Bupropion versus selective serotonin-reuptake inhibitors for treatment of depression

Sexual dysfunction and commonly used drugs in neurology

Sexual dysfunction is common in men and women with neurological diseases. Medications used in neurology can cause sexual dysfunction independently of the disease process and this may adversely affect patients' quality of life. This review focuses on medications commonly prescribed to neurological patients that may contribute to altered sexual function, and discusses how they may differ in men and women.

Patterns and predictors of antidepressant prescribing among adults with cancer and depression in ambulatory care settings in the United States

OBJECTIVE

Despite depression being a common comorbidity among adults with cancer, limited literature is available regarding pharmacologic depression treatment patterns and predictors in this population. This study aims to examine patterns and predictors of antidepressant prescribing among adults with cancer and depression in ambulatory care settings in the United States (US).

METHODS

This retrospective, cross-sectional study utilized data collected from the 2014 to 2015 National Ambulatory Medical Care Survey (NAMCS). The study sample consisted of adults (age ≥ 18 years) with cancer and depression (unweighted N = 539; weighted N = 11,361,000). A multivariable logistic regression analysis was used to adjust for individual-level factors to identify predictors of antidepressant prescribing.

RESULTS

Most patients were adults aged ≥ 65 years, female, and non-Hispanic whites. Thirty-seven percent of the study sample received antidepressant treatment. Multivariable logistic regression analysis revealed that race/ethnicity, physician specialty, and number of medications were significantly associated with receiving antidepressant(s). For example, non-Hispanic whites were two-and-half times more likely to receive an antidepressant [OR 2.43, 95% confidence interval 1.13-5.23] compared to other race/ethnic groups. Every unit increase in the number of prescribed medications increased the likelihood of receiving an antidepressant by 6% (OR 1.06, 95% CI: 1.01-1.11).

CONCLUSION

Among adults with a comorbid cancer and depression diagnosis and a recorded U.S. ambulatory care visit in 2014-2015, 37% received antidepressant treatment. This suggests most patients with cancer and depression do not receive pharmacologic treatment for depression. Future studies are needed to investigate the impact of antidepressant treatment on health outcomes in this patient population.

Different Effects of SSRIs, Bupropion, and Trazodone on Mitochondrial Functions and Monoamine Oxidase Isoform Activity

Mitochondrial dysfunction is involved in the pathophysiology of psychiatric and neurodegenerative disorders and can be used as a modulator and/or predictor of treatment responsiveness. Understanding the mitochondrial effects of antidepressants is important to connect mitochondria with their therapeutic and/or adverse effects. Pig brain-isolated mitochondria were used to evaluate antidepressant-induced changes in the activity of electron transport chain (ETC) complexes, monoamine oxidase (MAO), mitochondrial respiratory rate, and ATP. Bupropion, escitalopram, fluvoxamine, sertraline, paroxetine, and trazodone were tested. All tested antidepressants showed significant inhibition of complex I and IV activities at high concentrations (50 and 100 µmol/L); complex II + III activity was reduced by all antidepressants except bupropion. Complex I-linked respiration was reduced by escitalopram >> trazodone >> sertraline. Complex II-linked respiration was reduced only by bupropion. Significant positive correlations were confirmed between complex I-linked respiration and the activities of individual ETC complexes. MAO activity was inhibited by all tested antidepressants, with SSRIs causing a greater effect than trazodone and bupropion. The results indicate a probable association between the adverse effects of high doses of antidepressants and drug-induced changes in the activity of ETC complexes and the respiratory rate of mitochondria. In contrast, MAO inhibition could be linked to the antidepressant, procognitive, and neuroprotective effects of the tested antidepressants.

Depression patient-derived cortical neurons reveal potential biomarkers for antidepressant response

Major depressive disorder is highly prevalent worldwide and has been affecting an increasing number of people each year. Current first line antidepressants show merely 37% remission, and physicians are forced to use a trial-and-error approach when choosing a single antidepressant out of dozens of available medications. We sought to identify a method of testing that would provide patient-specific information on whether a patient will respond to a medication using in vitro modeling. Patient-derived lymphoblastoid cell lines from the Sequenced Treatment Alternatives to Relieve Depression study were used to rapidly generate cortical neurons and screen them for bupropion effects, for which the donor patients showed remission or non-remission. We provide evidence for biomarkers specific for bupropion response, including synaptic connectivity and morphology changes as well as specific gene expression alterations. These biomarkers support the concept of personalized antidepressant treatment based on in vitro platforms and could be utilized as predictors to patient response in the clinic.

