L-methylfolate Effective in the Treatment of a MDD

Pharmacotherapy for major depressive disorder (MDD) includes monotherapy with either a selective serotonin reuptake inhibitor (SSRI) or a selective norepinephrine reuptake inhibitor (SNRI). SSRI/SNRI combination therapy has also proven to be effective. Recent research has been conducted to determined the efficacy of l-methylfolate, a prescription medical food for the dietary management of suboptimal L-methylfolate levels in patients with depression, for a major depressive episode (MDE).

Lawrence D. Ginsberg, MD, and colleagues conducted a retrospective chart review and studied 242 patients with a primary diagnosis of MDD with a single or recurrent MDE and Clinical Global Impression-Severity (CGI-S) score of >4. Patients were broken into two groups. The combination group (n=96) received an SSRI or an SNRI combined with l-methylfolate 7.5–15 mg/day. The monotherapy group (n=147) received either an SSRI or SNRI. The CGI-S was used as the primary outcome measure.

“I conducted the study after I used this medical food in many patients and started to see significant improvement without any additional adverse events,” Dr. Ginsberg wrote via e-mail. “I initially started using l-methylfolate in geriatric patients because this was the safest adjunctive therapy in a patient population that can least tolerate side effects. I next started to use this adjunctively in at-risk patients (those with medical conditions that deplete l-methylfolate, those on medications which deplete l-methylfolate, and those with lifestyle habits that deplete l-methylfolate).”

Ginsberg and colleagues found that combination therapy was more effective than monotherapy. Eighteen percent of patients in the combination group had a >2-point reduction in CGI-S scores. Only 7.4% of the monotherapy group showed this same reduction. On average, it took patients in the combination group 177 days to show major improvement. It took patients in the monotherapy group an average of 231 days to show the same amount of improvement, thus indicating a more rapid response for patients receiving combination therapy. Regarding the side effects, there was no statistical difference between either group. When combined with an antidepressant, l-methylfolate is more effective in reducing the symptoms of MDD. It  can be used as long-term therapy due to its high tolerance and fewer discontinuations when compared to the monotherapy group.

“I was not surprised that the outcomes were positive because this is what I suspected from my daily patient interactions. I was surprised by the magnitude of the differences between the SSRI/SNRI monotherapy and methylfolate plus SSRI/SNRI groups. Additionally, the methylfolate plus SSRI/SNRI group had medical comorbidity; despite this there were significant improvements over the monotherapy group,” Dr. Ginsberg wrote.

The researchers believe that more randomized, controlled trials on this subject are needed.
Funding for this research was supported by Pamlab. (APA 2010, Poster NR3-46) –CDN

Effects of Ethnicity and Education on Mental Health Literacy

Mental health literacy is a key factor in promoting recognition and destigmatization of mental illness. Proper knowledge about mental illness helps management and prevention as well. However, mental health literacy is lacking in both developed and undeveloped areas. Although studies have examined age and gender in relation to mental health literacy, little work has been conducted to measure differences between ethnic and educational groups.

Christian Reusche, MD, of Charleston, South Carolina, and colleagues, studied ethnicity and education’s effects on mental health literacy, as well as evaluated such literacy in an urban population. Focus groups and inner-city adults from Newark, New Jersey, were consented for the survey after Institutional Review Board certification, human subject protection, and project approval. Thirteen true or false questions and two opinion questions were provided in a mental health literacy survey that assessed knowledge of facts, stigma and stereotypes, and spiritual/religious beliefs about mental illness. Of the survey participants, there were 104 African Americans, 2 Asians, 34 Caucasians, 40 Hispanics, 11 “other,” and 26 who chose not to disclose ethnicity.

Level of education and ethnicity were related to differences in mental health literacy. African Americans and Latinos scored significantly worse than Caucasians in terms of stereotypes and stigma toward the mentally ill, and were more likely to believe in religion as a cure for mental illness. Participants with higher education exhibited decreased stigma and stereotypes toward mentally ill individuals as well as decreased beliefs in religion as a cure.
The authors concluded that mental health literacy may be improved by tailoring education to diverse cultural backgrounds and needs.

