Kathleen S. Peindl

Postpartum depression: a randomized trial of sertraline versus nortriptyline.

Abstract: Symptom reduction and improvement in functioning in women with postpartum major depression treated with a tricyclic antidepressant versus a serotonin reuptake inhibitor were compared. The design was a double-blind, 8-week comparative trial of nortriptyline (NTP) versus sertraline (SERT) with a 16-week continuation phase. Women aged 18 to 45 years with postpartum major depression and a 17-item Hamilton Rating Scale for Depression score of 18 or more were eligible. Subjects were randomized to NTP or SERT and treated with a fixed-dosing strategy. Of 420 women interviewed, 109 eligible women received medication, and 95 provided follow-up data. The proportion of women who responded and remitted did not differ between drugs at 4, 8, or 24 weeks. Times to response and remission also did not differ. Psychosocial functioning improved similarly in both drug-treated groups of mothers. The total side effect burden of each drug was similar, although side effect profiles differed between agents. No clinical or demographic variables differentiated responders by drug. Women who were responders and remitters at week 8 could be identified earlier if they were treated with SERT than with NTP. Breast-fed infant serum levels were near or below the level of quantifiability for both agents.

A randomized, double-blind, placebo-controlled trial of augmentation with an extended release formulation of methylphenidate in outpatients with treatment-resistant depression.

We examined the efficacy and tolerability of augmentation with an extended release formulation of methylphenidate (OROS MPH, Concerta) in patients with major depression who were nonresponders or partial responders to antidepressants. Sixty subjects with treatment-resistant depression (TRD) participated in a 4-week, randomized, double-blind, placebo-controlled study of augmentation with methylphenidate (18-54 mg/d). The preexisting antidepressant dose was unchanged. The primary efficacy measure was change in the 21-item Hamilton Depression Rating Scale from randomization to end of treatment. Data were analyzed with intent-to-treat with last observation carried forward approach. There were no statistically significant differences between the methylphenidate (n = 30) and placebo (n = 30) groups in reduction in 21-item Hamilton Depression Rating Scale scores (drug, −6.9; placebo, −4.7) from baseline to end of treatment (F1,47 = 1.24, P = 0.22), although responders were numerically higher in the extended-release methylphenidate group (40.0%) than in the placebo group (23.3%). On the secondary efficacy measures of changes in Clinical Global Impression-Improvement and Severity scores and Beck Depression Inventory-Second Edition, the drug failed to separate from placebo, although the proportion of responders in the drug group were numerically higher than placebo. There were no significant differences in weight, heart rate, and blood pressure changes between the 2 groups. The common adverse events were loss of appetite, nausea, headache, and anxiety. The mean dose of drug was 34.2 mg/d. The study did not demonstrate a statistically significant benefit for augmentation with methylphenidate in TRD. Combination of methylphenidate with antidepressants was well tolerated. Adequately powered, randomized, controlled trials are necessary to fully evaluate the efficacy of extended-release methylphenidate in TRD.

Symptomatology of affective and psychotic llnesses related to childbearing

Symptom patterns in women with childbearing-related onset illnesses (CBROI) and nonchildbearing-related onset illnesses (NCBROI) were compared. Women with diagnoses of Affective Disorders and Psychoses (n = 762) were divided into four groups: CBROI with psychosis, CBROI with non-psychotic affective illnesses, NCBROI with psychosis, and NCBROI with non-psychotic affective illness. Principal components analysis of 64 symptoms revealed 9 factors. The most dramatic result was the high score for psychotic women with CBROI on the factor cognitive disorganization/psychosis. Psychotic women with CBROI also reported homicidal ideation more frequently. Symptoms of non-psychotic women with CBROI and NCBROI did not differ.

Identifying depression in the first postpartum year: guidelines for office-based screening and referral.

BACKGROUND Some 10-15% of women experience postpartum-onset major depression (PPMD). The objective of this study was to determine if the Edinburgh Postnatal Depression Scale (EPDS) is an effective screen for major depression (MD) prospectively. The outcome of the study was identification of a recurrence of major depression in the first year postpartum by a clinical interview and the EPDS. We had the unique opportunity to examine the relationship between EPDS scores and PPMD. METHODS Participants were pregnant women who had experienced an episode of previous PPMD but were well during their index pregnancy. This study was part of a double-blind, randomized clinical trial in which new mothers received nortriptyline or placebo within 24 h following delivery for prevention of PPMD. Recurrence of depression was established according to Research Diagnostic Criteria. Participants completed the EPDS weekly through 20 weeks postpartum and into a 1-year follow-up phase. RESULTS Out of 50 women, 13 experienced recurrence of MD in the first 20 weeks postpartum with a total of 20 out of 50 recurring in the first year. The EPDS score of >9 at week 4 postpartum identified 60% of women who nurtured in the first 20 weeks and 80% who recurred in the first postpartum year. LIMITATIONS The study population included only women who had a previous episode of postpartum depression. The generalizability to all women is limited. CONCLUSIONS The EPDS is an effective depression screen for women who had a previous episode of PPMD. Clinical guidelines are provided for use of the EPDS to identify MD in the first postpartum year in primary care settings.

The atypical antipsychotics olanzapine and risperidone in the treatment of posttraumatic stress disorder: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials.

