Depression Symptoms Treatment
Archive for the ‘Pharmacotherapy’ Category
Questions
[1] Which of the following agents is contraindicated in a patient with epilepsy?
A. Bupropion
B. Fluoxetine
C. Mirtazapine
D. Venlafaxine
[2] The antidepressant action of imipramine is thought to be caused by which of the following?
A. Blockade of prejunctional α2-adrenoceptors
B. Blockade of prejunctional neuronal norepinephrine and serotonin uptake transporters in the CNS
C. Increased numbers of β-adrenoceptors
D. Inhibition of monoamine oxidase
[3] Which of the following antidepressant agents inhibits hepatic microsomal enzymes to cause clinically significant drug-drug interactions?
A. Fluoxetine
B. Imipramine
C. Phenelzine
D. Trazodone
Answers
[1] A. Bupropion causes seizures in a small but significant number of patients. This number is reduced with use of the slow-release form.
[2] B. Imipramine and other TCAs block prejunctional neuronal norepinephrine and or serotonin uptake transporters in the CNS. Phenelzine and tranylcypromine inhibit monoamine oxidase. The heterocyclic agent mirtazapine blocks prejunctional α2-adrenoceptors to enhance serotonin and norepinephrine Read more [...]
Class
Drugs used to treat depression are classified as TCAs, atypical heterocyclic (second- and third-generation) agents, SSRIs, and monoamine oxidase inhibitors (MAOIs). Other conditions for which certain antidepressant agents are used include panic disorder, obsessive-compulsive disease (OCD), bipolar affective disorder, chronic pain, and enuresis.
SSRIs are the most extensively prescribed antidepressant agents because, unlike tricyclic and heterocyclic agents, they produce less sedation, have fewer antimuscarinic cholinoreceptor effects, and are safer in overdose. Nevertheless, they may cause sexual disturbances, GI dysfunction, headache, and stimulation (insomnia, tremor, and anxiety). TCAs may cause sedation, tremor, insomnia, blurred vision, constipation, urinary hesitancy, weight gain, and sexual disturbances. The MAOI phenelzine may cause weight gain, sexual disturbances, and sleep disturbances. The adverse effects of heterocyclic agents vary depending on the agent. Bupropion is contraindicated in patients with seizure disorders (Table Antidepressant agents).
Table: Antidepressant agents Read more [...]
A 30-year-old woman presents to your office for the evaluation of fatigue. For the past 2 months she has felt run down. She says that she doesn't feel like participating in activities that she previously enjoyed, such as her weekly softball games. She has not been sleeping well and has not had much of an appetite. On questioning, she admits to feeling "down in the dumps" most of the time and has found herself crying frequently. She has never gone through anything like this before. She denies any thoughts of wanting to hurt herself or anyone else. Other than becoming tearful during her interview, her physical examination is normal. Her blood tests, including a complete blood count and thyroid function, are normal. A serum pregnancy test is negative. You diagnose her as having a major depression and, along with referring her for counseling, start her on fluoxetine.
What is the mechanism of action of fluoxetine?
What are the common side effects of fluoxetine?
Answers to case: Antidepressant agents
Summary: A 30-year-old woman with major depression is prescribed fluoxetine.
Mechanism of action of Read more [...]
Results from a recent study suggest that olanzapine (Zyprexa) given in moderate to high doses may be useful in treating schizophrenia in patients who have shown resistance to trials with other antipsychotic medications.
Published in the September 1999 issue of the Canadian Journal of Psychiatry, the prospective, open-label study by Serdar Dursun et al. reported on 16 patients (11 male, five female; mean age 40±7 years) having a documented history of resistance to treatment. Dursun is associate professor and head of clinical pharmacology and experimental psychiatry in the department of psychiatry's psychopharmacology research unit at Dalhousie University, Halifax, Nova Scotia, Canada.
Patients in the study were consecutive outpatient referrals who had shown poor response to antipsychotic treatment. All patients met the DSM-IV criteria for schizophrenia (mean duration of illness was 16±7 years) and scored at least 45 on the 18-item version of the Brief Psychiatric Rating Scale (BPRS) at baseline. Researchers defined treatment resistance by the following criteria: no significant symptomatic relief Read more [...]
Atypical Antipsychotics
Most initial published data on atypical antipsychotic drugs in the elderly are clinical trials in nondemented patients with schizophrenia or Parkinson's disease. In the last two to three years, controlled trials evaluating risperidone (Risperdal) and olanzapine (Zyprexa) in patients with dementia have been published. There is now evidence that these two atypical antipsychotic drugs offer efficacy in this patient population with fewer adverse effect concerns than the typical antipsychotic drugs.
