Amitriptyline major depression

Two recently introduced antidepressants are notable m that they are selective serotonin uptake inhibitors Citalopram (19) is reported to be as effective as amitriptyline m the treatment of endogenous depression [75, 16] Fluoxetine (20) as the hydrochlonde is approved for major depressive disorders mcludmg those with concomitant anxiety Interestmgly, it also appears useful m the treatment of obesity [17]... 

Versiani, M., Ontiveros, A., Mazzotti, G., Ospina, J. et al. (1999). Fluoxetine versus amitriptyline in the treatment of major depression with associated anxiety (anxious depression) a doubleblind comparison. Int. Clin. Psychopharmacol, 14, 321-7. 

Compared to antipsychotics, there are even fewer studies on the prescribing patterns of antidepressants done in Asian countries. Pi etal. (1985) conducted a survey of psychotropic prescribing practices reported by psychiatrists in 29 medical schools in 9 Asian countries. Daily dose range of tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, and nortriptyline in Asian countries was comparable to the practice in USA. This is despite differences found between Asian and non-Asian populations in the pharmacokinetics of TCAs (Pi et al, 1993). A questionnaire on the practical prescribing approaches in mood disorders administered to 298 Japanese psychiatrists was reported by Oshima et al. (1999). As first-line treatment, the majority of respondents chose newer TCAs or non-TCAs for moderate depression and older TCAs for severe depression. Combination of antidepressants and anxiolytics was preferred in moderate depression, while an antidepressant and antipsychotic combination was common in severe psychotic depression. Surprisingly, sulpiride was the most favored drug for dysthymia. In a naturalistic, prospective follow-up of 95 patients with major depression in Japan, the proportion of patients receiving 125 mg/day or less of imipramine was 69% at one month and 67% at six months (Furukawa et al., 2000). 

Seven TCA drugs are available in the United States for treatment of major depression. They are generally categorized as tertiary or secondary amines. Tertiary amines include imipramine (Tofranil), amitriptyline (Elavil), trimipramine (Surmontil), and doxepin (5m-equan). Desipramine (Norpramin), nortriptyline (Pam-elor), and protriptyline (Vivactil) are secondary amines. 

Eckmann, E, Fichte, K., Meya, U., and Sastre-y-Hernandez, M. (1988) Rolipram in major depression results of a double-blind comparative study with amitriptyline. Curr Ther Res 43 291-295. 

Birmaher, B., Waterman, G.S., Ryan, N.D., Perel, J., McNabb, J., Balach, L., Beaudry, M.B., Nasr, F.N., Karambelkar, J., Elterich, G., Quintana, H., Williamson, D.E., and Rao, U. (1998) Randomized, controlled trial of amitriptyline versus placebo for adolescents with treatment-resistant major depression. J Am Acad Child Adolesc Psychiatry 37 527-535. 

DeKloet ER, Kovacs GL, Szabo G, et al Decreased serotonin turnover in the dorsal hippocampus of rat brain shortly after adrenalectomy selective normalization after corticosterone substitution. Brain Res 239 659-663, 1982 Del Zompo M, Bernadi F, Burrai C, et al A double-blind study of minaprine versus amitriptyline in major depression. Neuropsychobiology 24 79-83, 1991 Delespaul PhAEG Schizophrenics in Daily Life. Maastricht, Universiteitspers Maastricht, 1995... 

Bremner JD A double-blind comparison of Org 3770, amitriptyline, and placebo in major depression. J Clin Psychiatry 56 519-525, 1995... 

Smith WT, Glaudin V, Panagides J, et al Mirtazapine vs. amitriptyline vs. placebo in the treatment of major depressive disorder. Psychopharmacol Bull 26 191-196, 1990... 

