Depression – Treatment

DEPRESSION – TREATMENT


DEPRESSION – TREATMENT

Treatment modalities:

  • Pharmacotherapy.
  • Psychotherapy.
  • Other somatic treatments.

1. Pharmacotherapy:

Considerations:  

  • All available antidepressants takes 3-4 weeks to exert significant therapeutic effect.
  • Usage of specific pharmacotherapy doubles chances for recover within 1 month.
  • All available antidepressants have similar profile except adverse effects.
    • Choice of drug also depends on their adverse effects.

Duration of therapy:

  • Antidepressant treatrnent should be maintained for atleast 6 months or equal to duration of previous episode, whichever is greater.
  • Prophylactic antidepressant treatment is effective in reducing number & severity of episodes.
    • Should be given to patients who have had 3 or more prior depressive episodes or in chronic major depressive disorder (> 2 years duration).

Drugs used – 

Tricyclic and tetracyclic antidepressants (TCAs):

  • 1st class of antidepressants used.

MOA: 

  • Primary action – Acts by blocking serotonin & norepinephrine transporters —> Increases neurotransmitters levels in synapses.
  • Secondary action– Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage. 
  • Responsible for their side effect.

Drugs included: 

  • lmipramine, desipramine, trimipramine, amitriptyline, nortriptyline, protriptyline, amoxapine, doxepin, maprotiline & clomipramine.
  • Clomipramine – Most serotinin selective drug.
  • Desipramine – Most norepinephrine selective drug.

Adverse effects: 

  • Anticholinergic side effects (constipation, urinary retention), cardiac arrhythmias, hypotension & seizures (Sodium channel bloack in heart & brain), & sedation.

Contraindications: 

  • Glaucoma, prostate hypertrophy, 

Selective serotonin reuptake inhibitors (SSRIs):

  • Most commonly prescribed antidepressants.
  • Lesser adverse effects.
  • DOC for depression, obsessive compulsivel disorder, post-traumatic stress disorder, panic disorder, generalized anxiety disorder & phobia.
  • MOA: Acts by blocking serotonin reuptake.
  • Drugs included: Fluoxetine, fluvoxamine, citalopram, escitalopram, sertraline, paroxetine, vortioxetine, & vilazodone.
  • Adverse effects: Nausea (most common) –> anxiety & diarrhoea.

Vortioxetine: 

  • Recent antidepressant.
  • MOA: Serotonin reuptake inhibitor. agonism at 5-HT1A receptor, partial agonism at 5-HT1B receptor & antagonism at 5-HT3. 5-HT1D & 5-HT7 receptors.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • MOA: Blockade of neuronal serotonin & norepinephrine uptake transporters.
    • Hence,“dual reuptake inhibitors”.
  • Drugs included:Venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran.

Monoamine oxidase inhibitors:

  • MOA: Inhibits monoamines enzyme (MAO-A & MAO-B) metabolism.
  • Drugs included: Non-selective MAO inhibitors – Tranylcypromine, phenelzine & isocarboxazid.

Atypical antidepressants:

Drugs included: 

  • SARI (serotonin antagonist & reuptake inhibitors): Trazodone & nefazodone.
  • NSSA (nor adrenergic and specific serotonergic antidepressant): Mirtazapin.
  • NDRI (norepinephrine-dopamine reuptake inhibitors): BupropionInhibition of norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer: Tianeptine & amineptine – Acts by enhancing serotonin reuptake.
  • Antipsychotics: In patient with depression & psychotic symptoms.

2. Psychotherapy:

Techniques used:

  • Cognitive behavioral therapy:
    • Aims at correcting cognitive distortions (faulty ways of thinking) & faulty behaviors.
    • Most effective psychotherapeutic technique for depression.
  • Interpersonal therapy.
  • Other therapies: 
    • Behavior therapy, family therapy & psychoanalytically oriented therapy.

3.  Other somatic treatments

Electroconvulsive therapy (ECT): 

Indications: 

  • Severe depression with suicide risk.
  • Severe depression with stupor.
  • Depression with psychotic symptoms
  • Refractoriness to other treatment modalities.

Transcranial magnetic stimulation:

  • Newer modality using magnetic energy.
  • Nonconvulsive.
  • Not requires anesthesia.
  • Lesser side effects.
  • Vagal nerve stimulation.

Deep brain stimulation – 

  • Used for chronic & intractable depression.

Exam Important

  • Choice of antidepresseant drug depends on their adverse effects.
  • Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage by TCA’s is responsible for their side effect.
  • NDRI (norepinephrine-dopamine reuptake inhibitors) like Bupropion inhibits both norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer like tianeptine & amineptine acts by enhancing serotonin reuptake.
  • Cognitive behavioral therapy is most effective psychotherapeutic technique for depression.
  • Electroconvulsive therapy (ECT) is therapy of choice for patient with severe depression with suicide risk & with stupor.
  • Somatic treatments methods used for treating depression includes transcranial magnetic stimulation, vagal nerve stimulation & deep brain stimulation.
  • Antidepressant drug used in nocturnal eneuresis is Imipramine.
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