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Full relapses/recur- a large cohort of patients recruited from primary and spe- rences range from 10% to 40% over 12 to 16 months fol- cialty care clinical sites (for a detailed description antifungal skin cream order 15mg butenafine with visa, see http:// lowing response to acute phase treatment antifungal used to treat thrush purchase butenafine with amex. Whether it is more likely with one or another medica- tion or medication class has not been well defined antifungal body shampoo butenafine 15mg cheap. Those POTENTIAL NEW ANTIDEPRESSIVE who attain remission (not just response) to acute phase treat- MEDICATIONS ment appear more likely to remain in remission (or to at least sustain a response) over continuation phase treatment Two new classes of possible antidepressant medications are than are those who with a response but with residual symp- under development: substance P antagonists and CRF an- toms at exit from acute phase treatment (40). A single, positive, 6-week double-blind trial in suggest that patients with an earlier, more complete, and outpatients with MDD study found a substance P antago- more sustained symptom benefit in acute treatment are less nist (MK 869) as effective as paroxetine, and both exceeded likely to encounter symptomatic breakthrough at least in the effects of pill placebo (140). The mechanism of antide- the continuation phase (134–136). Although clinical con- systems are directly affected. Direct effects on the substance sensus suggests dose increases (137), others suggest dose P NK receptors, perhaps in the stratum or amygdala, to decreases (138). CRH produces signs and support the hypothesis that TCAs are either ineffective or symptoms of depressive and anxiety disorders by activation much less effective in this age group than in adulthood. These findings provide Furthermore, TCAs are particularly toxic in deliberate or a rationale for attempts to develop medications that antago- accidental overdose in youth, and they are all off patent; nize the CRH1 receptor. Zobel and colleagues (144), using therefore, more studies of TCAs in this population are un- R121919 (an agent that binds to CRH1 receptors) in an likely. CRH1 receptor blockade did not to placebo (155,156) and they appear equally efficacious in impair corticotropin and cortisol secreting activity either at prepubertal children as in adolescents and in both sexes baseline or after an exogenous CRH challenge. Encouraged by regulatory changes, randomized, pla- These early reports are tantalizing. The field awaits more cebo-controlled trials in youth are planned or underway for definitive, placebo-controlled clinical trials for both CRH essentially all antidepressants now on patent. Whether these agents will have One of us has argued, post hoc, that because the TCAs predictable, substantial, and prolonged antidepressant or as a group are all relatively noradrenergic in youth because anxiolytic (e. In theory, if they modify stress responses, such noradrenergic antidepressants as a class will prove less useful agents may be important in the treatment of residual symp- in youth, whereas serotonergic antidepressants will show toms or symptomatic breakthroughs that occur with cur- efficacy throughout the lifespan. Alternatively, they may prevent the able RCTs on newer agents other than SSRIs in youth to onset of a depressive episode following a stress in vulnerable further address this question (157). Although available and ongoing work in antidepressant Combinations of standard medications, especially the use pharmacology in youth with MDD provides guidance for of atypical antipsychotic agents, alone or combined with the initial treatment step for depression, the field is only antidepressants, have begun to be a focus of research for now considering the arguably more important studies of treatment-resistant depression (145,146). The rationale for chronic maintenance, combination treatment, treatment of the use of olanzapine combined with fluoxetine, for exam- refractory depression, and the other questions that arise in ple, is provided by evidence of increases in norepinephrine this recurrent disorder. In a recently completed, 8-week, double- blind trial in 28 patients with treatment-resistant depres- sion, large reductions in MADRS scores were obtained with 'ALTERNATIVE' THERAPIES the combination, as compared to either agent alone (146). These extracts contain at least 10 biologically active substances. One study has suggested that hyperforin may be the critical active constitu- ANTIDEPRESSIVE TREATMENTS IN ent (158). Extracts of hypericum inhibit reuptake of seroto- CHILDREN AND ADOLESCENTS nin, norepinephrine, and dopamine and lead to down-regu- lation of -adrenoceptors and serotonin (5-HT2) receptors The psychotherapeutic approaches of cognitive behavioral (159). However, limiting the studies to date is the lack of therapy (CBT) and IPT appear to have specific efficacy in a standardized concentration of the active ingredient(s) in adolescent depression (147–152), whereas psychotherapeu- the preparation of hypericum extract. As reviewed elsewhere (154), RCTs of TCAs versus less in all but the Philipp study that used 100 mg of imipra- placebo have been uniformly negative in both children and mine for 8 weeks). Many of these negative studies were relatively and the SSRI fluoxetine also found no statistically signifi- small. However, when considered in aggregate, the data best cant difference between treatments (mean decrease in Chapter 75: Current and Emerging Therapeutics for Depression 1089 HAM-D score 10. In a recent double-masked randomized study (165) of In aggregate, these data seem to point toward efficacy 201 outpatients with major depression and a baseline 17- and perhaps very rapid onset of SAMe in the treatment of item HAM-D score 20 treated for 8 weeks with either adult major depressive disorder. However, there was no significant differ- almost all comparison studies were conduct for far too short ence seen between St. The roles of either the continuous outcome measures, including the HAM-D, SAMe or St. The very low rate of response both to active may be a useful focus of study. Acupuncture Thus, although the randomized clinical studies using pla- cebo suggest that hypericum has some antidepressant effect As reviewed in Ernst and colleagues (171), several case series in humans (and has effects in animal models for depression), and open clinical trials suggest possible efficacy of acupunc- the data are simply inadequate to say how well St.

