Depression
Treating Major Depressive Disorder in Adults in Primary Care— What to Expect from Escitalopram
Pratap R Chokka, MD, FRCPC
Clinical Professor, Faculty of Medicine, University of Alberta, and Psychiatrist, Grey Nuns Community Hospital and Health Centre, Edmonton
Abstract
Escitalopram, the S-enantiomer of citalopram, exhibits higher relative selectivity for the serotonin transporter than any other currently available selective serotonin re-uptake inhibitor (SSRI), including its parent compound. In both clinical trials and practice-based studies, patients experienced improvement within the first week or two of treatment, and the vast majority were in remission within six months. Interestingly, response to escitalopram appears to be especially good in patients with severe depression (which many patients in primary care have). Over the long term, escitalopram has been shown to help patients achieve normal functioning and to dramatically reduce the time patients have to be away from work. Roughly two-thirds of patients will not need a dose increase beyond the starting dose of 10mg. Side effects do occur (most notably nausea and headache), but these are likely to resolve over time without the need for dose adjustment, and rarely lead to discontinuation. Two large systematic analyses published in 2009 support the position that escitalopram is one of the more effective and tolerable SSRIs available to primary care physicians.
Keywords
Escitalopram, primary care, depression, tolerability, remission, functioning
pratapchokka@shaw.ca
With over a dozen selective serotonin re-uptake inhibitors (SSRIs) and serotonin–noradrenaline re-uptake inhibitors (SNRIs) currently available, today’s primary care physicians have a great deal of choice when it comes to the pharmacological management of major depression. The purpose of this paper is to help primary care physicians, for whom time is always in short supply, review what to expect when treating major depression with escitalopram (Lexapro®, Cipralex®).
Escitalopram—A Unique Medication
Because escitalopram is simply the S-enantiomer of citalopram, many physicians were confused when it first came to market. Was it the same drug with a different name? Would it offer identical results with a better side-effect profile? Or was it an entirely new medication? However, we now know that in terms of both pharmacology and symptomatic efficacy, escitalopram and citalopram have proved to be very different medications. In the lab, escitalopram exhibits higher relative selectivity for the serotonin transporter than any other currently available SSRI, including citalopram.1
In the clinic, escitalopram has been shown to be
significantly more effective than citalopram in achieving both acute response and long-term remission.2
This stands to reason, given that
escitalopram was actually developed after pharmacological studies revealed that the potency of citalopram resides exclusively in its S-enantiomer (the R-enantiomer being inactive).
© TOUCH BRIEFINGS 2010
Early Response to Escitalopram
One of the primary care physician’s first priorities when seeing a patient with depression is to relieve his or her symptoms as quickly as possible. This means choosing a therapy that has been shown to provide acute symptomatic improvement, quickly putting patients on the road to recovery.
Studies suggest that patients taking escitalopram begin to experience noticeable improvement as early as week one. In one randomized, double-blind, placebo-controlled trial, escitalopram 10mg had a significantly larger effect than placebo on the Clinician’s Global Impression-Improvement scale (CGI-I) beginning at week one, on the Montgomery-Asberg Depression Rating Scale (MADRS) beginning at week two, and on the CGI-Severity scale (CGI-S) beginning at week three.3
In another similarly designed study, escitalopram 10mg had a significantly larger effect on all of these scales as early as week one.4 Studies also suggest that a significant number of patients who start escitalopram will achieve full remission within just two months. In the trials discussed above, the rate of response (defined as a ≥50% decrease in MADRS total score from baseline to last assessment) at week eight was as high as 63.7% (p=0.009 versus placebo) and the rate of remission (defined as a MADRS score ≤12) was as high as 52.1% (p=0.055 versus placebo).4
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