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Hippocampal Volume in Young Patients With Major Depression Before and After Combined Antidepressive Therapy (COATS)

The recruitment status of this study is unknown. The completion date has passed and the status has not been verified in more than two years.
Verified July 2008 by University of Erlangen-Nürnberg Medical School.
Recruitment status was:  Recruiting
Information provided by:
University of Erlangen-Nürnberg Medical School Identifier:
First received: September 6, 2005
Last updated: November 20, 2008
Last verified: July 2008

The proposed study is a randomized, placebo-controlled, double-blind trial to evaluate the safety and efficacy of antidepressant combination for the treatment of depression.

Depressive disorder is one of the most common human diseases with a high burden for every patient, her/his family, health care system and society as a whole. Actual treatment concepts of depressive disorders include pharmacologic, biologic (e.g. electroconvulsive therapy, light therapy) and psychologic therapy. Even though effective therapeutic options are at hand, therapy needs time. It is often not possible to reach full remission of the disease and 10-25% of patients suffering from depression are regarded as "treatment-resistant". In treatment resistant depression, the use of a combination of antidepressive drugs is considered safe and effective. However, at present no data exist concerning the use of drug combination as primary therapeutic option. The aim of the study is to examine the hypothesis, that significantly more patients achieve full remission of depressive symptoms when treated with the combination of two antidepressants and as a secondary hypothesis, that patients receiving a drug combination will achieve remission faster than patients treated with monotherapy. To test these hypotheses, a two group parallel design is used comparing the efficacy and safety of mirtazapine in combination with venlafaxine or placebo.

Condition Intervention Phase
Depressive Disorder, Major
Drug: Mirtazapine
Drug: Venlafaxine
Phase 4

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Caregiver, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Hippocampal Volume in Young Patients With Major Depression Before and After Combined Antidepressive Therapy - a Monocentric, Double-Blind, Placebo-Controlled Trial

Resource links provided by NLM:

Further study details as provided by University of Erlangen-Nürnberg Medical School:

Primary Outcome Measures:
  • Categorial response to the medication. Categorial response is defined on the basis of CGI Improvement scale and 50% reduction in MADR-S score [ Time Frame: Whole duration of study ]

Secondary Outcome Measures:
  • Tolerability of treatment as assessed using the DOTES scale [ Time Frame: Whole duration of study ]
  • Cognitive deficits as judged by the SKT system [ Time Frame: Study duration ]
  • Self assessment of depression and anxiety using Beck's Depression/Anxiety Inventory (BDI/BAI) [ Time Frame: Whole study ]
  • Changes is blood levels of homocysteine, folate, vit B12, P11 [ Time Frame: whole study duration ]

Estimated Enrollment: 80
Study Start Date: March 2006
Estimated Study Completion Date: December 2009
Estimated Primary Completion Date: December 2009 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: 1
Probands receive mirtazapine and venlafaxine
Drug: Venlafaxine
Patients receive mirtazapine 45mg and venlafaxine 300mg.
Other Names:
  • Remergil SolTab (R)
  • Trevilor retard (R)
Placebo Comparator: 2
Patients receive mirtazapine and placebo
Drug: Mirtazapine
Patients receive mirtazapine 45mg and placebo.
Other Name: Remergil SolTab (R)

  Hide Detailed Description

Detailed Description:

Background Information

Combining antidepressants is a well-established medical procedure for the treatment of therapy refractory depression, that may also be applied successfully under non-refractory conditions. The goal of the study is to test this hypothesis. All participants are to be treated with Remergil Soltab®, a sedative antidepressant containing mirtazapine. In a double-blind, parallel-group design, all participants are treated with either Trevilor® retard, an antidepressant of the selective-serotonin-norepinephrine-reuptake-inhibitor class containing venlafaxine or placebo.

Especially in the treatment of therapy-resistant depression augmentation- and combination strategies are widely used (Demling and Frieling 2004).

Only limited data exist on the efficacy and safety of combination of antidepressants: Carpenter et al. have shown, that adjunctive use of mirtazapine added to the prior used antidepressant (mostly SSRIs) was more effective than placebo (Carpenter et al 2002). Devarajan and Dursun report a more effective antidepressive therapy with the combination of citalopram and reboxetine (Devarajan and Dursun 2000). Rubio et al. found the combination of reboxetine, SSRI or venlafaxine and mirtazapine effective (Rubio et al 2004). Smith et al. report less side effects of venlafaxine use when combined with mirtazapine.

All mentioned studies were conducted in treatment-resistant depression. Only the study by Carpenter et al. was done in a randomized, controlled, double-blind design. No data exist on the efficacy and safety of combined antidepressant use as primary therapy of depression.

Pallanti et al. were able to show, that combination of SSRI and mirtazapine leads to an earlier onset of therapeutic effects in OCD (Pallanti et al 2004).

There exists little evidence on the benefits of combined antidepressant use in depression. However, combination of antidepressants proved to be effective and safe in treatment-resistant depression. All used antidepressants have side-effects (see "Fachinformation" for further details). Drug-drug interactions have not been described for the drugs used in the trial. A risk-potentiation therefore seems unlikely.

Route of administration:

Venlafaxine and placebo are administered orally, the usual mode of administration for antidepressive drugs. Only Remergil Soltab®is administered using an orodispersible tablet. This way of administering mirtazapine has proven to be effective.


All participants are to be treated with Remergil Soltab® 45mg, the highest dosage of its license in Germany.

Trevilor® retard will be used 300mg/d. It is licensed for 375mg/d, but for practicability reasons, especially blinding procedures, the modestly lower dosage will be entertained.

