Between 80-90% of all depressed people respond to treatment and almost all sufferers who are appropriately treated will experience at least some symptom relief.
The first aim of treatment is to ensure the safety of the patient for which hospitalisation may be required (i.e. suicidal/unable to care for self). Secondly, a complete diagnostic evaluation must be carried out. This includes a full personal and family history as well as a history of illnesses, medication and recreational drugs/alcohol used, activities, personality type and support system.
A physical examination may also be required to evaluate underlying physical illness, which may cause or worsen depression e.g. thyroid illness. It is important to detect medical problems, as these require separate, appropriate treatment.
Thirdly, a treatment plan has to be formulated which takes into account both immediate symptoms and the patient’s future well being. This would include medication, psychotherapy, life-style changes and the addressing of stressors. Stressful life events are associated with an increased relapse rate in mood disorder sufferers.
Psychotherapy is also known as “talking therapy” and involves a verbal interaction between a trained mental health professional and a patient who may be experiencing emotional or behavioural problems. There are several different types of psychotherapy, which may differ in the techniques used on the psychological principles emphasised, but the underlying aim is to enable the patient to gain insight into him or herself and thereby change maladaptive thoughts, feelings and behaviour.
Research has shown that some forms of psychotherapy are as effective as medication in treating mild to moderate depression. Medication tends to bring about results more rapidly, but the benefits of psychotherapy may be more enduring. It is generally agreed that the best form of treatment is a combination of both pharmacotherapy or psychotherapy.
Pharmacotherapy for depressive disorders has advanced considerably over the past twenty years and there are now a large number of drugs to choose from. All antidepressants are equally effective providing an adequate dosage is taken for a sufficiently long time. Different drugs may be prescribed for different individuals depending on the symptoms presented. Some antidepressants are more energising, while others may cause weight loss or gain. A decision regarding which drug to use is often made on the basis of tolerability of potential side effects.
Antidepressants do not act rapidly. A certain dosage and concentration has to be reached before they become effective. This usually takes about a month but may take six to eight weeks in the elderly. It is important to persevere and to use the prescribed drug at the correct dosage for long enough.
Patients often feel significantly better after two to three months on antidepressants, but it is important that medication be continued for as long as your doctor advises. For a first episode of depression this usually means taking medication six to nine months on optimal dosage after symptom relief has been achieved, two to five years for a subsequent episode and possibly life-long if episodes recur frequently and are severe. Stopping medication too soon increases the likelihood of relapse and the development of a chronic recurring illness.
The different types of antidepressants
1. Selective Serotonin Reuptake Inhibitors (SSRI’S)
These are among the newer antidepressants, which have been available from 1988. They act on the neurotransmitter (brain chemical) serotonin. Some of the trade names in this class include Aropax (paroxetine), Prozac, Lorien, Nuzak, Lily-Fluoxetine (fluoxetine), Cipramil (citalopram), escitalopram (Cipralex), Zoloft (sertraline) and Luvox (fluvoxamine). This group of drugs, together with the other newer agents, is the most widely prescribed due to the favourable side-effect profile and relative safety if taken in overdose. Different drugs in this class are also registered for treatment of anxiety disorders, panic disorders, post-traumatic stress disorders, obsessive-compulsive disorder and social phobia.
Side effects may be present during the first few weeks of therapy, but usually disappear after a while. These are often diminished by starting medication in low dosages and gradually increasing until a therapeutic dosage is reached.
Common side-effects include:
- nausea – (take after food)
- headache – (improves after a while; start with low dosages)
- sleep disturbances
- decreased appetite
- sexual disturbances (sexual problems may change, but if worrisome discuss with your doctor as treatment options are available)
2. SNRI (Serotonin and Noradrenaline Reuptake Inhibitors)
This class of medications is closely related to the SSRI’s, but have an additional mechanism of action in that they also affect noradrenaline reuptake. There are two medications in this class available at present, namely venlafaxine (Efexor, Venlor) and duloxetine (Cymbalta). There is some evidence that this class of medications may be more effective in preventing relapse episodes of depression. They are also used when the depression is accompanied by painful physical symptoms such as headaches and muscle pain. Their side-effect profile is similar to that of the SSRI’s.
This is an older group of drugs, which has been in use since 1957. These drugs affect predominantly noradrenaline. Some of the drugs in this class include Tryptanol, Trepiline (amitriptyline); Tofranil, Ethipramine (imipramine); Anafranil (clomipramine); Emdalen (lofepramine); Aventyl (nortriptyline) and others. Tricyclics are also used for the treatment of anxiety disorders, sleep disorders, pain relief, migraine prophylaxis and bedwetting (imipramine). Some patients, particularly the elderly, find the side effects of these drugs more difficult to tolerate. Tricyclics are not safe in overdose, and in the event of more tablets being taken than prescribed, medical advice should be sought urgently. Despite the side-effect profile, tricyclics are extremely effective antidepressants.