Bupropion monotherapy alters neurotrophic and inflammatory markers in patients of major depressive disorder

BACKGROUND

Emerging hypotheses in the pathophysiology of major depressive disorder (MDD) indicate the role of neurotrophic factors and inflammation. This study assessed the association between therapeutic response of bupropion and serum brain-derived neurotrophic factor (BDNF) and tumour necrosis factor-α (TNF-α) levels in patients with MDD.

METHODS

Thirty patients (aged 18 to 60 years) with MDD diagnosed by DSM-5 criteria, with Hamilton Depression Rating scale (HAM-D) score ≥ 20 were included in the study. Patients were given bupropion sustained release (SR) in the doses of 150 mg once daily. All patients were followed up for 12 weeks.

RESULTS

HAM-D score at the start of the treatment was 25.57 ± 1.85 which significantly reduced to 10.8 ± 4.24 at 12 weeks of treatment. The serum BDNF level increased significantly (p < 0.05) from 2.42 ± 0.19 ng/ml to 2.97 ± 0.10 ng/ml and the levels of serum TNF-α reduced significantly (p < 0.05) from 4.45 ± 0.95 pg/ml to 2.11 ± 0.84 pg/ml at 12 weeks of treatment, in responders to treatment.

CONCLUSION

The results of our study suggest that bupropion SR monotherapy is effective and well tolerated in MDD patients with moderate to severe depression, and its therapeutic efficacy is accompanied by an increase in serum BDNF levels and a decrease in serum TNF-α levels.

Antidepressants appear safe in patients with carcinoid tumor: Results of a retrospective review

INTRODUCTION

Patients living with neuroendocrine tumors have high rates of depression, often necessitating antidepressants, including selective serotonin reuptake inhibitors (SSRI). Neuroendocrine tumors (NETs) secrete vasoactive substances, including serotonin, which contribute to the cluster of symptoms known as carcinoid syndrome (flushing and diarrhea). Controversy exists over whether or not antidepressants are safe in NET. We aimed to study the safety of antidepressant use in NET patients.

METHODS

We conducted a retrospective chart review of patients with well differentiated NET who were also prescribed antidepressants from January 2008 through April 2015. The study took place at Memorial Sloan Kettering Cancer Center and was approved by the hospital's institutional review board.

RESULTS

Ninety-two patients were included. There were 16 (17.4%) patients with carcinoid syndrome (10 ileum, 1 duodenum, 1 jejunum and 4 unknown primary); and 76 (82.6%) patients without (41 lung, 9 pancreas, 8 ileal, 5 duodenum, 5 appendix, 2 unknown primary, 1 jejunum and 5 other). Median duration of antidepressant prescription was 11.6 months (range, 0-121) among those with carcinoid syndrome (N = 16) and 14.3 months (range, 0-172) among those without carcinoid syndrome (n = 76). Antidepressants were stopped in 31 cases (33.7%), though the reason was not specified in the majority of cases (n = 18; 58%). None of the patients developed carcinoid syndrome while being prescribed antidepressants. No patients developed carcinoid crisis.

CONCLUSION

Our findings do not support previous authors' recommendations that SSRIs must be avoided in NET patients. Several classes of antidepressants appeared safe in NET patients with and without carcinoid syndrome.

Loss of NMDA receptors in dopamine neurons leads to the development of affective disorder-like symptoms in mice

The role of changes in dopamine neuronal activity during the development of symptoms in affective disorders remains controversial. Here, we show that inactivation of NMDA receptors on dopaminergic neurons in adult mice led to the development of affective disorder-like symptoms. The loss of NMDA receptors altered activity and caused complete NMDA-insensitivity in dopamine-like neurons. Mutant mice exhibited increased immobility in the forced swim test and a decrease in social interactions. Mutation also led to reduced saccharin intake, however the preference of sweet taste was not significantly decreased. Additionally, we found that while mutant mice were slower to learn instrumental tasks, they were able to reach the same performance levels, had normal sensitivity to feedback and showed similar motivation to exert effort as control animals. Taken together these results show that inducing the loss of NMDA receptor-dependent activity in dopamine neurons is associated with development of affective disorder-like symptoms.

Effects of Ketamine and Ketamine Metabolites on Evoked Striatal Dopamine Release, Dopamine Receptors, and Monoamine Transporters

