Treatments for Depression

Management issues

• In-patient or out patient
• Risk of suicide
• Risk to dependants
• Work?

Activity

• Suitable activity
• Occupy patient and provide social stimulation
• Not be too demanding because failure may make depression worse

Psychotherapy

• Specific psychotherapies can be used in mild to moderate depression esp. if patient doesn’t want to take drugs
• Can be as effective as drug therapy
• Can be slower than drugs
• In severe depression too much self examination at early stage can make condition worse

Cognitive Therapy

• Developed by Beck, 1976
• Aim is to help patients modify ways of thinking about life situations and depressive symptoms
• Negative intrusive thoughts
• Assumptions that render ordinary situations stressful
• Errors of logic that allow assumptions to persist despite evidence to contrary
• ? less effective in severe depression esp. melancholic illness
• ? lower relapse rates
• Features
• Patient as partner
• Attention to provoking and maintaining factors
• Treatment as experiment
• Homework assignments
• Highly structured sessions
• Monitoring of progress
• Treatment manuals
• Techniques used to change cognitions
• Distraction
• Neutralising
• Challenging
• Reassessing

Supportive Psychotherapy

• Identification and resolution of current life difficulties
• Interpersonal Psychotherapy
• Systemic and standardised approach to personal relationships and life events
• As effective as antidepressants
• Marital Therapy
• May be useful adjunct to treatment where marital discord seems to have contributed to causing or maintaining depressive disorder

Antidepressants

Tricyclics

• severe depression, inpatients

• individual tricyclics
• clomipramine - very effective
• lofepramine - not cardiotoxic in overdose, fewer side effects, insomnia
• Withdrawal
• Nausea, anxiety, sweating, GI symptoms, insomnia
• Interactions
• Should not be used in conjunction with anti-arrythmic drugs, e.g. amiodarone
• MAOIs
• Levels increased by numerous other drugs e.g. cimetidine, valproate, Ca-channel blockers, SSRIs

SSRIs

• Fewer side effects than tricyclics

·         less cardiotoxic

·         Side Effects

• Interactions
• MAOIs
• “Serotonin syndrome” -agitation, hyperpyrexia, rigidity, myoclonus, coma, death
• P450 inhibition
• tricyclics
• antipsychotics
• anticonvulsants
• warfarin

MAOIs

·         Non-responsive

·         Troublesome interactions with food and drugs

·         Side effects

• Interactions
• tyramine containing foods, e.g red wine, cheese
• sympathomimetic amines
• L-dopa
• opiates, cocaine, insulin, potentiation of oral hypoglycaemic drugs
• metabolism of carbemazepine, phenytoin may be slowed
• Specific drugs
• phenelzine
• isocarboxazid
• tranylcypromine
• moclobemide - reversible inhibitor of MAOI-A, short offset, easing of dietary restrictions

Other drug treatments

Lithium

• Addition to antidepressant therapy
• ~50% patients show useful response at 1-3 weeks
• Caution with SSRIs and venlafaxine due to 5-HT toxicity
• Requires regular blood levels

Tri-iodothyronine

Olanzapine

 ECT

• Administration of electrical current to temples under general anaesthetic and muscle relaxant
• Can only be given under informed consent or if patient under MHA then independent consultant appointed by MHA Commisioners
• Can be initiated before assessment under section 62 of MHA
• Indications
• First line treatment only if patient too severely psychomotor retarded to drink or severe risk of suicide
• May be considered in severe postnatal depression, where delay in onset of action of antidepressants may adversely effect mother and child
• Contra-indications (all relative)
• Raised ICP
• Recent stroke
• Recent myocardial infarction
• Crescendo angina
• Side effects
• Anaesthetic complications
• Dysrythmias
• Post-ictal headache and confusion
• Retro-anterograde amnesia – diificulties in registration and recall may persist for several weeks

Other Treatments

Sleep deprivation

• Keeping patient up all night can help alleviate symptoms of depression but effect very short lived
• Research and possibly to speed onset of action of medication

Bright Light Treatment

• For treatment of seasonal effective disorder
• 1-2 hours / day exposure to bright (10,000 lux) light
• Patients with atypical symptoms appear to respond best

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