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Dopamine , Depression and Bupropion
Dr. BillyPanTaipei Wanfang Medical Center
Psychiatry Departmenthttp://www.wretch.cc/blog/billypan101
HPA axis
CMAJ. 2009 February 3; 180(3): 305–313.
The hypothalamic–pituitary–adrenal axis.
This system is activated by stress directly at the level of the hypothalamus or indirectly at the level of the amygdala.
Chronic stress increases the level of corticotropin-releasing factor and cortisol and decreases expression of corticotropin-releasing factor type 1 receptors and glucocorticoid receptors.
Stress-and depression-associated changes at the level of the hippocampus in particular are thought to underlie the structural changes seen in this brain region, which in turn may contribute to chronic disinhibition of the hypothalamic– pituitary– adrenal axis.
HPA axis and Neurotransmitter Acute Stress HPA axis corticotropin-releasing factor a
mygdala, hippocampus, ect.
These neurons may also contribute to activation of the serotonin and norepinephrine systems.
Reciprocal connections between the norepinephrine system and the hypothalamus create a feed-forward cascade in which stress progressively activates corticotropin-releasing factor and norepinephrine signalling.
Activation of this system is thought to increase vigilance and fear.
Pharmacol Biochem Behav 2002;73:147-58.
HPA axis and Neurotransmitter Chronic Stress Excessive glutamate activation of NMDA t
ype glutamate receptor
decrease brain derived neurotrophic factor (BDNF)
degeneration of glial cell
brain atrophy
CMAJ. 2009 February 3; 180(3): 305–313.
Brain structural and functional abnormalities in mood disorders
Brain Struct Funct (2008) 213:93–118
Brain structural and functional abnormalities in mood disorders
CMAJ. 2009 February 3; 180(3): 305–313.
HPA axis and Neurotransmitter Stress Amygdala
increse dopamine in Prefrontal Cortext and Ventral Straitum
altering striatal levels of BDNF.
Acute irritable
Chronic anhedonia
Pharmacol Biochem Behav 2002;73:147-58.
Prefrontal Cortext and Ventral Straitum
Dopamine and Serotonin Pathway
Depressive s/s
Dopamine and Substance Abuse
Monoamine neurotransmitter regulation of mood and behavior
Stahl SM. Essential Psychopharmacology. 2000.Foote SL, Aston-Jones GS. Psychopharmacology. 1995: 335-345Nutt DJ et al., J Psychopharmacol 2007, in press [Epub ahead of print,18 Oct 2006]Shelton AJ, Tomarken RC, Psychiatric Services 2000; 52 (11):1469–1478Stahl SM J Clin Psychiatry 2003;64:1145-1146
Dopamineattention
motivationpleasure reward
Dopamineattention
motivationpleasure reward
Noradrenalinealertnessenergy
Noradrenalinealertnessenergy
Serotoninobsessions
compulsions
Serotoninobsessions
compulsions
anxietyanxiety
moodmood
interestinterest
The Dopamine Pathway
The Serotonin Pathway
NDRI
From the study of smoke cessation
Antidepressants - History
1958 Monoamine oxidase inhibitors (MAOIs) 1958 Tricyclics (TCA’s) 1982 Trazodone (Deseryl) 1988 Fluoxetine (Prozac) 1989 Bupropion (Wellbutrin IR) Tid 1994 Nefazodone (Serzone) 1994 Venlafaxine (Effexor) 1996 Mirtazapine (Remeron) 1996 Bupropion (Wellbutrin SR) Bid 2003 Bupriopion (Wellbutrin XL) Qd
Wellbutrin, Failed in 1986… Wellbutrin was withdrawal from mark
et due to significant incidence of seizure.
Risk of seizure was found to highly dose–dependent.
Wellbutrin was reintrodued in 1989 for limit maximum dose of 450mg. (originally recommended dosage was 400-600mg)
Wellbutrin seizure incidence
Wellbutrin® XL is associated with a dose-related risk of seizure but risk is relatively low- overall incidence in clinical trials (up to 450mg/day) is > 0.1%1 and is similar to other newer antidepressants (0-0.4%)2
Incidence of first seizure in the general population is estimated to be 0.07 to 0.09%2
Wellbutrin® XL is contraindicated in patients with a current seizure disorder or any history of seizures1
1. Wellbutrin XL Prescription Information.2. Montgomery SM Int J Clin Pract 2005;59(12):1435-1440.
Efficacy of Wellbutrin® XL vs. Escitalopram (lexapro)
HAD = Hospital Anxiety and Depression Scale
*P<0.05 vs placebo.