Following administration at subanesthetic doses, (R,S)-ketamine (ketamine) induces rapid and robust relief from symptoms of depression in treatment-refractory depressed patients. Previous studies suggest that ketamine's antidepressant properties involve enhancement of dopamine (DA) neurotransmission. Ketamine is rapidly metabolized to (2S,6S)- and (2R,6R)-hydroxynorketamine (HNK), which have antidepressant actions independent of N-methyl-d-aspartate glutamate receptor inhibition. These antidepressant actions of (2S,6S;2R,6R)-HNK, or other metabolites, as well as ketamine's side effects, including abuse potential, may be related to direct effects on components of the dopaminergic (DAergic) system. Here, brain and blood distribution/clearance and pharmacodynamic analyses at DA receptors (D1-D5) and the DA, norepinephrine, and serotonin transporters were assessed for ketamine and its major metabolites (norketamine, dehydronorketamine, and HNKs). Additionally, we measured electrically evoked mesolimbic DA release and decay using fast-scan cyclic voltammetry following acute administration of subanesthetic doses of ketamine (2, 10, and 50 mg/kg, i.p.). Following ketamine injection, ketamine, norketamine, and multiple hydroxynorketamines were detected in the plasma and brain of mice. Dehydronorketamine was detectable in plasma, but concentrations were below detectable limits in the brain. Ketamine did not alter the magnitude or kinetics of evoked DA release in the nucleus accumbens in anesthetized mice. Neither ketamine's enantiomers nor its metabolites had affinity for DA receptors or the DA, noradrenaline, and serotonin transporters (up to 10 μM). These results suggest that neither the side effects nor antidepressant actions of ketamine or ketamine metabolites are associated with direct effects on mesolimbic DAergic neurotransmission. Previously observed in vivo changes in DAergic neurotransmission following ketamine administration are likely indirect.

Augmentation with antidepressants in schizophrenia treatment: benefit or risk

We focused on the application of antidepressants in schizophrenia treatment in this review. Augmentation of antidepressants with antipsychotics is a common clinical practice to treat resistant symptoms in schizophrenia, including depressive symptoms, negative symptoms, comorbid obsessive-compulsive symptoms, and other psychotic manifestations. However, recent systematic review of the clinical effects of antidepressants is lacking. In this review, we have selected and summarized current literature on the use of antidepressants in patients with schizophrenia; the patterns of use and effectiveness, as well as risks and drug-drug interactions of this clinical practice are discussed in detail, with particular emphasis on the treatment of depressive symptoms in schizophrenia.

Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis

BACKGROUND

Sexual dysfunction (SD) is prevalent in patients with major depressive disorder (MDD) and is also associated with second-generation antidepressants (SGADs) that are commonly used to treat the condition. Evidence indicates under-reporting of SD in efficacy studies. SD associated with antidepressant treatment is a serious side effect that may lead to early termination of treatment and worsening of quality of life.

OBJECTIVES

Our objective was to systematically assess the harms of SD associated with SGADs in adult patients with MDD by drug type.

METHODS

We retrieved English-language abstracts from PubMed, EMBASE, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to October 2012 as well as from reference lists of pertinent review articles and grey literature searches. Two independent reviewers identified randomized controlled trials (RCTs) of at least 6 weeks' duration and observational studies with at least 1,000 participants.

STUDY SELECTION

Reviewers abstracted data on study design, conduct, participants, interventions, outcomes and method of SD ascertainment, and rated risk of bias. A senior reviewer checked and confirmed extracted data and risk-of-bias ratings.

ANALYSES

Random effects network meta-analysis using Bayesian methods for data from head-to-head trials and placebo-controlled comparisons; descriptive analyses calculating weighted mean rates from individual trials and observational studies.

RESULTS/SYNTHESIS

Data from 63 studies of low and moderate risk of bias (58 RCTs, five observational studies) with more than 26,000 patients treated with SGADs were included. Based on network meta-analyses of 66 pairwise comparisons from 37 RCTs, most comparisons showed a similar risk of SD among included SGADs. However, credible intervals were wide and included differences that would be considered clinically relevant. We observed three main patterns: bupropion had a statistically significantly lower risk of SD than some other SGADs, and both escitalopram and paroxetine showed a statistically significantly higher risk of SD than some other SGADs. We found reporting of harms related to SD inconsistent and insufficient in some trials.

LIMITATIONS

Most trials were conducted in highly selected populations. Search was restricted to English-language only.

CONCLUSION AND IMPLICATIONS

Because of the indirect nature of the comparisons, the often wide credible intervals, and the high variation in magnitude of outcome, we rated the overall strength of evidence with respect to our findings as low. The current degree of evidence does not allow a precise estimate of comparative risk of SD associated with a specific antidepressant. In the absence of such evidence, clinicians need to be aware of SD as a common adverse event and should discuss patients' preferences before initiating antidepressant therapy.

Agonist replacement for stimulant dependence: a review of clinical research

Stimulant use disorders are an unrelenting public health concern worldwide. Agonist replacement therapy is among the most effective strategies for managing substance use disorders including nicotine and opioid dependence. The present paper reviewed clinical data from human laboratory self-administration studies and clinical trials to determine whether agonist replacement therapy is a viable strategy for managing cocaine and/or amphetamine use disorders. The extant literature suggests that agonist replacement therapy may be effective for managing stimulant use disorders, however, the clinical selection of an agonist replacement medication likely needs to be based on the pharmacological mechanism of the medication and the stimulant abused by patients. Specifically, dopamine releasers appear most effective for reducing cocaine use whereas dopamine reuptake inhibitors appear most effective for reducing amphetamine use.

