Depression and Its Treatment

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Depression and Its Treatment

• Les Secrest, M.D.

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• Worldwide Depression accounts for a high level of
  disability and decreased functioning

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• Depression is a frequent occurrence with
  approximately 20 of the population affected by
  Depression

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• Depression is more frequent in women than in men.

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• Suicide is greater in men than women.
• Suicide attempts are greater in women than in men

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• Consider
• The faces of 20 of the population with Depression

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• Consider
• The woman who has recently given birth to her
  child and has post partum depression

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• Consider
• The alcoholic who drinks constantly or
  episodically and is depressed

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• Consider
• The child or adolescent who is irritable and
  performing poorly in school

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• Consider
• The person who is persistently pessimistic and is
  rarely happy or humorous

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• Consider
• The person with mood swings varying from highly
  productive to apathy and unable to get out of bed

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• Consider
• The person with somatic complaints and few
  confirming findings

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Depression Disorders Reviewed

• Major Depressive Disorder
• Single Episode
• Recurrent
• Dysthymic Disorders
• Bipolar Disorder
• Most recent episode Depressed
• Most recent episode Mixed
• Mood disorder due to a medical condition
• Substance induced mood disorder

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Major Depressive Episode is Characterized by

1. Either depressed mood or loss of interest or
   pleasure
2. Weight change
3. Change in sleep patterns
4. Psychomotor agitation on

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Major Depressive Episode is Characterized by

1. Fatigue
2. Feelings of worthlessness/ excessive
   inappropriate guilt
3. Decreased Concentration
4. Recurrent thoughts of death/suicide.

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AntidepressantsConsidered -

• Tricyclic Antidepressants have safety issues in
  overdose situations
• New generation Safer profile with overdose

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Antidepressants Considered -

• Selective Serotonin Reuptake Inhibitors
• Norepinepherine Reuptake Inhibitors
• Dopamine Reuptake Inhibitors

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StarD

• Level I
• Citatalopram approximately
• 30 respondents to remission
• 50 respondents but not with remission
• Non remission Level II
• Augmented to Wellbutrin/bupropion or with
  bupropion
• on cognitive therapy - 30.2
• Switch to monotherapy
• Buproprion - 21.3
• Cognitive therapy
• Sertraline -17.6
• Venlafaxine - 24

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StarD

• Level III Non Remission
• Monotherapy
• Noratriptyline 19.8/12.4
• Mirtazapine - 12.3/80
• Augmentation
• Lithium
• T3 Thyroid Hormone

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• Mirtazapine/Remeron
• Antagonist of Presynaptic Alpha2
• Adrenergic Autoreceptors
• Heteroreceptors on Serotonin and Norepinephrine
  Neurons
• Antagonist postsynaptic serotonin 5-Ht2
• and 5-Ht 3 Receptors
• 3. Inhibits the release of corticotropin
  releasing hormone

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• Nortriplyline
• Inhibits Nonepinephrine Transporter
• Antagonizes Serotonin 3
• Modestly inhibits Gaba Transporters
• Mild inhibition of Seratonin Transporters

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Star D Study

• (Sequenced treatment alternatives to relieve
  depression)
• - Illustrated that we should

1. Continue citalpram/Celexa for eight weeks
2. Use rating scales routinely to monitor
   response to treatments

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Treatment

• Highest treatment response rated thought to be
  related to medication and cognitive therapy

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Cognitive Therapy

1. Stimulus
2. Perception
3. Process
4. Response

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Treatment of Depression

• Use any antidepressant
• Consider antidepressants
• Cognitive Stimulation
• Appetite Stimulation
• Sedation
• Consider stopping
• Caffeine
• Alcohol
• Side effects
• Sexual

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Refer where

• Manic symptoms emerge
• Need to augment
• Antidepressant combination
• Mood stabilizers
• Antipsychotics
• Psychotherapy
• Possible ECT

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