![[dr. bob]](/oculus.jpg)
|
Dr. Bob's |
Date: Thu, 9 Mar 1995 10:15:01 -0500
From: hrohan@pobox.upenn.edu (Mady Hornig-Rohan, M.D.)
Subject: Pindolol as augmenting agent for antidepressants
I've used pindolol (5-20 mg/d) a number of times to augment SSRI or SNRI (venlafaxine) trials in treatment-resistant MDD with moderate success. In addition to its beta-blockade (and having considerable partial agonist activity to boot), pindolol is I believe unique amongst currently marketed US beta-blockers in also having a high affinity for 5HT1A somatodendritic receptors and antagonizing 5HT1A-mediated responses in humans. Since it is thought that the activation of somatodendritic autoreceptors causes inhibition of serotonergic activity, the idea is that blockade of these autoreceptors may then increase serotonergic activity.
I have observed no noxious side effects. On occasion, it has been helpful only for the "peripheral" symptoms of anxiety and agitation associated with the individual's depression, as is regularly seen with other beta-blockers (e.g., with use for performance anxiety). In others, pindolol has contributed to complete remission of residual symptoms that had remained with the SSRI/SNRI alone. I have also had several failed augmentation trials. Although the maximum dose I've tried is 20 mg/d, apparently one can go up to 60 mg/d.
Relevant case series: Artigas F, Perez V, Alvarez E. Pindolol induces a rapid improvement of depressed patients treated with serotonin reuptake inhibitors [letter]. Archives of General Psychiatry. 51 (3): 248-51, 1994 Mar. Comment: Arch Gen Psychiatry 1995 Feb; 52 (2): 156.
Date: Sat, 30 Sep 1995 15:18:17 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Pindolol as augmenting agent for antidepressants
On Mon, 25 Sep 1995 evb@YKnet.YK.CA (Jaime Smith, MD) wrote:
Last week at the CPA meeting Pierre Blier of Montreal reported that adding pindolol 2.5 mgm tid to paroxetine in 13 patients with both major depression and OCD who were resistant to SSRIs resulted in significantly attenuated depressive symptoms of depression (but not OCD) in 11 of the 13.The following points should be noted:
Some people need 5 mg of pindolol t.i.d.
Pindolol potentiation works with all SSRIs although one published study says it does not work with sertraline. It also works with venlafaxine.
An asthma history is a contradiction for pindolol.
With patients who have a "treatment-resistant" depression the success rate is about 40%, with people being treated initially, about double that.
Date: Thu, 30 Nov 1995 19:29:09 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Pindolol as augmenting agent for antidepressants
I have successfully used pindolol with:
I doubt that it is a placebo response, but sure would like to see some double blind placebo controlled studies.
Date: Mon, 4 Dec 1995 18:46:42 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Pindolol as augmenting agent for antidepressants
On Mon, 4 Dec 1995, Charles S Berlin wrote:
Given your report of some experience of use of pindolol with Parnate, I have a few questions:Some people taking pindolol + an MAOI have complained about some orthostatic problems, but (so far) nothing severe enough to require anything more than the suggestion that they increase the salt content of their diets.1) Was orthostasis a problem? (I know the doses of pindolol used are well below the amounts used for cardiovascular purposes, but would have some worries about this especially with MAOIs).
2) Has your experience also demonstrated very rapid response, i.e. within 1 week, to this intervention, as others have reported?I start people on 2.5 mg of pindol tid, if there is no response within a week I increase the dose to 5 mg tid, if there is no response within 2 weeks I discontinue the pindolol.
3) Has the response to pindolol augmentation been maintained longer term?I have some people who have been on the pindolol for nearly a year . . . everytime I try to reduce it (with the idea of eventually discontinuing it) they relapse.
Date: Thu, 21 Dec 1995 00:02:07 -0800 (PST)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: SSRI + pindolol + lithium
I have found adding lithium sometimes to make the difference when an SSRI + pindolol is not effective.
