1
COMORBILIDADE ANSIEDADE-DEPRESSÃO
Questões Aprofundadas
MÓDULO 4.
AVANÇOS NO TRATAMENTO FARMACOLÓGICO DOS ESTADOS DE
COMORBILIDADE ANSIEDADE-DEPRESSÃO
Dr. Fernando Medeiros Paiva
Casa de Saúde Santa Catarina
Mestre da Faculdade de Medicina da Universidade do Porto
PROGRAMA
•
Introdução
•
Tratamento farmacológico. Princípios gerais
•
Antidepressivos (indicações, efeitos colaterais, posologia e resultados)
ƒ
ATC
ƒ
SSRI, SNRI
ƒ
IMAO e RIMA
ƒ
NaSSA
•
Derivados benzodiazepínicos (indicações, efeitos colaterais, posologia e resultados)
•
Outros Fármacos
ƒ
Azapironas (Buspirona)
ƒ
Beta-bloqueadores
ƒ
Antipsicóticos de Segunda Geração
•
Associações medicamentosas e momento adequado para a sua
introdução e suspensão
•
Novos fármacos
•
Psicoterapias
•
Conclusões
OBJECTIVOS PEDAGÓGICOS
•
Em cada uma das unidades temáticas será apresentada uma série de diapositivos com
comentários vocalizados que expliquem, de modo simples e conciso, os conceitos
teóricos do mecanismo de acção dos psicofármacos antidepressivos e na medida do
possível a sua aplicação na prática clínica.
•
A bibliografia que sustenta este módulo será de fácil acesso quer na Internet quer, no
que se refere a livros, em livrarias portuguesas.
Copyright © 2007 Vale & Vale Editores, Lda. Todos os direitos reservados.
Comorbilidade Ansiedade-Depressão
2
BIBLIOGRAFIA
Alves A, Furtado C. Análise do crescimento da despesa no mercado total de medicamentos
2003-2004. Observatório do Medicamento e Produtos de Saúde (INFARMED) Junho
2005.
Andersch S, Rosenberg NK, Kullingsjo H, et al. Efficacy and safety of alprazolam, imipramine
and placebo in treating panic disorder: a Scandinavian multicentre study. Acta Psychiatr
Scandin 1991; 365:18-27.
Angst J, Dobler-Mikola A. A continuum from depression to anxiety disorders? Eur Arch
Psychiatry Clin Neurosci 1985; 235:179-186.
Ballenger JC, Burrows GD, DuPont RL, et al. Alprazolam in panic disorder and agoraphobia:
results from a multicentre trial. Arch Gen Psychiatry 1988; 45:413-422.
Bakish D, Saxena BM, Bowen D, D’Souza J. Reversible monoamine oxidase-A inhibitors in
panic disorder. Clin Neuropsychopharmacol 1993; 16(2):77-82.
Becker JR, Thomas S. Future Treatments for depression, anxiety, sleep disorders, psychosis,
and ADHD. Disponível em http://www.neurotransmitter.net/newdrugs.html. Actualização
em 13.05.2007.
Carli V, Sarchiapone M, Camardese G, Romano L, De Risio S. Mirtazepine in the treatment of
panic disorder. Arch Gen Psychiatry 2002; 59:661-662.
Carpenter LL, Leon Z, Yasmin S, Price LH, Clinical experience with mirtazepine in the treatment
of panic disorder. Ann Clin Psychiatry 1999; 9:81-86.
Chosack A, Baker SL, Thorn GR, et al. Psychological treatment of panic disorder, in Panic
Disorder. Clinical Diagnosis, management and mechanisms. Nutt DJ, Ballenger JC,
Lepine J-P, Editors. 1998, London: Martin Dunitz.
Connor KM, Davidson JR, Weisler RH, Ahearn E. Pilot study of mirtazepine in post-traumatic
stress disorder. Int Clin Psychopharmacol 1999; 14:29-31.
Cross-National Collaborative Panic Study, Second Phase Investigators, Drug treatment of panic
disorder: comparative efficacy of alprazolam, imipramine, and placebo. Br J Psychiatry
1992; 160:191-202.
Davidson JR, DuPont RC, Hedges D, Haskins JT. Efficacy, safety and tolerability of venlafaxine
extended release and buspirone in outpatient with generalized anxiety disorder. J Clin
Psychiatry 1999; 60(8):528-535.
