Bright light therapy is a safe and effective treatment for seasonal affective disorder, a depression characterized by depressed mood and vegetative symptoms (increased sleep and appetite, decreased energy and motivation) during winter months. Two recent studies suggest that bright light therapy can also be used in the treatment of non-seasonal depression. In a study published in 2015 in the Journal of Clinical Psychiatry, Dr. Özdemir and collaborators conducted an 8-week study comparing 150 mg venlafaxine Extended Release (ER) with (25 patients) or without (25 patients) light therapy (60-minute light of 7000 lux the initial week of clinical management (venlafaxine + bright light therapy) daily at 7:00 AM) in non-seasonal major depressive disorder. They found that venlafaxine+light therapy is more effective and works more quickly than venlafaxine alone to improve mood. In a more recent study published in 2016 in JAMA Psychiatry, Dr. Lam and collaborators conducted a randomized, double-blind, placebo-controlled study in patients with non-seasonal depression treated with either light therapy alone (32 patients), light therapy combined with 20 mg of fluoxetine (29 patients), fluoxetine alone (31 patients) or placebo (30 patients). The light therapy consisted of 8-week, 30-minutes (if possible bewteen 7 and 8 am), daily exposure to a 10,000-lux fluorescent white light box light box. Patients treated with light monotherapy or light combined with fluoxetine had more improvement in depressive symptoms than patients treated with fluoxetine alone or placebo. Thus, both studies suggest that light therapy is well tolerated and more effective than an antidepressant alone for the treatment of non-seasonal depression. Larger studies will be necessary to corroborate these results.
There is some controversy on whether antidepressants increase or reduce the risk of cardiovascular problems (myocardial infarction, stroke or transient ischemic attack, arrhythmia). To address this issue, Coupland and colleagues report the results of an observational study on 238 963 patients aged 20 to 64 years with a first diagnosis of depression. In a five-year follow-up, there was no evidence of an association between SSRI’s and an increased risk of arrhythmia or stroke/transient ischemic attack. The risk of arrhythmia and myocardial infarction seems to be reduced with some selective SSRI’s, particularly fluoxetine. In contrast, an older class of antidepressants, the tricyclics, increase the risk of arrhythmia in the first 28 days of treatment, with the tricyclic lofepramine having the highest risk of cardiovascular problems in the first year of follow-up. The authors conclude that the results are reassuring in light of recent concerns regarding the cardiovascular effects of antidepressants.
Genetic testing as an additional measure to determine responses and side effects to psychotropic medications is now available in my private practice. The Genecept Assay is a simple, non-invasive, buccal test developped by Genomind. It analyzes ten genes shown to have implications for response to treatments used in depression, bipolar disorder, schizophrenia, anxiety disorders, OCD and ADHD. The analyzed genes target major hepatic enzymes and key neurotransmitter pathways including serotonin, dopamine and glutamate.
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Previous studies suggest that mirtazapine has a better efficacy and faster onset of action than other antidepressants (for a review, see Watanabe et al, 2011). Mirtazapine also differs from SSRIs (e.g., fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine) by its side effect profile. It has a higher risk of dry mouth, weight gain or increased appetite, fatigue and somnolence but less risk of sweating, diarrhea, nausea or vomiting, sexual dysfunction, headache, tremor and sleep disturbance. Ueno and colleagues also report that a dose increase of mirtazapine after one week of treatment is an effective strategy in early non-improvers with depression. Thus, these studies suggest that mirtazapine should be considered as a first-line treatment for depressive disorders. However, patients may be concerned by the risk of weight gain and somnolence, and therefore may prefer to be treated with another antidepressant.
Dr. Zhou and colleagues conducted a meta-analyses on 48 randomized controlled trials (total of 6654 participants) of augmentation agents in adults with treatment-resistant depression. According to the network meta-analysis, the best agents for augmentation therapy were quetiapine, aripiprazole, thyroid hormone, and lithium. Although thyroid hormone and lithium are better tolerated, they seem to be less efficacious than quetiapine and aripiprazole. The authors acknowledge that further studies comparing these augmentation agents head-to-head and addressing the limitations of previous studies (e.g., longer duration, dosing, sample size, study design, financial bias) will be required to confirm these results. In a commentary, Dr. Richard Shelton discusses about the limitations of meta-analyses and suggests interpreting these results with caution.
Burnout is a state of emotional exhaustion related to chronic stress from work or personal issues. Madsen and colleagues found that burnout is associated with an increased risk of antidepressant treatment in 2936 Danish human service workers. As noted by the authors, these results suggest that individuals with high levels of burnout are at substantial risk of developing a clinically significant mental health condition that may require antidepressant treatment.
In the November 2014 issue of BMC Psychiatry, David Veale and colleagues from King’s College in London conducted a meta-analysis of the clinical effectiveness of adding atypical anti-psychotics (aripiprazole, olanzapine, quetiapine, or risperidone) to Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants (e.g., fluoxetine, fluvoxamine, citalopram) in treatment-resistant patients with Obsessive Compulsive Disorder (OCD) . They found limited evidence for using a low dose of risperidone or aripiprazole and no evidence for using olanzapine or quetiapine. They suggest considering other augmentation strategies such as combining the SSRI antidepressant with cognitive-behavioral therapy or clomipramine.