Psychiatr Clin North Am 1996 Sep;19(3):515-547
Psychiatry Consultation Service, SUNY Health Science Center, State University of New York, Syracuse, USA.
This article discusses the use of psychostimulants, such as dextroamphetamine, methylphenidate, and pemoline, in a variety of illnesses, including depression in the medically ill, cancer, HIV, and AIDS. The chemistry and pharmacology, side effects, drug interactions, dosing, and abuse potential also are reviewed.
Ann Pharmacother 1996 Feb;30(2):151-157
Department of Pharmacy Practice, University of Illinois at Chicago, USA.
OBJECTIVE: To describe depression in the medically ill elderly and discuss methylphenidate as a treatment option. DATA SOURCES: A MEDLINE search from 1986 to 1995 was done to identify the literature published on depression in the medically ill as well as the literature on the use of methylphenidate for depression in the medically ill elderly. The references of articles found were evaluated for other relevant articles. STUDY SELECTION: Retrospective and prospective studies that evaluated the use of methylphenidate in depressed, medically ill elderly were reviewed. DATA EXTRACTION: Information on depression in the medically ill elderly was abstracted from original and review articles on the subject. The information pertaining to methylphenidate came from clinical studies. CONCLUSIONS: Depression in the medically ill elderly occurs frequently and is underdetected in part because of the difficulty in diagnosing depression in this population. Methylphenidate has been found to be a safe and effective treatment of depression in the medically ill elderly. A potential advantage of methylphenidate over other antidepressants is its relatively quick onset of action, usually within 2-5 days. Older patients whose depressive symptoms are interfering with their functional capabilities or participation in prescribed therapies to improve or restore function after a medical illness should be considered for a trial of methylphenidate.
Am J Psychiatry 1995 Jun;152(6):929-931
VA Medical Centers in White River Junction, Vt. 05009, USA.
OBJECTIVE: The authors examined the efficacy of methylphenidate in the treatment of depression in a group of older, medically ill patients. METHOD: Sixteen patients underwent an 8-day double-blind, randomized, placebo-controlled crossover trial; 13 completed the trial. RESULTS: Statistically and clinically significant treatment responses were found. CONCLUSIONS: These results support the use of methylphenidate in older, medically ill patients in whom rapid resolution of depressive symptoms is crucial.
Harefuah 1992 Oct;123(7-8):251-252
Psychiatry Dept., Kaplan Hospital, Rehovot.
Psychostimulants, including ritalin (methylphenidate), were used as antidepressives in the '50s but were then replaced by tricyclics and MAO inhibitors. Treatment of depression with psychostimulants is still controversial. Several anecdotal reports in the past decade approved the use of tricyclic antidepressants (TCA) together with methylphenidate in apathetic and withdrawal states in medically ill and in elderly patients. Ritalin elevates mood by releasing catecholamines and blocking their re-uptake, and also increases serum TCA levels. 5 men and 5 women between the ages of 65 and 79 were diagnosed as suffering from major depressive disorders, either single or recurrent, based on the Revised Diagnostic and Statistical Manual for Mental Disorders (DSM-III-R). They had been treated with TCA for up to several months with no response. Following addition of methylphenidate, 5-15 mg/d for 2 weeks, 4 men and 3 women improved rapidly, 2 of them within 24 hours.
South Med J 1992 Oct;85(10):985-991
Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, La.
