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December 2007

Index, Volume 30, 2007

High-Dose Ziprasidone
Patients with treatment-resistant psychosis may benefit from higher-than-recommended doses of ziprasidone (Geodon).

Baby Steps
Our clinical knowledge in psychiatry has increased over the past year, but scientific understanding and intervention technology still leaves much to be desired.

High Doses of Venlafaxine
Higher doses of venlafaxine (Effexor and others) likely increase the chance of antidepressant response, but also increase the risk of side effects.

SSRIs and Bleeding Risk in Patients with Hepatitis C
The risk of selective serotonin reuptake inhibitors causing bleeding in patients with hepatitis C is modest.

Bupropion versus SSRIs for Anxiety in MDD
According to Papakostas and colleagues, bupropion (Wellbutrin and others) appears to work as well as selective serotonin reuptake inhibitors to treat anxiety in patients with major depressive disorder.

Torsades de Pointes with Haloperidol
Intravenous administration of haloperidol (Haldol and others), especially at high doses, can cause QT prolongation and torsades de pointes.

In Brief
Ziprasidone for borderline personality disorder: A negative trial; Adjunctive medications for weight loss in patients with schizophrenia or bipolar disorder

Bupropion versus SSRIs for Anxiety in MDD

December 2007

Bupropion (Wellbutrin and others), a pharmacologically distinct antidepressant, inhibits reuptake of norepinephrine and dopamine and has no appreciable affinity for the serotonin transporter. Its side effects are quite different from those of other antidepressants, presumably because it does not bind to serotonin, acetylcholine, or histamine receptors. Last month, we reported that bupropion works no faster than selective serotonin reuptake inhibitors (SSRIs) in depressed patients (BTP 2007;30:39-40).

Anxiety frequently accompanies major depressive disorder (MDD), burdening at least half of depressed patients. Most SSRIs are labeled by the US Food and Drug Administration for the treatment of anxiety disorders, but bupropion is not. Papakostas and colleagues compared the efficacy of bupropion versus SSRIs in treating anxiety symptoms associated with MDD.1

The authors pooled patient data from 10 double-blind, random-assignment clinical trials that compared bupropion with an SSRI—sertraline (Zoloft and others), fluoxetine (Prozac and others), paroxetine (Paxil and others), or escitalopram (Lexapro)—for the treatment of MDD. The combined subject sample comprised 2890 subjects.

Contrary to popular impression, anxiety improved as much in MDD patients treated with bupropion as it did in those treated with an SSRI, with a similar time course. Among patients who achieved remission from MDD, there was no difference in residual anxiety symptoms between bupropion- and SSRI-treated cases.

The "bottom line" from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial was that patient improvement on antidepressant therapy should be assessed with regular frequency and treatment should be adjusted if response is inadequate (BTP 2007;30:27-28). The ability to tailor specific pharmacologic interventions to particular groups of patients continues to elude us. The Papakostas et al analysis suggests that the presence of anxiety in MDD patients does not dictate the use of an SSRI versus bupropion: either should work well. Of course, the side effect profiles of SSRIs and bupropion are markedly different. In current practice, bupropion is often combined with a serotonergic antidepressant, perhaps increasing efficacy and doubtlessly combining side effects.

1Papakostas GI, Trivedi MH, Alpert JE, Seifert CA, Krishen A, Goodale EP, Tucker VL: Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: A meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. J Psychiatr Res, in press.