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Antidepressants are effective in treating dysthymia; the mean response for any antidepressant in a review study was 55% among dysthymic patients (compared with 31% response for placebo).Doses are the same as those used for major depression.The evaluation and management of excessive daytime sleepiness is based on the identification and treatment of underlying conditions (particularly obstructive sleep apnea), and the appropriate use of activating medications.

An estimated 26 to 32 percent of adults are at risk of or have obstructive sleep apnea, and the prevalence is expected to increase.The AHRQ noted that in a fair-quality placebo-controlled study, a subgroup of patients older than 60 years showed a significantly greater improvement on paroxetine than did those on placebo, whereas paroxetine was no more effective than placebo in a subgroup of patients younger than 60 years.While the older antidepressants, such as tricyclics and MAOIs, are effective, the SSRIs are the medications most commonly used for dysthymia, likely because of their relative safety and milder side-effect profile.Comparisons of agents within or between classes have not been reported for dysthymia.A 2007 research summary by the Agency for Healthcare Research and Quality (AHRQ) identified no head-to-head trial comparing different second-generation antidepressants for treatment of dysthymia; comparison between placebo-controlled trials was stymied by significant differences in population characteristics.See the related Letter to the Editor and Editor's Note that appeared in the October 15, 2009 issue of Excessive daytime sleepiness is one of the most common sleep-related patient symptoms, and it affects an estimated 20 percent of the population.Persons with excessive daytime sleepiness are at risk of motor vehicle and work-related incidents, and have poorer health than comparable adults.A systematic review of antidepressant treatment in dysthymia suggested that SSRIs, tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs) are all equally effective, but SSRIs may be slightly better tolerated.Success has also been reported with more noradrenergic agents such as mirtazapine (Remeron), nefazodone (Serzone), venlafaxine (Effexor), duloxetine (Cymbalta), and bupropion (Wellbutrin).Amitriptyline is metabolized to nortriptyline, which accounts for most of the norepinephrine-reuptake inhibition after amitriptyline administration.Nortriptyline itself also possesses antidepressant activity. Additional hydroxy metabolites apparently are active as well.

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