The use of psychostimulants as antidepressants remains controversial in the field of psychiatry. While methylphenidate hydrochloride (MPH) and dextroamphetamine (DA) are often considered to be equivalent drugs, differences in their neurobiologic mechanism of action may account for different clinical response patterns. Hence, clinical trials and literature reviews that examine the antidepressant efficacy of psychostimulants without distinguishing between MPH and DA may reach inaccurate conclusions. This paper is a critical review of controlled and uncontrolled studies examining the use of MPH as an antidepressant. We discuss the methodologic limitations of existing placebo-controlled trials that have reached mixed conclusions about the efficacy of MPH as an antidepressant. These studies are offset by uncontrolled open trials and clinical case reports that endorse the drug's effectiveness in alleviating depressive symptoms. The series of patients we treated with MPH demonstrates the safety and efficacy of this drug in alleviating depressive symptoms in the medically ill elderly with a variety of mood disorders. Reviewing these six cases and balancing the positive and negative reports in the literature, we provide practical guidelines for identifying patients who are potential candidates for treatment with MPH.
J Clin Psychiatry 1991 Jun;52(6):263-267
Tufts-New England Medical Center Department of Psychiatry, Boston, Mass. 02111.
BACKGROUND: The purpose of the authors' study was to evaluate the efficacy of methylphenidate in the medically ill depressed patients and to examine the factors that appear to affect therapeutic response and side effects. METHOD: Hospital charts were reviewed for 29 patients who received trials of methylphenidate for treatment of depressive disorders while admitted to a medical/surgical unit. RESULTS: Of the 29 patients, 16 (55%) had moderate or marked improvement, all within 2 days of commencing treatment with the maximal dose. Of the 25 nondelirious patients, 16 (64%) had moderate or marked improvement, and the presence of delirium was significantly associated with decreased response. Therapeutic response was significantly correlated with maximum methylphenidate dose. Side effects were noted in 8 (28%) patients; most side effects were mild (tachycardia or agitation), and all reversed after the medication was discontinued. CONCLUSIONS: Methylphenidate provides a safe and effective alternative to tricyclic antidepressants in medically ill populations but appears to be less effective in the presence of delirium.
Am Fam Physician 1991 Jan;43(1):163-170
University of Louisville School of Medicine, Kentucky.
Medically ill patients who show signs of depression may have problems with traditional antidepressant therapy, because of the side effect profile and the delayed onset of action of these agents. Psychostimulants such as methylphenidate and dextroamphetamine are another treatment option. The beneficial effects of these drugs are usually noted within 36 hours, and drug habituation is generally not a problem. The primary obstacle to the use of these agents for depression in medically ill patients is the hesitancy of physicians to prescribe them.
J Dev Behav Pediatr 1990 Aug;11(4):195-197
Department of Psychiatry and Behavioral Sciences, University of Texas Medical School, Houston.
Stimulants once used to treat depression have been overshadowed by tricyclic antidepressants and monoamine oxidase inhibitors. Recently, their use has been reported in the treatment of depression in medically ill adults in whom tricyclics are contraindicated, or for whom a rapid response is critical. This report documents the successful use of methylphenidate in a depressed adolescent with AIDS.
J Geriatr Psychiatry Neurol 1990 Jul;3(3):146-151
Psychiatric Consult Service, Massachusetts General Hospital, Boston 02114.
The records were reviewed for 129 medically ill geriatric inpatients treated with either dextroamphetamine or methylphenidate for secondary depression during a five year period at the Massachusetts General Hospital. Eighty-one percent of patients demonstrated at least some improvement following psychostimulant treatment. Sixty-six percent of these experienced marked to moderate amelioration of their depressive symptoms. Improvement was rapid and usually occurred within the first or second day of treatment. No significant difference in efficacy was noted between the two psychostimulants or across diagnostic categories for depression. Only 8% of patients experienced adverse reactions significant enough to warrant termination of the psychostimulant trial. No instances of anorexia due to psychostimulant treatment were observed.
Can J Psychiatry 1990 Feb;35(1):3-10
Department of Psychiatry, University of Alberta, Edmonton.
