied and appear to be safe and in some studies effective in reducing depressive symptoms in patients with cardiac disease. The impact on cardiac outcomes remains unclear. This review briefly focuses on the prevalence of depression in patients with CVD, the physiological links between depression and CVD, and largely is concerned with the clinical trials that seek to demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population.

METHODS

PubMed and PsycINFO databases were searched through July 2012. Publications were included if they were in English, a review article, or a clinical trial in the CVD population with comorbid depression. The search was completed with key words of antidepressants, CVD, coronary artery syndrome, SSRIs, depression, treatment of depression, post-MI (where MI is myocardial infarction), major depression, and cardiac disease. Trials were included if the patients were above the age of 18, both male and female genders, and had cardiac comorbidity. No trials were excluded.

RESULTS

A total of 61 articles and/or book chapters were included. The majority were from North America and Europe. There were 7 clinical trials of tricyclic antidepressants (TCAs), one of TCAs and bupropion, and 10 trials of selective serotonin reuptake inhibitors (SSRIs). We also evaluated five trials involving psychotherapeutic techniques and/or collaborative care.

CONCLUSIONS

There is considerable evidence from randomized controlled clinical trials that antidepressants, especially SSRIs, are safe in the treatment of major depression in patients with CVD. Although efficacy has been demonstrated in some, but not all, trials for both antidepressants and certain psychotherapies, large, well-powered trials are urgently needed. There are virtually no data available on predictors of antidepressant response in depressed patients with CVD. Whether successful treatment of depression is associated with a reduction in cardiac morbidity and mortality remains unknown.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in patients with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH STRATEGY

CENTRAL, DARE, HTA and EED on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ISRCTN Register and CardioSource Registry were searched. Reference lists of included randomised controlled trials (RCTs) were examined and primary authors contacted. No language restrictions were applied.

SELECTION CRITERIA

RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression were included. Primary outcomes were depression, mortality and cardiac events. Secondary outcomes were healthcare costs and health-related quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two reviewers independently examined the identified papers for inclusion and extracted data from included studies. Random effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3,253 references. Sixteen trials fulfilled the inclusion criteria. Psychological interventions show a small beneficial effect on depression compared to usual care (range of SMD of depression scores across trials and time frames: -0.81;0.12). Based on one trial per outcome, no beneficial effects on mortality rates, cardiac events, cardiovascular hospitalizations and QoL were found, except for the psychosocial dimension of QoL. Furthermore, no differences on treatment outcomes were found between the varying psychological approaches. The review provides evidence of a small beneficial effect of pharmacological interventions with selective serotonin reuptake inhibitors (SSRIs) compared to placebo on depression outcomes (pooled SMD of short term depression change scores: -0.24 [-0.38,-0.09]; pooled OR of short term depression remission: 1.80 [1.18,2.74]). Based on one to three trials per outcome, no beneficial effects regarding mortality, cardiac events and QoL were found. Hospitalization rates (pooled OR of three trials: 0.58 [0.39,0.85] and emergency room visits (OR of one trial: 0.58 [0.34,1.00]) were reduced in trials of pharmacological interventions compared to placebo. No evidence of a superior effect of Paroxetine (SSRI) versus Nortriptyline (TCA) regarding depression outcomes was found in one trial.

AUTHORS' CONCLUSIONS

Psychological interventions and pharmacological interventions with SSRIs may have a small yet clinically meaningful effect on depression outcomes in CAD patients. No beneficial effects on the reduction of mortality rates and cardiac events were found. Overall, however, the evidence is sparse due to the low number of high quality trials per outcome and the heterogeneity of examined populations and interventions.

Elderly and drugs: risks and necessity of rational use

In recent decades, the world has undergone a demographic transformation with a rapid growth of the elderly population, resulting in an increased demand for funds to maintain their health and drug consumption. Pharmacokinetic and pharmacodynamic changes occurring in the elderly can interfere directly in the adverse effects of drugs and increase the risk of intoxication. In addition, there are external factors interfering with the pharmacotherapy of the elderly, such as inappropriate use and the lack of access to information. Many therapeutic classes of drugs should be used with caution or avoided in the elderly population, such as anti-inflammatory and some anti-hypertensive drugs, diuretics and digitalis. If not managed carefully, these medicines can affect the safety and quality of life in the elderly. Thus, the aim of this review was to identify drugs that should be used with caution in elderly patients in order to avoid intoxication and/or adverse drug events.

Antidepressants for depression in physically ill people

BACKGROUND

There is an increased risk of depression in people with a physical illness. Depression is associated with reduced treatment adherence, poor prognosis, increased disability and higher mortality in many physical illnesses. Antidepressants are effective in the treatment of depression in physically healthy populations, but there is less clarity regarding their use in physically ill patients. This review updates Gill's Cochrane review (2000), which found that antidepressants were effective for depression in physical illness. Since Gill there have been a number of larger trials assessing the efficacy of antidepressants in this context.

OBJECTIVES

To determine the efficacy of antidepressants in the treatment of depression in patients with a physical illness.

SEARCH STRATEGY

Electronic searches of the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) trial registers were conducted together with supplementary searches of The Cochrane Central Register of Controlled Trials (CENTRAL) and the standard bibliographic databases, MEDLINE, EMBASE and PsycINFO. Reference lists of included studies were scanned and trials registers were searched to identify additional unpublished data. Last searches were run in December 2009.

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of antidepressants and placebo in the treatment of depression in adults with a physical illness. Depression included diagnoses of Major Depression, Adjustment Disorder and Dysthymia based on standardised criteria.