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For example fungus gnats inside house buy cheap butenafine 15mg line, in an outpatient geriatric study carefully documented the presence of major depressive clinic antifungal vaginal cream generic 15mg butenafine, Reifler et al definition for fungus butenafine 15 mg with amex. Patients were treated for a mean duration contrast, Burke et al. HAM-D scores significantly and substantially de- included a longitudinally followed normal control group creased from a mean of 19 on admission to a mean of 5 matched for age, sex, race, and social position. This degree of improvement did not differ symptoms of depression occurred in both patients with AD significantly from that in an elderly, nondemented, de- and controls, but criterion-based major depression could pressed inpatient group treated in a similar naturalistic man­ not be diagnosed. However, the mean length of stay to achieve compara­ depression in a sample of subjects with AD screened to ble improvement in the elderly nondemented, depressed exclude those with a past history of major psychiatric disor­ group was substantially shorter than that in the demented, ders was reported by Kumar et al. Possible differential treatment responses mood was more frequent in the AD subjects than in age- between AD subjects with major depression and MID sub­ matched normal controls, depressed mood in the AD sub­ jects with major depression were not reported. Both Rey­ jects was unaccompanied by classic vegetative signs and nolds et al. These investigators, therefore, in­ results as suggesting that major depression complicating de­ terpreted depressed mood as reflecting 'demoralization' mentia is responsive to somatic antidepressant treatments, rather than major depressive disorder. Given these prob­ but both investigators acknowledged that standardized, lems, it is not surprising that estimates of the prevalence of double-blinded, placebo-controlled studies of antidepres­ depression in AD are widely disparate. Perhaps the true sants in dementia patients with major depression are prevalence of concurrent depression in AD lies somewhere needed. As early as 1955, Sir Mar- The SSRI antidepressants are theoretically attractive tin Roth (21) addressed the issue of differentiating the com­ drugs for the treatment of depression in AD. Decreased mon 'affective coloring' seen in dementia patients from numbers of serotoninergic neurons in the dorsal raphe nu­ the relatively uncommon 'sustained depressive symptom cleus and decreased concentrations of the serotonin metabo- complex. Enhancing serotoninergic neurotransmission by inhib­ iting serotonin reuptake theoretically might alleviate depres­ sion in AD. Furthermore, the adverse effect profile of SSRIs Psychopharmacologic Approaches is relatively benign compared with those of the tricyclics It continues to be disappointing that the extensive interest and MAOIs. SSRIs are not anticholinergic, nor do they in defining the prevalence of depression complicating AD produce orthostatic hypotension. These theoretic advan­ has generated few interpretable studies evaluating the out- tages likely account for the increasing use of SSRIs in elderly come of antidepressant treatment in such patients. These reports Placebo-Controlled Outcome Trials suggest that depression complicating AD may respond to tricyclic antidepressants (22,23), monoamine oxidase inhib­ Despite the widespread use of antidepressants in patients itor (MAOI) antidepressants (24), or selective serotonin with AD and other dementing disorders (32), it is clear that reuptake inhibitors (SSRI) (25). In an open trial of nortrip­ this use is not grounded in an adequate empiric database. Depression Scale (HAM-D) scores (27) from 17 before Reifler et al. Although the reduction in (n � 13) or placebo (n � 12) subjects who met DSM­ depressive signs and symptoms was substantial in AD pa­ III criteria for both primary degenerative dementia of the tients with concurrent depression, it was less robust than in Alzheimer type and major depressive episode. AD outpa­ a similarly treated group of elderly nondemented depressed tients (mean age, 72) had a mean Mini-Mental State Exami­ patients. Another open trial of 'naturalistic' somatic antide- nation (MMSE) score of 17 [very comparable with the mean pressant treatment of inpatients with dementia and concur- MMSE scores of the demented, depressed patients studied rent depression was reported by Greenwald et al. Imipramine (mean depression have several implications. First, the robust re­ dose, 83 mg/d; mean plasma level of imipramine plus des­ sponses of the placebo group make it essential to include a methylimipramine, 116 ng/mL) or placebo was prescribed placebo group in future antidepressant drug outcome trials for 8 weeks. Substantial, highly significant, and almost iden­ in dementia patients if the results are to be interpretable. Imipramine was controlled trial demonstrating efficacy of behaviorally based generally well tolerated in these subjects. However, its cen­ psychotherapy for depression in AD outpatients is consis­ tral anticholinergic effect likely accounted for subtle decre­ tent with this interpretation (38). Second, the absence of ments in cognitive function in the imipramine group. The SSRI adverse effects on cognitive function or blood pressure improvement in HAM-D scores was similar to that achieved regulation is an advantage for this class of antidepressant in the open inpatient studies reported by Greenwald et al. More placebo-controlled trials of (28) and Reynolds et al. This outpatient study demon­ SSRIs (and other newer antidepressants, such as venlafaxine strated that depressive signs and symptoms can be reduced and nefazodone) in AD patients with concomitant depres­ in outpatients with AD, but the mechanism of treatment sion would be informative. As in the The prevalence rates of psychotic symptoms (delusions and imipramine trial reported by Reifler et al.