RISK FACTORS: Females more likely to develop depressive illness than males, Strong family history (depression, suicide, alcoholism,other substance abuse), Presence of chronic disease, especially multiple diseases, Migraine headaches, Chronic pain
GENERAL MEASURES :
β’ Psychotherapeutic interventions act synergistically with pharmacologic therapy
β’ Psychotherapy alone is effective and appropriate for milder forms of depression
β’ Use the correct medication
β’ Use the correct dosage
β’ Use the correct medication long enough
β’ ECT can be very effective in refractory cases
DRUG(S) OF CHOICE :
All of the below listed medications are equally efficacious for depression. Selection is based on side effects
profile.
. Polycyclic (mostly tricyclic [TCAs]) antidepressants with sedating properties (also have anticholinergic properties, potential for fatal overdose):
. Amoxapine (Asendin) 50-400 mg/day in divided doses. Maximum hs dose 300 mg
. Amitriptyline (Elavil, Endep) 150-300 mg/day qhs
. Maprotiline (Ludiomil) 75-225 mg/day. Useful with associated anxiety.
. Mirtazapine (Remeron) 15-45 mg/day at hs
. Nortriptyline (Pamelor, Aventyl) 75-150 mg/day qhs (a metabolite of amitriptyline)
. Doxepin (Adapin, Sinequan) 150-300 mg/day qhs
. Trimipramine (Surmontil) 75-250 mg/day qhs
. Trazodone (Desyrel) 150-300 mg/day qhs
. Polycyclic antidepressants with activating properties (also have anticholinergic properties, insomnia, anxiety,
potentially fatal overdose):
. Imipramine (Tofranil) 150-300 mg/day
. Desipramine (Norpramin, Pertofrane) 150-300 mg/day
. Protriptyline (Vivactil) 30-60 mg/day
. Selective serotonin reuptake inhibitors (can cause insomnia, anxiety, appetite suppression, sexual dysfunction [a common reason why patients discontinue their use]; overdose less likely to be fatal):
. Fluoxetine (Prozac) 20 mg/day q am
. Sertraline (Zoloft) 50-100 mg/day q am
. Paroxetine (Paxil) 10-30 mg/day q am
. Citalopram (Celexa) 20-40 mg q am
. Escitalopram (Lexapro) 10-20 mg q am (metabolite of citalopram)
. Others:
. Venlafaxine (Effexor) 75-100 mg/day in divided doses. Increases effective serotonin and norepinephrine;
can cause insomnia, anxiety, anorexia.
. Bupropion (Wellbutrin) 100-450 mg/day in divided doses (catecholamine reuptake inhibitor); seizure risk in higher doses, minimal risk of sexual dysfunction
ALTERNATIVE DRUGS :
β’ Clomipramine (Anafranil) 100-250 mg/day (although primarily used to treat obsessive-compulsive disorder)
β’ Fluvoxamine (Luvox) 100-300 mg/day in divided doses. Indicated for obsessive-compulsive disorder.
β’ MAO inhibitors - signifi cant drug and food interactions limit their use, but can be useful in refractory cases
β’ Hypericum perforatum (St. Johnβs Wort) maybe useful in mild depression, avoid simultaneous use of SSRIs or
MAO inhibitors
PATIENT MONITORING :
β’ See patient within 2 weeks after starting medication. The patient will probably not feel greatly improved at
this visit.
β’ During followup visits evaluate side effects, dosage and effectiveness of the medication
β’ Follow about every 2 weeks until improvement begins. If treatment is adequate, the depression should improve within 4 weeks of initiating treatment.
β’ Follow every 3 months thereafter
β’ Explain to the patient that the treatment must continue even after improvement
β’ Plan to treat at least 6 months to 2 years. Longer in patients with family history of depression and the very
young.
β’ The quality of the relationship (therapeutic alliance) between the patient and the health care professional is
important in the overall success of treatment of depression
POSSIBLE COMPLICATIONS :
β’ Suicide
β’ Failure to improve
EXPECTED COURSE/PROGNOSIS :
β’ This is one of the most rewarding conditions to treat because once you fi nd the right drug, the right dose,
and have a positive relationship with the patient, improvement is likely
β’ Anticipate recurrences