DATA COLLECTION AND ANALYSIS

The primary outcome was efficacy 6-8 weeks after randomisation. Data were also extracted at three additional time-points (4-5 weeks, 9-18 weeks, >18 weeks). Acceptability and tolerability were assessed by comparing the number of drop-outs and adverse events. Odds ratios with 95% confidence intervals were calculated for dichotomous data (response to treatment). Standardised mean differences with 95% CI were calculated for continuous data (mean depression score). Data were pooled using a random effects model.

MAIN RESULTS

Fifty-one studies including 3603 participants were included in the review. Forty-four studies including 3372 participants contributed data towards the efficacy analyses. Pooled efficacy data for the primary outcome provided an OR of 2.33, CI 1.80-3.00, p<0.00001 (25 studies, 1674 patients) favouring antidepressants. Antidepressants were also more efficacious than placebo at the other time-points. At 6-8 weeks, fewer patients receiving placebo dropped out compared to patients treated with an antidepressant. Dry mouth and sexual dysfunction were more common in patients treated with an antidepressant.

AUTHORS' CONCLUSIONS

This review provides evidence that antidepressants are superior to placebo in treating depression in physical illness. However, it is likely that publication and reporting biases exaggerated the effect sizes obtained. Further research is required to determine the comparative efficacy and acceptability of particular antidepressants in this population.

Differences in adverse effect reporting in placebo groups in SSRI and tricyclic antidepressant trials: a systematic review and meta-analysis

BACKGROUND

Biases in adverse effect reporting in randomized controlled trials (RCTs) [e.g. due to investigator expectations or assessment quality] can be quantified by studying the rates of adverse events reported in the placebo arms of such trials.

OBJECTIVE

We compared the rates of adverse effects reported in the placebo arms of tricyclic antidepressant (TCA) trials and placebo arms of selective serotonin reuptake inhibitor (SSRI) trials.

METHODS

We conducted a literature search for RCTs across PUBMED, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL). Only studies allowing adverse effect analysis were included. Publication year ranged from 1981 to 2007.

RESULTS

Our systematic review and meta-analysis included 143 placebocontrolled RCTs and data from 12,742 patients. Only 21% of studies used structured and systematic adverse effect ascertainment strategies. The way in which trials recorded adverse events influenced the rate of adverse effects substantially. Systematic assessment led to higher rates than less systematic assessment. Far more adverse effects were reported in TCA-placebo groups compared with SSRI-placebo groups, e.g. dry mouth (odds ratio [OR] = 3.5; 95% CI 2.9, 4.2); drowsiness (OR = 2.7; 95%CI 2.2, 3.4); constipation (OR= 2.7; 95%CI 2.1, 3.6); sexual problems (OR =2.3; 95%CI 1.5, 3.5). Regression analyses controlling for various influencing factors confirmed the results.

CONCLUSION

Adverse effect profiles reported in clinical trials are strongly influenced by expectations from investigators and patients. This difference cannot be attributed to ascertainment methods. Adverse effect patterns of the drug group are closely related to adverse effects of the placebo group. These results question the validity of the assumption that adverse effects in placebo groups reflect the 'drug-unspecific effects'.

Psychiatric disorders in hypertrophic cardiomyopathy

OBJECTIVE

Depression is undertreated in cardiac disease. Our aim was to evaluate frequency and risk factors of psychiatric disorders in hypertrophic cardiomyopathy.

METHODS

This was a two-phase epidemiological approach, using screening questionnaire then gold standard structured clinical interview. A cohort of 148 patients aged > or =18 (78% response rate) attending a dedicated hypertrophic cardiomyopathy clinic (1996-1998) were screened for psychiatric morbidity using Hospital Anxiety and Depression Scale and Social Adjustment Scale. Likely cases and noncases were evaluated by Structured Clinical Interview for DSM-III-R. The main outcome measure was prevalence of psychiatric diagnoses, with descriptive comparison against population statistics.

RESULTS

Thirty-seven percent of cardiomyopathy patients fulfilled criteria for anxiety disorder and 21% for mood disorder. Presence of mood disorder was associated with chest pain [relative risk (RR) 4.5, 95% CI 2.8-17.5], older age (2.8, 1.4-5.6), higher perceived risk of death (5.4, 2.3-13.0), poorer social adjustment (2.1, 1.1-4.2) and problems with sexual relations (1.5, 1.2-3.6). Presence of anxiety disorders was associated with chest pain (RR 3.5, 95% CI 2.1-26.0), higher perceived risk of death (2.0, 1.2-3.4), perception of physical symptoms as 'severe' (2.2, 1.2-4.2) and more recent diagnosis (1.7, 1.0-2.7).

CONCLUSIONS

Patients with cardiomyopathy have an elevated risk of mood disorders and anxiety disorders. Several demographic and clinical factors were found to be associated with these psychiatric conditions. Proper treatment intervention is likely to improve quality of life.

WITHDRAWN: Antidepressants for depression in medical illness

BACKGROUND

Depression in the physically unwell is common and an important cause of morbidity. There are problems with diagnosing depression in the physically ill which may lead to under-recognition and under-treatment. In clinical practice antidepressants are available and a feasible option for treating depressive disorders. Therefore we thought it would be a reasonable first step in addressing this problem to describe the literature of randomised controlled trials in this area.

OBJECTIVES

To determine whether antidepressants are clinically effective and acceptable for the treatment of depression in people who also have a physical illness.

SEARCH STRATEGY

MEDLINE, Cochrane Library Trials Register and Cochrane Depression and Neurosis Group Trials Register were all systematically searched, supplemented by hand searches of two journals and reference searching.

SELECTION CRITERIA

All relevant randomised trials comparing any antidepressant drug (as defined in the British National Formulary) with placebo or no treatment, in patients of either sex over 16, who have been diagnosed as depressed by any criterion, and have a specified physical disorder (for example cancer, myocardial infarction). "Functional" disorders where there is no generally agreed physical pathology (e.g. irritable bowel syndrome) were excluded. The main outcome measures are numbers of individuals who recover/improve at the end of the trial and, as a proxy for treatment acceptability, numbers who complete treatment.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by the reviewers onto data collection forms and differences settled by discussion.