Date: Fri, 19 Jan 1996 09:19:34 -0800 (PST)
From: rlam@unixg.ubc.ca (Dr. Raymond W. Lam)
Subject: Pindolol as augmenting agent for antidepressants
Our experience with pindolol in the Mood Disorders Clinic is that it is a useful strategy with a response similar to other augmentation strategies. Unfortunately, in our hands, we have not had the 80% reponse rates of the initial investigators (not surprising I guess, given the original lithium augmentation story). There are now large placebo-controlled studies being initiated -- in a year we should have a very good idea of how good pindolol augmentation really is.
From: "Watsky, Eric J." <WATSKYE@dirpc.nimh.nih.gov>
Subject: Pindolol as augmenting agent for antidepressants
Date: Fri, 19 Jan 96 12:24:00 est
I have found pindolol thus far to be quite effective as an adjunct. In one patient with depression and borderline personality disorder who had initially responded to paroxetine 10 mg/day, migraine-like headaches emerged with a dose increase to 20 mg/day. After an amitriptyline augmentation trial strongly pushed by her internist to treat the headaches, suicidal ideation and dysphoria developed, a phenomenon which has been noted in some patients with BPD treated with amitriptyline (Soloff, 1986). The paroxetine dose was changed to 10 mg bid as headaches seemed to follow qd dosing at 20 mg. The addition of pindolol produced a robust antidepressant effect. Headaches persisted until we increased the pindolol dose from 2.5 tid to 5 bid. In addition, this patient had borderline hypertension which was exacerbated by a previous trial of venlafaxine and now seems to be under better control since starting pindolol.
Date: Mon, 22 Jan 1996 20:33:41 -0500 (EST)
From: "Dr. Robert P. Kraus" <rkraus@julian.uwo.ca>
Subject: Pindolol as augmenting agent for antidepressants
Being Canadian, I have used pindolol as an augmentation agent since last summer, when Pierre Blier's article (Blier P, Bergeron R. Effectiveness of pindolol with selected antidepressant drugs in the treatment of major depression. Journal of Clinical Psychopharmacology. 15 (3): 217-22, 1995 Jun.) came out. I had absolutely no success with several patients on desipramine (which I had turned to after several trials of SSRIs, before I had heard about pindolol), which is in keeping with the theory of Blier and Artigas (Artigas F. Pindolol, 5-hydroxytryptamine, and antidepressant augmentation [letter]. Archives of General Psychiatry. 52 (11): 969-71, 1995 Nov. Comment on: Arch Gen Psychiatry 1995 Feb; 52 (2): 156.) about a specific serotonergic mode of action.
Then in one such patient, after I turned to paroxetine up to 40 mg without success, I added pindolol 2.5 mg tid. After 10 days she started to suddenly rapid-cycle (no previous history of bipolarity), with 4-8 hour mixed or hypomanic phases alternating with two day phases of sluggish anergic depression (her original state for the previous 2 years). I briefly added valproate, which plunged her back into anergic depression. I gradually withdrew the valproate, and five days after the last dose she began rapid-cycling again. This time I just waited on the conbination, and the cycling gradually faded into euthymia and remission. The detailed case is being submitted to the new journal "Depression" (Dr. Charles Nemeroff, chief editor), which publishes long case studies. The two noteworthy points:
However, I agree with Ray Lam, my old friend in Vancouver, who notes a general lack of success with pindolol. I have had only one other partial success, out of a total of 15 patients, so far, even now concentrating on paroxetine, venlafaxine, and fluoxetine.
Date: Sun, 20 Oct 1996 11:03:35 -0700
From: "Dr. Raymond W. Lam" <rlam@unixg.ubc.ca>
Subject: Tryptophan as augmenting agent for pindolol
Pierre Blier in Montreal (who did some of the initial SSRI-pindolol work) has recently published a case series of severe, refractory OCD patients who showed marked improvement after addition of l-tryptophan to their SSRI-pindolol regimen:
Blier P, Bergeron R. Sequential administration of augmentation strategies in treatment-resistant obsessive-compulsive disorder: preliminary findings. International Clinical Psychopharmacology. 11 (1): 37-44, 1996 Mar.