Davidson RT. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry 2001;
62(11):46-50.
Eaddy TM, Regan TS, Sheehan DV. Undertreatment of depression and comorbidity anxiety
translates into costly mismanagement of resources and poor patient outcomes. Manged
Care 2005; 14(7): 1-12.
Feltner DE, Pollack MH, Davidson JRT, et al. A placebo-controlled, double-blind study of
pregabalin treatment of social phobia: outcome and predictors of response. J Eur Coll
Neuropsychopharmacol. 2000;10(suppl 3):S345.
Furtado C, Teixeira I. Utilização de benzodiazepinas em Portugal Continental (1999-2003). Acta
Med Port 2006; 19:239-46.
Golden RN. Efficacy and tolerability of controlled-release paroxetine. Psychopharmacol Bull
2003; 37(1):176-186.
Goodnick PJ, Puig A, DeVane CL & Freund BV. Mirtazepine in major depression with comorbid
generalized anxiety disorder. J Clin Psychiatry 1999; 60:446-448.
Gorman JM. Treatment of generalized anxiety disorder. J Clin Psychiatry 2002; 63(8):17-23.
Hamner M,Deitsh S, Brodrick P, Ulmer H, Lorberbaum J. Quetiapine treatment in patients with
post-traumatic stress disorder: an open trial of adjunctive therapy. J Clin
Psychopharmacol 2003; 23:15-20.
INE.
Anuário
Estatístico
de
Portugal
http://www.ine.pt/prodserv/quadros/quadro.asp
2006.Disponível
em:
Judd LL, Kessler RC, Paulus MP, Zeller PV, Wittchen HU, Kunovac JL. Comorbidity as a
fundamental feature of generalized anxiety disorders: results from the National
Comorbidity Study (NCS). Acta Psychiatr Scand 1998; 393:6-11.
Copyright © 2007 Vale & Vale Editores, Lda. Todos os direitos reservados.
Comorbilidade Ansiedade-Depressão
3
Kasper S, Pharmacologic treatment of mixed anxiety and depression [abstract]. Proceedings of
the VII Congress of the European College of Neuropsychopharmacology; Oct 16-21,
1994; Jerusalem, Israel.
Kasper S. Neurobiology and new psychopharmacological strategies for treatment of anxiety
disorders., in Current Therapeutical Approaches on Panic and Other Anxiety Disorders,
Racagni, Brunelli, Editors. 1995, Basel, Switzerland: Karger.
Katsching H, Stein MB, Buller R. International Clinical Trial Group on moclobemide in Social
Phobia. Moclobemide in social phobia. Eur Arch Psychiatry Clin Neurosci 1997; 247:7180.
Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder:
results from the National Comorbidity Survey Replication (NCRS-R). JAMA 2003;
289:3095-3105.
Krishnan KRR. Depression and comorbid anxiety: evaluation and treatment of better outcomes.
Medscape
Psychiatry
Mental
Health
2007;
5.
Disponível
em:
http://www.medscape.com/viewprogram/6380_index
Kunovac JL, Stahl SM. Future directions in anxiolytic pharmacotherapy. Psychiatr Clin Nirth Am
1995; 18(4):895-909.
Lader M, Scotto JC. A multicentre double-blind, comparison of hydrxyzine, buspirone and
placebo in patients with generalized anxiety disorder. Psychopharmacolgy (Berl) 1998;
139:402-406.
Lader MH. Limitations on the use of benzodiazepines in anxiety and insomnia: are they
justified? Eur Neuropsychopharmacol 1999; 9(6):339-405.
Laufer N, Weizman A. Efficacy of applied relaxation and cognitive behavioural therapy in the
treatment of generalized anxiety disorder. J Consult Clin Psychol 1993; 61:611-619.
Laufer N, Weizman A. Other drug treatments and augmentation therapies for panic disorder, in
Panic Disorder. Clinical Diagnosis, management and mechanisms, Nutt DJ, Ballenger
JC, Lepine J-P, Editors. 1999, London: Martin Dunitz.
Laws D, Ashford JJ, Anstee JA. A multicentre double-blind comparative trial of fluvoxamine
versus lorazepam in mixed anxiety and depression treated in general practice. Acta
Psychiatr Scand 1990; 81:185-189.
Lydiard RB, Brawman-Mintzer O. Anxious depression. J Clin Psychiatry 1998; 59(18):10-17.