MAIN RESULTS

18 studies were included, covering 838 patients with a range of physical diseases (cancer 2, diabetes 1, head injury 1, heart 1, HIV 5, lung 1, multiple sclerosis 1, renal 1, stroke 3, mixed 2). Depression was diagnosed clinically in 3 studies, otherwise by structured interview or checklist. Only 5 studies described how they performed randomisation. 1 study compared drug with no treatment, and the rest with placebo: all of the latter said they were double blind.6 studies used SSRIs, 3 atypical antidepressants, and the remainder tricyclics.Patients treated with antidepressants were significantly more likely to improve than those given placebo (13 studies, OR 0.37, 95% CI 0.27-0.51) or no treatment (1 study, OR 3.45, 95% CI 11.1-1.10). About 4 patients would need to be treated with antidepressants to produce one recovery from depression which would not have occurred had they been given placebo (NNT 4.2, 95% CI 3.2-6.4). Most antidepressants (tricyclics and SSRIs together, 15 trials ) produced a small but significant increase in dropout (OR 1.66, 95% CI 1.14-2.40. NNH 9.8, 95% CI 5.4-42.9). The "atypical" antidepressant mianserin produced significantly less dropout than placebo. Only 2 studies used numerical scales designed to measure effects on function and quality of life; in HIV (Karnofsky scale), drug was better than no treatment; in lung disease (Sickness Impact Profile), drug was not significantly different from placebo. Only 7 studies reported looking for changes in the physical disease. Antidepressants produced no change in immune function in HIV relative to placebo (2 studies) or no treatment (1 study). Relative to placebo, antidepressants produced no change in cardiovascular function in heart disease, in respiratory function in lung disease, or in vital signs or laboratory tests in cancer (1 study each). Nortriptyline produced worse control in diabetes. Trends towards tricyclics being more effective than SSRIs, but also more likely to produce dropout were noted, but these are based on non-randomised comparisons between trials.

AUTHORS' CONCLUSIONS

The review provides evidence that antidepressants, significantly more frequently than either placebo or no treatment, cause improvement in depression in patients with a wide range of physical diseases. About 4 patients would need to be treated with antidepressants to produce one recovery from depression which would not have occurred had they been given placebo (NNT 4.2, 95% CI 3.2-6.4). Antidepressants seem reasonably acceptable to patients, in that about 10 patients would need to be treated with antidepressants to produce one dropout from treatment which would not have occurred had they been given placebo (NNH 9.8, 95% CI 5.4-42.9).The evidence is consistent across the trials, apart from 2 trials in cancer, where the "atypical" antidepressant mianserin produced significantly less dropout than placebo. Trends towards tricyclics being more effective than SSRIs, but also more likely to produce dropout were noted, but these are based on non-randomised comparisons between trials. Problems with the evidence include most of the trials' use of observers, rather than patients, to decide on improvement, and concentration mainly on symptoms rather than function and quality of life. There is also a possibility of undetected negative trials.Nevertheless, the review provides evidence that use of antidepressants should at least be considered in those with both physical illness and depression. Regarding diagnosis, the existence of a cheap and readily available treatment for depression should encourage detailed assessment of persistent low mood in the physically ill.

Heart failure induced by non-cardiac drugs

Although heart failure is predominantly caused by cardiovascular conditions such as hypertension, coronary heart disease and valvular heart disease, it can also be an adverse reaction induced by drug therapy. In addition, some drugs have the propensity to adversely affect haemodynamic mechanisms in patients with an already existing heart condition. In this article, non-cardiac drugs known to be associated with the development or worsening of heart failure are reviewed. Moreover, drugs that may adversely affect the heart as a pump without causing symptoms or signs of heart failure are also included. The drugs discussed include anticancer agents such as anthracyclines, mitoxantrone, cyclophosphamide, fluorouracil, capecitabine and trastuzumab; immunomodulating drugs such as interferon-alpha-2, interleukin-2, infliximab and etanercept; antidiabetic drugs such as rosiglitazone, pioglitazone and troglitazone; antimigraine drugs such as ergotamine and methysergide; appetite suppressants such as fenfulramine, dexfenfluramine and phentermine; tricyclic antidepressants; antipsychotic drugs such as clozapine; antiparkinsonian drugs such as pergolide and cabergoline; glucocorticoids; and antifungal drugs such as itraconazole and amphotericin B. NSAIDs, including selective cyclo-oxygenase (COX)-2 inhibitors, are included as a result of their ability to cause heart disease, particularly in patients with an already existing cardiorenal dysfunction. Two drug groups are of particular concern. Anthracyclines and their derivatives may cause cardiomyopathy in a disturbingly high number of exposed individuals, who may develop symptoms of insidious onset several years after drug therapy. The risk seems to encompass all exposed individuals, but data suggest that children are particularly vulnerable. Thus, a high degree of awareness towards this particular problem is warranted in cancer survivors subjected to anthracycline-based chemotherapy. A second group of problematic drugs are the NSAIDs, including the selective COX-2 inhibitors. These drugs may cause renal dysfunction and elevated blood pressure, which in turn may precipitate heart failure in vulnerable individuals. Although NSAID-related cardiotoxicity is relatively rare and most commonly seen in elderly individuals with concomitant disease, the widespread long-term use of these drugs in risk groups is potentially hazardous. Pending comprehensive safety analyses, the use of NSAIDs in high-risk patients should be discouraged. In addition, there is an urgent need to resolve the safety issues related to the use of COX-2 inhibitors. As numerous drugs from various drug classes may precipitate or worsen heart failure, a detailed history of drug exposure in patients with signs or symptoms of heart failure is mandatory.

