http://exhibits.library.stonybrook.edu/mfp/files/original/8848d465f594d51b535381e87ef44182.pdf 419e0b147078e721972bed5eaab80568 PDF Text Text 3‘ n1..~svm~.—m w: w-mvwvm-wu—p.. -« vs. -.-rm.—.\—~‘ 7,, w—NW-W mm—v—a— “T's“ mu n—‘w—wle-‘m‘w-q. .—.. w— m (Maw ‘- \a mvmmmm—q——-‘vW'I-C-nt-wI'I-Lw—r-mvl- ’5\ April 11, 1975 Michael Dykes, M.D. AMA 535 North Dearborn Chicago, Illinois Street 60610 Dear Dr. Dykes, I have had an opportunity to review the chapter #30, "Antidepressants" and am pleased to share the following notes and comments. These follow the pagination of the text. The classification of espression is that which has pg. 1: been used for many years. however, in the past decade, other classifiattions have been developed, and these are more directly useful in the determination of treatment. The terms: Bipolar, unipolar, and neurotic depression, with the subtypes of involutional, depression of the elderly, and post—partum seem to have more use in regard to drug selection. I urge you to review the classifications of Woodruff and Guze, Spitzer, and Robins to name some U.S. authors have shown the merit of a revised classification. who This classification is particularly useful in allowing a place for the use of lithium.in the management of depression as it may appear in bipolar disease. The omission of lithium may be a significant omission, despite the fact that the use of lithium in depression is still in research. This is particularly true since the report includes the use of stimulants and monoamine oxidase inhibitors—— two treatments that are clearly no longer considered efficacious except under exceptional circumstances. statement that 'different patients given the . ." seems strong to me. The finding of genetic components is a suggestion at best and 'are' could be changed pg h: The same dose are caused by genetic. to 'may be'. The recommendation that therapy with the antidepressants should be started with low doses, combined with the later dosage recommendations in the individual sections on each compound is unfortunate for a number of reasons. For the most part, these compounds are effective only when given in 'adequate' dosages] When one asks clinical psychiatrists who use antidepressants actively, dosages are )r awn . �-2for rarely started slowly, except in the elderly, and mean dosages PDR The in recommended the dosages mg/day. 250-350 imipramine are are a bureaucratic hhlance arrived at in discourse by lawyers and administrators, which somehow is repeated in official reports. In checking the summaries for the use of imipramine by Klein Davis, & Hollister, Cole & Davis, and Fink & for the higher dosages. Abrams, the recommendations are I believe that a major cause of failure in treatment with antidepressants is inadequate therapy, and unrealistic schedules. In a similar vein, the suggestion that treatment should be given for 3 to 6 months and then reduced gradullly is a plea for a regimen that is not common in my practice. Patients who do well, will not continue medication beyond the second month. If their symptoms persist, they will also not continue beyond the third month, in prescription particularly since they will request and obtain a change and effective raised rapidly are dosages in If change physician. or a 2—5 weeks; be in expected can treatment a levels obtained, response then therapy should be if sustainedandfor h—G weeks thereafter, the patient seen more regularly in follow—up. As an terminated example of a more vigorous approach to therapy, the recommendations A from some European centers for the use of intravenous thymoleptics given by infusion over two to five days show some promise and their findings are consistent with the experiences cited above. The concurrent use of MAOI and thymoleptics may be pg 5: recommended under certain conditions, notably in treatment failures to thymoleptics alone and ECT. The last sentence regarding deanol is gratuitous. sentence should read ' demonstrated." pg 6: The . . . as an antidepressant has not been The suggestion that other agents, as the antipsychotic agents, may be useful as adjuncts to therapy is partially correct. There is considerable evidence that antipsychotic agents (thioridazine, chlorpromazine) have been iused successfully in treating some depressive, not as adjuncts but as primary therapy. See refernces to work by Hollister and by myself and Klein in the early 1960's. It seems worthwhile to consoder the inclusion of to the use of lithium; since this section is a some reference grab—bag of assorted recommendations. With regard to the report of the unsuccessful use of TRH, this seems a bit harsh since the results some are not yet in and the studies are still in progress. There seems(TRH) and (deaner) those included rejected unusual selection of drugs when the evidence for deaner is non-existent, and that for TRH still under study. I would be more Judicious in suggesting that TRH is the first of a series of peptides under study and that such investigations should be followed with interest. pg 7/8: �-3pg 12: Fatalities are rare, pg 1h: Regarding the question of the concurrent use of I have no experience. too strong and the tone of the paragraph is guanethidine and thymoleptics, The combined use of thymoleptics and MAOI has been based largely on anecdotal and uncontrolled studies. As interdicyed you suggest, lately some authors have suggested both regimens may he used concurrently. If true, then the caveat on this page is too strong and the paragraph may be rewritten indicating that some reports ahve been made but these are unsupported and that combined use may be given Judiciously. (Considering the low rate of response of depressives to MAOI, I wonder why anyone would want to use the MAOI alone or in combination, except specialists who have adequate hospital facilities at their disposal. From a cost/benefit ratio analysis, the use of MAOI should be limited to occasional use by pg 10: qualified specialists. Dosages of imipramine are from the PDR and are low.. doses at night are useful; the reports beginning in 1961 Single show that the experience has been a lengthy one. See comments page 1. pg 19: A few years ago, I had an occasion to review the data recommendation of combined drug therapy. The dosages are low for the and the data unconvincing. Unless there is some recent data (since 1972) to Justify the recommendation of a combination, I can recall no data, including those presented by the manufacturer, that would justify the recommendation even on a 'may be more useful' basis. The data for the successful use of the single drugs doxepin in cases wheree anxiety and depression co-exist is more convincing, and that conviction is a weak one. page 29: answer your specific questions: for MAOI, see for single daily dosage, see below; and for guanethidine, see page 1h. To comment on page 10; It is reasonable stress daily dosage for the at night, since given thymoleptics, particularly if this dosage is MAOI, For there is no such the evidence of the efficacy is clear. above). 10 (see evidence to my knowledge pg I trust these to comments once are helpful. I am less than enthusiastic about the chapter since the fermat follows our under— standing of some years ago; and I do believe that some progress has occurred, notably in dosages of thymoleptics; diagnoses; use of lithium; single administration; relation to ECT;'and the downgrading of MAOI, stimulants which are reflected unclearly in the present document. Thank you for the opportunity to raise some questions. Sincerely yours, Fink, M.D. Professof of Psychiatry Max � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. 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