A systematic review of randomized controlled trials of bupropion versus methylphenidate in the treatment of attention-deficit/hyperactivity disorder

BACKGROUND

Some trials have suggested that bupropion, as well as methylphenidate, is beneficial in the treatment of attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVES

The purpose of this systematic review was to summarize the efficacy, acceptability, and tolerability of bupropion in comparison with methylphenidate for ADHD treatment. Included studies were randomized controlled trials (RCTs) that compared bupropion and methylphenidate. Clinical studies conducted between January 1991 and January 2014 were reviewed.

DATA SOURCES

MEDLINE(®), EMBASE™, CINAHL, PsycINFO(®), and the Cochrane Controlled Trials Register were searched in January 2014. Additionally, clinical trials were identified from the databases of ClinicalTrials.gov and the EU Clinical Trials Register.

STUDY ELIGIBLE CRITERIA PARTICIPANTS AND INTERVENTIONS

All RCTs of bupropion and methylphenidate reporting final outcomes relevant to 1) ADHD severity, 2) response or remission rates, 3) overall discontinuation rate, or 4) discontinuation rate due to adverse events. Language restriction was not applied.

STUDY APPRAISAL AND SYNTHESIS METHODS

The relevant clinical trials were examined and the data of interest were extracted. Additionally, the risks of bias were also inspected. The efficacy outcomes were the mean changed scores of ADHD rating scales, the overall response rate, and the overall remission rates. The overall discontinuation rate and the discontinuation rate due to adverse events were determined. Relative risks and weighted mean differences or standardized mean differences with 95% confidence intervals were estimated using a random effect model.

RESULTS

A total of 146 subjects in four RCTs comparing bupropion with methylphenidate in the treatment of ADHD were included. The pooled mean changed scores of the Iowa-Conner's Abbreviated Parent and Teacher Questionnaires and the ADHD Rating Scale-IV for parents and teachers of children and adolescents with ADHD in the bupropion- and methylphenidate-treated groups were not significantly different. Additionally, the pooled mean changed score in adult ADHD between the two groups, measured by the ADHD Rating Scale-IV and the Adult ADHD Rating Scale, was also not significantly different. The pooled rates of response, overall discontinuation, and discontinuation due to adverse events between the two groups were not significantly different.

CONCLUSION

Based on limited data from this systematic review, bupropion was as effective as methylphenidate for ADHD patients. Additionally, tolerability and acceptability were also comparable. However, these findings should be considered as very preliminary results. To confirm this evidence, further studies in this area should be conducted.

Sexual side effects of serotonergic antidepressants: mediated by inhibition of serotonin on central dopamine release?

Antidepressant-induced sexual dysfunction adversely affects the quality of life of antidepressant users and reduces compliance with treatment. Animal models provide an instructive approach for examining potential sexual side effects of novel drugs. This review discusses the stability and reproducibility of our standardized test procedure that assesses the acute, subchronic and chronic effects of psychoactive compounds in a 30 minute mating test. In addition, we present an overview of the effects of several different (putative) antidepressants on male rat sexual behavior, as tested in our standardized test procedure. By comparing the effects of these mechanistically distinct antidepressants (paroxetine, venlafaxine, bupropion, buspirone, DOV 216,303 and S32006), this review discusses the putative mechanism underlying sexual side effects of antidepressants and their normalization. This review shows that sexual behavior is mainly inhibited by antidepressants that increase serotonin neurotransmission via blockade of serotonin transporters, while those that mainly increase the levels of dopamine and noradrenaline are devoid of sexual side effects. Those sexual disturbances cannot be normalized by simultaneously increasing noradrenaline neurotransmission, but are normalized by increasing both noradrenaline and dopamine neurotransmission. Therefore, it is hypothesized that the sexual side effects of selective serotonin reuptake inhibitors may be mediated by their inhibitory effects on dopamine signaling in sex brain circuits. Clinical development of novel antidepressants should therefore focus on compounds that simultaneously increase both serotonin and dopamine signaling.

A case of treating cathinone dependence and comorbid depression using bupropion

Cathinone is a potent CNS stimulant found in khat leaves. Cathinone and synthetic cathinone-derivatives have become popular recreational drugs in recent years, commonly marketed as "legal highs." In addition to acute physical and psychiatric adverse effects, dependence on these substances is a concern. The following case reports describes a young man with cathinone dependence and depression that was treated using bupropion. Bupropion is a cathinone-derivative with a dual dopamine-norepinephrine reuptake inhibiting mechanism, which is approved for the treatment of depression and smoking cessation. Clinical awareness to the addictive potential of cathinone and cathinone-derivatives is important. Research regarding the potential effectiveness of bupropion in these cases is needed.

