Depression nortriptyline

Nortriptyline. Nortriptyhne, a tricychc antidepressant, has been shown in double-blind, placebo-controlled randomized trials to be superior to placebo for smoking cessation (Prochazka et al. 1998). Nortriptyline appears to have efficacy comparable to that of bupropion for smoking cessation (Hall et al. 2002). The efficacy of this agent may be improved with more intensive behavioral therapies (Hall et al. 1998). Nortriptyline s mechanism of action is thought to relate to its noradrenergic and serotonergic reuptake blockade, because these two neurotransmitters have been implicated in the neurobiology of nicotine dependence. Side effects of nortiptyline are typical of tricyclic antidepressants and include dry mouth, blurred vision, constipation, and orthostatic hypotension. Nortriptyline appears to have some utility for smokers with a past history of major depression, and it can be recommended as a second-... 

Hall SM, Reus VI, Munoz RF, et al Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry 55 683-690, 1998 Hall SM, Humfleet GL, Reus VI, et al Psychological intervention and antidepressant treatment in smoking cessation. Arch Gen Psychiatry 59 930-936, 2002 Hayford KE, Patten CA, Rummans TA, et al Efficacy of bupropion for smoking cessation in smokers with a former history of major depression or alcoholism. Br J Psychiatry 174 173-178, 1999... 

Various forms of psychotherapy are regarded as effective interventions in mild to moderate depression, but studies comparing the economics of psychotherapy and pharmacotherapy are few (Rosenbaum and Hylan, 1999). One study found that the total health-care costs for patients who received psychotherapy were no different from those for patients who received an antidepressant. However, no efficacy measure was used (Edgell and Hylan, 1997). A randomized, prospective study which evaluated the treatment of depression with nortriptyline, interpersonal therapy or treatment as usual, with outcomes expressed in quality-adjusted life years, found that nortriptyline but not interpersonal therapy was a cost-effective alternative to treatment as usual (Lave et al, 1998). 

SkaerTL, Sclar DA, Robison LM, et al (1995). Economic valuation of amitriptyline, desipramine, nortriptyline, and sertraline in the management of patients with depression. Curr Ther Res 56, 556—67. 

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). 

In acutely depressed patients, there is a correlation between antidepressant effect and plasma concentrations for some TCAs. Table 70-3 shows suggested therapeutic plasma concentration ranges. The best-established therapeutic range is for nortriptyline, and data suggest a therapeutic window. 

TCAs Imipramine, doxepin, nortriptyline, or desipramine (25-100 mg at bedtime) TCAs are generally reserved for patients with an additional indication (e.g., depression, neuropathic pain). 

The TCAs are the only antidepressant class in which effectiveness is dependent on serum level. Attainment of the minimal therapeutic level is typically required for effectiveness. Exceeding the maximum treatment level usually provides no additional benefit and risks toxicity. Unique in this regard is nortriptyline, which is the only TCA with a therapeutic window. This means that beyond the maximum therapeutic level of 150ng/mL nortriptyline not only risks toxicity but is actually less effective at treating depression. Please refer to Table 3.9 for a summary of dosing guidelines and therapeutic levels. 

Tricyclic Antidepressants (TCAs). The TCAs have been nsed to treat ADHD for 30 or more years. Most often used are imipramine (Tofranil) and desipramine (Norpramin), mainly becanse they are the TCAs that most specihcally increase norepinephrine activity. Remember, boosting norepinephrine activity in the brain shonld improve attention. Other TCAs, namely, amitriptyline (Elavil, Endep) and nortriptyline (Pamelor), have been used, though they also increase norepinephrine activity. TCAs do offer a modest benefit for both the inattention and the hyperactivity of ADHD. In addition, they are often effective at doses mnch lower than those required to treat depression. However, their effectiveness nsnally falls short of the stimulant medications. In addition, TCAs have considerable side effects including dry mouth, constipation, drowsiness, weight gain, and adverse cardiac effects. 

Depression SSRIs SNRIs Mirtazapine Bupropion Nortriptyline Desipramine ... 

B34. Burrows, G. D., Davies, B., and Scoggins, B. A., Plasma concentration of nortriptyline and clinical response in depressive illness. ImticH ii, 619-623 (1972). 

A few modifications of the described methods have been suggested for making nortriptyline [27-32], Nortriptyline is a drug with a relatively short latent period of action. It is practically devoid of sedative effects. It is used in manic-depressive psychoses, in all forms of endogenous depression, and also in major depressive conditions. The most common synonyms of nortriptyline are aventyl, nortrilen, motival, vivactil, and pamelor. 

Fig. 9. Relationship between amelioration scores in depressed patients and steady-state plasma concentrations of the antidepressant nortriptyline. Both low and high concentrations are associated with minimum therapeutic effect. (From Asherg M, Cronholm B, Sjoqvist F, Tuck D. Relationship between plasma level and therapeutic effect of nortriptyline. Br Med J 1971 3 331-4, with permission from the BMJ Publishing Group.)...

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. 

K. White, J. Razani, B. Cadow, R. Gelfand, R. Palmer, G. Simpson, R.B. Sloane, Tranylcypromine vs. nortriptyline vs. placebo in depressed out patients A controlled trial, Psychopharmacology 82 (1984) 258-262. 

Roose SR Laghrissi-Thode F, Kennedy IS, et al. Comparison of paroxetine and nortriptyline in depressed patients with ischemic heart disease. lAMA i998 279 287-29i. 

Geller, B., Cooper, T.B., and Chestnut, E.C. (1985a) Serial monitoring and achievement of steady state nortriptyline plasma levels in depressed children and adolescents preliminary data. / Clin Psychopharmacol 5 213—216. 

---