Bupropion XL Escitalopram Placebo
0
–10
–4
–8
–6
–12
–2
Mea
n c
han
ge
fro
m
bas
elin
e at
wee
k 8
n = 263 n = 266 n = 256
–5.2–4.5
–3.6
n = 263 n = 266 n = 2560
–10
–4
–8
–6
–12
–2
Mea
n c
han
ge
fro
m
bas
elin
e at
wee
k 8
HAD Anxiety Subscale ScoreHAD Total Score
–11.1–10.5
–8.1
*
**
*
Clayton et al J Clin Psychiatry, 2006
Efficacy of Wellbutrin® XL vs. venlafaxine XL
Response and remission rates from the US clinical trial
Venlafaxine XR
* Statistically significant: odds ratio 1.75, 95% CI 1.04, 2.93# Includes doses above the maximum recommended dose in South KoreaResponse = 50% reduction in HAMD-17 total scoreRemission = HAMD-17 total score ≤7
Thase ME et al. J Clin Psychopharmacol 2006: 26:482-488
0
10
20
30
40
50
60
Response Remission
Bupropion XL (150-450mg/day#)
(75-225mg/day)
*
Rem
issi
on
rat
e (%
)
Wellbutrin XL improves low energy and motivation
0
5
10
15
20
25
MEI to
tal sc
ore
m
ean c
hange f
rom
base
line
Placebo(n = 180)
17
24*
*p = 0.001 vs placeboMEI = Motivation and Energy Inventory
Chrzanowski W et al., Eur Neuropsychopharmacol 2006; 16 (Suppl 4): S315.
Wellbutrin XL150-300mg/day
(n = 188)
Wellbutrin XL improves depressive in energy, interest and pleasure
Impro
vem
ent
in s
ym
pto
ms
of
energ
y, in
tere
st a
nd p
leasu
re(I
DS-s
ubse
t#)
Placebo Wellbutrin XL
0
2
4
6
8
5.3
6.7*
Some patients in this analysis received doses of Wellbutrin that are above the licensed dose
* p=0.007 significant improvement vs placebo
#patient rated subscaleJefferson JW et al., J Clin Psychiatry 2006;67:865-873
Comparison of adverse events (%) for Wellbutrin® XL vs the SSRI escitalopram
Wellbutrin XR150-450mg/day
(n=276)
Escitalopram10-20mg/day (n=
281)
Placebo (n=273)
Dry mouth 22% 13% 11%
Fatigue 4% 14% 6%
Insomnia 14% 10% 8%
Constipation 9% 3% 6%
Somnolence 3% 8% 5%
Decreased appetite
5% 6% 4%
Nasopharyngitis 5% 5% 3%
Irritability 5% 1% 4%
Yawning <1% 5% 1%
Clayton AH et al.,J Clin Psychiatry 2006;67(5):736-46
Some patients in this analysis received doses of Wellbutrin that are above the licensed dose
Comparison of adverse events (%) for Wellbutrin® XL vs the SNRI venlafaxine
Wellbutrin XL150-450mg/day
(n=168)
Venlafaxine XR75-225mg/day
(n=174)Dry mouth 24% 29%
Nausea 15% 26%
Nasopharyngitis 10% 5%
Diarrhoea 5% 10%
Decreased appetite
4% 9%
Somnolence 1% 7%
Sedation 1% 6%
Yawning 0% 7%
Thase ME et al., J Clin Psychopharmacol 2006;26:482-88
Some patients in this analysis received doses of bupropion that are above the maximum licensed dose for Taiwan
Wellbutrin XL has similar rates of discontinuation symptoms to placebo
GSK data on file
Discontinuation symptoms during taper and follow-up periods
% of patients
0 1 2 3 4 5
Nausea
Irritability
Insomnia
Dizziness
Headache
PlaceboWellbutrin XLVenlafaxine XL
Overall rates of discontinuation symptoms similar to placebo
(Venlafaxine XR: 21%; Wellbutrin XL: 12%; Placebo: 12%)
Somnolence vs SSRIs
Thase ME et al., J Clin Psychiatry 2005; 66(8):974-81
5
12 *
3†
Inci
den
ce o
f so
mn
ole
nce
as
an A
E (
%)
Placebo Pooled SSRIs Bupropion (n=524) (n=758) (n=748)
*p<0.001 significantly higher incidence vs placebo†p<0.001 significantly lower incidence vs pooled SSRIs
