Omega-3 Augmentation of Sertraline in Depressed Patients with Coronary Heart Disease Proves Ineffective

Studies have shown that patients who are depressed but otherwise medically well benefit from omega-3 fatty acids as augmentation to antidepressant treatment. However, according to a recent study conducted between May 2005 and December 2008 by Robert M. Carney, PhD, at Washington Unviersity School of Medicine in St. Louis, Missouri, and colleagues, use of omega-3 fatty acids to augment antidepressant treatment in patients with coronary heart disease (CHD) is ineffective.

“Because depression is a risk factor for cardiac-related mortality and morbidity, we are very interested in finding more effective treatments for depression in these patients,” Dr. Carney said. “Based on smaller studies of depressed psychiatric patients, we had hoped for a positive result.”

The randomized, double-blind, placebo-control trial of sertraline augmented by omega-3 in patients with CHD and major depressive disorder (MDD) included 122 patients on sertraline 50 mg/day randomized to receive omega-3 acid ethyl esters (n=62) or corn oil placebo capsules (n=60) for 10 weeks. The Beck Depression Inventory (BDI-II) and Hamilton Rating Scale for Depression (HAM-D) scores were used to gauge depression. At least 97% of participants in both groups for both medications adhered to the regimen. Difference in improvement was not found between groups on weekly BDI-II scores (treatment x time interaction=.02; 95% confidence interval [CI], -.33-.36; t(112)=.11; P=.91), pre-post BDI-II scores (placebo, 14.8 vs. omega-3, 16.1; 95% difference-in-means CI, -4.5-2.0; t(116)=-.77; P=.44), or HAM-D scores (placebo, 9.4 vs. omega-3, 9.3; 95% difference-in-means CI, -2.2-2.4; t(115)=.12; P=.9). Measurements of depression and anxiety did not differ between the omega-3 and placebo groups at 10 weeks. Rates of remission or treatment response between the groups showed no significant difference.

The authors concluded that treatment of MDD and CHD with sertraline and omega-3 fatty acids did not produce better results than treatment with sertraline and placebo.

“There was little data available to us when we were planning the study regarding how much omega-3 would be needed to augment the effect of sertraline,” Dr. Carney said. “We do not know whether a higher dose would have been effective.”

Funding for this study was provided by the National Institutes of Health. Pfizer and GlaxoSmithKline provided study drugs. (JAMA. 2009;302(15):1651-1657). –DC

Comorbid Medical Conditions in Hospital Discharges with Schizophrenia

People with schizophrenia and other psychotic disorders have a high rate of comorbid illness. A large study evaluated the prevalence of psychiatric and general medical comorbidities in people with schizophrenia using hospital discharge records dating from 1979–2003.

Natalya S. Weber, MD, MPH, at Walter Reed Army Institute of Research, and colleagues, studied a sample of >5.7 million hospital discharges. Patients (15–64 years of age) in this sample with a primary diagnosis of schizophrenia (N=26,279) were compared to those with other primary diagnoses (N=1,936,876). The researchers then calculated proportional mortality ratios (PMRs).

This national study appears to be the first of its kind, in that most other comorbidity studies focus on smaller samples or only verify the prevalence of specific comorbidities.

Over time, the number (and proportion) of discharges involving schizophrenia—primary or secondary diagnosis—and schizoaffective disorder increased significantly in both men and women. Those with a primary schizophrenia diagnosis had more psychiatric comorbid conditions. General medical comorbidities included acquired hypothyroidism (PMR=2.0), contact dermatitis and other eczema (PMR=2.9), obesity (PMR=2.0), epilepsy (PMR=2.0), viral hepatitis (PMR=1.4), type II diabetes (PMR=1.2), essential hypertension (PMR=1.2), and a various chronic obstructive pulmonary diseases (PMR=1.2–1.5).

The proportion of schizophrenia and schizoaffective disorders among hospital discharges was greater among men, blacks, and the Northeast. The authors suggest that awareness and treatment of such medical cormorbidities could improve prognosis for schizophrenia patients, and they advocate early detection and treatment. (Psychiatr Serv. 2009;60(8):1059-1067.) –LS

Anxiety and Conduct Disorders Linked to Higher Suicide Risk

According to a multinational study by Matthew K. Nock, PhD, at Harvard University, and colleagues, people with mental illnesses involving anxiety and poor impulse control are more likely to act on suicidal thoughts than those with other types of mental illness. The study, which pulled information from the ongoing World Health Organization (WHO) World Mental Health Survey Initiative, included data from ~110,000 adults in 21 countries.

Using the WHO Composite International Diagnostic Interview, researchers conducted in-person interviews with adults living in the community and pulled data on participants’ lifetime mental health histories. Data was then analyzed to identify patterns in suicidality among different psychiatric disorders.

Fifty-two percent of adults in developed countries and 43% of adults in developing countries with suicidal ideation had a prior psychiatric disorder. Sixty-six percent of adults in developed countries and 55% of adult in developing countries who made suicide attempts had a prior psychiatric disorder. The study found that the number of comorbid psychiatric disorders was also related to suicide attempts. In developing countries, people with one disorder had a risk ratio of 3.9 compared with those with no disorder, whereas three disorders were associated with a 14.2 risk ratio.

Although depression was one of the strongest predictors of suicidal thoughts, depression was not a strong predictor of thoughts being carried out in attempts. Among the different psychiatric disorders, after controlling for psychiatric comorbidity, individuals with posttraumatic stress disorder (PTSD), bipolar disorder, conduct disorder, and substance use disorders—disorders characterized by anxiety and poor impulse control—were most likely to carry out suicidal ideation with plans and attempts. However, predictors of suicide attempts different between developed and developing countries. While bipolar disorder, depression, and PTSD were the strongest predictors of attempts in developed countries, PTSD, substance use disorders, and conduct disorder were the strongest predictors in developing countries.

This study was limited in its use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, in addition to its narrow focus on mental disorders as predictors of nonfatal suicidal behaviors. Further research is necessary to determine whether there are different mechanisms of suicidal thoughts and suicide attempts.

Funding for this study was provided by Bristol-Myers Squibb, Eli Lilly, the Fogarty International Center, GlaxoSmithKline, the John D. and Catherine T. MacArthur Foundation, the National Institute of Mental Health, Ortho-McNeil, the Pan American Health Organization, the Pfizer Foundation, and the United States Public Health Service. (PLoS Med. 2009;6(8):e1000123.) –DC

Psychiatric dispatches is written by Dena Croog and Lonnie Stoltzfoos.