Common side-effects include:
- dry mouth
- dizziness (due to decreased blood pressure – alleviated by standing up slowly)
- blurred vision (this will usually go away with time so new glasses or lenses are not necessary)
- drowsiness (less of a problem with imipramine and lofepramine)
- weight gain
These side effects are often transient and of nuisance value only. They may be managed by altering diet, water intake and rising slowly from a lying or sitting position.
4. Monoamine Oxidase Inhibitors (MAOI’s)
This is an older group of antidepressants, which is used less frequently today. These agents act by inhibiting an enzyme called monoamine oxidase which usually breaks down serotonin, noradrenaline and dopamine in the brain. This results in an increase in these neurotransmitters, the deficiency of which is associated with depressive illness. However, certain foodstuffs containing tyramine (e.g. cheese, red wine, processed meats and many others) also require monoamine oxidase for their metabolism.
The inhibition of this enzyme results in an excess of tyramine which acts upon the blood vessels to cause a rise in blood pressure. This rise may sometimes be fatal and hence patients taking MAOI’s need to observe dietary restrictions. The danger of any food or drug reaction persists for about 14 days after stopping treatment with a MAOI. A washout period is therefore required before starting a different antidepressant.
The only MAOI as described above that is available in South Africa is Parnate (tranylcypromine). There is a newer MAOI available, which does not completely inhibit the monoamine oxidase enzyme and dietary restrictions are thus not that important. A severe hypertensive episode is much less likely and these drugs are only contra-indicated if the patient already suffers from uncontrolled high blood pressure. This drug is called Aurorix (moclobemide).
MAOI’s are thought to be particularly useful in treating atypical depression. They are also useful when depression is not responding to other drugs and in phobia and panic disorder.
Common side-effects include:
- headache – may be a warning sign of a severe increase in blood pressure
- sexual problems
- drug interactions - discuss all medications, including over-the-counter drugs, with your doctor before taking
- interactions with certain foods
Again most of these side effects usually improve after taking the medication for a few weeks.
These antidepressants do not fit into the aforementioned groups and many of them are newer agents.
- Edronax (reboxetine) – launched in South Africa during 2000. This inhibits noradrenaline reuptake and there is more neurotransmitter available in the synaptic cleft. It is generally considered to be an energising antidepressant. It may cause insomnia, dry mouth, vertigo, sweating and some sedation initially. Not a good choice if there is a high level of anxiety associated with the depression.
- Lantanon (mianserin) – classified as a tetracyclic. Affects noradrenaline but via a different mechanism to the tricyclics. This is a sedative antidepressant, which is taken at night – useful if insomnia is a prominent complaint. Also useful if low blood pressure is a problem as it tends not to exacerbate this, unlike the tricyclics. May cause weight gain.
- Molipaxin (trazodone) – a triazolopyridine antidepressant unrelated to any of the aforementioned antidepressants. It affects the serotonin neurotransmitter system working on pre- and postsynaptic neurones (SSRI’s exert their effects on presynaptic neurones only). The main side effect is sedation. Priapism (sustained penile erection) has been reported and may result in irreversible impotence, but this is not a common side effect.
- Remeron (mirtazapine) – belongs to a new class of antidepressant called NaSSA’s (noradrenergic and specific serotonergic antidepressants) which are particularly useful if anxiety and insomnia are problems. Side effects include sedation and weight gain.
Some general points regarding antidepressantsIt is important to inform your prescribing doctor of the following:
- any known illness, especially cardiac problems, epilepsy, diabetes, thyroid disease, liver disease, prostrate problems, glaucoma and high blood pressure
- any other medication which you may be taking. Ask your doctor or pharmacist about potential drug interactions before taking any other prescribed or over-the-counter medication e.g. cough syrup, beta-blockers, anti-histamines, antacids.
- pregnancy or plans to fall pregnant in the near future and also if you are breast-feeding. Some medications can affect your baby.
It is also a good idea to try and avoid alcohol while taking antidepressants. Alcohol acts as a central nervous system depressant and can worsen depression or undermine the benefits of the medication. It also increases the likelihood of drowsiness and hence the risk for accidents while driving or operating machinery.
Electroconvulsive therapy (ECT)
It is not known exactly how ECT works but it remains the most effective treatment for severe depression. The brain displays similar changes after ECT as after taking antidepressant medication, but the onset of improvement is more rapid with ECT.
ECT is a treatment which involves electrical stimulation of the brain while under a general anaesthetic. A muscle relaxant is also given before treatment is initiated. Because of bad publicity (films such as “One flew over the cuckoo's nest”) and general anxiety about using electricity near the brain it is a much underused therapy.
As a general anaesthetic is required, it is only reserved for severe depression or treatment-resistant depression or when a rapid improvement is important (as in post-natal depression which responds particularly well to ECT) and where physical health is good enough for an anaesthetic. ECT is also useful for patients who cannot tolerate the side effects of medication (such as the frail, elderly and pregnant women). Several ECT sessions are required for full therapeutic benefit, usually at a rate of three per week.
Reviewed by Dr Piet Oosthuizen, Dept. Psychiatry, University of Stellenbosch, January 2008