Depression and Medical Drugs Treatment

Introduction

Sadness is a natural reaction to a disappointing event. Usually after something happens that makes us sad, we rebound. But sometimes, we don't. When sadness exists over a steady period of time and seems to occur for no apparent reason, it may be called "clinical depression." It's important to realize that this type of depression is a medical illness - not a sign of weakness. It cannot be "willed away" nor is it "all in your head." The good news is that in most cases, it can be successfully treated.

What is it?

Depression is an illness that can cause noticeable changes in your moods, your perceptions of yourself and your environment. There are several types of depression, each varying in the number, severity and length of symptoms.

In real life, depression does not always fall into neat categories. It is sometimes hard to know when depression crosses the line from being a normal reaction to a difficult life situation to being a depressive illness. Friends, relatives, and busy family doctors often miss the symptoms of a major depression, particularly in the case of an elderly person who may have other medical concerns. Depression in an adolescent or teenager may be mistaken for the normal mood swings that seem to happen at this age. This is one of the reasons why clinical depression if often not diagnosed and treated.

• Post-Partum Depression
• Adjustment Disorder with Depressed Mood
• Mild Depression (Dysthymia)
• Normal Depressed Mood and Grief
• Major Depression
• Bipolar disorders
• Seasonal Affective Disorder (SAD)
• Atypical Depression

What causes it?

Depression is thought to be due to a combination of mental and physical factors; although it may also occur (or reoccur) at any time for no obvious reason. Some individuals appear to be genetically predisposed to depression and may, therefore, have a family history of it. Other factors involved in the development of clinical depression can be related to:

• extreme stress
• trauma
• physical illness
• environmental conditions

Clinical depression also can occur if some of the chemicals in your brain are not functioning effectively. A decrease in the amount of the following chemicals in your brain can affect your mood:

• dopamine
• norepinephrine
• serotonin

Who has it?

The true prevalence of depression in the United States is unknown. According to the National Institute of Mental Health, in 2003, 35 million Americans (more than 16% of the population) suffer from depression severe enough to warrant treatment at some time in their lives. In addition, one out of every four adults experiences depression at some point in life with about 7% of Americans living with depression in a given year. Depression is two to three times as frequent in women as in men; although anyone, including children, can develop depression. According to the World Health Organization in their 2002 report, depression (including complications of depression) was the fourth leading cause of premature death and disability worldwide in 2000 and will be the second greatest cause of this by the year 2020.

While there is help for depression, nearly two-thirds of depressed people do not seek or receive appropriate treatment.

Authorities estimate that depression costs the nation $43 billion a year for medications, professional care, and time lost from school and work. Of that figure, the direct cost of medication and treatment is estimated at $12 billion. However, these figures do not reflect the toll that depressive illness takes on the lives of family members and loved ones. There is also an economic cost for the premature deaths of individuals whose depression impacts on their health, as well as for deaths by suicide. Each year, tens of thousands of depressed people attempt suicide and, sadly, about 16,000 succeed.

What are the risk factors?

Risk factors for depression include the following:

• Family history of depression (3 times greater risk)
• Age (highest incidence between 20-40 years old)
• Postpartum (greater risk 6 months following delivery for women)
• Marital status (associated more with married and divorced individuals. Single individuals that have never been married have the least risk).
• Major stresses at home or work
• Medications such as some drugs used for high blood pressure, sleeping pills, heartburn, or birth control pills
• The loss of a loved one
• Reaching your senior years
• Having an overall negative attitude
• An inability to handle stress
• Medical conditions such as heart disease, stroke, diabetes, cancer or Alzheimer's disease, Parkinsons disease, Multiple sclerosis, certain infections, and thyroid disorders.
• Eating disorders
• Abuse of drugs or alcohol

What are the symptoms?