Agonist replacement therapy for cocaine dependence: a translational review

Cocaine use disorders are prevalent throughout the world. Agonist replacement therapy is among the most effective strategies for managing substance use disorders including nicotine and opioid dependence. This paper reviews the translational literature, including preclinical experiments, human laboratory studies and clinical trials, to determine whether agonist-replacement therapy is a viable strategy for managing cocaine dependence. Discussion is limited to transporter blockers (i.e., methylphenidate) and releasers (i.e., amphetamine analogs) that are available for use in humans in the hope of impacting clinical research and practice more quickly. The translational review suggests that agonist-replacement therapy, especially monoamine releasers, may be effective for managing cocaine dependence. Future directions for medications development are also discussed because the viability of agonist-replacement therapy for cocaine dependence may hinge on identifying novel compounds or formulations that have less abuse and diversion potential.

Expression of monoamine transporters, nitric oxide synthase 3, and neurotrophin genes in antidepressant-stimulated astrocytes

BACKGROUND

There is increasing evidence that glial cells play a role in the pathomechanisms of mood disorders and the mode of action of antidepressant drugs.

METHODS

To examine whether there is a direct effect on the expression of different genes encoding proteins that have been implicated in the pathophysiology of affective disorders, primary astrocyte cell cultures from rats were treated with two different antidepressant drugs, imipramine and escitalopram, and the RNA expression of brain-derived neurotrophic factor (Bdnf), serotonin transporter (5Htt), dopamine transporter (Dat), and endothelial nitric oxide synthase (Nos3) was examined.

RESULTS

Stimulation of astroglial cell culture with imipramine, a tricyclic antidepressant, led to a significant increase of the Bdnf RNA level whereas treatment with escitalopram did not. In contrast, 5Htt was not differentially expressed after antidepressant treatment. Finally, neither Dat nor Nos3 RNA expression was detected in cultured astrocytes.

CONCLUSION

These data provide further evidence for a role of astroglial cells in the molecular mechanisms of action of antidepressants.

A model to incorporate genetic testing (5-HTTLPR) in pharmacological treatment of major depressive disorders

OBJECTIVE

To evaluate the benefit of pharmacogenetics in antidepressant treatment.

METHODS

In a simulated trial 100,000 subjects in a current episode of major depressive disorder (MDD) received citalopram or bupropion based on the clinician's decision (algorithm A) or following indications from 5-HTTLPR genetic testing (algorithm B), which effect size of was estimated from a meta-analysis of pharmacogenetic trials. A and B were compared in a cost-utility analysis (12 weeks). Costs (international $, 2010) were drawn from official sources. Treatment effects were expressed as quality-adjusted life weeks (QALWs). Outcome was incremental cost-effectiveness ratio (ICER).

RESULTS

Under base-case conditions, genetic test use was associated with increases in antidepressant response (0.062 QALWs) and tolerability (0.016 QALWs) but cost benefit was not acceptable (ICER = $2,890; $1,800-$4,091). However, when the joint effect on antidepressant response and tolerability was analyzed in two recurrent episodes, ICER dropped to $1,392 ($837-$1,982). Cost-effectiveness acceptability curve (CEAC) showed a >80% probability that ICER value fell below the commonly accepted 3 times Gross Domestic Product (GDP) threshold (World Health Organization) and therefore suggesting cost-effectiveness.

CONCLUSION

Notwithstanding some caveats (exclusion of gene-gene and gene-environment interactions; simple 5-HTTLPR architecture), this simulation is favourable to incorporate pharmacogenetic test in antidepressant treatment.

Agonist-like pharmacotherapy for stimulant dependence: preclinical, human laboratory, and clinical studies

A variety of natural and synthetic agents have long been used for stimulant properties, with nontherapeutic use producing multiple waves of stimulant abuse and dependence. The multitude of effects of stimulants exist on continua, and accordingly, here we characterize stimulant abuse/dependence and candidate pharmacotherapies in this manner. Behavioral therapy and medications have been investigated for treatment of stimulant abuse/dependence. Effectiveness of some behavioral interventions has been demonstrated. Most medications studied have been found to lack efficacy. However, an expanding literature supports use of agonist-like medications to treat stimulant abuse/dependence, a strategy effective for nicotine and opiate dependence. The agonist-like conceptualization for stimulant dependence posits that medications with properties similar to that of the abused drug, but possessing lesser abuse liability, will normalize neurochemistry and stabilize behavior, thus reducing drug use. Data suggest use of a range of medications, from l-dopa/carbidopa to amphetamine preparations, depending on the severity of use. This report reviews preclinical, human laboratory, and clinical trial data supporting the agonist-like approach, including risks and benefits. Future directions for development of agonist-like medications are also discussed.