Risperidone (Risperdal). In 1999, Katz et al. published the first large multicenter, double-blind, placebo-controlled study of risperidone in treating psychosis and behavioral disturbances in an elderly demented population. Among the 625 patients, 73% had a diagnosis of Alzheimer's disease; average age was 83 years; and their mean baseline Mini-Mental State Examination (MMSE) score was 6.6+6.3, indicative of the most severe stages of dementia. In this 12-week trial, patients received either placebo or risperidone 0.5 mg, 1 mg or 2 mg daily. At endpoint, significantly greater reductions Read more [...]
Patients with dementia display a broad range of cognitive impairments and behavioral and psychotic symptoms. Common behavioral symptoms include verbal and physical aggression, hyperactivity, disinhibition, and pacing and wandering; common psychotic symptoms include paranoia, delusions and hallucinations. These behavioral and psychotic symptoms are the leading cause for the use of more restrictive supervised environments, including institutionalization.
Effective pharmacologic and nonpharmacologic treatment of these symptoms is desirable and, in addition, might delay nursing home placement. Pharmacologic and nonpharmacologic interventions are indicated based upon consideration of the safety of both the patient and those around them. Conventional antipsychotic drugs have limited value for psychotic and behavioral symptoms, but recently the results of several large controlled trials of atypical antipsychotic drugs have become available.
Conventional Antipsychotics
The use of conventional antipsychotic drugs in patients with dementia has a long history of concerns regarding limited efficacy as well Read more [...]
Major depression affects 5% to 10% of patients seen by primary care physicians. Despite the advent of new antidepressant drugs, up to 20% of patients remain fully resistant to treatment and a further 20% to 30% only partly respond to treatment. Therapy should aim at eradicating depressive symptoms completely (i.e., complete remission) because incomplete recovery is associated with continued functional impairment and a greater risk of relapsing to full-blown depression. One way to approach treatment of major depression is through the mnemonic, OSCAR, which highlights the five steps for treating depressed patients: Optimization, Substitution, Combination, Augmentation, and Review. While optimization is always the first step, there is no clear consensus on what the next step should be if optimization fails.
Quality of evidence
Relevant articles were identified by MEDLINE search from 1966 to January 1999. MeSH headings included depression, combination, augmentation, lithium, triiodothyronine, pindolol, buspirone, methylphenidate, and electroconvulsive therapy (ECT). The search was limited Read more [...]
Though panic disorder and panic disorder with agoraphobia or phobic avoidance (PDA) are common (the mean lifetime prevalence of panic disorder is 1.5%), the diagnosis is frequently missed: 70% of patients with PDA in one large study had more than ten medical consultations before receiving the correct diagnosis and treatment.
The "classic" presentation of panic disorder consists of sudden, unexpected, discrete attacks of intense fear or discomfort without a recognizable precipitant, accompanied by at least four of the following symptoms during at least one of the attacks: dyspnea or smothering sensations; dizziness, unsteadiness, or faintness; palpitations or tachycardia; trembling or shaking; sweating; choking; nausea or abdominal distress; depersonalization or derealization; numbness or paresthesias; flushes or chills; chest pain or discomfort; fear of dying; and fear of going crazy or doing something uncontrolled. Panic disorder, however, frequently occurs with symptoms referable to only a single organ system. Such single system presentations include chest pain and dyspnea (33% to 59% of patients Read more [...]
Over the years, most of the research into the pharmacotherapy of major depression has focused on the treatment of the acute depressive episode. There is a vast literature which documents the efficacy of the tricyclic antidepressants, monoamine oxidase inhibitors and, more recently, the serotonin reuptake inhibitors in the acute management of unipolar major depressive disorder. Recently however, there has been an effort to define particular subtypes of major depression which may predict response to specific classes of antidepressants. Second, there has been an increasing recognition of the chronic and recurrent nature of unipolar affective illness so that studies have addressed issues such as the longitudinal natural course of the disorder and long term pharmacotherapy to prevent relapse and recurrence of episodes.
The antidepressant treatment of major depression has been divided into three components (Prien and Kupfer 1986; Quitkin et al 1976). The first, acute treatment, involves the use of antidepressants to control the acute symptoms. The second, continuation treatment, is predicated Read more [...]