Men on Tricyclic Antidepressant More Likely to Think of Suicide

All antidepressants may not be created equal when it comes to worsening of suicidal ideation during treatment, researchers found.

Men taking nortriptyline (Aventyl, Pamelor) were 2.4 times more likely to have an increase in suicidal thoughts than were those taking escitalopram (Lexapro), Nader Perroud, MD, of King's College London, and colleagues reported online in BMC Medicine.

Nortriptyline, a tricyclic antidepressant, was also associated with a 9.8-fold higher risk of new onset of suicidal ideation compared with the selective serotonin reuptake inhibitor (SSRI) in the prospective open-label trial.

The reason behind the difference may be that nortriptyline acts predominantly on the noradrenergic system, which, when overactive, is associated with anxiety and agitation.
Because "suicidal ideation is more common in agitated and irritable types of depression," the researchers said, "it is possible that nortriptyline may induce or worsen suicidal thoughts in some male subjects possibly through an induction of this more agitated type of depression."

Another possibility is that nortriptyline is less effective against mood symptoms, they noted.

All antidepressants now carry black box warnings of suicidality risk, particularly in children and young adults, and especially early in treatment, but whether this risk differs between agents or by gender has been debated.

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Older antidepressant spurs more suicidal thinking in men than newer medication

The largest clinical trial to date comparing an older, tricyclic antidepressant with a newer antidepressant of the selective serotonin reuptake inhibitor (SSRI) class has found that the emergence of suicidal thinking was almost 10 times more common in men taking the older drug than in those taking the newer medication.

The study also found that for men and women taking either medication, suicidal thinking was spread over the first six weeks of treatment, but peaked at roughly the fifth week before declining significantly after week six. Taking place at academic medical institutions across Europe, the trial, called Genome-Based Therapeutic Drugs for Depression--or GENDEP--gauged the responses to antidepressants of 811 persons ranging from 18 to 72 with depression.

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What Is Neuropathy? What Causes Neuropathy?

Neuropathy is a collection of disorders that occurs when nerves of the peripheral nervous system (the part of the nervous system outside of the brain and spinal cord) are damaged. The condition is generally referred to as peripheral neuropathy, and it is most commonly due to damage to nerve axons. Neuropathy usually causes pain and numbness in the hands and feet. It can result from traumatic injuries, infections, metabolic disorders, and exposure to toxins. One of the most common causes of neuropathy is diabetes.

Neuropathy can affect nerves that control muscle movement (motor nerves) and those that detect sensations such as coldness or pain (sensory nerves). In some cases - autonomic neuropathy - it can affect internal organs, such as the heart, blood vessels, bladder, or intestines.

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Older drug seen better for Parkinson's depression

People with Parkinson's disease who need treatment for depression seem to do better with an older antidepressant than a newer agent, according to a small clinical trial.

"Individuals with depression and Parkinson's disease do respond to antidepressants," Dr. Matthew Menza told Reuters Health. "This is important because depression in Parkinson's disease is often under-recognized, under-appreciated and under-treated. Commonly, the attitude is, 'of course you're depressed, you have a serious illness.' We have now demonstrated that one should be hopeful that treatment will help."

There have been few head-to-head trials of different antidepressants for Parkinson's patients with depression, Menza, of the Robert Wood Johnson Medical School in Piscataway, New Jersey, and his group note in the medical journal Neurology.

To investigate, they compared the older "tricyclic" antidepressant nortriptyline with the newer "SSRI" agent paroxetine in 52 people with Parkinson's disease diagnosed with major depression. Nortriptyline is available in generic form and under the brand name Pamelor, and paroxetine CR is known by the brand names Paxil and Seroxat.

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Older Antidepressants May Be Better for Parkinson's Patients

For Parkinson's disease patients with depression, an older tricyclic antidepressant outperformed a newer selective serotonin reuptake inhibitor, one of a class that is commonly prescribed, according to researchers here.

In a randomized trial, the older tricyclic antidepressant, nortriptyline, significantly improved symptoms of depression after eight weeks compared with placebo (P<0.002) Matthew Menza, M.D., of Robert Wood Johnson Medical School here, and colleagues reported online in Neurology. A newer SSRI, paroxetine CR, did not (P=0.165) help.

The percentage of patients who had at least a 50% reduction in their depression symptoms was significantly higher in those taking nortriptyline than in those taking paroxetine CR (53% versus 11%, P=0.034).

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Combination of Antidepressants Linked to Risk of Diabetes

The use of two types of antidepressants at the same time was associated with an increased risk for type 2 diabetes, a nested case-control study showed.

Patients taking both a tricyclic antidepressant and a selective serotonin reuptake inhibitor (SSRI) were nearly twice as likely to develop type 2 diabetes as those taking a tricyclic antidepressant alone, Jeffrey Johnson, Ph.D., of the University of Alberta, and colleagues reported in the January issue of Diabetes Research and Clinical Practice.

"If our findings are confirmed by others," they concluded, "it could be that antidepressant therapy will need to be tailored to depressed individuals' risk of developing diabetes, and that patients on combination therapy will require vigilance regarding the development of glucose intolerance."

The increased risk of diabetes in depressed patients is well-documented, the researchers said, but the mechanisms are unknown.

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Antidepressant linked to worsening white matter in elderly

The results of a study employing serial cranial MRI suggest that elderly adults who use tricyclic antidepressants may be at increased risk for progression of white matter lesions, which have been linked with late-life depression by previous studies.

Still, the progression of these lesions may be the indication for use, or certain side effects, such as hypotension, may be directly responsible.

Late-life depression has been tied to white matter lesions on MRI. The contribution of the various antidepressant agents to this finding has been unclear. Prior research has suggested that selective serotonin reuptake inhibitors (SSRI) inhibit platelet aggregation, which might be expected to slow progression of these lesions.

Dr. David C. Steffens, from Duke University Medical Center in Durham, North Carolina and associates addressed this topic by comparing the initial and five-year follow-up MRI scans in 1829 adults, 65 years or older, who were not using antidepressants at baseline.

The use of an antidepressant from any class during the study period hastened the progression of white matter disease, according to the report in the March issue of Stroke.

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