Who benefits from tricyclic antidepressants: a survey

To determine what patients are likely to benefit from treatment with a tricyclic antidepressant, the authors surveyed American researchers, teachers of psychiatry, general psychiatric practitioners, and foreign researchers. Areas of agreement were appreciable and can serve as an index of accepted community practice and as guidelines for teaching. Responses indicated that patients most likely to benefit from a tricyclic antidepressant are those with primary depression; early morning awakening; motor retardation; loss of appetite; weight loss; prior positive response to a tricyclic antidepressant; loss of interest in work or hobbies; sad, blue, or depressed feelings; improved mood in evening; and loss of interest in sex. Amitriptyline was preferred for agitated depressions, and imipramine was preferred for retarded depressions.     

The use of bethanechol chloride with tricyclic antidepressants.

The author describes the use of bethanechol chloride to relieve side effects, including salivary inactivation, constipation, and bladder inhibition, which result from the anticholinergic action of tricyclic antidepressants. He suggests that the use of cholinergic medication during antidepressant therapy may extend the use of the tricyclics to patients who find anticholinergic side effects especially troublesome.     

Therapeutic responses to tricyclic antidepressants and related drugs in non-affective disorder patient populations

Although therapeutic responsiveness to tricyclic antidepressants has been primarily associated with the affective disorders, clinical investigations in the last decade have suggested that non-affective disorders such as panic disorder, obsessive-compulsive disorder, anxiety disorder, bulimia, enuresis, migraine, and the chronic pain syndrome may also respond to tricyclics and other antidepressants. This therapeutic responsiveness may sometimes be related to improvement in secondary depressive symptoms, but may also clearly occur in the absence of secondary depression; in particular, improvement in the core symptoms of at least some of these disorders may occur without a change in mood. Furthermore, many patients with these disorders display psychobiologic abnormalities that show many similarities, but also some differences, compared to those observed in patients with affective disorders, despite the frequent absence of affective symptoms. While an improvement in subclinical or "masked" depression remains one hypothesis linking tricyclic responsiveness and shared biological abnormalities in this diverse group of diagnostic entities, an alternative hypothesis (the "ven disorder" hypothesis) is presented, suggesting the possibility that tricyclic and other antidepressant-responding patients have a core disorder with common psychobiologic abnormalities but multiple clinical and diagnostic presentations. An alternative hypothesis (the "shotgun" hypothesis) suggests that the multiple actions of tricyclics (e.g. on adrenergic receptors vs. muscarinic receptors vs. serotonin system changes) may each be differentially important in the therapeutic outcome in patients with specific or predominant problems in one or another of these areas. An examination of both the similarities and differences among the non-affective, tricyclic-responsive disorders and the affective disorders may provide clues about the important psychobiologic elements in these disorders, and to the mode of action of tricyclic antidepressants and related drugs across the psychiatric disorder spectrum.     

A pilot survey of geriatric psychiatrists' views on the use of electroconvulsive therapy in fractures

Psychiatrists are cautious in administering electroconvulsive therapy (ECT) to patients with fractures and bony disease for fear of complications. Drawing on the collective experience of geriatric psychiatrists may allow a better understanding of the use of ECT in fractures. The views of all consultant geriatric psychiatrists in west London on the use of ECT in patients with fractures were acquired by a questionnaire survey based on two fictitious case vignettes. Most geriatric psychiatrists would use ECT in the two cases. Moreover, they would almost always seek specialist advice from orthopaedic surgeons and anaesthetists before and during the course of ECT. These findings were consistent with the existing anecdotal literature of case‐reports. As individual geriatric psychiatrists and general psychiatrists are likely to see only a few patients with fractures requiring ECT, randomized and controlled studies of efficacy and side effects are not possible. A questionnaire survey of a larger multi‐centre sample of geriatric psychiatrists and general psychiatrists can build on this pilot study by using a modified questionnaire to provide more detailed and clinically relevant information. Copyright © 2000 Whurr Publishers Ltd.     

Profound behavioral toxicity due to tricyclic antidepressants

The incidence of tricyclic antidepressant-induced behavioral toxicity appears to be fairly high in elderly patients but has rarely been reported in the young. We present a case of significant behavioral side effects in a young woman secondary to elevated plasma levels of imipramine and desipramine, masquerading as an agitated psychotic depression.     

Effect of flupenthixol on depression with special reference to combination use with tricyclic antidepressants

In an open, uncontrolled trial flupenthixol was administered to 45 patients with endogenous depression. The drug was markedly effective in eight patients, effective in nine patients, fairly effective in 12 patients, and ineffective or aggravating in 16 patients. Four patients showed transient manic symptoms. Dosage was 1–3 mg daily. In 36 patients flupenthixol was used in combination with previously administered tricyclic antidepressants, and in nine patients it was used alone. Clinical effect was quickly apparent. It appeared within 1 week in 63% and within 2 weeks in 93 % of subjects. Side-effects were observed in 13 patients: insomnia, five patients; slight extrapyramidal symptoms, nine patients. Sedative-hypnogenic effects were rarely seen. In 71 % of 17 patients in whom the drug was found to be markedly effective or effective, flupenthixol's influence on psychomotor retardation was particularly strking. Other clear benefits were relief of depressive mood, psychic anxiety, and agitation. It is recommended that flupenthixol is given, as supplementary medication, to patients (1) whose depressive symptoms other than psychomotor retardation have already improved with current tricyclic antidepressants, and (2) in whom, before antidepressant medication, psychomotor retardation is a principal feature.     