Physical measures for treating depression in dialysis patients

BACKGROUND

Depression is the most common psychological problem in the chronic dialysis population. The diagnosis of depression in patients on chronic dialysis is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects their physical, psychological and social well-being. Furthermore, the frequent occurrence of cardiovascular problems and the pharmacokinetic consequences of renal impairment may make drug treatment of depression difficult.

OBJECTIVES

The aim of this systematic review was to assess the efficacy and safety of physical measures in the treatment of depression in patients who are dialysed for end-stage renal disease.

SEARCH STRATEGY

A comprehensive search strategy was employed to identify all Randomised Controlled Trials (RCTs) relevant to the treatment of depression in patients on chronic dialysis. The following database were searched - MEDLINE (1966-March 2004), EMBASE (1980-March 2004), PSYCHINFO (1872-March 2004), The Cochrane Library (Issue 1, 2004). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened.

SELECTION CRITERIA

RCTs comparing drugs with placebo or no treatment, or a comparison of drugs against a combination of electroconvulsive therapy and drugs.

DATA COLLECTION AND ANALYSIS

Data were abstracted by two investigators independently onto a standard form and subsequently entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (WMD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Only one trial, with a total of 12 patients and of eight weeks duration was identified. The trial compared fluoxetine against placebo in depressed patients on chronic dialysis. This study did not show any significant difference in depression scores between the treatment and control groups or safety.

AUTHORS' CONCLUSIONS

Firm conclusions on the efficacy of physical methods of treatment cannot be made as we identified only one small RCT that was of short duration. More larger and longer term RCTs are needed in this area. Current screening tools for depression are recognised to have poor specificity in the medically ill due to overlap of somatic symptoms of the medical illness. The development of a valid diagnostic tool would be helpful.

Should selective serotonin reuptake inhibitors be prescribed to all patients with ischemic heart disease?

Recent studies have uncovered more and more evidence demonstrating the adverse relationship between depression and ischemic heart disease. One of the most significant mechanisms that may explain the adverse relationship is the increased platelet activity, otherwise known as aggregation, observed to occur in patients with depression or ischemic heart disease. Platelet activity is further elevated in patients with depression and ischemic heart disease. Selective serotonin reuptake inhibitors are antidepressants and also act like platelet inhibitors. The results of large-scale clinical trials suggest that the use of selective serotonin reuptake inhibitors may reduce cardiac events in post-myocardial infarction patients or in those with unstable angina that may be related to the effects of selective serotonin reuptake inhibitors on platelet aggregation.

Diagnosis and treatment of depression in the elderly medicare population: predictors, disparities, and trends

OBJECTIVES

To develop nationally representative estimates of rates of diagnosis of depression; to determine rates and type of treatment received by those diagnosed with depression; and to ascertain socioeconomic differences and trends in treatment rates of depression, including the effect of supplemental insurance coverage, for elderly Medicare fee-for-service beneficiaries.

DESIGN

Analysis of merged interview and Medicare claims data for multiple years from merged Medicare claims and interview data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare participants.

SETTING

Community dwellers.

PARTICIPANTS

Twenty thousand nine hundred sixty-six community-dwelling respondents aged 65 and older in the MCBS cost and use files for 1992 through 1998.

MEASUREMENTS

Diagnoses recorded in Medicare claims were used to identify individuals who received a diagnosis of depression from a healthcare provider; pharmacy and claims data were used to identify receipt of antidepressants and psychotherapy by those diagnosed.

RESULTS

The rate of depression diagnosis more than doubled, reaching 5.8% in 1998. Overall, about two-thirds of those diagnosed received treatment in each year; but those aged 75 and older, those of "Hispanic or other" ethnicity, and those without additional coverage to supplement Medicare were significantly less likely to receive treatment, controlling for other characteristics. If treated, members of these disadvantaged subgroups were less likely to receive psychotherapy.

CONCLUSION

Although depression has been thought until recent years to be underrecognized in the elderly, rates of diagnosis increased dramatically in the 1990s, with concomitant increases in treatment. Nevertheless, significant disparities by age, ethnicity, and supplemental insurance coverage persist in treatment of those diagnosed. Because depression is a major source of potentially treatable morbidity in older people, increased efforts are needed to ensure access to appropriate treatment across all subgroups of older people and to remove economic barriers to treatment.

Diagnosis and treatment of depression in the elderly medicare population: predictors, disparities, and trends

OBJECTIVES

To develop nationally representative estimates of rates of diagnosis of depression; to determine rates and type of treatment received by those diagnosed with depression; and to ascertain socioeconomic differences and trends in treatment rates of depression, including the effect of supplemental insurance coverage, for elderly Medicare fee-for-service beneficiaries.

DESIGN

Analysis of merged interview and Medicare claims data for multiple years from merged Medicare claims and interview data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey of Medicare participants.

SETTING

Community dwellers.

PARTICIPANTS

Twenty thousand nine hundred sixty-six community-dwelling respondents aged 65 and older in the MCBS cost and use files for 1992 through 1998.

MEASUREMENTS

Diagnoses recorded in Medicare claims were used to identify individuals who received a diagnosis of depression from a healthcare provider; pharmacy and claims data were used to identify receipt of antidepressants and psychotherapy by those diagnosed.

RESULTS

The rate of depression diagnosis more than doubled, reaching 5.8% in 1998. Overall, about two-thirds of those diagnosed received treatment in each year; but those aged 75 and older, those of "Hispanic or other" ethnicity, and those without additional coverage to supplement Medicare were significantly less likely to receive treatment, controlling for other characteristics. If treated, members of these disadvantaged subgroups were less likely to receive psychotherapy.

