Posted by Phillipa on August 14, 2009, at 20:21:48
Seems that new study states zoloft and zyprexa together mor effective for psychotic Major Depression but concern for metabolic changes. Phillipa
Sertaline Plus Olanzapine Effective in the Treatment of Psychotic Depression
Read more August 13, 2009 Combination therapy with an atypical antipsychotic and a selective serotonin reuptake inhibitor is more effective in treating psychotic depression than treatment with an atypical antipsychotic alone, a 12-week randomized controlled trial suggests.
Investigators from the Study of Pharmacotherapy of Psychotic Depression (STOP-PD) found that olanzapine plus sertraline achieved higher remission rates in patients with major depression (MD) and psychotic features compared with olanzapine plus placebo. Combination treatment was also superior to monotherapy in both younger and older patients.
However, both treatment groups experienced metabolic changes attributed to the use of an atypical antipsychotic including increased cholesterol and triglyceride concentrations as well as weight gain, with younger adults gaining significantly more weight than their older counterparts.
"Combination treatment with olanzapine plus sertraline was associated with a greater remission rate than with olanzapine monotherapy among patients with MD with psychotic features. The benefits of the combination therapy became more apparent as the 12-week trial progressed, with separation favouring olanzapine/sertraline from week 8 to the end of the trial," the investigators write.
The study was published in the August issue of Archives of General Psychiatry.
Electroconvulsive Therapy Current Treatment of Choice
According to the study, 15% to 20% of individuals with MD have psychotic features. However, at an estimated 45%, prevalence rates reported among elderly inpatients are much higher.
Further, the authors note that psychotic depression is associated with poorer short-term outcomes, longer recovery time, greater residual disability, and higher mortality than MD without psychosis.
To date, recommended treatment has been limited to electroconvulsive therapy or combination therapy with a tricyclic antidepressant and conventional antipsychotic medication. However, the evidence for combination therapy has been limited.
The authors point out that, in contrast to studies with young adults, studies in geriatric populations have not shown greater efficacy of combination treatment with tricyclic antidepressants and conventional antipsychotics.
Given this background, the researchers sought to determine whether combination therapy with newer-generation antipsychotics and antidepressants was more effective than atypical antipsychotic monotherapy in patients with psychotic depression. They also examined whether treatment response differed by age.
The selection of the 2 study drugs was based on previous research showing that olanzapine, an atypical antipsychotic, has an acute antidepressant effect and that sertraline, a selective serotonin reuptake inhibitor, is effective for MD with psychotic features.
A total of 259 subjects aged 18 years or older with MD and psychotic features were included in the trial. Participants were randomized by age: younger than 60 years or 60 years or older. In total, there were 117 younger adults and 142 geriatric participants.
Eligible participants included the presence of at least 1 delusional belief, a score of 2 or higher on 1 of the conviction items of the Delusional Assessment Scale, and a score of 3 or higher on the delusion severity rating item of the Schedule of Affective Disorders and Schizophrenia.
All patients had scores of 21 or higher on the Hamilton Depression Scale. Patients with histories of dementia or impaired cognitive function before the current depressive episode were excluded. Subjects were also ineligible if they met criteria for another Axis I psychotic or mood disorder, current body dysmorphic disorder, or obsessive compulsive disorder; or for substance abuse during the previous 3 months.
Subjects were randomly assigned to receive target doses of 15 to 20 mg/day of olanzapine plus masked sertraline or placebo at 150 to 200 mg/day.
Metabolic Effects a Major Concern
At the conclusion of the 12-week trial, investigators found that treatment with olanzapine/sertraline was associated with higher remission rates during the trial than olanzapine/placebo (odds ratio, 1.28; 95% confidence interval, 1.12 1.47; P < .001) and that 49% of subjects in the combination therapy group were in remission at their last assessment vs 23.9% of those treated with olanzapine alone.
In addition, the study showed that combination therapy was comparably superior in both younger and older age groups. Although both age groups experienced significant increases in cholesterol and triglyceride concentrations, statistically significant increases in glucose occurred in younger adults.
Further, whereas both age groups experienced weight gain, younger adults gained significantly more weight than their older counterparts a mean gain of 6.5 vs 3.3 kg.
The study findings suggest that combination therapy is effective and offers physicians and their patients a viable alternative to electroconvulsive therapy, which is generally considered the treatment of choice for this condition but is not without challenges.
The researchers note that although bilateral electroconvulsive therapy has a response rate of 87% when administered in academic centers, the response when delivered in the community setting is much lower, ranging from 30% to 47%. Further, they add, pharmacological treatment may be more practical and less stigmatizing for patients.
Nevertheless, the investigators say, the adverse metabolic effects associated with atypical antipsychotics are a major concern.
"Further study of the optimal duration of continued combination therapy is needed to balance the high risk of early relapse of MD with psychotic features against the metabolic abnormalities and significant weight gain associated with atypical antipsychotic medications," they write.
poster:Phillipa
thread:912167
URL: http://www.dr-bob.org/babble/20090810/msgs/912167.html