Posttraumatic stress disorder (PTSD) is a prevalent and disabling mental illness. Small studies found atypical antipsychotics (AAs) to be beneficial in the treatment of patients with PTSD regardless of psychotic symptoms who are unresponsive to conventional pharmacological treatments such as serotonin selective reuptake inhibitors. This study reports the results of a meta-analysis of existing randomized, double-blind, placebo-controlled clinical trials (RCTs) of AAs as a monotherapy or augmentation therapy for the treatment of patients with PTSD. Seven RCTs were identified through extensive scans of databases, which included PubMed, MedLine, the National PTSD Center Pilots database, PsycINFO, Cochrane Central Register of Controlled Trials, and the Abstracts Library of the American Psychiatric Association with predefined inclusion criteria. Dichotomous and continuous measures were performed using a fixed effects model, heterogeneity was assessed, and subgroup analyses were done. Data from seven RCTs involving a total of 192 PTSD patients (102 randomized to AAs and 90 randomized to placebo) were analyzed. The results show that AAs may have a beneficial effect in the treatment of PTSD, as indicated by the changes from baseline in Clinician Administered PTSD Scale total scores [standardized mean difference (SMD)=−0.45, 95% confidence interval (CI) (−0.75, −0.14), P=0.004]. In addition, the overall SMD of the mean changes in the three Clinician Administered PTSD Scale subscores was statistically significant (P=0.007) between AAs and placebo groups, favoring AAs over placebo (SMD=−0.27, 95% CI=−0.47, −0.07). In particular, the symptom of ‘intrusion’ was mainly responsible for this significance. Clinical significance of the results, however, should be carefully interpreted and translated into clinical practice, given that the quality and availability of currently existing RCTs included in the analysis.

Relationship of psychiatric illness to childbearing status: a hospital-based epidemiologic study

Women who presented to a University psychiatric hospital were categorized into those with childbearing-related onset illness (CBROI, n = 168) and compared to those with non-childbearing-related onset illness (NCBROI, n = 1004). Women with CBROI were an average of five years younger. The two groups did not differ in membership across five major psychiatric diagnostic categories. However, women with CBROI were given the specific diagnosis adjustment disorder with depressed mood more frequently. Anxiety disorders were also common in women with CBROI. Most women with CBROI had the onset of illness during the postpartum period compared to during pregnancy or after pregnancy loss.

A Double-Blind, Randomized, Placebo-Controlled Trial of Paroxetine Controlled-Release in Irritable Bowel Syndrome

BACKGROUND Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disease that causes significant impairment in quality of life and accounts for

Timing of depression recurrence in the first year after birth

8 billion per year to the healthcare system and loss of productivity in the workplace. OBJECTIVE The authors examined the efficacy and safety of paroxetine controlled-release (paroxetine-CR) in patients with IBS. METHOD Seventy-two patients with IBS participated in a 12-week, double-blind, randomized, placebo-controlled study of paroxetine-CR (12.5 mg-50 mg/day). Efficacy was measured by Composite Pain Scores (primary outcome) and the Clinical Global Impression-Improvement (CGI-I) and Severity (CGI-S) ratings. RESULTS In intent-to-treat analyses, there were no significant differences between paroxetine-CR (N=36) and placebo (N=36) on reduction in Composite Pain Scores, although the proportion of responders on CGI-I was significantly higher in the paroxetine-CR group. The treatment was well tolerated. CONCLUSION The study did not demonstrate a statistically significant benefit for paroxetine-CR over placebo on the primary outcome measure, although there was improvement in secondary outcome measures. Overall, paroxetine-CR seems to have potential benefit in IBS. Studies with adequate samples may clarify the role of paroxetine-CR in IBS.

Effects of childbearing on the natural history of panic disorder with comorbid mood disorder.

BACKGROUND Women who have suffered from one episode of postpartum-onset major depression (PPMD) experience increased risk for recurrence in the year following another birth. METHODS Non-depressed women (N=51) who had at least one past episode of PPMD were recruited during pregnancy. After birth, subjects were assessed prospectively each week for 20 weeks with the Hamilton Rating Scale for Depression and Research Diagnostic Criteria for recurrence of major depression. Evaluations were carried out at 24, 36, and 52 weeks to assess for episodes beyond 20 weeks postpartum. RESULTS The data revealed a clustering of cases, with five of the 21 recurrences (24%) occurring in the first 2 weeks. Thirteen of the 21 recurrences (67%) and 19/21 recurrences (90%) occurred in the first 20 and 28 weeks following birth, respectively. LIMITATIONS Although it is unusual for studies of this type to be prospective, the sample size is relatively small. CONCLUSIONS The 1-year recurrence rate was 21/51 or 41%, with a clustering of cases near delivery. All recurrences except two occurred by 28 weeks postpartum.

Prevention of postpartum episodes in women with bipolar disorder.

This historical prospective study included 22 women with panic disorder. They experienced 45 pregnancies associated with or after their first lifetime episode of panic disorder. Mood disorder predated or was associated with 32 of these pregnancies. The most common effect of pregnancy was No Change in symptoms from baseline during pregnancy and continued No Change postnatally for both panic attacks (n = 22; 49%) and depression (n = 19; 59%). The pattern of panic attack across gestations was consistent for only 5 of 14 multiparae. An interesting observation was that first lifetime onset of panic disorder was common postpartum (n = 4) or post-miscarriage (n = 2). First-onset depression was also common postpartum (n = 4).