CONCLUSION

Although depression has been thought until recent years to be underrecognized in the elderly, rates of diagnosis increased dramatically in the 1990s, with concomitant increases in treatment. Nevertheless, significant disparities by age, ethnicity, and supplemental insurance coverage persist in treatment of those diagnosed. Because depression is a major source of potentially treatable morbidity in older people, increased efforts are needed to ensure access to appropriate treatment across all subgroups of older people and to remove economic barriers to treatment.

Broken heart: depression in cardiovascular disease

Heart disease and depression are among the most common diseases seen in developed countries. The relation-ship between heart disease and depression has been the subject of both popular interest and scientific research. Sadness is often portrayed as a feeling of heaviness in the chest or as a "broken heart." Interestingly as we learn more about the expression of emotions, it appears that these perceptions may simply be the language representation of somatic feelings. Large, prospective, longitudinal studies that have examined the relationship between depression and development of coronary artery disease (CAD) have shown that depression is a risk factor for the development of CAD. Depression also increases mortality in patients with stable CAD or myocardial infarction compared with patients without depression. The recent Sertraline AntiDepressant HeARt attack Trial (SADHART) has shown that selective serotonin reuptake inhibitors like sertraline can be safely used in patients with depression following myocardial infarction. There is also intriguing evidence that treating depression with antidepressants may improve outcomes, including mortality.

Safety of antidepressant drugs in the patient with cardiac disease: a review of the literature

Patients with cardiac disease, specifically ischemic heart disease and heart failure, have a higher frequency of major depressive disorder than patients without cardiac disease. The pathophysiologic reason for this is not completely understood. Previous depression, other debilitating illnesses, and type A personality are risk factors for the development of depression in cardiac patients. Depression has been shown to lower the threshold for ventricular arrhythmias. Therefore, treatment of depression potentially may prolong life in these patients. Antidepressant options that have been evaluated include several of the tricyclic antidepressants, trazodone, bupropion, and several of the selective serotonin reuptake inhibitors. Individual antidepressant drugs vary in their pharmacologic activity and side-effect profiles. Although clinical data are limited, it is important to individualize therapy in order to minimize cardiac adverse effects. Clinicians are encouraged to evaluate patients with cardiac disease for major depressive disorder and to consider antidepressant drug therapy for these patients when appropriate.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Clinical depression is common and significantly associated with reduced survival in patients with non-ischaemic heart failure

Several studies have shown that depression is an important predictor of morbidity and mortality in patients with ischaemic heart failure. We have investigated whether clinically recognised depression is linked to mortality in patients with non-ischaemic heart failure due to dilated cardiomyopathy (DCM) in the Royal Brompton Hospital (RBH), a tertiary cardiac centre located in London, UK. We retrospectively examined a cohort of 396 consecutive adult patients with DCM who satisfied our inclusion and exclusion criteria identified from an echocardiographic database and the hospital medical records. Mean age was 53+/-15 years. In all, 83 patients (21%) were clinically depressed, the majority of which (60%) were taking antidepressant therapy. After a follow-up period of 48 months, 83 (21%) patients died, 15 (4%) underwent cardiac transplantation and 130 (33%) were readmitted; 29 (35%) of the deaths and 40 (31%) of the readmissions were among clinically depressed patients. After 5 years, clinically depressed patients had significantly higher mortality and readmission rates than non-depressed; 36 vs. 16% (hazards ratio for death, 3.0; 95% CI, 1.4-6.4; P=0.004), and 87 vs. 74% (hazards ratio for readmission, 0.25; 95% CI, 0.07-0.90; P=0.03), respectively. The risk of depression was greatly increased in the presence of other recognised adverse clinical variables at baseline. Depression increases the risk of death and readmission in patients with heart failure secondary to non-ischaemic DCM. The risk associated with depression appears to be greatest among patients with milder disease, those with a shorter duration of symptoms and those demonstrating a lower systolic or diastolic blood pressure, renal impairment, or a restrictive left ventricular physiology on echocardiography. Interventions targeted at reducing depression warrant further study as a possible way to improve quality of life and/or outcome in patients with heart failure.

Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management

Despite many predictions that electroconvulsive therapy (ECT) would be replaced by pharmacotherapy, ECT has remained an invaluable adjunct in the management of severe psychiatric disease. Both pharmacotherapy and ECT continue to be used extensively, and will frequently be administered concurrently. The majority of patients requiring ECT will need anaesthesia; therefore, interactions could conceivably occur between the psychotropic drugs, ECT and the anaesthetic agents utilised. In managing an anaesthetic for ECT the effects of the anaesthetic agents and other medications on seizure intensity are important determinants influencing outcome. With regard to the antidepressants, tricyclic antidepressants (TCAs) and ECT can be combined safely and beneficially. More care is required when ECT is administered in the setting of a monoamine oxidase inhibitor (MAOI), especially the older irreversible varieties and in patients recently placed on MAOI therapy. Of the anticonvulsants and mood stabilisers, lithium and ECT given concurrently add significant risk of delirium and/or organic syndromes developing. Possible concerns with valproate, carbamazepine, lamotrigine, gabapentin and topiramate are that they may inhibit seizure activity. Additionally, carbamazepine may prolong the action of suxamethonium (succinylcholine). The combination of antipsychotics and ECT is well tolerated, and may in fact be beneficial. As regards the anxiolytics, benzodiazepines have anticonvulsant properties that might interfere with the therapeutic efficacy of ECT. CNS stimulants on the other hand may prolong seizures as well as produce dysrhythmias and elevate blood pressure. Calcium channel antagonists should be used with great care to avoid significant cardiovascular depression. The anaesthesiologist should therefore remain vigilant at all times, as untoward responses during ECT might occur suddenly due to interactions between psychotropics, anaesthetic agents and/or ECT.

