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Treatment of Depression With Antiglucocorticoid Drugs

From the Department of Psychiatry (O.M.W., V.I.R.), University of California, San Francisco, School of Medicine, San Francisco, CA.

Address reprint requests to: Owen M. Wolkowitz, MD, Department of Psychiatry, University of California, San Francisco, School of Medicine, 401 Parnassus Ave., San Francisco, CA 94143-0984. Email: owenw{at}itsa.ucsf.edu

OBJECTIVE: The theoretical and empirical rationales for the potential therapeutic use of antiglucocorticoid agents in the treatment of depression are reviewed.

METHOD: Individual case reports, case series, open-label, and double-blind, controlled trials of the usage of cortisol-lowering treatments in Cushing’s syndrome and major depression are evaluated and critiqued.

RESULTS: In each of the 28 reports of antiglucocorticoid treatment of Cushing’s syndrome, antidepressant effects were noted in some patients; the largest two series document a response rate of 70% to 73%. Full response, however, was at times erratic and delayed. Across the 11 studies of antiglucocorticoid treatment of major depression, some degree of antidepressant response was noted in 67% to 77% of patients. Antidepressant or antiobsessional effects of antiglucocorticoid augmentation of other psychotropic medications have also been noted in small studies of patients with treatment-resistant depression, obsessive-compulsive disorder, and schizoaffective disorder or schizophrenia.

CONCLUSIONS: These promising results with antiglucocorticoid treatment must be interpreted cautiously because of the small sample sizes and heterogeneity of the studies reviewed, the bias favoring publication of positive results, and the open-label nature of most of the studies. Although definitive controlled trials remain to be conducted, there is a consistent body of evidence indicating that cortisol-lowering treatments may be of clinical benefit in select individuals with major depression and other hypercortisolemic conditions.

Key Words: antiglucocorticoid • depression • cortisol • Cushing’s syndrome • Cushing’s disease • antidepressant

Abbreviations: ACTH = adrenocorticotropic hormone; CRH =corticotropin-releasing hormone; DST = dexamethasone suppressiontest; HDRS = Hamilton Depression Rating Scale; LHPA =limbic-hypothalamic-pituitary-adrenal; PRL = prolactin; UFC =urinary free cortisol; 5HT = serotonin.

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