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
- SSRIs are effective, well-tolerated medications used as a first-line treatment for MDD.
- Possible adverse effects with SSRIs include serotonergic syndrome, impaired sexual dysfunction, withdrawal symptoms, and SIADH.
- Co-administration with monoamine oxidase inhibitors is contraindicated.
- Fluoxetine (Effective dose range: 20-80mg)
- Benefits: It is associated with a low risk of withdrawal symptoms upon tapering due to its long-half-life
- Adverse effects: See SSRIs side effects
- Sertraline (Effective dose range: 50-200mg): has a dual mechanism of action, i.e., SSRI and dopamine reuptake inhibitor
- Benefits: Low transplacental transmission during pregnancy; relatively low concentrations in breast milk
- Adverse effects: Transient diarrhea during first few weeks of initiation of therapy
- Paroxetine (Effective dose range: 20-50mg)
- Benefits: Low transplacental transmission during pregnancy; relatively low concentrations in breast milk
- Adverse effects: higher risk of withdrawal symptoms than other SSRIs, weight gain, potential higher risk of teratogenic effects (FDA pregnancy category D)
- Citalopram (Effective dose range: 20-40mg)
- Benefits: Few drug-drug interactions
- Adverse effects: May prolong QTc interval, in particular at higher doses. It is not recommended in patients with congenital long QT syndrome of acute cardiac conditions (e.g. acute decompensated heart failure). It should be discontinued in patients with QTc interval >500ms. Doses of >20 mg are not recommended in the elderly or in patients with hepatic dysfunction.
- Escitalopram (Effective dose range: 10-20mg)
- Benefits: Few drug-drug interactions
- Adverse effects: Modest effects on QTc interval
Serotonin-norepinephrine reuptake inhibitors
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also considered first-line medications for the treatment of MDD. SNRIs have a dual mechanism of action. They may be effective in treating concomitant pain conditions.
- Adverse effects: Neuradrenergic symptoms (hypertension, dry mouth, constipation, insomnia, decreased appetite), serotonergic side effects ([[nausea, diarrhea, nervousness, insomnia, sexual dysfunction, withdrawal symptoms, and hyponatremia).
- Duloxetine (Effective dose range 60-120 mg)
- May be effective in treating neuropathic pain and other pain condition. Smoking decreases the plasma levels of duloxetine.
- Venlafaxine (Effective dose range 75-350 mg)
- Adverse effects: Compared to other serotonergic antidepressants, is associated with a slightly increased incidence of nausea and vomiting, higher risk of withdrawal symptoms, and hypertesnion.
- Desvenlafaxine (Effective dose range 50-100 mg)
- Benefit: may reduce neuropathic pain
- Levomilnacipran (Effective dose range 40-120 mg)
Tricyclic antidepressants
- TCAs are considered second-line medications in the treatment of MDD due to greater side effects compared to SSRIs and SNRIs, in particular in the elderly.
- Amitriptyline
- Nortriptyline
- Imipramine
- Desipramine
- Clomiprramine
- Doxepine
- Amoxepine
Monoamine oxidase inhibitors
- Phenelzine
- Tranylcipromine
Other antidepressants
- Bupropion XR (Effective dose range 300--450 mg)
- Atypical antidepressant
- Approved for smoking cessation
- Benefits: Weight neutral, minimal to no risk of sexual impairment, minimal withdrawal symptoms.
- Adverse effects: Lower seizure threshold, particularly at higher doses.
- Mirtazapine (Effective dose range 15-45 mg)
- Atypical antidepressant
- Benefits: faster onset of action than SSRIs, minimal sexual impairment, minimal withdrawal symptoms.
- Adverse effects: increased appetite and sleep (may be beneficial in patients with reduced appetite and insomnia as symptoms of MDD), higher risk of weight gain
- Trazodone
- Vilazodone (Effective dose range 10-40 mg):
- Serotonin partial agonist and reuptake inhibitor.
- Benefits: May have a lower risk of sexual impairment than other serotonergic antidepressants
- No generic formulation is currently available.
- Vortioxetine (Effective dose range 10-20 mg):
- Serotonin reuptake inhibitor and serotonin modulator
- Benefits: May have a lower risk of sexual impairment than other serotonergic antidepressants. A long half-life may reduce the risk of withdrawal symptoms upon tapering.
- Adverse effects: Despite 5-HT3 receptor antagonism, it has high rates of nausea.
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.[2] 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."[2]
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 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]