Consultation-liaison psychiatrists' use of antidepressants in the physically ill

In a practice-based, prospective study of 917 inpatients referred to a consultation-liaison psychiatry service and diagnosed as depressed, 41% were prescribed an antidepressant: 40% tricyclics, 35% selective serotonin reuptake inhibitors (SSRIs), 15% monoamine oxidase inhibitors (MAOIs)/reversible inhibitors of monoamine (RIMAs) (mainly moclobemide), and 11% tetracyclics (mianserin). Factors associated with choice of antidepressant type included age, referral for pain, length and seriousness of physical illness, type of physical illness, and concurrent antipsychotics (P < 0.01). Tetracyclics and MAOI/RIMAs were used significantly more often than tricyclics in the more severely physically ill and the elderly. The percentage of patients prescribed an antidepressant increased significantly over time, which is accounted for by the greater use of SSRIs across all age groups and degrees of seriousness of illness. There is a paucity of randomized controlled trials on which to base practice guidelines. Practice-based research such as this helps inform those guidelines.

Depression and heart disease: evidence of a link, and its therapeutic implications

Over several decades, a large body of evidence has emerged to suggest that depressive disorder is a risk factor for heart diseases, both aetiologically and prognostically. Several large, prospective, longitudinal studies have examined the relationship between depression and the development of coronary artery disease (CAD); they reveal that the relationship is significant and independent of conventional risk factors. Prognostic studies have shown that depression is associated with two to three times higher mortality after myocardial infarction, unstable angina or coronary artery bypass grafting, and in patients with stable CAD compared with such patients without depression. Depression also has been found to increase mortality and morbidity in patients with heart failure, regardless of its aetiology. Such adverse associations persist after adjustment for conventional prognostic risk factors. Despite all of these findings, depressed patients with heart disease are less likely to be recognised clinically as being depressed than those patients who have depression but no heart disease. The very limited evidence available from pharmacological clinical trials raises concern about the safety of antidepressants in CAD and heart failure. In addition, no research has addressed whether the treatment of depression in patients with heart disease will improve their prognosis.

Management of Depression in Patients with Comorbid Cardiovascular Disease

Evidence suggests that depression commonly occurs in patients with cardiovascular disease and is associated with a poor prognosis including increased risk of cardiac mortality. Proposed pathophysiologic mechanisms include decreased heart rate variability, altered sympathetic and parasympathetic activity, increased ventricular instability, and abnormal platelet reactivity. Other proposed mechanisms involve the interference of depression with medication adherence and cardiac risk factor reduction. Despite this evidence, depression during cardiovascular disease is commonly unrecognized and inadequately treated. Tricyclic antidepressants (TCA) are efficacious for treating depression in this population but cause serious cardiac side effects and should be avoided in patients with significant cardiovascular disease. More recent studies with bupropion and the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline) indicate that they are acceptable alternatives to TCAs with regard to cardiac risk in depressed patients with heart disease, although larger studies are needed to validate their safety and efficacy in this special population. There are 3 studies currently being conducted to investigate the effect of antidepressant therapy and/or psychotherapy on cardiac morbidity and mortality in post–myocardial infarction patients with depression and/or low social support. These studies will hopefully answer the long-posed question of whether appropriate treatment of depression can improve cardiac prognosis.

Serum levels and cardiovascular effects of tricyclic antidepressants and selective serotonin reuptake inhibitors in depressed patients

Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are used to treat depression. Whereas cardiovascular effects have occasionally been reported during controlled studies with SSRIs, TCA treatment poses a well-known problem in this respect. To investigate the putative correlation between antidepressant dose or serum levels and adverse effects, the authors devised a naturalistic study to evaluate the tricyclic antidepressants' and SSRIs' effect on the cardiovascular system. The authors also compared antidepressant serum levels to adverse effects. Inpatients treated with TCAs or SSRIs were included; an electrocardiogram (ECG) and a Schellong test were carried out on the day patients entered the hospital and during steady-state treatment with antidepressant drugs when blood was drawn for therapeutic drug monitoring. The patient population consisted of 114 acutely depressed patients; 81 patients were treated with TCAs and 33 with SSRIs. The TCAs comprised amitriptyline (n = 43), clomipramine (n = 11), doxepin (n = 19) and imipramine (n = 8); the SSRIs comprised fluvoxamine (n = 14) and paroxetine (n = 19). In TCA-treated patients, the authors observed the same type of abnormalities in conduction and orthostatic hypotension as had been observed earlier. The authors also observed cases of first-degree atrioventricular block, prolonged QTc interval, and orthostatic hypotension in SSRI-treated patients. Thus SSRIs also appear to affect the cardiovascular system, which might pose a problem for patients with preexisting conduction disease. The authors observed a strong correlation between the decrease in systolic pressure and antidepressant serum concentration (except for clomipramine and paroxetine), suggesting that antidepressant serum level is a better correlate than dose.