Depression is frequently overlooked, because it can present itself in a range of signs and symptoms that are not necessarily obvious, particularly because there may be no clear cause, or triggering event. The condition often manifests itself in physical symptoms like headaches, back pain, and chronic fatigue. There are also non-physical symptoms of depression that are sometimes harder to identify or separate from everyday behavior and can last weeks, months or even years if not treated, these symptoms include:

• A persistent feeling of worthlessness or sadness
• A numb or empty feeling or the absence of any feelings at all
• An inability to experience pleasure in hobbies and activities that were once enjoyed
• Irritability
• Restlessness
• Insomnia, early-morning awakening, or oversleeping
• Abrupt changes in eating habits; decreased appetite and/or weight loss or overeating and weight gain
• Difficulty concentrating
• Decreased ability to perform normal daily tasks
• Recurrent thoughts of death or suicide

Depression can also be associated with other disorders, such as alcoholism, anorexia, anxiety, and obsessive-compulsive disorders. This can make it hard to correctly diagnose a patient with depression.

• Diagnosis of Depression
• Symptoms of Bipolar Disorder
• Depression in Adolescents
• Depression in the elderly

How is it treated?

Severe depression is a complex illness that should be treated by professionals who are familiar with all of its manifestations. A complete clinical evaluation will include a physical examination, a medical and psychiatric history, and a mental status examination.

The first step in the treatment of depression is a physical examination. This is done to rule out disorders like thyroid disease, anemia or a recent viral infection, which can produce symptoms similar to those found in a depressive illness. In an estimated 20 to 25 % of major depressive episodes, the cause is an underlying factor such as a particular medication or a medical condition.

A neurological examination should also be done to rule out the possibility that the depressive symptoms are being caused by a neurological disorder.

An important part of the evaluation should be a detailed case history, which can give the family practitioner or mental health specialist valuable clues about the person's condition. Usually, the doctor will ask about the reasons for the visit and carefully discuss all of the person's symptoms. This will permit the doctor to evaluate whether specific events in the person's life could be contributing to their depression or whether the depression appears to have occurred for no obvious reason. The doctor will probably also inquire whether other family members have suffered from depression. A vital element of this examination is to assess the severity of the depression, particularly whether there is any danger that the patient will attempt suicide. In cases such as this, the individual may be hospitalized until the danger passes.

The treatment of depression is tailored to the individual, with the severity and cause of the depressive episode taken into account. Antidepressant medications are frequently prescribed, but it is usually helpful for depressed individuals to receive some form of psychotherapy as well.

The two most common types of antidepressants used are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). With these medications, it may take up to eight weeks before an improvement in depressive symptoms is seen. Since it can take several weeks for the symptoms of depression to improve after treatment has begun, it is helpful for friends and family to encourage the depressed person to continue taking his or her medication. In some cases, different types of antidepressants will need to be tried to find the right match. Antidepressants may cause significant side effects, so drugs and dosages must be monitored closely by a doctor. SSRIs are associated with fewer side effects than TCAs or monoamine oxidase inhibitors (MAOIs). Treatment is usually evaluated six weeks after starting an antidepressant medication. It is then generally re-evaluated after 12 weeks. If the person improves somewhat on a particular medication, treatment can appropriately be continued with dosage adjustments. If there is no improvement, however, treatment should be augmented or changed.

Usually, by the twelfth week of treatment, the most suitable medication for the person has been established. If the individual clearly appears to be benefiting from the medication, it should be continued for four to nine months. After this time, maintenance therapy may be considered.

Studies are ongoing to establish the optimal length of time that antidepressant medications should be taken. Most mental health professionals now recommend that persons who suffer from recurring episodes of major depression and those with bipolar, or manic-depressive disorders stay on maintenance therapy.

• Treatment Overview of Depression

• Treating Adolescent Depression
  

  An estimated 2-10% of children and adolescents in the U.S. have depression. In light of this, it is important to try and find the best therapy for this younger population with the fewest side effects. However, in recent years, several antidepressant medications have been in the news due to reports of increased suicide risk among adolescent users. Because of these reports, beginning in 2004, the U.S. Food and Drug Administration (FDA) now requires manufacturers to add a black-box warning to the labeling of antidepressant medications to inform healthcare providers and the public of the increased risk of suicidal tendencies in adolescents who use antidepressants. This warning was extended by the FDA in May 2007 to include young adults aged 18-24 years who are just starting antidepressant therapy (usually the first 1-2 months of antidepressant therapy). A medication guide has also been developed to be distributed at the pharmacy with each new or refilled prescription for antidepressants. This doesn't mean that antidepressants shouldn't be used to treat younger depressed persons; however, more caution needs to be exercised to determine if the benefits of the antidepressant truly outweigh the potential risks.