The use of the psychostimulants in psychiatry is reviewed. A brief historical perspective on dextroamphetamine is presented, and a brief review of the psychopharmacology of dextroamphetamine, methylphenidate and magnesium pemoline is given. The literature on the use of stimulants in the treatment of resistant depression, apathetic geriatric patients and patients medically ill with a secondary depression is summarized and two case histories given to illustrate the clinical usefulness of the stimulants. The literature on the use of stimulants as an adjunct to antidepressant therapy and as a diagnostic test is also discussed. Finally the use of stimulants in obsessional illness and adult attention deficit disorder is summarized. The writer concludes by commenting that the stimulants have a very useful role in the treatment of certain categories of depression as well as other psychiatric syndromes and such patients should not be deprived of symptom relief by these drugs. The approach to therapy should be much the same as the use of analgesics for chronic pain sufferers.
J Clin Psychiatry 1989 Jul;50(7):241-249
Department of Psychiatry, West Haven Veterans Administration Hospital, Conn. 06516.
The authors reviewed the efficacy and safety of stimulant drugs in the treatment of depression. Although uncontrolled studies were generally positive, the 10 placebo-controlled studies of stimulant drugs in primary depression, with one exception, indicated little advantage of drug over placebo. Although several of these studies were methodologically unsophisticated, they were comparable with and performed during the same period as studies establishing the efficacy of imipramine. Controlled studies of stimulants in apathetic or depressed geriatric patients were more likely to be positive, but outcome frequently consisted of partial improvement. Studies in medically ill patients with depression were promising but uncontrolled. Side effects have not been severe, and these drugs may pose less of a risk than tricyclics in the medically ill or elderly. Habituation is suggested, but there are no placebo-controlled studies to confirm this. In short, the stimulant drugs do not appear to be as effective as the conventional antidepressants in primary depression, but may be of value in refractory cases or in special cases, such as those involving the medically ill patient. Placebo-controlled trials are needed to explore these questions.
J Geriatr Psychiatry 1989;22(1):77-112
Harvard Medical School, Boston, Mass.
Affective illness is common, frequently debilitating, and sometimes life-threatening in the elderly. Considerations pertaining to treatment with heterocyclic drugs, MAOIs, lithium, psychostimulants and thyroid hormone, as well as ECT, have been reviewed. Amitriptyline and imipramine cause significant orthostatic hypotension and probably should be avoided in the elderly. In addition, amitriptyline is extremely anticholinergic. Amoxapine is essentially a neuroleptic sequelae, including tardive dyskinesia. If a patient has had a prior positive response or has a relative who had a good outcome from a particular drug, it may be best to begin treatment with that drug. Initial choice of antidepressant can be based largely on the clinical picture. For example, if a depressed patient is sleeping much more than usual, try a potentially activating agent like desipramine or protriptyline. if, on the other hand, the patient is unable to sleep, a more sedating agent like nortriptyline, maprotiline, trimipramine, or trazodone should be tried. Risks and side effects of these drugs, as well as their use in cardiac patients, have been reviewed in detail. Many clinicians avoid MAOIs in elderly patients because of fear of adverse reactions. This fear is largely unfounded. Precautions, side effects, and specific recommendations have been outlined. Using lithium in the elderly requires special precautions because of decreased GFR and potential interactions with concomitantly used drugs. This paper has discussed possible side effects and toxicity. The usage of psychostimulants, such as methylphenidate and amphetamine, to treat medically ill depressed patients is reviewed. These agents are also sometimes useful in demented individuals or in patients with abulic frontal lobe syndromes. Poststroke depressions are common, and recent evidence indicates that they can be adequately treated. Stroke patients have many difficulties dealing with rehabilitation and should not be forced to suffer concomitant depression when we have the tools at hand to effectively treat such symptoms. Recent data on the potentiation of antidepressant effects by lithium or T3 indicate that they may be useful adjuvants in some tricyclic-resistant patients. Risks, side effects, and recent procedural advances in the use of ECT have been reviewed. Electroconvulsive therapy is both more effective and faster-acting than drugs in the treatment of depression. Many depressed elderly patients, especially those with psychotic symptoms, do not respond to drugs but improve with ECT.