Conventional and new antidepressant drugs in the elderly

Depression in the elderly is nowadays a predominant health care problem, mainly due to the progressive aging of the population. It results from psychosocial stress, polypathology, as well as some biochemical changes which occur in the aged brain and can lead to cognitive impairments, increased symptoms from medical illness, higher utilization of health care services and increased rates of suicide and nonsuicide mortality. Therefore, it is very important to make an early diagnosis and a suitable pharmacological treatment, not only for resolving the acute episode, but also for preventing relapse and enhancing the quality of life. Age-related changes in pharmacokinetics and in pharmacodynamics have to be kept into account before prescribing an antidepressant therapy in an old patient. In this paper some of the most important and tolerated drugs in the elderly are reviewed. Tricyclic antidepressants have to be used carefully for their important side effects. Nortriptyline, amytriptiline, clomipramine and desipramine as well, seem to be the best tolerated tricyclics in old people. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose and include the so called atypicals, such as selective serotonin reuptake inhibitors, serotonin noradrenalene reuptake inhibitors and noradrenaline reuptake inhibitors. Monoamine oxidase (MAO) inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy; the last generation drugs (reversible MAO inhibitors), such as meclobemide, seem to be very successful. Mood stabilizing drugs are widely used for preventing recurrences of depression and for preventing and treating bipolar illness. They include lithium, which is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients for its side effects, the anticonvulsants carbamazepine and valproic acid. Putative last generation mood stabilizing drugs include the dihydropyridine L-type calcium channel blockers and the anticonvulsants phenytoin, lamotrigine, gabapentin and topiramate, which have unique mechanisms of action and also merit further systematic study. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide or drug resistant forms.

Cardiac disorders and antidepressant medications

Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have been associated with an increase in cardiovascular disorders, especially in depressed patients who have pre-existing cardiac disease. These disorders are less likely to occur when a therapeutic dosage is administered. Injuries because of falls are more likely in elderly depressed patients, and orthostatic hypotension occurs with the use of TCAs. Selective serotonin reuptake inhibitor (SSRI) antidepressants differ structurally and in side effects from TCAs and MAOIs. They appear to be effective for treatment of depression, and their side-effect profiles appear safer than those of earlier approved antidepressants used by depressed patients with cardiovascular disorders.

Can treating depression reduce mortality after an acute myocardial infarction?

Major depression affects about one in five patients in the weeks after an acute myocardial infarction and is associated with an increased risk of cardiac morbidity and mortality. Consequently, there is considerable interest in the question of whether treating depression will improve medical prognosis in these patients. Safe, effective treatments for depression are available, but unless they also improve the underlying pathophysiological or behavioral mechanisms that contribute to cardiac morbidity and mortality, they may not have beneficial effects on prognosis. Altered cardiac autonomic tone is one of the leading candidate mechanisms. Unfortunately, a review of the available research reveals that cardiac autonomic tone often fails to normalize in patients treated for depression, and the research suggests that currently available treatments for depression will not necessarily improve cardiac event-free survival in patients who have had an acute myocardial infarction. Until there is convincing evidence that treatment can reduce the risk of cardiac morbidity and mortality, the principal reason to treat depression should continue to be to improve the quality of life of the patient who has had an acute myocardial infarction. Key words: depression, coronary heart disease, mortality.

A systematic review of the treatment of depression with antidepressant drugs in patients who also have a physical illness

To determine whether antidepressants are clinically effective and acceptable for the treatment of depression in people who also have a physical illness. The method used was a systematic review of all randomised controlled trials (found by computer and hand searches) comparing any antidepressant drug with placebo or no treatment, in depressed adults with a specified physical disorder. The main outcome measures are numbers of individuals who recover/improve at the end of the trial and, as a proxy for treatment acceptability, numbers who complete treatment. 18 studies were included, covering 838 patients with a range of physical diseases. 6 studies used SSRIs, 3 atypical antidepressants, and the remainder tricyclics. Patients treated with antidepressants were significantly more likely to improve than those given placebo: about 4 patients would need to be treated with antidepressants to produce one recovery from depression which would not have occurred had they been given placebo (NNT 4.2, 95% CI 3.2-6.4). Most antidepressants (tricyclics and SSRIs together, 15 trials) produced a small but significant increase in dropout (OR 1.66, 95% CI 1.14-2.40. NNH 9.8, 95% CI 5.4-42.9). The "atypical" antidepressant mianserin produced significantly less dropout than placebo. Trends towards tricyclics being more effective than SSRIs, but also more likely to produce dropout were noted. The review provides evidence that antidepressants, significantly more frequently than either placebo or no treatment, cause improvement in depression in patients with a wide range of physical diseases.

Drug-induced heart failure

Heart failure is a clinical syndrome that is predominantly caused by cardiovascular disorders such as coronary heart disease and hypertension. However, several classes of drugs may induce heart failure in patients without concurrent cardiovascular disease or may precipitate the occurrence of heart failure in patients with preexisting left ventricular impairment. We reviewed the literature on drug-induced heart failure, using the MEDLINE database and lateral references. Successively, we discuss the potential role in the occurrence of heart failure of cytostatics, immunomodulating drugs, antidepressants, calcium channel blocking agents, nonsteroidal anti-inflammatory drugs, antiarrhythmics, beta-adrenoceptor blocking agents, anesthetics and some miscellaneous agents. Drug-induced heart failure may play a role in only a minority of the patients presenting with heart failure. Nevertheless, drug-induced heart failure should be regarded as a potentially preventable cause of heart failure, although sometimes other priorities do not offer therapeutic alternatives (e.g., anthracycline-induced cardiomyopathy). The awareness of clinicians of potential adverse effects on cardiac performance by several classes of drugs, particularly in patients with preexisting ventricular dysfunction, may contribute to timely diagnosis and prevention of drug-induced heart failure.

Liability in prescribing choice: the example of the antidepressants

OBJECTIVE

The aim of this study is to review issues of legal liability in prescribing choice. Prescribing not only occurs in a medical setting, but also in a social and legal context in this era of evidence-based medicine and greater consumer awareness. Prescribers may be unaware of the legal consequences of medical decision-making and prescribing choice. This issue affects all areas of medicine and can be illustrated by antidepressant choice for major depression.

METHOD

A review was undertaken of liability issues that may arise in the context of prescribing, with particular reference to prescribing antidepressants.

