Clinical depression medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The treatment of depression is highly individualized to the patient, based on the patient's unique combination of biological, psychological and social health factors and the severity of their condition.[1] The three most conventional treatments for depression include medication, psychotherapy, and Electroconvulsive therapy, however new treatments and less conventional options are also available, including self help, life style changes, and vagus nerve stimulation.[1] If there is an imminent threat of suicide or the patient is a danger to others, hospitalization is employed as an intervention method to keep at-risk individuals safe until they cease to be a danger to themselves or others. At-risk individuals may also be placed in a partial hospitalization therapy, in which the patient sleeps at home but spends most of the day in a psychiatric hospital setting. This intensive treatment usually involves group therapy, individual therapy, medication management, and is used often in the case of children and adolescents.
Medical Therapy
Pharmacologic medical therapies for Major Depressive Disorder include:
Serotonin reuptake inhibitors
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
- Citalopram
- Escitalopram
Serotonin-norepinephrine reuptake inhibitors
- Duloxetine
- Venlafaxine
- Desvenlafaxine
- Milnacipran
- Levomilnacipran
Tricyclic antidepressants
- Amitriptyline
- Nortriptyline
- Imipramine
- Desipramine
- Clomiprramine
- Doxepine
- Amoxepine
Monoamine oxidase inhibitors
- Phenelzine
- Tranylcipromine
Atypical antidepressants
Treatment failure
| Intervention | Outcome | ||
|---|---|---|---|
| Medication | Mean final dose | Remision % | Quit 2˚ ADRs (%) |
| Switch meds (NEJM 2006; PMID: 16554525[2]) | |||
| Bupropion SR | 283 mg | 21% | 27% |
| Sertraline (SSR) | 136 mg | 18% | 21% |
| Venlafaxine ER (SNRI) | 194 mg | 25% | 21% |
| Augment meds (NEJM 2006; PMID: 16554526[3]) | |||
| Bupropion SR | 268 mg | 30% | 13% |
| Buspirone | 41 mg | 30% | 21% |
When treated with monotherapy for depression, approximately 30% of patients have remission of symptoms while 50% have a response to medications.[4] For patients with inadequate response, either adding sustained-release bupropion ("bupropion was 200 mg per day during weeks 1 and 2, increasing to 300 mg per day by week 4 and to 400 mg per day (the final dose) during week 6") or buspirone (up to 60 mg per day) for augmentation as a second drug can cause remission in approximately 30% of patients (bupropion may be more effective than buspirone)[3], while switching medications can achieve remission in about 25% of patients[2]. Alternatively, "extended-release venlafaxine, the starting daily dose of 37.5 mg for 7 days was increased to 75 mg from day 8 to 14, to 150 mg from day 15 to 27, to 225 mg from day 28 to 41, to 300 mg from day 42 to 62, and to 375 mg from day 63 onward."[2]
The STAR*D trial has reported the frequency of re-emrgence of suicidality for different second levels of treatment.[5]
In level 3 of the STAR*D trials, patients who had failed two trials of a second-generation antidepressant, tended to better with nortriptyline than mirtazapine.[6]
Aripiprazole, originally introduced as an atypical antipsychotic agent, is approved as an adjunct to other antidepressants.[7]
Stopping medications
Patients are generally advised not to stop taking an antidepressant suddenly and to continue its use for at least four to months to prevent the chance of recurrence.[8] For patients that have chronic depression, medication may need to be continued for the remainder of their life.
Patients should be treated indefinitely if they have "three or more prior major depressive episodes or who have chronic major depressive disorder should proceed to the maintenance phase of treatment after completing the continuation phase."[8]
Antidepressant discontinuation syndrome
References
- ↑ 1.0 1.1 Mayo Clinic Staff (2006-03-06). "Depression Treatment Guide". Mayo Clinic. Retrieved 2007-10-20.
- ↑ 2.0 2.1 2.2 Rush AJ, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME; et al. (2006). "Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression". N Engl J Med. 354 (12): 1231–42. doi:10.1056/NEJMoa052963. PMID 16554525. Review in: Evid Based Ment Health. 2006 Nov;9(4):100
- ↑ 3.0 3.1 Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D; et al. (2006). "Medication augmentation after the failure of SSRIs for depression". N Engl J Med. 354 (12): 1243–52. doi:10.1056/NEJMoa052964. PMID 16554526.
- ↑ Trivedi MH, Rush AJ, Wisniewski SR; et al. (2006). "Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice". The American journal of psychiatry. 163 (1): 28–40. doi:10.1176/appi.ajp.163.1.28. PMID 16390886.
- ↑ http://dx.doi.org/10.4088/JCP.12m07777
- ↑ Fava M, Rush AJ, Wisniewski SR, Nierenberg AA, Alpert JE, McGrath PJ; et al. (2006). "A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report". Am J Psychiatry. 163 (7): 1161–72. doi:10.1176/appi.ajp.163.7.1161. PMID 16816220. Review in: Evid Based Ment Health. 2007 Feb;10(1):16
- ↑ Marianna Mazza, Maria Rosaria Squillacioti1, Riccardo Daniele Pecora, Luigi Janiri1 & Pietro Bria (December 2008), "Beneficial acute antidepressant effects of aripiprazole as an adjunctive treatment or monotherapy in bipolar patients unresponsive to mood stabilizers: results from a 16-week open-label trial", Expert Opinion on Pharmacotherapy, 9 (18): 3145–3149, doi:10.1517/14656560802504490
- ↑ 8.0 8.1 American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p. [1170 references]