0
2
4
6
8
10
12
14
Some patients in this analysis received doses of Wellbutrin that are above the maximum licensed dose for South Korea
Somnolence vs SSRIs
Mean change in body weight at study endpoint for patients
receiving Wellbutrin SR as a function of baseline body mass index (BMI)
Patients who had responded to 8 weeks of open-label treatment with bupropion (SR) followed by 44 weeks of double-blind treatment with bupropion (150mg SR bid) or placeboAdapted from Croft H et al., Clin Ther 2002;24;662-672
-0.1
-0.6
-1.4
-2.4-3
-2.5
-2
-1.5
-1
-0.5
0BMI <22 BMI 22-26 BMI 27 BMI 30
Mean c
hange in b
ody w
eig
ht
(kg)
Weight change during treatment
Orgasm dysfunction vs. SSRI Escitalopram
0
10
20
30
40
Pat
ien
ts (
%)
Week2 4 6 8
30%
15%
9%
††
††
*
1
Clayton AH et al., J Clin Psychiatry 2006;67:736-746.
Bupropion XL (n=263)Escitalopram (n=266)Placebo (n=256)
*p < 0.01 Escitalopram vs bupropion XL and placebo†p < 0.001 Escitalopram vs bupropion XL and placeboNo statistical difference between bupropion XL and placebo
Minimal sexual side-effects compared with the SNRI venlafaxine XL
Thase ME et al. J Clin Psychopharmacol 2006; 26, 482-488.
*p0.011 vs venlafaxine XR
-1
*
**
*
*
0
1
PleasureDesire/
FrequencyDesire/Interest Arousal Orgasm
Bupropion XL (n=160)Venlafaxine XR (n=164)
Ad
just
ed m
ean
ch
ang
e fr
om
bas
elin
e CSFQ Subscale Mean Change Scores
(Average of Weeks 5-12)
Improvement
Some patients in this analysis received doses of Wellbutrin® XL that are above the licensed dose
Better Adherence with XL Formulation
American Journal of Therapeutics 2007; 14: 241–246
Refill adherence over the study period
% C
ohor
t Rem
aini
ng
*p<.0001 bupropion XL versus bupropion SR++p<.0005 bupropion XL versus bupropion SR +p<.005 bupropion XL versus bupropion SR
Number of Refills for index Product
Seasonal affective disorder
Smoking Cessation
Smoking Cessation
Weight Reduction
Weight Reduction
Improving Cognitive Function
N=541, Neurocognition Index was measured on a computerized battery of tests, CNS Vital Signs (CNSVS)
For Bipolar Depression
Am J Psychiatry. 2006 Feb;163(2):232-9.
For Bipolar Depression
BRITISH JOURNAL OF P SYCHIATRY ( 2 0 0 6 ) , 1 8 9, 1 2 4 ^ 131.
How Effective is an SSRI in Real World Practice?
~1/3 met criteria for remission (HAM-D ≤ 7)
~ 1/2 met criteria for response (≥ 50% decrease in depressive severity)
(Trivedi et al, Am J Psychiatry, 2006)
In STAR*D Level 2 Switch: Beat CBT
In STAR*D Level 2 augmentation: :lead to 46% remission
Augumention with escitalopram 12 weeks, Rates of response 62%
and remission 50% Only 6% patient discontinued
treatment due to side effect.
J Psychiatr Pract. 2008 September ; 14(5): 271–280.
AUGMENTATION IN LATE-LIFE DEPRESSION
Am J Psychiatry 164:6, June 2007
XL :Better Compliance and Sleep
Wellbutrin XL For depressive symptoms involving dopamine, suc
h as anhedonia, fatigue, concentration, interesting Seasonal affective disorder Smoking cessation Weight reduction Bipolar depression Less Sexual dysfunction Augmentation Switching Better Compliance
Thank you for your attention !