Depression Symptoms Treatment

All antidepressants are indicated for the treatment of acute major depressive episodes; there is also evidence for their use in the prevention and relapse and recurrence. In addition, a number of more minor forms of depression may also respond to antidepressant medication, including dysthymic disorder, minor depression, and recurrent brief depression.

All antidepressants appear to treat more than depressive disorders. Particularly consistent have been data showing their utility for anxiety disorders; they have begun to supplant the sedative/hypnotics for these conditions. Many other psychiatric and medical disorders have all been successfully treated with these agents.

Panic Disorder (PD)

Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line treatment for anxiety disorders, with good evidence of efficacy in panic disorder. Patients are begun at low doses (e.g., 5mg of fluoxetine), and increased slowly to an effective dose to minimize potential side effects. There is also strong evidence for the use of tricyclic antidepressants (TCAs) and moderate evidences for the use of monoamine oxidase inhibitors (MAOIs).

Obsessive-Compulsive Disorder (OCD)

Selective serotonin reuptake inhibitors (SSRIs) show strong evidence of effectiveness in the treatment of obsessive-compulsive disorder and are considered the first-line treatment option in this disorder; all agents appear equally effective. The recommended starting dose is the same as that for depression, although higher doses (60-80 mg of fluoxetine) may be required for adequate response. There is evidence for slow but continued improvement in symptoms for many months after initiation of treatment; medication should therefore be trialed for up to four months if the patient shows a partial response. There is also strong evidence for the use of the TCA clomipramide in this disorder. Augmentation with lithium may be beneficial in partial responders.

Generalized Anxiety Disorder (GAD)

Several agents have shown efficacy in this disorder. Good evidence exists for the use of selective serotonin reuptake inhibitors (SSRIs), venlafaxine, nefazodone and mirtazapine. Both tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have also shown moderate effectiveness; MAOIs also show efficacy in other anxiety disorders.

Social Phobias and Posttraumatic Stress Disorder (PTSD)

Selective serotonin reuptake inhibitors (SSRIs) and venlafaxine have shown efficacy in social phobia (or social anxiety disorder); this condition may also be at least partially responsive to TCA medications. SSRIs have shown effectiveness in posttraumatic stress disorder (PTSD).

Bulimia

Selective serotonin reuptake inhibitors (SSRIs) are commonly used in the treatment of bulimia nervosa. As with obsessive-compulsive disorder (OCD), there appears to be a dose-response effect, with larger doses often required.

There is strong evidence for the use of tricyclic antidepressants (TCAs), either alone or in combination with cognitive therapy, to decrease the binging and purging of bulimic patients. Monoamine oxidase inhibitors (MAOIs) have also been reported successful in the treatment of bulimia, although the many dietary restrictions have made physicians reluctant to prescribe these agents.

Anorexia Nervosa

The American Psychiatric Association Practice Guidelines for Eating Disorders states that medications should not be used routinely for anorexia nervosa. They should be considered after weight gain and for persistent depression. A few published controlled studies show unimpressive results, and bupropion is contraindicated because of elevated seizure risk in patients with eating disorders.

Body Dysmorphic Disorder (BDD)

Selective serotonin reuptake inhibitors (SSRIs) have also shown efficacy in the treatment of BDD. It may be at least partially responsive to TCA medications, particularly those selective for serotonin. Moderate evidence exists for the use of monoamine oxidase inhibitors (MAOIs).

Premenstrual Dysphoria (PMDD)

PMDD is a chronic cyclical disorder in which serotoninergic function is reduced during the luteal phase. The treatment of choice is a SSRI; either sertraline or modified-release paroxetine, taken daily or only during the luteal phase. Treatment with sertraline should be initiated at a dose of 50 mg/day and if necessary increased in increments of 50 mg/day at each menstrual cycle to a maximum of 150 mg/day if taken every day or 100 mg/day if taken during the luteal phase only. The initial dose of modified-release paroxetine is 12.5 mg/day increasing to 25 mg/day after one week if necessary.

Intermittent dosing is usually as effective as continuous administration. Beneficial effects are seen within one to two days and response rates for improvements in mood and physical symptoms are about 50 to 60%. Evidence of long-term efficacy is lacking. Specialists recommend continuing treatment until the menopause as there is evidence that stopping treatment precipitates recurrence. Nevertheless, a trial period off treatment may be worthwhile after two years if supported by the patient.

