DEPRESSION – TREATMENT
DEPRESSION – TREATMENT
- Other somatic treatments.
- 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.
- 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.
- lmipramine, desipramine, trimipramine, amitriptyline, nortriptyline, protriptyline, amoxapine, doxepin, maprotiline & clomipramine.
- Clomipramine – Most serotinin selective drug.
- Desipramine – Most norepinephrine selective drug.
- Anticholinergic side effects (constipation, urinary retention), cardiac arrhythmias, hypotension & seizures (Sodium channel bloack in heart & brain), & sedation.
- 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.
- 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.
- SARI (serotonin antagonist & reuptake inhibitors): Trazodone & nefazodone.
- NSSA (nor adrenergic and specific serotonergic antidepressant): Mirtazapin.
- NDRI (norepinephrine-dopamine reuptake inhibitors): Bupropion – Inhibition of norepinephrine & dopamine reuptake.
- Serotonin reuptake enhancer: Tianeptine & amineptine – Acts by enhancing serotonin reuptake.
- Antipsychotics: In patient with depression & psychotic symptoms.
- 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):
- 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.
- Not requires anesthesia.
- Lesser side effects.
- Vagal nerve stimulation.
Deep brain stimulation –
- Used for chronic & intractable depression.
- 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.