Rapid improvement of depressive symptoms in suicide attempters following treatment with milnacipran and tricyclic antidepressants - a case series

Abstract

Suicide is a serious social problem in many countries, including Japan. The majority of people who commit suicide suffer from depression. Suicide attempt patients suffering from serious physical injuries are initially treated in hospital emergency departments. The present post hoc analysis examined data from patients admitted to an emergency hospital for treatment of physical injuries, resulting from a suicide attempt, and initial psychiatric treatment for depression and prevention of future suicide attempts. The effects on depressive symptoms were studied in two groups of patients using the 17-item Hamilton depression scale (HAMD). One group (n = 6) had received intravenous tricyclic antidepressants (TCA) (amitriptyline or clomipramine) while the other group (n = 7) had been treated orally with milnacipran, a serotonin and norepinephrine reuptake inhibitor antidepressant. Prior to treatment the four highest scoring items on the HAMD scale were the same in both groups namely, item 1 (depressed mood), item 3 (suicidality), item 7 (interest in work and activities), and item 10 (psychic anxiety). After 1 week of treatment, mean global HAMD scores were significantly reduced in both groups. Treatment resulted in a significant reduction of five HAMD items in the TCA group, whereas in the milnacipran group 12 HAMD items were significantly reduced. Suicidality (item 3) was significantly improved by 1 week treatment with milnacipran, but not by TCAs. Milnacipran rapidly improved a wide range of depressive symptoms, including suicidality within the first week. The improvement with milnacipran would appear to be, at least, equivalent to that achieved with TCAs, possibly affecting a wider range of symptoms. Since milnacipran has been shown in comparative studies to be better tolerated than TCAs, this antidepressant offers an interesting option for the treatment of suicidal patients in an emergency setting.

Keywords: depression; milnacipran; suicide attempt; tricyclic antidepressant.

Figure 1

Mean scores of individual HAMD items at baseline (dark gray columns) and after 1 week of tricyclic antidepressant treatment (light gray columns). The HAMD items are as follows: (1) depressed mood, (2) feeling of guilt, (3) suicide, (4) early insomnia, (5) middle insomnia, (6) late insomnia, (7) work and activities, (8) retardation, (9) agitation, (10) psychic anxiety, (11) somatic anxiety, (12) gastrointestinal somatic symptoms, (13) general somatic symptoms, (14) genital symptoms, (15) hypochondriasis, (16) loss of weight, and (17) insight. Notes: *P < 0.05; ***P < 0.001 compared to before treatment values (paired t-test) n = 6. Treatment details are given in Table 1. Abbreviation: HAMD, 17-item Hamilton depression rating scale.

Figure 2

Mean scores of individual HAMD items at baseline (dark gray columns) and after 1 week of milnacipran treatment (light gray columns). The HAMD items are as follows: (1) depressed mood, (2) feeling of guilt, (3) suicide, (4) early insomnia, (5) middle insomnia, (6) late insomnia, (7) work and activities, (8) retardation, (9) agitation, (10) psychic anxiety, (11) somatic anxiety, (12) gastrointestinal somatic symptoms, (13) general somatic symptoms, (14) genital symptoms, (15) hypochondriasis, (16) loss of weight, and (17) insight. Notes: *P < 0.05; **P < 0.01; ***P < 0.001 compared to before treatment values (paired t-test) n = 7. Treatment details are given in Table 2. Abbreviation: HAMD, 17-item Hamilton depression rating scale.