There have been five double-blind studies comparing the antidepressant efficacy of different SSRIs versus different TCAs in patients with HDRS scores of 25 or more (122, 123,124, 125 and 126). Three of these studies permitted inclusion of both inpatients and outpatients ( 122, 123 and 124), whereas the other two were solely done in outpatients (125, 126). Three were placebo-controlled (1.23, 125,126). In these three studies, the SSRI (i.e., fluvoxamine, paroxetine, or sertraline) was either superior to both the f CA and placebo or was comparable with the TCA and superior to placebo. In the other two studies, the SSRI was not different from the TCA and there was no placebo control. There have also been four studies and one metaanalysis of European clinical trials which found no difference in antidepressant efficacy between several different SSRIs and several different tertiary amine TCAs in patients hospitalized for major depression ( 127,128, 129,130 and 131). Finally, there have been two relatively small studies showing that fluoxetine and fluvoxamine both had antidepressant efficacy superior to placebo in patients with melancholia ( 132, 133). Another larger study failed to find a difference between paroxetine and amitriptyline in treating such patients ( 134). 

The approval of mirtazapine in the United States was based on six double-blind, placebo- and amitriptyline-controlled studies in which it was found to be superior to placebo and comparable with amitriptyline in terms of antidepressant efficacy (173,174). In a double-blind, crossover study, 63% of patients who failed to respond to 6 weeks of double-blind treatment with amitriptyline responded to mirtazapine (175). In two studies, mirtazapine was found to be efficacious in the treatment of patients hospitalized for major depression. In the first study, the antidepressant efficacy of mirtazapine was comparable with that of amitriptyline and superior to placebo (176). In the other study, the antidepressant efficacy was superior to that of fluoxetine (118). There are advantages and disadvantages to mirtazapine, including the following ... 

Zivkov M, Roes KCB, Pols AB. Efficacy of Org 3770 (mirtazapine) vs. amitriptyline in patients with major depressive disorder a meta-analysis. Hum Psychopharmacol 1995 10 S135-S145. 

Catterson M, Preskorn SH. Double-blind crossover study of mirtazapine, amitriptyline, and placebo in patients with major depression. In New Research Program and Abstracts of the 149th annual meeting of the American Psychiatric Association, New York, May 6, 1996 NR157. 

Kashani JH, Shekim WO, Reid JC. Amitriptyline in children with major depressive disorder. A double blind crossover pilot study. J Am Acad Child Psychiatry 1984 23 348-351. 

Fawcett J, Zajecka JM, Kravitz HM, et al. Fluoxetine versus amitriptyline in adult outpatients with major depression. Psychiatry Res 1989 45 821. 

Staner L, Kerkhofs M, Detroux D, Leyman S, Linkowski P, Mendlewicz J (1995) Acute, subchronic and withdrawal sleep EEG changes during treatment with paroxetine and amitriptyline a double-blind randomized trial in major depression. Sleep 18 470-477... 

Bauer M, Zaninelli R, Muller-Oerlinghausen B, Meister W. Paroxetine and amitriptyline augmentation of lithium in the treatment of major depression a doubleblind study. J Chn Psychopharmacol 1999 19(2) 164—71. 

Shaw DM, Crimmins R. A multicenter trial of citalopram and amitriptyline in major depressive illness. In Montgomery SA, editor. Citalopram—The New Antidepressant from Lundbeck Research. Amsterdam Excerpta Medica, 1989 43. 

Sexual disturbance has also been associated with sertraline (14), and a high frequency of such adverse effects has been reported in studies in which high doses were used. In a double-blind, placebo-controlled study of sertraline and amitriptyline in patients with major depression, male sexual dysfunction, mainly ejaculatory disturbance, was reported significantly more often with sertraline (in 21% of the patients) (15). Male sexual dysfunction in 15% of sertraline-treated patients has also been reported (16). 

Reimherr FW, Chouinard G, Cohn CK, Cole JO, Itil TM, LaPierre YD, Masco HL, Mendels J. Antidepressant efficacy of sertraline a double-blind, placebo- and amitriptyline-controlled, multicenter comparison study in outpatients with major depression. J Clin Psychiatry 1990 51(Suppl. B) 18-27. 

In major depression, the efficacy of mirtazapine is comparable to that of amitriptyline, clomipramine, doxepin, fluoxetine, paroxetine, citalopram, and venlafaxine. 

Zaninelli R, Bauer M, Jobert M, Muller-Oerlinghausen B. Changes in quantitatively assessed tremor during treatment of major depression with lithium augmented by paroxetine or amitriptyline. J Clin Psychopharmacol 2001 21(2) 190-8. 

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