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Many
authors demonstrated in their patients that sertraline was an evidently
safer and better tolerated drug and that it produced significantly less
adverse effects than amitriptiline and imipramine.
Sertraline is an antidepressant drug that is exceptionally safe in patients
with severe somatic diseases. It is6 a selective serotonin central reuptake
inhibitor. It increases6 serotoningergic transmission, exerting thus
antidepressant effect. Its biological half-life (about 26 hours) suggests
that sertraline can be administered in single daily dose. Sertraline
is better tolerated than tricyclic antidepressants. The cholinolytic
effect of sertraline is minimal. The drug exerts practically no influence
on the circulatory system. These premises make possible to use the drug
in patients with serious somatic diseases. Many authors administered
the drug9 to patients in the treatment of major depression for 5 to
30 days following admission to hospital due to acute myocardial infarction.
During the treatment no significant changes were observed in the heart
rate, arterial pressure, cardiac conduction or left ventricular ejection
fraction. No changes were found in blood-clotting system. Other authors1,
in view of drug safety, used sertraline in patients aged 70 years and
more with major depression. These patients, in spite of worse somatic
status adequate to their age, tolerated the drug well. Many authors
demonstrated in their patients that sertraline was safer and better
tolerated than fluoxetine. Yet other authors7 found that sertraline
is a very safe drug, since they administered sertraline to a female
patient with major depression in the course of disseminated malignancy
with multiple metastases. |
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CASE
REPORT |
The
female patient, PJ aged 77 years never received psychiatric treatment.
The patient was born after normal pregnancy and labour. The childhood
was very successful. At home, the atmosphere was present, full of warmth
and love. The parents (dead since many years) were very good, gentle,
hard working and emotional people. The patient was the only child in
the family. No mental diseases had occurred in the family. In primary
school the patient achieved medium results. She terminated her education
at primary school level since then, for many years she cared for her
severely ill parents (father - disseminated malignancy, mother - numerous
cerebral strokes). Then she was married successfully. She had three
adult sons who are decent, fully independent men. The patient reported
no head trauma or loss of consciousness. The patient had the following
serious physical diseases.
- arterial hypertension, pharmacologically controlled,
- chronic coronary artery disease,
- obesity,
- diabetes mellitus treated with diet,
- crural varices,
- status after cholecystectomy due to empyema.
However, the main disease in the patient was thyroid cancer with multiple
metastases to regional lymph nodes, sigmoid and colon, liver, lungs
and uterine appendages. In view of serious somatic condition she was
disqualified for chemotherapy and radiotherapy. Only symptomatic treatment
was instituted. The stress connected with malignancy released another
phase of major depression (she had had previously three phases of major
depression but they were mild and were untreated).
At the beginning of treatment by the author of this paper of the fourth
phase of major depression, the formal and emotional contact with the
patient was good. The mood was greatly decreased. The patient had very
strong groundless anxiety. She experienced frequent obsessive ideas
on her malignancy and feeling of lack of sense and hopelessness of life.
The patient was extremely tearful, frequently complained of her somatic
manifestations. She developed intense nausea and lack of appetite. She
lost 20 kg body weight during the last three months and experienced
a feeling of strong internal restlessness and dither. Insomnia of early
morning awakening type with impossibility to fall asleep was present.
The patient had very emotional attitude towards very slight and insignificant
family disagreements. She looks at her and her family’s future
with deep pessimism. A feeling of great physical weakness was present,
the patient was very fatigable physically and mentally. She reported
weakening of fresh memory and attention concentration. She was feeling
that she deserved contempt and condemnation and was saying that she
was a sinner. She denied other depressive delusions. Periodically, due
to anxiety and restlessness the patient experienced psychomotor agitation.
Transiently she had very variable suicidal ideation, she was then thinking
of suicide and of killing her youngest son to spare him suffering after
her death - extended suicide. She was sure to control these toughts
- she has been believing and practising Roman catholic. The worst general
feeling used to occur in morning hours, slightly better during day and
the best in evening hours.
Detailed psychiatric examination disclosed a typical phase of endogenous
depression. The diagnosis was confirmed by test in Hamilton scale, Montgomery-Asberg
scale and Beck’s Self-Assessment Inventory and also ICD-10, DSM
III and DSM IV scales.