Research for this study was provided through the Helping Hands Grant by the American Psychiatric Foundation. (APA 2010, Poster NR2-42) –DC

Generic or Brand Name? Psychiatrists’ Prescribing Habits In a Single Site Study

Prescription drug costs are receiving plenty of scrutiny during the ongoing United States national healthcare debate. Prescribing generic medications is cited frequently as a cost-saving measure, but even that thread of conversation prompts questions about whether generics are as safe or effective as their branded counterparts. In this publication, editor Norman Sussman, MD, wrote last month that, in his own practice, prescribing branded medications in lieu of an available generic equivalent can start a protracted “fax war” with insurance companies or managed care providers, who question the more expensive therapy. In other cases, he wrote, pharmacies might fill a prescription with a generic medication, unbeknownst to clinician or patient.

Yakir Vaks, MD, at the Bergen Regional Medical Center in Paramus, New Jersey, and colleagues, conducted a retrospective analysis of antipsychotic and antidepressant prescriptions in a single outpatient psychiatric setting. Out of 200 charts for patients seen by a group of 10 physicians over a 1-month period, they identified 84 charts of patients who received a prescription for an antipsychotic or antidepressant; the patient cohort was not selected by any criteria. Among this cohort, 48 charts indicated an antidepressant prescription and 36 charts an antipsychotic prescription. The charts were categorized further between those containing generic and brand name prescriptions.

The overwhelming majority of prescriptions in this cohort were brand name: 40 of 48 antidepressants prescribed, and 35 of 36 antipsychotics prescribed, were brand name. Across both groups, 11% of prescriptions were for generics, 89% for brand name.

“Generics offer a lower cost treatment alternative helping to lessen total health care expenditures and improve patient compliance,” Vaks and colleagues wrote.

The authors also wish to see clinicians made aware of the advantages of generics for some patients, concluding that “[i]t is imperative for clinicians to switch their prescribing practices to this beneficial alternative whenever possible.” (APA 2010, Poster NR2-57) –LS

Open-label Trial of Escitalopram in Women with Postpartum Mood and Anxiety Disorders

Postpartum mood and comorbid anxiety disorders can negatively affect both mother an newborn. Decreasing suffering while promoting mother-baby bonding and improving quality of life is key during this time period. Although past studies have examined the efficacy of escitalopram for treatment of major depressive disorder, no research to date has examined the efficacy of escitalopram on postpartum women with mood and anxiety disorders.

Shaila Misri, MD, FRCPC, from St. Paul’s Hospital in Vancouver and the University of British Columbia, and colleagues, conducted a 10-week, open-label trial in postpartum, non-breast feeding women with mood and comorbid anxiety disorders. It followed 15 women 18–40 years of age (mean age was 34 [SD=5.37] years) through six visits on escitalopram 10–20 mg/day. Previous history of depression and anxiety disorders were exhibited in 84.2% and 42.1% of patients, respectively. A study psychiatrist monitored symptoms ever two weeks using the Montgomery-Asberg Depression Rating Scale (MADRS), the Mini-International Neuropsychiatric Interview, the Hamilton Rating Scale for Anxiety (HAM-A), the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Penn State Worry Questionnaire, and the Quality of Life Enjoyment and Satisfaction Questionnaire.

Remission rates at Visit 6 were 93.4% for major depressive disorder (MADRS score ≤10), 73.4% for anxiety (HAM-A score ≤7), and 66.7% for obsessive-compulsive disorder (YBOCS score ≤11) at the 10-week mark. Although generalized anxiety disorder symptoms decreased by 14.24% according to PSWQ scores, they did not reach significant remission.

The most common side effects were sedation, dry mouth, change in appetite, change in sleep, headache, nausea, diarrhea, shakiness, jitteriness, and decrease in sexual desire. No weight gain was reported. With each visit there was a decrease in frequency of side effects.

This study was limited because of its small sample size. The study was approved by The Research Ethics Committee at the University of British Columbia.

Funding for this study was provided by Lundbeck Canada. (APA 2010, Poster NR5-64). –DC

Psychiatric dispatches is written by Dena Croog, Christopher Naccari, and Lonnie Stoltzfoos.