  Treatment Options

  First-line treatment options for depression in adolescents include Cognitive Behavioral Therapy (CBT), interpersonal psychotherapy, antidepressants, psychosocial intervention, or a combination of the above. Non-drug options should be generally considered before starting a medication for depression.

  The only antidepressant medication officially approved by the FDA for children 8 years of age or older is fluoxetine (brand name: Prozac). This generally should be the first medication considered. Other antidepressant options that are available but with less evidence to support their use in children and adolescents include sertraline (brand name: Zoloft) and paroxetine (brand name: Paxil).

  If antidepressant medication is used in a child or adolescent, he or she should be monitored closely due to the potential increased risk for suicidality (thoughts or attempts of suicide). All pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening of their depression, suicidality, and unusual changes in behavior, especially during the initial few months of therapy, or any time the antidepressant dose is changed. Monitoring should include at least weekly face-to-face contact with the child or adolescent or their family members or caregivers during the first 4 weeks of treatment, then every other week visits for the next 4 weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks. Additional contact by telephone may be appropriate between face-to-face visits.

Drug classes used to treat Depression

• Miscellaneous Antidepressants
• Monoamine Oxidase Inhibitors
• Selective Serotonin Reuptake Inhibitors
• Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
• Tricyclic Antidepressant & Benzodiazepine Combination
• Tricyclic Antidepressants
  

What is on the horizon?

Because the newer antidepressants are effective and widely used, most current research focuses on compounds that work like the drugs that are already on the market.

Other drug research involves products that affect dopamine or serotonin and dopamine together. Researchers are also studying a different type of drug called an alpha-1 adrenergic blocker. Drugs developed from these studies may improve mood, energy and alertness. Among the non-drug therapies being studied is one that uses the magnetic stimulation of the brain as an alternative to conventional shock treatment. Investigators are also studying the benefits of light therapy to treat seasonal depression, which can be a problem during winter months.

Because of the high public interest in herbal remedies for minor depression, the National Institute of Mental Health has launched a study to determine the safety and effectiveness of St. John's Wort, a common herbal supplement, and citalopram, a prescription antidepressant, compared to placebo. This study started in Februrary 2003 and is still ongoing. Once finished, researchers will assess the changes in a patient's symptoms, functioning, and quality of life.

A current research question is how best to maintain the benefits of electroconvulsive therapy (ECT) over time. Although ECT can be very effective for relieving acute depression, there is a high rate of relapse when the ECT treatments are discontinued. One study has compared maintenance medication therapy to maintenance ECT. This study found high relapse rates with both medication and ECT and neither was superior to the other. However, the medication regimen used included nortriptyline and lithium, which may have more side effects and may be less effective than SSRIs (another widely used antidepressant drug class). Because of this, a study comparing SSRIs to ECT or one that includes both medication plus ECT to avoid relapses may be warranted in the future.

Research continues in the quest to more clearly identify the causes of depression. Studies that are underway are examining genetic and environmental factors that may have a role in depression. A possible relationship between the substances released from the body when inflammation occurs and the onset of depression in healthy men has just recently been discovered. A study showed that men with depression had higher levels of inflammatory substances in their blood circulation than men without depression.

Another study showed that the drug, ketamine (a drug more commonly used for anesthesia during surgery), demonstrated rapid antidepressant effects. These effects were seen within hours as opposed to weeks or months for current therapy. Ketamine probably would not be the drug of choice for depression because it is used as an anesthetic and has been abused recently as a "party drug." Therefore, research has shifted to other drugs.

A study done in 2006 used Namenda (memantine), a medication currently approved to treat Alzheimer's disease, for persons with major depression. The trial was ended early because no effect was noticed; but low doses of the drug were used. Therefore, higher doses of memantine should be evaluated for major depression. Once the causes of depression are better identified, new treatments and techniques for prevention can be developed.