Childhood Disorders

Tricyclic antidepressants (TCAs), especially imipramine, are indicated for the treatment of enuresis. Anxiety and phobias in children (such as separation anxiety or school phobia and ADHD) are responsive to TCAs.

Uses for selective serotonin reuptake inhibitors (SSRIs) in children include repetitive-type abnormalities associated with autism and mental retardation, ADHD (as an adjunct to methylphenidate), and chronic enuresis. Bupropion has been used successfully in the treatment of ADHD in both children and adults. It may, however, exacerbate tics in attention-deficit patients with concomitant Tourette’s syndrome.

Other Psychiatric Disorders

Other indications for selective serotonin reuptake inhibitors (SSRIs) may include depersonalization disorder, obsessive jealousy, pathological gambling, Tourette’s syndrome, hypochondriasis, and both paraphiliac and nonparaphiliac sexual disorders.

SSRIs have shown effectiveness in a number of more complex behavioral disorders such as obesity (particularly fluoxetine in higher doses), binge eating (sertraline), substance abuse, and to alleviate certain aggressive behaviors such as impulsivity and uncontrolled anger in adults, children, and the demented elderly.

Trazodone is frequently used as a sedative in the elderly; as it can cause or worsen orthostatic hypotension, blood pressure should be monitored when used in this group. In the demented elderly, trazodone is useful in treating behavioral disorders associated with dementia.

The sedative effect of trazodone makes it useful in weaning patients from benzodiazepines and other sedative drugs.

Nefazodone has shown efficacy in treating anxiety associated with major depression. Similarly, mirtazapine has shown efficacy in anxiety symptoms in general.

Other Medical Conditions

Migraine and cluster headaches have been responsive to both tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). Diabetic neuropathy and other pain syndromes such as facial pain, fibrositis, and arthritis have been responsive to both TCAs and SSRIs and the SNRI duloxe-tine. TCAs such as protriptylene have shown efficacy for sleep apnea. SSRIs have been used in the treatment of restless leg syndrome.

A full list of indications is shown in Table: Various Uses of Antidepressants.

Table: Various Uses of Antidepressants

Major Depression

— Acute depression

— Prevention of relapse

— Other depressive syndrome

—  — Bipolar depression

—  — Atypical depression

—  — Dysthymia

Other Uses

Tricyclic Antidepressants

Strong evidence

— Panic disorder (most)

— Obsessive-compulsive disorder (clomipramine)

— Bulimia (imipramine, desipramine)

— Enuresis (imipramine)

Moderate evidence

— Separation anxiety

— Attention-deficit/hyperactivity disorder

— Phobias

— Generalized anxiety disorder

— Anorexia nervosa

— Body dysmorphic disorder

— Migraine (amitriptyline)

— Other headaches

— Diabetic neuropathy, other pain syndromes (amitriptyline, doxepin)

— Sleep apnea (protriptyline)

— Cocaine abuse (desipramine)

— Tinnitus

Evidence for but rarely used for these disorders

— Peptic ulcer disease

— Arrhythmias

Monoamine Oxidase Inhibitors

Strong evidence

— Panic disorder

— Bulimia

Moderate evidence

— Other anxiety disorders

— Anorexia nervosa

— Body dysmorphic disorder

Atypical Agents

Trazodone

— Insomnia

— Dementia with agitation

— Minor sedative/hypnotic withdrawal

Bupropion

— Attention-deficit/hyperactivity disorder

Serotonin Reuptake Inhibitors

Strong evidence

— Obsessive-compulsive disorder (high-dose fluoxetine, sertraline)

— Bulimia (fluoxetine)

— Panic disorder

Moderate evidence

— Generalized anxiety disorder

— Obesity (high-dose fluoxetine)

— Substance abuse

— Impulsivity, anger associated with personality disorder

— Pain syndromes, including diabetic neuropathy

Preliminary evidence

— Obsessive jealousy

— Body dysmorphic disorder

— Hypochondriasis

— Behavioral abnormalities associated with autism and mental retardation

— Anger attacks associated with depression

— Depersonalization disorder

— Social phobia

— Attention-deficit/hyperactivity disorder (as an adjunct)

— Chronic enuresis

— Paraphilic sexual disorders

— Nonparaphilic sexual disorders

Selective Serotonin Noradrenaline Reuptake Inhibitors

Duloxetine

— Moderate evidence

—  — Diabetic peripheral neuropathic pain

Venlafaxine

— Moderate evidence

—  — Generalized anxiety disorder

—  — Social phobia

—  — Panic disorder