RESULTS

There are legal precedents which illustrate prescribers' potential liability. These impose duties on the prescriber including those of care, to inform, and to respond to patients' wishes. In particular, the duty of care requires that if medicines are of equal efficacy, one should prescribe the best tolerated and least toxic medicine that is most likely to be taken at an effective dose for an adequate duration. While older and newer antidepressants are generally of equal efficacy, the newer agents have higher tolerability, lower toxicity and are less likely to be associated with treatment failure (due to sub-therapeutic dose regimens, or the patient discontinuing medication), disabling psychomotor impairment, dietary interaction or fatal overdose.

CONCLUSIONS

There needs to be compelling reasons for prescribing medicines with a greater likelihood of adverse outcomes such as the older antidepressants (e.g. tricyclics) rather than the newer antidepressants such as RIMAs, SSRIs, SNRIs and 5HT2 receptor antagonists. The higher likelihood of an adverse outcome of treatment where an older antidepressant has been prescribed raises the potential for professional negligence claims to be brought against medical practitioners who prescribe such medicines for reasons other than established medical need.

Antidepressant drugs in the elderly

1. In this article some of the most important and tolerated drugs in the elderly are reviewed. 2. Tricyclic antidepressants have to be used carefully because of their important side effects. Nortriptyline and desipramine appear to be the best tolerated tricyclics in old people. 3. Second generation antidepressants are preferred for the elderly and those patients with heart disease as they have milder side effects and are less toxic in overdose. 4. MAO inhibitors are useful drugs in resistant forms of depression in which the above mentioned drugs have no efficacy and the last generation drugs (reversible MAO inhibitors), such as moclobemide, seem to be very successful. 5. Lithium is sometimes used especially to prevent recurrence of depression, even if its use is limited in old patients due to its side effects. 6. Psychotherapy is often used as an adjunct to pharmacotherapy, while electroconvulsant therapy is used only in the elderly patients with severe depression, high risk of suicide, or drug-resistant forms.

Management of chronic pain. Part I

Chronic pain is associated with substantial psychosocial and economic stress, coupled with functional loss and various levels of vocational dysfunction. The role of a pain center is to focus on chronic pain in a multidisciplinary, comprehensive manner, providing the patient with the most effective opportunity to manage his or her chronic disease syndrome. This article focuses on methods to manage many types of chronic pain and describes a broad range of pharmacologic and nonpharmacologic interventions and options available to the patient. Part I of this two-part monograph describes pharmacotherapeutic interventions and regional nerve blocks. Part II focuses on psychologic assessment and treatment and physical therapy. A multimodal management strategy offers patients the greatest improvement potential for specific chronic pain syndromes. Cognitive and behavioral therapies and physical therapies are described. This combination of therapies may provide patients with the skills and knowledge needed to increase their sense of control over pain. The integration of appropriate pharmacotherapeutic regimens, neural blockades, physical therapy, and psychologic techniques maximizes a patient's effectiveness in dealing with chronic pain. Three case studies are presented in Part II.

Evaluation of myocardial cell damage by In-111-monoclonal antimyosin antibodies in patients under chronic tricyclic antidepressant drug treatment

BACKGROUND

The capability of chronic tricyclic antidepressant drug (TAD) treatment to elicit myocardial damage has been a subject of debate. Lack of an adequate noninvasive method to detect such damage has prevented an in-depth study.

METHODS AND RESULTS

A prospective study with In-111-monoclonal antimyosin antibodies was undertaken in a series of 21 young patients with major depression on TADs and a control group of 19 healthy subjects. A heart-to-lung ratio (HLR) of antimyosin uptake was used to discriminate normal from abnormal scans. HLR in healthy subjects was 1.39 +/- 0.08. Patients on imipramine (HLR, 1.41 +/- 0.09) or clomipramine (HLR, 1.44 +/- 0.06) showed normal studies. Those under amitriptyline had a higher HLR (1.58 +/- 0.12) compared with nonamitriptyline or normal groups (P < .05). None of the 15 patients on imipramine or clomipramine showed abnormal HLR, while 3 of 6 on amitriptyline did (P < .01). In these 3 patients, uptake decreased or disappeared after drug withdrawal. Ejection fraction was normal in every patient.

CONCLUSIONS

Monoclonal antimyosin antibody studies are normal in imipramine- and clomipramine-treated patients. Antibody uptake in those under amitriptyline treatment, which disappears after drug withdrawal, would suggest early evidence of myocardial toxicity.

A naturalistic study of 24-hour electrocardiographic recordings and echocardiographic findings in children and adolescents treated with desipramine

OBJECTIVE

Recent studies assessing cardiovascular effects of desipramine (DMI) in pediatric patients consistently have found small, clinically benign, but statistically significant, increases in heart rate and electrocardiographic (ECG) conduction parameters. However, single, routine ECG recordings cannot fully assess potential infrequent rhythm disturbances.

METHOD

We analyzed data from 24-hour ECG monitoring, two-dimensional Doppler echocardiography, and expert clinical cardiac examination of DMI-treated patients. Subjects were 71 children (N = 35) and adolescents (N = 36) receiving long-term treatment (means +/- SD = 1.5 +/- 1.2 years, median = 1.0 year) with DMI (means +/- SD = 3.5 +/- 1.6 mg/kg).

RESULTS

Compared with previous observations in untreated healthy children. DMI-treated patients had significantly lower rates of sinus pauses and junctional rhythm, but significantly higher rates of single or paired premature atrial contractions and runs of supraventricular tachycardia. There was an association between DMI serum levels and paired premature atrial contractions, but no other associations were detected.

CONCLUSIONS

These findings support the impression from previous ECG studies that DMI-associated cardiac effects in pediatric patients are quite benign. Nevertheless, it remains to be ascertained whether even minor cardiac abnormalities may predict later, evidently rare, adverse cardiovascular effects that may include sudden death.