Varying symptom profiles of depression correlated with specific triggering events
We generally think of major depression as a single disorder with various possible symptoms. The only specific profile that we sometimes look for is atypical depression, encompassing reverse neurovegetative symptoms and reactivity of mood. A new study of nearly 5,000 people who had experienced various depressive symptoms hints that specific kinds of life events trigger specific depressive symptoms. For example, deaths of loved ones and romantic losses are associated with high levels of sadness, anhedonia, and appetite loss. Chronic stress and failure, on the other hand, were weakly associated with these three symptoms, but were strongly associated with fatigue and hypersomnia (Keller MC et al., Am J Psychiatry 2007;164:1521-1529).
TCPR’s Take: This suggestive data should encourage us to look at our depressed patients with fresher eyes. While it may be easier to say that “a depression is a depression is a depression,” this may not be true, and paying more attention to the specifics of each patient’s road to their symptoms may allow us to predict which depressive symptoms will become most problematic.
A new study dampens glutamine enthusiasm
Because standard antipsychotics don’t do much for the negative symptoms of schizophrenia (such as affective flattening and paucity of speech), there has been a fair amount of interest in the so-called “hypoglutaminergic hypothesis” of schizophrenia. This was first prompted by the observation that the recreational drugs PCP (angel dust) and ketamine (the date rape drug) can cause shizophrenia-like symptoms in abusers. Both drugs block NMDA glutamine receptors; this prompted some small positive studies of glycine and cycloserine in schizophrenics, both of which stimulate glutaminergic neurotransmission.
These results led to the large CONSIST trial, in which 165 patients with schizophrenia or schizoaffective disorder were randomly assigned to glycine, D-cycloserine, or placebo. But after 16 weeks of treatment, there were no differences in either negative symptoms or cognitive symptoms among the three treatments (Buchanan RW et al., Am J Psychiatry 2007;164:1593- 1602).
TCPR’s Take: These results are very disappointing and essentially put the kaibosh on development of these particular agents for schizophrenia. Trying to redeem the results, the researchers point out that the glycine dose used was rather low (0.7 mg/kg. as opposed to two positive studies that used 0.8 mg/kg). Nonetheless, don’t expect to see either of these compounds being marketed any time soon.
Walmart includes more psychiatric meds at $4/month
In case you haven’t heard, Walmart has started offering certain generic prescription drugs at $4 per month supply. These are available at all Walmart pharmacies, so you can be assured that your patients can take advantage of this amazing deal wherever they are. As of this writing, these are the drugs covered under the plan.
SSRIs: citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil)
Tricyclics: amitriptyline, doxepin, nortriptyline
Antipsychotics: fluphenazine (Prolixin), haloperidol (Haldol), thioridazine (Mellaril)
Anticholinergics: benztropine (Cogentin), trihexyphenidyl (Artane)
Antianxiety/hypnotics: buspirone (BuSpar), hydroxyzine (Vistaril), trazodone (Desyrel)
Mood stabilizers: lithium carbonate, carbamazepine (Tegretol)
Stimulants: methylphenidate (Ritalin)
As you can see, there are a few glaring omissions, including any benzodiazepines, sertraline (Zoloft), bupropion (Wellbutrin), perphenazine (Trilafon), divalproex sodium (Depakote) and zolpidem (Ambien). Don’t worry, you can bet that Walmart’s pharmacy purchasers are very busy negotiating with
generic companies to bring them on board as well. It’s good news for our patients, but probably not great for neighborhood pharmacies. Expect to see fewer of them soon. You can get more information on the program and download the list of all medications covered at http://www.walmartfacts.com/articles/5314.aspx.
Topiramate (Topamax) is somewhat effective for alcohol dependence, but heavy on side effects
Medications only work modestly for the treatment of alcohol dependence. In TCPR’s last issue on substance abuse (June 2006) we reviewed the evidence on disulfiram (Antabuse), naltrexone, and acamprosate, and concluded that naltrexone works modestly, acamprosate works less well, and Antabuse has little high quality data but probably works modestly for highly motivated patients. In this new study, funded by the manufacturer of Topamax, 371 men and women with moderate alcohol dependence (5 drinks/day for men, 4 drinks/day for women – but note that the quantity used to define a “standard” drink was quite low: 4 oz. of wine and 10 oz. of beer) were randomly assigned to receive either Topamax, tapered gradually up to 300 mg/day, or placebo. After 14 weeks, patients in the Topamax group decreased percentage of heavy drinking days (HHDs) from 82% to 44%, vs. patients in the placebo group, who decreased HHDs from 82% to 52% (Johnson BA, et al., JAMA 2007;298(14): 1641-1651).
TCPR’s Take: This was a very modest effect. To put it in concrete terms, before treatment, these patients had about 5.5 heavy drinking days (HDDs) per week. After 14 weeks, placebo patients decreased to about 3.5 HHDs, while Topamax patients decreased to about 3 HHDs. And there’s a price to pay: patients on Topamax had side effects such as paresthesias (51% on Topamax vs. 11% on placebo), taste perversion (23% vs 5%), anorexia (20% vs 7%), and difficulty concentrating (15% vs 3%).