Prophylaxis Discussing prevention of relapse or recurrence of major depression is beyond the scope of this paper but is clearly important. Long-term use of antidepressants is sometimes necessary particularly if patients have two or more episodes. Compliance becomes absolutely necessary, but side effects often cause patients to stop taking medications. Tricyclics and, to a lesser degree, traditional monoamine oxidase inhibitors (MAOIs) have many side effects because they act on the muscarinic, ... Read More

Less common approaches. Many less commonly used antidepressant therapies are supported by anecdotal evidence only. They include light therapy (non-seasonal affective disorder), high-dose TCA or MAOI therapy (only if serum levels can be monitored), intravenous clomipramine or maprotiline (allows for rapid perfusion, avoids first pass liver metabolism), bromocriptine, high-dose selegiline, and psychosurgery. Modern stereotaxic psychosurgical procedures offer symptom relief with minimal risk, and reports of large trials indicate that up to ... Read More

Common strategies for treatment resistance. Electroconvulsive therapy An important and effective treatment for depression, electroconvulsive therapy (ECT) is effective in about 90% of cases of major depression. The success rate drops when it is used for drug-refractory cases. Using ECT depends on patient-related factors: it clearly is the treatment of choice for depression with psychomotor slowing, stupor, psychotic symptoms, or depression requiring rapid response because of suicidal risk or malnutrition. Use of ... Read More

If lithium augmentation is ineffective, it should be discontinued and the antidepressant changed (Table 5). A lack of response to one of the newer agents in a class, such as the selective serotonin reuptake inhibitors (SSRIs), does not predict lack of response to others in that class. If the first drug used was a reversible inhibitors of monoamine oxidase A (RIMA) with only one drug in the class, the ... Read More

Major depression is best managed through a treatment algorithm. The more resistant to treatment a patient's illness is, the further treatment proceeds through the steps. As each trial of therapy is deemed ineffective, diagnosis should be reviewed and physical and psychosocial factors reassessed before making a decision about the next step. Psychotherapy is an essential accompaniment to any form of somatic treatment. Supportive psychotherapy offers reassurance and time for patients ... Read More

Are there underlying physical factors? Many physical diseases present with depressive symptoms or complicate depressive illness (Table 2). Some of these illnesses remain undetected for years and account for an apparent treatment-resistant depression (TRD). Normal thyroid function is particularly important; even mild or subclinical hypothyroidism can impair response to antidepressants. Hypothyroidism can be induced by lithium therapy, and many drugs, both medical and nonmedical, can cause depression or complicate treatment (Table ... Read More

Diagnosis of uncomplicated anxiety disorders may be made by competent physicians in many specialties who have a thorough understanding of the etiology, signs and symptoms, impact and treatment of anxiety disorders. The accepted guidebook in making a diagnosis is the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). However, as mentioned earlier, psychiatrists have the most expertise in diagnosing and treating anxiety disorders, and in some cases may ... Read More

Nearly one-half of patients with panic attacks do not seek care for their problem. Patients may endure symptoms for years before they seek treatment. For others, it may take years for their symptoms and disorder to be correctly diagnosed and adequately treated. One study reported that it routinely takes more than 10 years for the correct diagnosis of an anxiety disorder to be made.Early studies found that 70% of patients ... Read More

Where Patients Seek Treatment A large number of patients with an anxiety disorder never seek treatment. These reasons will be discussed in depth in the next section. Those who do seek help often turn to practitioners in acute care clinics or emergency departments. As many as 28% to 57% of patients with panic attacks will seek treatment in the emergency room of a hospital. This is the most logical place for ... Read More

The American Psychiatric Association (1983) reports that recurrent episodes occur in at least 50% of patients who seek treatment for major depressive disorder (MDD). Most studies, though, have examined only single occurrences. To help describe the episodic nature of MDD, the National Institute of Mental Health initiated the Collaborative Program on the Psychobiology of Depression, a prospective, naturalistic, longitudinal investigation. This program's early research found the cumulative probability of recurrence ... Read More