Detailed psychiatric examination and ICD-10 scale test diagnosed the
depression as severe (as the criteria of depression intensity, minor,
medium and severe depressions were taken into account).
|
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Laboratory
tests |
-
laboratory blood tests (very high malignancy markers, three-digit ESR
value, neoplastic anaemia, extremely high bilirubin and hepatic transaminase
levels),
- urine analysis: proteinuria, leucocyturia,
- large chest radiogram: multiple disseminated round shadows in both
lungs (malignant metastases),
- ECG record: diffuse ischaemia of the anterolateral wall,
- EEG record was normal,
- Eye fundus examination : grade II hypertensive angiopathy,
- Neurological examination : without focal and meningeal manifestations,
- Numerous fine-needle biopsies, USG examination confirmed the diagnosis
of disseminated malignant disease,
- Detailed oncological tests confirmed the diagnosis of disseminated
malignant disease.
- Physical examination (manifestations of circulatory failure).
The patient was treated from the beginning with sertraline in 50 mg
daily dose, orally. Complete remission was achieved of the endogenous
depression phase. However, reactive depression immediately occurred
due to stress factors connected with the malignant disease but the course
of this depression was significantly milder than that of the described
phase of endogenous depression. Sertraline was continued in the same
dose achieving some alleviation of reactive depression manifestations.
|
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DISCUSSION |
The
author decided to treat “major depression” in the severely
somatically ill patients with sertraline in view of high safety and
good tolerance of the drug.1-6,9 The very intense somatic manifestations
and elderly age of the patient forced the author to administer low drug
doses, i.e. only 50 mg daily, orally. This was in agreement with studies
by some authors8 who thought that the optimal sertraline dose in depression
treatment was 50 mg daily. These authors obtained a great improvement
using such a low dose of the drug in most patients. The author of the
present paper observed in the described patient a significant slowing
down of malignant disease progression rate after sertraline administration,
when major depression changed into reactive depression. Besides that,
after sertraline administration, the sensitivity of the described patient
to neoplastic pain was significantly reduced. This made possible to
reduce analgesic drug dose. This was very beneficial since this drug
was morphine which in so severly somatically ill patient could be dangerous.
In this case, morphine could easily cause respiratory arrest paralysing
the central respiratory centre.
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REFERENCES |
1. |
Finkel SL, Richter EM, Clary CM. Comparative efficiency and
sefty of sertraline verus nortriptyline in major depression
in patients 70 and older. International Psychogeriatrics 1999;
11 (1) : 85-99. |
2. |
Keller
MB, Gelenberg AJ, Hirschfeld RM. The treatment of chronic depression,
part 2 : a double-blind, randomized trial of sertraline and
imipramine. Journal of Clinical Psychiatry 1998; 59 (11) : 598-607. |
3. |
Keller
MB, Harrsion W, Fawcett JA. Treatment of chronic depression
with sertraline or imipramine : preliminary blinded response
rates and high rates of undertreatment in the community. Psychopharmacology
Bulletin 1995; 31 (2) : 205-12. |
| 4. |
Kirli
S, Caliskan M. A comparative study of sertraline versus imipramine
in postpsychotic depressive disorder of schizophrenia. Schizophrenia
Research 1998; 33 (1-2). |
| 5. |
Moller
HJ, Gallinat J, Hegerl U. Double-blind, multicenter comparative
study of sertraline and mitriptyline in hospitalized patients
with major depression. Pharmacopsychiatry 1998; 31 (6) : 170-7. |
| 6. |
Murdoch
D, McTavish D. Sertraline. A review of its pharmacodynamic and
pharmacokinetic properties, and therapeutic potential in depression
and obsessive compulsive disorder. (Review) (72 refs) Sertralina.
Drugs 1992; 44 (4) : 604-24. |
| 7. |
Oinan
TG. Lithium augmentation in sertraline - resistant depression
: a preliminary dose - response study. Psychiatrica Scandinavica
1993; 88 (4) : 300-1. |
| 8. |
Preskorn
SH, Lane RM. Sertraline 50 mg daily : the optimal dose in the
treatment of depression. (Review) (55 refs). International Clinical
Psychopharmacology 1996; 10 (3) : 129-41. |
| 9. |
Shapiro
PA, Lesperance F, Frasure-Smith N. An open-label preliminary
trial of sertraline for treatment of major depression after
acute myocardial infarction. |
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SCREENING
PATIENTS ON LONG TERM NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDs)
FOR NEPHROTOXICITY - WHY NECESSARY AND HOW FREQUENTLY?
Cautious practitioners may want to consider the findings in
Pathan study that may help them in deciding whether to routinely
monitor renal functions in their patients on long term NSAID
therapy. Further epidemiological evidence that NSAIDs do increase
the risk of chronic renal disease and the risk differs across
the various subgroups will help in formulating guidelines on
how frequently renal function monitoring is required in patients
on long term NSAID therapy.
AR Chogle JAPI 2003; 51 : 1042 |
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