J Clin Psychiatry 1986 Sep;47(9):467-469
The records of 13 medically ill geriatric patients whose depression interfered with their participation in a hospital rehabilitation program were retrospectively reviewed. Treatment with methylphenidate at dosages ranging from 2.5 mg/day to 20 mg/day produced mild to marked improvement in 54% of the patients; the fact that 6 of the 7 responders were female may be indicative of a more responsive subgroup. Methylphenidate treatment of illness-related, nonpsychotic depression in the elderly appears to be an effective, quick-acting, and relatively safe therapeutic option.
J Clin Psychiatry 1986 Jan;47(1):12-15
Hospital charts were reviewed for 66 medical and surgical patients who received dextroamphetamine or methylphenidate to treat a depressive disorder. Approximately three-fourths showed some improvement; in half of the sample, improvement was marked or moderate. Of those who improved, 93% reached their peak response within the first 2 days. Relapse occurred in only 5 patients. Side effects were minimal. Nonsignificant trends suggested that dextroamphetamine was more effective for major depression than adjustment disorder, while methylphenidate tended to be more effective for adjustment disorder. Psychostimulants appear to be a therapeutic option in the medically ill depressed population and may be more rapidly effective with fewer side effects than tricyclic antidepressants.
Int J Psychiatry Med 1985;15(1):75-79
Methylphenidate (Ritalin Hydrochloride) has been recommended as a treatment for depressed medical and geriatric patients. The rationale for this treatment includes both its safety (even in patients with contra-indications that prevent the use of other antidepressants) and its quick onset of action. In addition the drug can be withdrawn after a few weeks of treatment without the danger of a recurrence of depression. The author reports having used the drug safety in depressed medically ill patients with a success rate of at least 50 percent.
Can J Psychiatry 1984 Feb;29(1):46-49
The effective therapeutic response to dextroamphetamine and methylphenidate by five depressed patients with neurological disease is described. In four of these patients tricyclic antidepressants had to be discontinued due to the concomitant deterioration of their cognitive functions, and in one case they were not used due to cardiovascular complications. There was a rapid remission of depressive symptomatology with no adverse side effects, consistent with the findings of other investigators. The possible association of right hemisphere strokes and depression is also discussed. Further evaluation of the therapeutic role of psychostimulants in the treatment of depressed patients with structurally-compromised brain function is recommended.
J Clin Psychiatry 1984 Feb;45(2):82-84
A positive therapeutic response to methylphenidate is described in four depressed patients who developed cardiovascular complications after cardiac surgery that contraindicated the use of tricyclic antidepressants. There was a rapid remission of depressive symptomatology with no adverse side effects. This observation is consistent with the findings of other investigators. Further evaluation of the therapeutic role of psychostimulants in the treatment of medically ill depressed patients is recommended.
J Clin Psychiatry 1982 Nov;43(11):463-464
A positive therapeutic response to d-amphetamine is described in three medically ill depressed patients in a general hospital. Two patients were either unable to tolerate or responded poorly to tricyclic antidepressants. In one patient, d-amphetamine was chosen because of the combination of postoperative pain and depression. There was a rapid remission of depressive symptomatology with no adverse side effects, consistent with the findings of other investigators. Further evaluation of the therapeutic role of d-amphetamine in the treatment of medically ill depressed patients is recommended.
Psychosomatics 1982 Aug;23(8):817-819
Am J Psychiatry 1980 Aug;137(8):963-965
Three depressed geriatric patients had a marked therapeutic response to the psychostimulant drug methylphenidate. These patients either had been unable to tolerate tricyclic antidepressants or had a medical illness that contraindicated tricyclic therapy. The lack of adverse effects in our elderly patients and methylphenidate's effectiveness as an antidepressant were consistent with the findings of other investigators. These results suggest that psychostimulants deserve further evaluation as antidepressant agents in the geriatric population.