Psychopharmacology in psychodermatology

BACKGROUND

The management of psychodermatologic disease often involves the use of psychotropics by dermatologists. A general approach to the psychopharmacologic management of psychodermatological disease may be of assistance to the dermatologist.

OBJECTIVE

We review and provide a current psychopharmacologically based approach to management of common psychopathologies associated with psychodermatologic disorders, common side effects, and potential drug interactions that may occur with selected psychotropics.

METHODS

Using relevant MeSH terms, we performed a review of the literature from 1980 to 2006.

RESULTS AND CONCLUSIONS

Effective psychopharmacologic management of psychodermatologic disease involves identifying and basing treatment on the associated psychopathology; familiarity with a variety of psychotropic agents, including antidepressants, anxiolytics, and antipsychotics; and the involvement of a psychiatrist when possible.

Bupropion hydrochloride versus placebo, in combination with cognitive behavioral therapy, for the treatment of cocaine abuse/dependence

Bupropion hydrochloride is a dopamine and norepinephrine reuptake inhibitor which may be an effective treatment for cocaine dependence due to its ability to reverse deficits in dopaminergic functioning that occur in chronic cocaine users. We performed a randomized, double-blind, placebo controlled trial comparing outpatient treatment with bupropion (N = 37) and placebo (N = 33) in combination with standard cognitive behavioral therapy. There were no statistically significant differences between bupropion and placebo in treatment outcomes, including aggregate measures of urine drug screen results (Joint Probability Index at 16 weeks: 0.43 for bupropion and 0.38 for placebo), treatment retention, cocaine craving ratings, and assessments of depressive symptoms. The failure to find an effect for bupropion relative to placebo, when combined with standard cognitive behavioral therapy, dampens enthusiasm for future development of bupropion as a cocaine pharmacotherapy.

The optometrist’s role in the management of clinical depressive disorders

The long-term relationship that optometrists have with their patients enables them to note changes in affect, behavior, and functioning that could indicate serious mental illness, including clinical depression. Given the significant disability associated with this disease and the increased risk of suicide, appropriate management is critical. This article reviews the diagnosis and treatment of clinical depression and its appropriate referral.

The effect of acute bupropion on sexual motivation and behavior in the female rat

Recent clinical studies have suggested that the atypical antidepressant, bupropion (Wellbutrin), may stimulate sexual desire in women. Two experiments were conducted, testing the effect of acute bupropion administration on the sexual motivation and copulatory behavior of female rats. In the first experiment, 63 sexually-experienced, female Long-Evans rats were tested in a runway for their motivation to approach an empty goalbox, a nonestrous female, and an adult male. Both latency to approach and time spent in close proximity to the targets were used as dependent variables. Subjects were tested in both a nonestrous (OVX) and estrous (OVX+15 microg estradiol+500 microg progesterone) state, and following administration of 0.0, 7.5, or 15 mg/kg bupropion hydrochloride (subcutaneous, 45 min prior to testing). Results indicated that pre-treatment with ovarian hormones significantly increased the sexual motivation of the subjects. Bupropion treatment had no significant effect, either stimulatory or inhibitory, on subjects' socio-sexual motivation. In the second experiment, 60 female subjects were paired with an adult male for a thirty-minute copulatory test. Subjects were tested under one of three hormonal conditions: nonestrous (no hormones), 15 mug estradiol, or 15 microg estradiol+500 microg progesterone. Subjects were also pre-treated with either physiological saline or 15 mg/kg bupropion. Results indicated that while hormonal administration had a strong effect on female sexual behavior, bupropion treatment did not significantly affect either lordosis or the emission of hop-darts. Males paired with bupropion-treated females successfully achieved a greater number of ejaculations and demonstrated significantly shortened post-ejaculatory intervals. It is possible that bupropion treatment enhanced female attractiveness.