Dosage regimen:

Remergil® medication starts with 15mg for two days after randomization. On day 3 and 4, 30mg are used. From day 5 on, 45mg are used.

In the Trevilor® group, treatment starts with 150mg for the first three days, afterwards 300mg are used.

Beginning with day 4, both groups are treated with two capsules of the blinded study medication.

Treatment period:

All patients are treated for 12 weeks in a double-blind fashion.

The trial will be conducted in compliance with this protocol, the guidelines for good clinical practice (CPMP/ICH/135/95) and the applicable regulatory requirements, namely the German law on drugs (AMG).


160 participants, both female and male are to be recruited when admitted to the open wards of the Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen. Participants have to suffer from depressive disorder and need to be 18-65 years old.

Treatment of Subjects

After screening and inclusion into the trial, all prior psychopharmacological medication is stopped and washed out. How dose reduction and cessation is done will be decided individually. The wash-out phase should not exceed 5-7 days. The use of irreversible inhibitors of monoamine oxidase (MAOI) during 14 days prior to screening is an exclusion criterion, as a wash-out period of 14 days is not suitable for the trial. After the wash-out, patients are randomized into two groups:

  1. VENLA - Participants receiving Trevilor®retard 150mg in a blinded capsule. For three days, one capsule is administered, afterwards two capsules are administered, representing a dosage of 300mg/d.
  2. CONT - Participants receiving placebo capsules. For three days, one capsule is administered, afterwards two capsules are administered.

All participants are receiving Remergil Soltab® starting with 15mg for two days, 30mg for days 3 and 4 and 45mg beginning with day 5

Medication permitted during the trial: all non-psychiatric medication, lorazepam and pipamperon.

Medication not permitted: Antidepressants other than the study medication, neuroleptics other than pipamperon, sedative other than lorazepam. Medication with known interactions with the study medication (according to the SPC).

All medication is allowed before the wash-out period of the trial with the exception of irreversible MAO inhibitors (MAOI).

Medication permitted after the trial: All medication is allowed after the trial. The use of MAOI and other monoaminergic substances should not be started earlier than 14 days after the end of intake of study medication.

Assessment of Efficacy

Efficacy is assessed using different psychometric scales either filled out by the participant or the investigator. Scales to be used are BDI, BAI, BSI, PSQuI as questionaires filled by the participant and CGI, MADR-S, HAM-D and HAM-A as rating scales filled out by the investigator. During the first week and week 13, a cranial magnetic resonance image is obtained, to assess morphologic changes of the brain.

During the weekly visits, BDI, BAI, CGI, HAM-D, HAM-A and MADR-S are entertained. BSI and PSQuI are entertained at screening, visit 4, visit 8, visit 12 and visit 13. (please see also the attached flow chart and 16 Supplement A for further details).


Ages Eligible for Study:   18 Years to 65 Years   (Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Women and men aged 18-55 years
  • Moderate to severe depressive episode according to ICD10-criteria ICD10:F32.1, F32.2, F33.1, F33.2) and MADRS-sum value >=18 points

Exclusion Criteria:

  • Bipolar affective disorder incl. BD-II.
  • Psychiatric or neurologic comorbidity.
  • Depression with psychotic symptoms.
  • Pregnancy or lactation period.
  • Significant cardiovascular or gastrointestinal disease.
  • Severe dysfunction of liver (defined according to Child-Pugh-Criteria (>=Child A)) or kidney (defined according to KDIGO stage I (albuminuria >=30mg/g).
  • Known and proven pharmacoresistance.
  • Proven contraindication against MRI (e.g. pacemaker).
  • Known incompatibility against one of the substances used.
  • Intake of irreversible inhibitors of monoamine oxidase (MAOI, e.g. tranylcypromine) during last 14 days.
  • Known phenylketonuria.
  • Women with childbearing potential not using a highly effective method of birth control (e.g. implants, injectables, combined oral contraceptives, some IUDs, sexual abstinence or vasectomised partner).
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its identifier: NCT00150839

Contact: Stefan Bleich, MD 004991318534262
Contact: Helge Frieling, MD 004991318534262

Department of Psychiatry and Psychotherapy, University Erlangen-Nuremberg Recruiting
Erlangen, Bavaria, Germany, 91054
Contact: Stefan Bleich, MD    004991318534262   
Principal Investigator: Stefan Bleich, MD         
Sub-Investigator: Julia Wilhelm, MD         
Sub-Investigator: Helge Frieling, MD         
Sponsors and Collaborators
University of Erlangen-Nürnberg
Principal Investigator: Stefan Bleich, MD University Erlangen-Nuremberg
  More Information

Responsible Party: Stefan Bleich, University of Erlangen-Nürnberg Identifier: NCT00150839     History of Changes
Other Study ID Numbers: COATS
Study First Received: September 6, 2005
Last Updated: November 20, 2008

Keywords provided by University of Erlangen-Nürnberg Medical School:
Depressive Disorder, Major
Double-blind RCT
Magnetic resonance imaging
Hippocampal volume

Additional relevant MeSH terms:
Depressive Disorder
Depressive Disorder, Major
Behavioral Symptoms
Mood Disorders
Mental Disorders
Antidepressive Agents
Venlafaxine Hydrochloride
Adrenergic alpha-Antagonists
Adrenergic Antagonists
Adrenergic Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action
Physiological Effects of Drugs
Antidepressive Agents, Tricyclic
Psychotropic Drugs
Histamine H1 Antagonists
Histamine Antagonists
Histamine Agents
Serotonin Antagonists
Serotonin Agents
Antidepressive Agents, Second-Generation
Serotonin and Noradrenaline Reuptake Inhibitors
Neurotransmitter Uptake Inhibitors
Membrane Transport Modulators processed this record on March 29, 2017