Psychiatry - December 2008 - (Page 37)

4.4 percent of the 295 had done so because of mood changes. The remaining women still using the implant were reported to have had lower depressive scores at baseline than those who discontinued the medication. In addition, for those users that experienced an increase in depressive score at the end of two years, it was found that relationship dissatisfaction was a strong predictor of higher scores. The authors concluded that Norplant use does not exacerbate pre-existing depression. In a study of 212 postpartum teenage mothers, depressive symptoms were monitored during the first 12 months after Norplant insertion.80 Three independent factors were found in those women who experienced increased depression scores: depression prior to Norplant; a new boyfriend at time of delivery; and late Norplant insertion (>4 weeks after giving birth). These researchers concluded that insertion within the first four weeks after birth did not exacerbate depression, and delaying insertion might actually increase the risk of postpartum depression. It is interesting to note that 2 of the 3 factors are similar to those suggested by Westhoff (higher depressive scores and potential for reduced relationship satisfaction). In our view, these two large trials suggest that clinicians should screen for depressive symptoms prior to Norplant implantation. If depression scores are high in a given patient, this would not necessarily be a contraindication to use Norplant; rather, it would point to the need for effective treatment of the depression. Indeed, such treatment might avert unsupervised discontinuation of Norplant. The most recent piece of literature supports this approach.81 This study examined discontinuation and depression scores in women who received Norplant for treatment of menorrhagia. The authors found that depressive symptoms, based on Beck’s Depression Inventory measured six months after the beginning of the treatment, were related to discontinuation of Norplant [Odds ratio (OR)=3.70]. The authors opined that diagnosing and treating depression among patients having menstrual problems may improve adherence to Norplant treatment. Considering all the (sometimes conflicting) data, we conclude that the association of Norplant and DID is only moderately strong. Clinicians should screen all patients prior to initiating therapy and again some months after implantation. Women with lower depression symptom ratings and those who are in stable relationships may be less likely to discontinue Norplant, secondary to depression. Some women may benefit from either antidepressant medication or psychotherapy, if screening points to clinically significant depressive symptoms. In any case, the evidence does not demonstrate a strong association between Norplant and DID. asthma patients, 536 of whom were treated with montelukast.84 In the three trials, measures of “quality of life” were assessed using the Juniper Mini Asthma Quality of Life Questionnaire and the Juniper Paediatric Asthma Quality of life Questionnaire. The authors attempted to correlate these measures with recognized measures of depression, such as the Center for Epidemiological Studies Depression Scale (CES-D). The authors’ findings did not support an association between montelukast and adverse effects on emotional well being. They acknowledged that their quality-oflife instruments were not designed to evaluate depression directly, but noted that they found “…good correlation between our measures of well being and recognized measures of depression.” Our overall assessment of the admittedly conflicting data is that the association between leukotriene inhibitors and DID is limited at this time. RESPIRATORY AGENTS (LEUKOTRIENE INHIBITORS) Leukotriene inhibitors comprise a new class of medications for the treatment of persistent asthma. In September of 2006, four case reports of depression were cited in the Netherlands Pharmacovigilance Centre Lareb for the leukotriene inhibitor montelukast.82 At that time, 43 cases were contained in the World Health Organizations database. Seven months later, depression was added as a side effect in the manufacturer’s labeling. The FDA has since issued an early communication letter noting that it was investigating reports of depression associated with this medication.83 Although the number of cases may suggest a relationship to DID, concomitant therapy with other treatments for asthma or seasonal allergic rhinitis (i.e., corticosteroids) cannot be dismissed. Holbrook and Harik-Khan recently analyzed three randomized, controlled trials examining “emotional well being” in 1,356 [VOLUME 5, CORTICOSTEROIDS The polymorphous psychiatric complications of corticosteroids have long been recognized. Symptoms of euphoria, depression, agitation, irritability, and psychosis are all potential side effects. Surprisingly, data confirming a direct causal link between corticosteroids and DID are limited and conflicting. When carefully evaluated, the three most frequently cited referenced articles in the literature85–87 do not clearly establish a causal link between corticosteroids and DID, in our judgment. Although one may agree that depression is evident in corticosteroid-treated patients, the ultimate question is whether the medication actually caused the depressive symptoms. Two cohort studies involving medical inpatients have suggested an association between corticosteroids and depression.85,86 Both investigations identified the cases through self reporting of depressive symptoms. Gift et al85 evaluated 40 inpatients, 20 of whom were 12, DECEMBER] NUMBER Psychiatry 2008 37

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

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