Montgomery SA, Kasper S. Comparison of compliance between serotonin reuptake inhibitors
and tricyclic antidepressants: a meta-analysis. Int Clin Psychopharcol 1995, 9(4):33-40.
Montgomery SA, Rickels K, Bielski RJ, et al. Pregabalin in generalized anxiety disorder: speed
of onset. NR775. Program and abstracts of the 156th Annual Meeting of the American
Psychiatric Association; May 17-22, 2003; San Francisco, California.
Noyes R Jr, Burrows GD, Reich JH, et al. Diazepam versus alprazolam for the treatment of
panic disorder. J Clin Psychiatry 1996, 57:349-355.
Noyes R, Moroz G, Davidson JR, et al. Moclobemide in social phobia: a controlled doseresponse trial. J Clin Psychopharmacol 1997; 17:247-254
Nutt D, Feeney A, Argyropolus S. Anxiety Disorders Comorbid with Depression. 2002, Martin
Dunitz, pp. 71.
Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a
placebo-controlled study. J Clin Psychopharmacol. 1999;19:341-348.
Pande AC, Pollack MH, Crockatt J, et al. Placebo-controlled study of gabapentin treatment of
panic disorder. J Clin Psychopharmacol 2000;20:467-471.
Pande AC, Crockatt JG, Feltner DE, Liu-Dumaw M, Werth JL. Three randomised, placebocontrolled, double-blind trials of pregabalin treatment of generalized anxiety disorder
(GAD). J Eur Coll Neuropsychopharmacol 2000;10(suppl 3):S344.
Petracca A, Nisita C, McNair D, et al. treatment of generalized anxiety disorder: preliminary
clinical experience with buspirone. J Clin Psychiatry 1990; 51:31-39.
Pohl R, Balon R, Yeragani VK, et al. Serotonergic anxiolytics in the treatment of panic disorder:
a controlled study with buspirone. Psychopathology 1989; 22(1):60-67.
Pollack MH, Worthington JJ, Otto MW, et al. Venlafaxine for panic disorder: results from a
double-blind, placebo-controlled study. Psychopharmacol Bull 1996, 32:667-670.
Copyright © 2007 Vale & Vale Editores, Lda. Todos os direitos reservados.
Comorbilidade Ansiedade-Depressão
4
Pollack MH. Exploring the relationship between anxiety disorders and depression. Anxiety
disorders and major depression: the added challenge of comorbidity. Program and
abstracts of the Anxiety Disorders Association of America 22nd National Conference;
March 21-24, 2002; Austin, Texas.
Pull CB. Combined pharmacotherapy and cognitive-behavioural therapy for anxiety disorders.
Curr Opin Psychiatry 2007, 20(1):30-35.
Ravaris CL, Robinson, DS, Ives JO, Nies A, Bartlett D. Phenelzine and amitriptyline in treatment
of depression. A comparison of present and past studies. Arch Gen Psychiatry 1980,
37:1075-1080.
Regier DA, Boyd JH, Burke JD, et al. One-month prevalence of mental disorders in the US:
based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry 1988; 45:977986.
Rickels K, Wiseman K, Norstad N, et al. Buspirone and diazepan in anxiety: a controlled study.
J Clin Psychiatry 1982; 43:81-86.
Rickels K, Schweizer E. The treatment of generalized anxiety disorder in patients with
depressive symptomatology. J Clin Psychiatry 1993; 54(1):20-23.
Rickles K, Rynn M. Pharmacotherapy of generalized anxiety disorder. J Clin Psychiatry 2002;
63(14):9-16.
Rickels LN, Schweizer EE. Benzodiazepines for treatment of panic attacks. Psychopharmacol
Bull 1986; 22:93-99.
Robinson DS, Alms DR, Shrotriya RC, et al. Serotoninergic anxiolytics and treatment of
depression. Psychopharmacology 1998; 22(1):27-36.
Rosenberg R. Treatment of panic disorder with tricyclics and MAOIs, in Panic Disorder. Clinical
diagnosis, management and mechanisms, Nutt DJ, Ballenger JC, Lepine J-P, Editors.
1999, London: Martin Dunitz, p. 125-144.
Rosenthal M. Tiagabine for the treatment of generalized anxiety disorder: a randomized, openlabel, clinical trial with paroxetine as a positive control. J Clin Psychiatry. 2003;64:12451249.
