Depression Symptoms Treatment

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October 17, 1956

We should like to discuss several aspects of the problem from a clinical point of view, namely, what kind of drugs should be selected for treatment, indications for the use of tranquilizing drugs, the question of dosages, and how long treatment should be continued. It also would be important to assay our present knowledge regarding the therapeutic efficacy of the drugs now available and what we are able to hope for with compounds which will be introduced in the future. It is important to discuss the side effects of some of these drugs, place them in proper perspective, and appraise them in relationship to what they are accomplishing.

The selection of drugs to be used for treatment is still largely made on the basis of the clinician’s preference rather than on clear-cut indications. Nevertheless a few observations have now crystallized even though no final judgment is permissible at present. In small numbers of psychotic patients intensively investigated and in large numbers of psychotic patients treated in state hospitals, it has been found that chlorpromazine acts more quickly than the Rauwolfia preparations. Therefore, it is preferred in the treatment of an acute mental disorder to reduce excitement or a state of agitation. It can be stated that chlorpromazine, when given orally is more effective in this group of patients than reserpine. If treated with reserpine, patients in an acute psychotic break usually need injections of the compound in the first phase of the treatment. Later on they can be switched to oral medication. Those patients treated only orally with reserpine do not fare as well as those treated orally with chlorpromazine.

Investigations are going on to determine which compound is most effective in patients when the medication is given in a non-acute phase of the disorder. No final decision has been reached in determining whether or not chlorpromazine is superior to Rauwolfia. My personal feeling is that Rauwolfia has a more limited range of application than chlorpromazine and that more patients respond favorably to chlorpromazine than to the Rauwolfia preparations. On the other hand it should be stated that chlorpromazine has more side-actions than the Rauwolfia drugs. This will have to be considered clinically in treating certain patients where it is suspected that there may be some complication, although today it is difficult to know how a patient will respond to a compound. However, we do have some observations. For instance, if we know that a patient has liver involvement or gallbladder disease, we would not want to expose the patient to chlorpromazine because of the possible development of jaundice. In such patients reserpine would be preferable.

It is undeniable that some patients respond better to one drug than to another but we have no clinical evidence yet as to why this is so. In other words, after examining the patient, we are unable to determine to which tranquilizing drug he will respond better. We speak here of individual responses and not on a statistical basis. Statistics indicate that chlorpromazine is probably the most effective drug in our hands today that is used in psychotic patients. This is followed by reserpine. The other available compounds such as Frenquel, Miltown, etc., are far less effective in psychotic patients than chlorpromazine or reserpine. Sparine or promazine is now under investigation and is effective in a number of patients but apparently it is milder in action than chlorpromazine.