Depression Symptoms Treatment

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Specific approaches to treatment-resistant depression

A stepped-care approach should be used to manage depression. Figure 1 summarizes the various steps and provides family physicians with a rational approach to case management.

Figure 1. Approach to managing depression

The more resistant to treatment a patient’s illness is, the further the physician will proceed down the flow chart, reaching a point where referral to a specialist becomes necessary. The point of referral will depend on the family physician’s knowledge and clinical expertise. In a stepped-care approach, it is important to remember that, as each treatment is deemed ineffective, the diagnosis should be reviewed and physical and psychosocial factors reassessed. Subtyping depression will help to determine when a tricyclic should be switched to an MAOI or ECT considered. Augmentation strategies can also be considered (Table 5). The role of psychotherapy is extremely important and needs to be emphasized. Psychotherapy is an essential accompaniment to any form of somatic treatment and includes reassurance, time for abreaction, support, and education. Destructive habits, guilt, low self-esteem, and anger are some of the many psychological issues that need to be addressed.

Lithium augmentation. If a patient fails to respond to an adequate course of an antidepressant, the most reasonable next step is lithium augmentation. This technique converts approximately 30% to 50% of nonresponders to responders and seems to work with all the antidepressants, including the MAOIs. Lithium has an antidepressant and mood stabilizing effect when used alone. It also has the ability to enhance postsynaptic receptor sensitivity. With lithium augmentation, the antidepressant is continued without dose reduction and lithium is initiated in a dose of 300 mg three times a day. If it works, a positive response can be seen in 5 to 12 days. The patient should be kept on lithium for a minimum of 6 months or, in some cases, for the duration of antidepressant therapy. Lithium levels should be monitored and the dose adjusted as necessary.

Trial of a second antidepressant.If lithium augmentation is ineffective, the lithium should be discontinued and the antidepressant changed. A serotonergic antidepressant should be changed to a noradrenergic one or vice versa. Table 6 lists the relative serotonergic and noradrenergic properties of antidepressants (for tricyclics, this is a guide only). The use of fluoxetine or fluvoxamine or sertraline might be considered because of their selective serotonin reuptake-inhibiting properties. An adequate trial of fluoxetine takes 5 weeks. If atypical symptoms, such as panic attacks or anxiety, are present, MAOIs can be considered after a suitable wash-out period for the previously used antidepressant. If the second antidepressant is ineffective, lithium augmentation should again be tried before the antidepressant is changed.

Relative serotonergic and noradrenergic properties of antidepressants

Electroconvulsive therapy. For depression, ECT is a very important and effective treatment. It can be effective in about 90% of cases of major depression, although the success rate drops considerably in drug-refractory cases. The appropriateness of ECT depends on several patient-related factors. It is clearly the treatment of choice for depression with psychomotor slowing, stupor, psychotic depression, or depressive states in which a rapid response is necessary because of suicidal ideation or malnutrition. Its use should be considered whenever therapeutic management is reviewed and about to be changed.