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
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.
3. 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
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
- 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
- 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 antidepressants
It 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