CNS guidelines available

New guidelines for the treatment of depression and bipolar disorder have been published in the Annals of Internal Medicine (vol. 132, no. 9) and the April 2000 issue of Postgraduate Medicine Special Report, respectively.

Depression

The American College of Physicians-American Society of Internal Medicine, Philadelphia, acknowledges the effectiveness of both older and newer antidepressant medications in the treatment of major depression and dysthymia in its guidelines titled "Pharmacologic Treatment of Acute Major Depression and Dysthymia," published in the Annals of Internal Medicine.

Older antidepressants, such as tricyclics, and newer drugs, such as selective serotonin reuptake inhibitors (SSRIs), have different side effects, interactions and costs. Patients taking tricyclics, most of which are available in generic form, need dosage monitoring - and tricyclics can be fatal in overdoses. SSRIs, and other newer drugs are not currently available in generic form, are generally more expensive, but are easier to take and do not require blood testing. Physicians should discuss with patients the uses and side effects of appropriate drugs, the guidelines say, and together, doctor and patient should come up with an antidepressant that fits the patient's needs.

The guidelines on treating mild depression with St. John's wort came with warnings. "Studies show that St. John's wort is better than placebo, but there are no good studies comparing St. John's wort directly with antidepressant drugs," said Herbert H. Waxman, M.D., ACP-ASIM senior vice president for education. Other concerns about St. John's wort cited in the ACP-ASIM background paper:

•Â St. John's wort studies were mostly done in Europe.

•Â In the United States, St. John's wort is sold as a dietary supplement, not as a drug, and therefore is not regulated by the FDA.

•Â The bottle labels can be misleading.

• The amounts of active St. John's wort ingredients vary in these supplements, and the pills often contain additional substances.

•Â St. John's wort has side effects, may interfere seriously with blood thinners and other important medications and should never be taken with other antidepressant drugs.

ACP-ASIM's new guidelines are appropriate for adult patients with no other medical conditions, and while they address drug treatment, Waxman noted that depression can be treated in other ways. "Our guidelines are aimed at helping internists, together with their adult patients, make informed choices about treating depression with antidepressant drugs and herbal therapies."

Bipolar disorder

"Medication Treatment of Bipolar Disorder 2000," guidelines to help physicians identify and appropriately treat bipolar disorder, represent a consensus among more than 50 psychiatry experts and are based on clinical experience and published data. The guidelines, originally published in the Postgraduate Medicine Special Report, are a revision and update of expert consensus guidelines published in 1996, taking into account new research and the availability of new medications.

Primary recommendations are:

•Â Use a mood stabilizer in all phases of treatment.

- Divalproex sodium (Abbott Laboratories' Depakote®) and lithium are the cornerstone choices for both acute-phase and preventive treatment.

•Â Mood stabilizers should be used first when monotherapy is desired, in combination when either has failed and as the bedrock upon which other medications may be layered.

Other recommendations include:

•Â Mania or depression with rapid cycling should be treated initially with a mood stabilizer alone, preferably divalproex sodium for either phase.

•Â Atypical antipsychotics, such as olanzapine and risperidone, are generally preferred over the older, so-called "typical" antipsychotics as adjunct treatment when psychosis accompanies mania or depression.

•Â Mild depressions should be treated with mood stabilizer monotherapy initially, while severe depressions should be treated from the start with an antidepressant plus mood stabilizer.

The guidelines also feature a section titled "Treatment of Bipolar Disorder: A Guide for Patients and Families," which answers some of the frequently asked questions about the disorder in everyday language. PR