6 VIEWS & REVIEWS

o d treatm nt ~ r n' il iIIn

-Amanda Hunt-

Selective serotonin reuptake inhibitors (SSRIs) are not only effective antidepressants but have many other potential uses, according to Dr Stuart Montgomery, President of the British Association of Psychopharmacology_

The leading English psychiatrist expressed these views during a visit to Auckland. New Zealand. in early September 1992. sponsored by SmithKline Beecham.

Benefits of SSRIs ... SSRIs began their career in the treatment of

depression. but potential indications include alcohol abuse and other addictions. and eating and pain disorders. These drugs are also effective in the treatment of panic disorder. and have shown benefit in severe depression. a condition which is often resistant to drug treatment.

••• and in particular, paroxetine While endorsing the benefits of SSRls as a class,

Dr Montgomery sees some specific advantages for paroxetine: • paroxetine does not accumulate for as long as

fluoxetine and thus much shorter washout periods are possible

• paroxetine has the best evidence for a minimum effective dose. being licensed at 20mg/day. and thus may be somewhat better tolerated than SSRls given in higher doses

• there are some reports of better early responses when initiating paroxetine. and also reports that paroxetine may cause less agitation than fluoxetine. Paroxetine is the only SSRI in the UK licensed

for the treatment of anxiety associated with depression.

Because the worldwide database on paroxetine is the largest for any antidepressant. Dr Montgomery feels it can be used with confidence.

'These drugs have much wider use than initiJJlly thought. '

Dr MOII/Romery

In Dr Montgomery's opinion. many of the differences between SSRls are minor. He stressed that the SSRIs represent a large improvement over other antidepressants. 'As a class' says Dr Montgomery 'they (SSRIs) have great advantages'.

Importantly. the incidence of adverse effects with this drug class is low. SSRIs lack the anticholinergic effects experienced with tricyclics.

SSRIs and suicidal ideation Dr Montgomery also has firm opinions on the

reports of suicidal ideation associated with SSRIs. During his involvement with FDA checks on fluoxetine. Dr Montgomery reanalysed a large amount of data and found that fluoxetine, far from causing suicidal ideation, reduced the emergence of

12 Sep 1992INPHARMA"

suicidal thoughts when compared with placebo. Similar results were found on examination of data on paroxetine. In fact. SSRIs are 'selectively indicated in the presence of suicidal thoughts'.

Long term treatment of dep~ recommended Both the Royal College of Psychiatrists and the

British Association of Psychopharmacology recommend a minimum treatment period of 4 months after apparent response to treatment of depression. If treatment is stopped too early, it is believed that there is a higher chance of recurrence of depression.

In a specific group of patients. Dr Montgomery advocates much longer term antidepressant therapy as a prophylactic measure. In recurrent depression, Dr Montgomery has found that long term therapy with SSRIs reduces the number of episodes of depression by a factor of 3. He believes that this new emphasis in treatment of unipolar depression will take time to gain acceptance. as it involves increased drug costs and educational programmes for both doctors and patients.

Obsessive compulsive disorder -link with serotonin

Obsessive compulsive disorder (OCD) is another of Dr Montgomery's areas of interest. A strong link with serotonin has been discovered in this disorder. However. the serotonergic mechanism appears to be different to that found in depression.

Clinical studies indicate that only serotonergic drugs. particularly clomipramine. are effective in OCD.

Elevated levels of growth hormone and prolactin have been found in OCD. There is also evidence of brain damage. basal ganglia changes and a genetic basis for the disease, but more investigation is needed before the significance of these findings is known.

It is clear is that OCD is a distinct disorder with a clear-cut serotonergic basis. Ten placebo­controlled trials of SSRIs in OCD are currently in progress.

~ Editorial comment: Forjurther 'state of the art' information on SSRls. refer to features inlnpharma 831: 12, 4 April 1992 and 840:6.6 June 1992.

ISSN 0156·2703l9210912-006/$1 .00~ Adls International Ltd