Treating Depression

Depression has a 6-month prevalence of 5.8 percent and a lifetime prevalence of 17%. Three fourths of patients with depression improve with therapy.

Diagnosis: Clinical evaluation should identify characteristics of depressed mood, loss of interest in usually pleasurable activities, and history of past depression. Insomnia, hallucinations, suicidal ideation and planning, or alcohol and drug abuse should be sought. Symptoms may also include guilt feelings, thoughts of worthlessness, energy changes/fatigue, concentration/attention impairment, and appetite/weight changes.

Family history may reveal depression, suicide, or drug or alcohol abuse.

Suicide risk: The risk of suicide is higher in depressed patients who are divorced or widowed, elderly, white, male or living alone, and in those with chronic medical illness or psychotic symptoms.

Laboratory evaluation may include a complete blood cell count, chemistry panel, thyroid stimulating hormone, and glucose. An electrocardiogram is recommended if the patient is more than 40 years of age.

Treatment of depression: Since all antidepressants are effective, selection of a drug is based on considerations of safety, tolerability, cost, and convenience of dosing.

Selective serotonin reuptake inhibitors

Drugs of choice for the treatment of major depressive disorder are the selective serotonin reuptake inhibitors (SSRIs), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), because they have favorable safety profiles and are easy to administer. They are not lethal in overdose, and patients are less likely to discontinue treatment because of adverse effects.

Side effects of SSRIs. Nausea, common during the first week, tends to wane as the patient develops tolerance. Fluvoxamine (LuVox) may cause less nausea. Insomnia can be a problem with SSRIs; therefore, these activating antidepressants are usually administered in the morning.

Patients taking sertraline and paroxetine might experience considerable improvement in sexual function with scheduled weekend drug holidays. Anorgasmia may be managed by dosage reduction, treatment with cyproheptadine, or prescribing a different antidepressant, such as bupropion (Wellbutrin).

Mixed serotonin-norepinephrine inhibitors

Tricyclic antidepressants (TCAs) and SSRIs are equivalent in efficacy for the treatment of depression. Anticholinergic effects, weight gain, sedation, and orthostatic hypotension are most troubling with amitriptyline, clomipramine, doxepin, imipramine, and trimipramine. Amoxapine, desipramine, maprotiline, nortriptyline and protriptyline cause less sedation and fewer anticholinergic effects.

TCAs are toxic in overdose, and patients at risk for suicide must be given limited amounts to avoid the potential for suicide. A lethal TCA dose for an adult is only three to five times the therapeutic dose, or a 1-week supply of the antidepressant.

Venlafaxine ( Effexor) is effective in treating severe, melancholic depression that has been unresponsive to other agents. Hypertension has been reported; therefore, this drug is usually reserved for patients unresponsive to first-line antidepressants.

Mixed serotonin effects

Trazodone ( Desyrel) is very sedating, which can be beneficial for insomnia caused by depression. It is sometimes used along with an SSRI in patients who have difficulty sleeping. It has fewer anticholinergic side effects than many of the TCAs, but it can cause postural hypotension, and it has been associated with priapism.

Nefazodone ( Serzone) is related to trazodone, but appears to have a more favorable side-effect profile. Sexual dysfunction has not been reported.

Mixed norepinephrine-dopamine reuptake inhibitors

Bupropion ( Wellbutrin) has similar efficacy to that of the SSRIs and TCAs, and efficacy has been shown in patients previously unresponsive to TCAs. Side effects can include agitation and insomnia, psychosis, confusion, and weight loss. Bupropion is contraindicated in patients with seizure disorders.

Adjunct therapy: Combined treatment may be beneficial in patients with incomplete response to a single antidepressant. A low-dose TCA or trazodone is often used along with an SSRI. Triiodothyronine may increase the efficacy of antidepressants.

Rate this:

2.5

The nicest compliment that you can give me is to to subscribe to the Dental Blogging Newsletter. Thanks for visiting!