A survey of psychiatrists' attitudes toward electroconvulsive therapy

Sixty-seven psychiatrists who were employed in state hospitals in Texas were surveyed about their attitudes toward use of electroconvulsive therapy (ECT) and the laws and regulations associated with its use. The majority of respondents agreed with accepted professional guidelines on ECT usage and had a positive attitude toward ECT treatment. However, the number of referrals for ECT by these psychiatrists was low, perhaps due to the view that Texas laws and policies about ECT are restrictive and limiting to patient care. The majority of respondents indicated that more professional education about laws and policies related to ECT is needed.     

The analgesic effect of tricyclic antidepressants

The analgesia produced by tricyclic antidepressants (TCAs) in rats and the role of serotonin in this analgesia have been investigated in this study. Rats received intraperitoneal injections of imipramine and amitriptyline, which are TCAs, and the serotonin synthesis inhibitor, pCPA. An acute analgesic effect was measured 90 min after the first injections; a chronic effect was measured 24 h after the last injections, on the 7th and 15th days using the hot-plate method. Both antidepressants elevated the pain threshold acutely, while pretreatment with pCPA largely blocked the analgesia. Based on these data it was found that in the acute case both of the antidepressants potentiate an endogenous analgesia mechanism, which acts on the serotonergic system. After long-term use, amitriptyline, which acts on serotonin, had an analgesic effect and this effect was blocked by pCPA. Imipramine, which acts on noradrenaline, had no effect on the pain threshold in chronic use. Consequently, serotonin is an important link in TCA analgesia; noradrenaline has no effect.     

Placental passage of tricyclic antidepressants.

BACKGROUND: The use of antidepressants during pregnancy continues to garner considerable attention, though there are limited investigations that have sought to quantify fetal exposure. METHODS: Maternal and umbilical cord sera were collected at delivery from ten women taking nortriptyline and seven taking clomipramine. Placental passage was calculated as the ratio of umbilical cord to maternal serum concentration. Obstetrical outcome data were gathered from subjects at delivery. RESULTS: The placental passage ratio of nortriptyline and its active metabolite, cis-10-hydroxynortriptyline, were .68 +/- .40, 1.40 +/- 2.40, respectively. Clomipramine and desmethylclomipramine ratios were .60 +/- .50, .80 +/- .60. Obstetrical complications, such as pre-term delivery and pregnancy induced hypertension, were increased compared to the national average. CONCLUSIONS: The in vivo ratios of umbilical cord to maternal serum drug concentrations demonstrate considerable fetal exposure and differ greatly from previous results utilizing ex vivo perfusion.     

Bowel obsessions responsive to tricyclic antidepressants in four patients

The authors report on four patients with disabling bowel obsessions who responded to tricyclic antidepressant medication despite the absence of depressive symptoms. The relationship of this symptom constellation to DSM-III obsessive-compulsive disorder and social phobia is discussed.     

Personality and response to tricyclic antidepressants in depressed patients

Several studies have shown that disturbances of personality are poor predictors of response to antidepressants. None of these studies, however, has used personality measures similar to the DSM-III. We evaluated the relationship between antidepressant response and personality scores obtained on the Millon Clinical Multiaxial Inventory, which provides personality measures congruent with DSM-III. Personality features such as assertiveness, independence, and competitiveness distinguished responders from nonresponders. However, the frequency of personality disorder diagnoses did not differ between responders and nonresponders.     

帕罗西汀替换三环类抗抑郁剂治疗抑郁症对照研究

目的：了解帕罗西汀替换三环类抗抑郁剂(TCAs)治疗抑郁症的有效性和安全性。方法：将经TCAs足量治疗6周疗效达好转及以下的、符合反复发作抑郁症诊断标准的患者随机分为帕罗西汀组和三环类组。帕罗西汀组渐停TCAs，渐增帕罗西汀治疗，剂量20～40mg／d；三环类组继续使用TCAs150～250mg／d治疗。用Hamilton抑郁量表(HAMD)、大体评定量表(GAS)、临床疗效总评量表病情严重程度(GGI-SI)，分别于人组时，治疗1周末、2周末、4周末、8周末评定其病情变化；副反应量表(TESS)评定不良反应。结果：与入组时比较，帕罗西汀组治疗2周末各种量表评分差异即有显著性；三环类组治疗4周末HAMD、GAS评分差异有显著性，CGI—SI评分治疗8周末差异有显著性。帕罗西汀组治疗后HAMD、GAS、CGI—SI减分明显多于三环类组，帕罗西汀组不良反应发生率显著少于三环类组。结论：帕罗西汀替换TCAs治疗效差的抑郁症安全有效，可在临床上试用。     

Rating scales as predictors of response to tricyclic antidepressants.

Fifty-three patients suffering from depressive illness were classified as 'responders' or 'non-responders' on the basis of an "amelioration score" of the Hamilton Rating Scale for depression after six weeks treatment with nortriptyline hydrochloride at 150 mgs. daily. A multivariate analysis of variance was performed on the four psychological rating scale scores used, to determine whether rating scales could predict treatment response to tricyclis antidepressants was found to be at 75% probability.ic anti-depressants was found to be at 757. probability.ic antidepressants. There was a significant difference between the two groups after adjustment for age. Subjects were then classified as 'non-responders' and 'responders' on the basis of their discriminant scores. The prediction of response to tricycl