Review of the pharmacology and clinical profile of bupropion, an antidepressant and tobacco use cessation agent

Bupropion hydrochloride ((+/-)-2-tert-butylamino)-3'-chloropropiophenone x HCl) is a nonselective inhibitor of the dopamine transporter (DAT) and the norepinephrine transporter (NET) and is also an antagonist at neuronal nicotinic acetylcholine receptors (nAChRs). In animal models used commonly to screen for antidepressant activity, bupropion shows a positive response. Also using animal models, bupropion has been shown to attenuate nicotine-induced unconditioned behaviors, to share or enhance discriminative stimulus properties of nicotine and to have a complex effect on nicotine self-administration, i.e., low doses augmenting nicotine self-administration and high doses attenuating self-administration. Current studies show that bupropion facilitates the acquisition of nicotine conditioned place preference in rats, further suggesting that bupropion enhances the rewarding properties of nicotine. Bupropion has been shown to attenuate the expression of nicotine withdrawal symptoms in both animal models and human subjects. With respect to relapse, current studies show that bupropion attenuates nicotine-induced reinstatement in rats, but large individual differences are apparent. Clinically, bupropion is used as a treatment for two indications, as an antidepressant, the indication for which it was developed, and as a tobacco use cessation agent. In clinical trials, bupropion is being tested as a candidate treatment for psychostimulant drug abuse, attention-deficit hyperactivity disorder (ADHD) and obesity. Bupropion is available in three bioequivalent oral formulations, immediate release (IR), sustained release (SR), and extended release (XL). Extensive hepatic metabolism of bupropion produces three pharmacologically active metabolites, which may contribute to its clinical profile.

An evidence-based approach to the management of depression

Increasing numbers of patients are using complementary medicine for the treatment of depression, which complicates management. What is the evidence in support of one medication over another? What medications are safe to use in children and pregnant women? Is there any evidence supporting over-the-counter supplements? These are just a few of the questions that primary care physicians face on a daily basis. This article attempts to answer these questions and many others in an evidence-based approach to the management of depression, which focuses on diagnosis, medical management, and complementary treatments.

The corticotropin-releasing factor receptor: a novel target for the treatment of depression and anxiety-related disorders

The treatment of mood disorders has been the subject of intense study for more than half a century and has resulted in the discovery and availability of a number of compounds that have seen tremendous success in the management of major depression and anxiety-related disorders. In spite of this success, these drugs have not provided a complete therapeutic solution for all patients and this has revitalised the need for a greater understanding of the underlying molecular mechanisms and targets involved in these disorders. Elucidation of these novel targets will enable the development of a better class of compounds which could benefit a greater majority of the patient population and be devoid of the current side effect liabilities. Towards that end, this review examines, in detail, the prospect of one such target, the corticotropin-releasing factor system, as having an enhanced therapeutic profile with the potential of a broader range of efficacy with reduced side effect liabilities.

Dopamine transporter availability in medication free and in bupropion treated depression: a 99mTc-TRODAT-1 SPECT study

BACKGROUND

Bupropion is thought to exert its antidepressive effect by blocking the dopamine transporter (DAT). The purpose of this study was to evaluate the DAT activity in depressed patients by means of 99mTc-TRODAT-1 SPECT in relation to the efficacy of bupropion treatment.

METHODS

In 12 healthy controls and 16 depressed patients the baseline DAT activity was examined. Nine of the 16 patients went through an additional second SPECT investigation, after 4 weeks of bupropion treatment.

RESULTS

In the depressed patients, the baseline DAT striatum-occipital ratio (SOR) (1.04+/-.36, mean+/-SD) was not significantly different from that in the control group (1.12+/-.33) (p>.05). Correlation was found between baseline SOR and HAM-D score change (r=-.745, p=.02) of the bupropion treated patients. The average DAT occupancy due to the bupropion treatment was 20.84+/-27.7%. No significant correlation between the therapeutical effectiveness and the occupancy was observed.

LIMITATIONS

One of the limiting factors of our study has been the lack of drug monitoring.

CONCLUSIONS

In good agreement with other PET studies, we found 20.84% DAT occupancy during bupropion treatment. The lack of correlation between the efficacy of therapy and occupancy of DAT may raise the question as to whether other mechanisms are involved in the effect of bupropion.

Conversion from sustained-release to immediate-release bupropion: patient tolerability and economic impact

STUDY OBJECTIVE

To assess patient tolerability and impact on institutional drug acquisition costs of converting patients from sustained-release bupropion to generic immediate-release bupropion.

DESIGN

Retrospective medical record review.

SETTING

Veterans Affairs medical center.

PATIENTS

One hundred three outpatients who had been receiving sustained-release bupropion and were converted to immediate-release bupropion at equal individual doses and frequencies.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed for documentation of adverse effects thought to be associated with bupropion treatment; reports of seizure occurrence were specifically sought. Patterns of bupropion dosing were also assessed. Institutional drug acquisition costs were evaluated by comparing actual costs of bupropion for each patient before and after conversion. Adverse effects reported with immediate-release bupropion were those commonly associated with this drug (headache, agitation, chest pain, and gastrointestinal complaints) and were neither unusually frequent nor severe. No seizures were reported after the drug conversion. Mean daily doses of bupropion were not significantly different after conversion. Mean single doses of immediate-release bupropion were below 150 mg; however, six patients did receive single doses of 200 mg. After conversion, the annual institutional drug acquisition cost for bupropion decreased by approximately $48,910.

