Psychiatry - December 2008 - (Page 36)

performed by a psychiatric practitioner if possible. Based on our overall assessment of the evidence, we conclude that the link between alpha interferon and DID is strong. Beta interferons. The literature is less convincing in demonstrating an association between DID and beta interferons, and clinicians should avoid extrapolating from data on alpha interferons. Although one randomized, controlled trial suggested depression as a side effect of beta interferons,62 three randomized, controlled trials and the work from the European Study Group have failed to validate such findings.63–66 Antidepressant use with interferons and glatiramer, a noninterferon used for multiple sclerosis, was also assessed.67 This study was designed to mimic real-world practice rather than to use a tightly controlled design. Cohorts of patients choosing beta interferons or glatiramer were followed and monitored for depression. Depression scores at baseline and throughout the trial did not differ between groups. Thus, this naturalistic study further suggests that DID is not a significant concern with beta-interferon therapy. DERMATOLOGICS Finasteride. Finasteride is currently used in the treatment of benign prostatic hyperplasia (BPH) as well as androgenic (androgenetic) alopecia. All reports of finasterideinduced depression have involved its use in alopecia. Finasteride works primarily by blocking conversion of testosterone to dihydrotestosterone via inhibition of the 5-alpha reductase enzyme. Finasteride also inhibits the conversion of progesterone to dihydroprogesterone, which is subsequently converted to allopregnanolone—a neurosteroid with antiepileptic and anxiolytic properties. Changes in the levels of allopregnanolone have also been linked to depression.68 A case series of 19 (14 male and 5 female) out of 23 patients who developed moderate-to-severe 36 Psychiatry 2008 [ V O L U M E 5, NUMBER depression during finasteride treatment for alopecia was published in 2002.69 In a confirmatory, prospective, noncontrolled trial, 128 men with androgenic alopecia were prescribed 1mg of finasteride daily and monitored for depressive and anxiety symptoms.70 After two months of therapy, finasteride was found to increase the depressive symptom scores for both the Beck Depression Inventory (BDI) and the Hospital Anxiety Depression Scale (HADS). Changes in anxiety scores were not significant. In the case series and prospective trial, the mean ages were 28.16 and 25.8 years, respectively, and the doses of finasteride were lower than that used for the treatment of BPH. In our view, the available literature provides moderately strong evidence for a DID-finasteride association, especially in the treatment of alopecia. Although there is no literature for DID in men being treated for BPH, caution is still warranted, in that the doses for BPH are typically five times higher for this indication and are often used in an older population. On this basis, we would hypothesize that finasterideinduced depression may be more prevalent than currently reported. Isotretinoin. Between 1982 and 2000, the FDA received approximately 400 reports of depression and 37 of suicide for patients who had received the acne medication isotretinoin.71,72 The FDA issued enhanced warnings in 2005 based upon these postmarketing reports. In April of 2008, Azoulay et al73 published their findings from a case-crossover study, which examined 19 years worth of prescription data from Quebec. Patients who received isotretinoin during this period were identified, as were cases of patients who received new diagnoses for depression, underwent hospitalization for depression, or filled a prescription for an antidepressant. The authors found that the adjusted relative risk for DID with isotretinoin was 2.68. Although a previously conducted study using prescription sequence 12, DECEMBER] symmetry alone reported no increase in antidepressant use with isotretinoin versus minocycline,74 the Azoulay et al73 investigation is the first and only controlled (crossover design) study of this question. Given that this study did find a statistical association between isotretinoin and DID and considering the data from more than 400 case reports of the FDA, we conclude that the evidence linking isotretinoin and DID is very strong. HORMONAL (CONTRACEPTIVES) In 1999, the manufacturer of the birth-control agent, Norplant® (a formulation of levonorgestrel) agreed to pay a settlement of $50 million in a claim filed by more than 36,000 women.75 The suit claimed that the company had downplayed side effects, such as irregular menstrual bleeding, headaches, nausea, and depression. Prior to this settlement, a 1988 study randomizing women to Norplant or Norplant-2 reported the second most common reason for discontinuation as depression.76 In 1994 and 1996, Wagner cited two separate reports of Norplant-induced major depression.77,78 The first was a case report of two women with no prior psychiatric history who developed major depression and panic disorder within two months after Norplant was inserted.77 Upon removal of the implants, the symptoms resolved within one month. The second was a case series78 in which Wagner presented the cases of five women with no psychiatric history who developed major depression 1 to 3 months after Norplant insertion. Again, the depressive symptoms resolved 1 to 2 months after removal. Contrary to the above reports, Westhoff et al79 described the results of a multicenter, prospective investigation evaluating depression in association with Norplant. Unlike the previous studies, this study evaluated depressive symptom scores at baseline and at six and 24 months. Of 910 women evaluated, 138 were lost to follow up and 295 had discontinued use. However, only

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.