Depression and Its Treatment

Les Secrest, M.D.

• Worldwide Depression accounts for a high level of disability and

decreased functioning

Depression is a frequent occurrence with approximately

20% of the population affected by Depression

• Depression is more frequent in women than in men.

• Suicide is greater in men than women.

• Suicide attempts are greater in women than in men

Consider The faces of 20% of the population with Depression

Consider The woman who has recently

given birth to her child and has post partum depression

Consider The alcoholic who drinks constantly or episodically and is depressed

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

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

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

Consider The person with somatic complaints and few confirming findings

Depression Disorders Reviewed

1. Major Depressive Disorder– Single Episode– Recurrent

2. Dysthymic Disorders3. Bipolar Disorder

– Most recent episode Depressed– Most recent episode Mixed

4. Mood disorder due to a medical condition

5. Substance induced mood disorder

Major Depressive Episode is Characterized by:

1. Either depressed mood or loss of interest or pleasure

2. Weight change3. Change in sleep patterns4. Psychomotor agitation on

Major Depressive Episode is Characterized by:

5. Fatigue6. Feelings of worthlessness/

excessive inappropriate guilt7. Decreased Concentration8. Recurrent thoughts of

death/suicide.

AntidepressantsConsidered -

• Tricyclic Antidepressants have safety issues in overdose situations

• New generation – Safer profile with overdose

Antidepressants Considered -

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

Star*DLevel 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 therapySertraline -17.6%Venlafaxine - 24%

Star*D

• Level III Non Remission– Monotherapy

• Noratriptyline – 19.8%/12.4%• Mirtazapine - 12.3%/80%

– Augmentation• Lithium• T3 Thyroid Hormone

• Mirtazapine/Remeron1. Antagonist of Presynaptic Alpha2

Adrenergic AutoreceptorsHeteroreceptors on Serotonin and Norepinephrine Neurons

2. Antagonist postsynaptic serotonin 5-Ht2

and 5-Ht 3 Receptors

3. Inhibits the release of corticotropin – releasing hormone

• Nortriplyline1. Inhibits Nonepinephrine Transporter2. Antagonizes Serotonin 3

3. Modestly inhibits Gaba Transporters4. Mild inhibition of Seratonin Transporters

Star* D Study

(Sequenced treatment alternatives to relieve depression)

- Illustrated that we should:

1. Continue citalpram/Celexa for eight weeks2. Use rating scales routinely to monitor

response to treatments

Treatment

Highest treatment response rated thought to be related to

medication and cognitive therapy

Cognitive Therapy

1. Stimulus2. Perception3. Process4. Response

Treatment of Depression1. Use any antidepressant2. Consider antidepressants

Cognitive StimulationAppetite StimulationSedation

3. Consider stopping• Caffeine• Alcohol

4. Side effects• Sexual

Refer where

• Manic symptoms emerge• Need to augment

– Antidepressant combination– Mood stabilizers– Antipsychotics

• Psychotherapy• Possible ECT