CONCLUSION

Conversion from sustained-release bupropion to immediate-release bupropion appears to be safe. Single 200-mg doses of immediate-release bupropion can apparently be administered to some patients without inducing excessive adverse effects, including seizures. Marked reduction in drug acquisition costs can be achieved with this conversion.

Adjunctive strategies in the treatment of refractory bipolar depression: clinician options in the absence of a systematic database

Multiple approaches to enhancing antidepressant treatment response in bipolar depression are available and should, in many instances, be explored despite a lack of definitive controlled trial literature supporting their efficacy. Given that the morbidity of depression is three times greater than mania in bipolar illness, a range of treatment approaches to this phase of illness should be pursued. This paper highlights the preliminary evidence of efficacy versus side effects, tolerability, and safety in order to suggest an overall provisional utility grade for each well-studied to highly-experimental option. Given the general paucity of evidence to support efficacy or to sequence different approaches for augmenting treatment of bipolar depression, it is critical that patient and physician adopt a systematic and, preferably, daily rating approach to the assessment of benefit for a given patient of each strategy contemplated. The goal is to achieve and maintain remission of depressive symptoms and associated comorbidities, which is often not accomplished using primary mood stabilizer treatments alone, or in combination; thus, an active clinical approach to augmentation strategies is indicated even when the literature provides only highly preliminary guidance.

Bupropion for fatigue and as a tumor necrosis factor-α lowering agent in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a chronic cholestatic disease which can often be severe, progressive and necessitate liver transplantation. The cause of PBC is not known, and treatments other than liver transplantation are often not effective. Among the more common and troublesome symptoms of PBC is fatigue. The etiology of fatigue in PBC is not well-understood, and there is no known treatment for it. Here, we suggest that for a number of reasons that the safe and commonly used oral antidepressant bupropion might be effective for fatigue in PBC: (1) increased monoaminergic and dopaminergic tone to combat fatigue, (2) treatment of concomitant depression, (3) in general for PBC as a tumor necrosis factor-alpha (TNF) lowering agent, if TNF is eventually found to play a role in PBC pathogenesis.

Are SSRIs really more effective for anxious depression?

BACKGROUND

Selective Serotonin Reuptake Inhibitors (SSRIs) are well-established first-line agents for Anxiety Disorders. Anxiety is also a frequent manifestation of major depression. Many psychiatrists assume that anxious depression is more responsive to SSRIs than to other antidepressants. The purpose of this literature review was to determine if SSRIs or any other antidepressants are superior.

METHODS

A computerized search was conducted of double-blind, English-language studies comparing antidepressants available in the United States. Databases searched included Medline and PsycINFO.

RESULTS

SSRIs were not found to be superior to other antidepressants in the treatment of anxious depression.

CONCLUSIONS

The above assumption is not supported. Treatment implications are discussed.

Dopamine overflow is increased in olfactory bulbectomized rats: an in vivo microdialysis study

Olfactory bulbectomy (OBX) in rats produces behavioral, physiological, and neurochemical changes that resemble symptoms of depression in humans. The procedure thus serves as a rodent model of affective disorder. Many of the behavioral effects of OBX resemble psychomotor agitation. The possible role of dysregulation of ventral striatal dopamine (DA) systems in this phenomenon was investigated. Basal levels of DA, norepinephrine (NE), homovanillic acid, dihydroxyphenylacetic acid, and 5-hydroxyindoleacetic acid were examined in the striatum of OBX and sham-operated controls using in vivo microdialysis. OBX rats exhibited significantly higher basal DA levels (192%) and lower NE levels (12%) than sham-operated controls. Locomotor activity in response to novelty and footshock stress was elevated in OBX rats. The finding of higher DA levels in striatum may explain this "agitation-like" behavior, a commonly observed phenomenon in the OBX model.

Safety of antidepressants in the elderly

Until the 1980s, the two major classes of antidepressants, the tricyclics and the monoamine oxidase inhibitors (MAOIs), were effective but had severe side effects, requiring monitoring by psychiatrists. The past several years have brought new classes of antidepressants that are safer for the patient to take and far easier for the non-psychiatrist to prescribe. Whilst this is of enormous value, it leaves the physician with the dilemma of which one to prescribe. These new antidepressants cannot safely be used interchangeably. This paper will discuss each of the antidepressants presently available, with particular emphasis on safety in the elderly. Drug interactions, side effects and particular challenges to the older patient will be described. The authors will then advise a general strategy for prescribing antidepressants.