Roth M, Gurney C, Garside RF, et al. Studies in classification of affective disorders: the
relationship between anxiety states and depressive illness. Br J Psychiatry 1972;
121:147-61.
Rowan PR, Paykel, ES, Parker RR, Barber HE. Tricyclic antidepressant and MAO inhibitor: are
there differential effects?, in Monoamine Oxidase Inhibitors – the State of the Art, BH
Youdim, ES Paykel Editors. 1981, New York, John Wiley & Sons.
Sarchiapone M, Amore M, De Risio S, et al. mirtazepine in the treatment of panic disorder: an
open-label trial. Int Clin Psychopharmacol 2003; 18:35-38.
Sargant W, Dally P, Treatment of anxiety states by antidepressant drugs. BMJ 1962; 1:6-9.
Schneier FR, Goetz R, Campeas R, et al. Placebo-controlled trial of moclobemide. Br J
Psychiatry 1998; 172:70-77.
Schweizer E, Rickels K, Weiss S, Zavodnick S. Maintenance drug treatment of panic disorder.
Results of prospective, placebo-controlled comparison of alprazolam and imipramine.
Arch Gen Psychiatry 1993; 50:51-60.
Schweizer EE, Amsterdam J, Rickels K, et al. Open trial of buspirone in the treatment of major
depressive disorder. Psychopharmacol Bull 1986; 22:183-185.
Sheehan DV, Raj AB, Harnett-Sheehan K, et al. The relative efficacy of high-dose buspirone
and alprazolam in the treatment of panic disorder: a double-blind placebo-controlled
study. Acta Psychiat Scadina 1993; 88:1-11.
Simpson HB, Schneier FR, Campeas RB, etal. Imipramine in the treatment of social phobia. J
Clin Psychopharmacol 1998; 18(2):132-135.
Spiegel DA, Bruce TJ, Gregg SF, Nuzzarello A. Does cognitive therapy assists slow-taper
alprazolam discontinuation in panic disorder. Am J Psychiatry 1994; 151:876-881.
Sramek JJ, Tansman M, Suri A, et al. Efficacy of buspirone in generalized anxiety disorder with
coexisting mild depressive symptoms. J Clin Psychiatry 1996; 57:287-291.
Stein M, Kline N, Matloff J. Adjunctive olanzepine for SSRI-resistant combat-related PTSD: a
double-blind, placebo-controlled study. Am J Psychiatry 2002; 159:1777-1779.
Copyright © 2007 Vale & Vale Editores, Lda. Todos os direitos reservados.
Comorbilidade Ansiedade-Depressão
5
Steyer R. FDA rejects expanding Lexapro marketing.March 30, 2005. Available at:
«http://www.thestreet.com/_mktwrm/stocks/biotech/10215442.html». Accessed June 15,
2005.
Strand M, Heta J, Rosen A, et al. a double-blind, controlled trial in primary care patients with
generalized anxiety: a comparison between buspirone and oxazepam. J Clin Psychiatry
1990; 51:40-45.
Tesar GE, Rosenbaum JF, Pollack MH, et al. Double-blind, placebo-controlled comparison of
clonazepam and alprazolam for panic disorder. J Clin Psychiatry 1991; 52:69-76.
Tiller JW, Bouwer C, Behnke K. Moclobemide for anxiety disorders: a focus on moclobemide for
panic disorder. Int Clin Psychopharmacol 1997; 12(6):27-30.
Valenstein M, Taylor KH, Austin K, Kales HC, McCarthy JF, Blow FC. Benzodiazepine use
among depressed patients treated in mental health settings. Am J Psychiatry 2004;
161(4):654-661.
Versiani M, Nardi AE, Mundim FD, et al. Pharmacotherapy of social phobia: a controlled study
with moclobemide and phenelzine. Br J Psychiatry 1992; 161:353-360.
Zwanzger P, Baghai T, Boerner RJ, Moller HJ, Rupprecht R. Anxiolytic effects of vigabatrin in
panic disorder. J Clin Psychopharmacol 2001;21:539-540.
Zwanzger P, Baghai T, Schule C, et al. Tiagabine improves panic and agoraphobia in panic
disorder patients [letter]. J Clin Psychiatry 2001;62:656-657.
Copyright © 2007 Vale & Vale Editores, Lda. Todos os direitos reservados.
Comorbilidade Ansiedade-Depressão