From: HRudMD@aol.com (Howard Rudominer)
Date: Mon, 18 Nov 1996 21:18:00 -0500
Subject: Pindolol as augmenting agent for bupropion
I keep hearing about pindolol augmentation only with SSRIs although I have a patient on Wellbutrin (bupropion) that was not effective until I augmented it with pindolol. Since then she has had a wonderful response.
Date: Thu, 22 May 1997 17:48:04 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Viskin as augmenting agent for antidepressants
Pindolol potentiation of SSRIs and MAOIs can be very useful. There was a poster on it yesterday at the APA and I had a chance to discuss the matter with the authors. We agreed that the generic form is not as useful as the brand product, Viskin. They suspected that the reason had to do with the stereochemistries of the two products. Also, 5 mg TID is a much more effective dose than the 2.5 mg TID dose that too many people are utilizing.
Date: Thu, 22 May 1997 21:35:23 -0400
From: Anthony Patterson <pattersona@InfoAve.Net>
Subject: Pindolol as augmenting agent for antidepressants
Owing to a teleconference, I became enamored with this idea as well. I was singularly unimpressed.
I will qualify this by adding that I only tried it in response to SRI poop-out, not as a start-up adjunct.
Date: Fri, 23 May 1997 14:33:43 -0400
From: Alex Cardoni <Acardon@harthosp.org>
Subject: Pindolol as augmenting agent for antidepressants
We studied pindolol augmentation (2.5 mg tid) in 8 inpatients (open study). Five of 8 improved significantly within 3 days (daily Becks used); Primary antidepressants were venlafaxine (2) paroxetine (2), and fluoxetine (1) in "usual" therapeutic dosages. There were no significant changes in blood pressure in any of the 8 patients at this lower dosage.
Date: Wed, 28 May 1997 19:40:02 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Pindolol as augmenting agent for antidepressants
At the moment it looks as if pindolol is the only beta-blocker that potentiates antidepressants.
Date: Thu, 29 May 1997 10:28:38 -0400
From: Ivan Goldberg <Psydoc@PsyCom.Net>
Subject: Pindolol as augmenting agent for antidepressants
"Increasing the speed of antidepressant effectiveness" will appear in the Lancet, 5/30/97: 1594-97. From the press release:
... Although depression can be treated with drugs, antidepressants are slow to take effect and are effective in up to only two-thirds of patients. In this week's Lancet, Dr. Victor Perez and colleagues from Spain and the USA present the results of an investigation into a combination of drugs...
In the trial, 111 patients with depression were randomly assigned [to] fluoxetine ... and either a placebo (56), or pindolol (55). The authors hypothesized that the addition of a drug such as pindolol would increase the efficacy of fluoxetine and decrease the time to clinical improvement. To check this, the degree of depression in patients was assessed twice a week for the first 3 weeks of the trial and once a week thereafter until the end of the trial (42 days).
The number of patients in the fluoxetine and pindolol group who responded to treatment was significantly greater than in the fluoxetine and placebo group (41 of 55 and 33 of 56...), ... a 16% increase. The number of days that it took to reach a sustained response to treatment and the proportion of patients who had a sustained response were also significantly greater in the fluoxetine and pindolol group.
The authors concluded that the addition of pindolol to treatment with fluoxetine seemed to enhance the effectiveness of therapy. However, they added, "further work is needed to resolve whether the time to clinical improvement benefits ... and ... increase in efficacy [occur] with other antidepressants."...
This topic is indexed under the following subjects:
![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
dr-bob@uchicago.edu
URL: http://www.dr-bob.org/tips/split/Pindolol-as-augmenting-age.html
Original tips copyright 1994-97 original authors.
Web page copyright 1995-97 Robert Hsiung.