Drugs used for recurrant depressive episode:
A i.e. Imipramine There is no ideal antidepressant. First choice is determined by side effect profile least objectionable to patient's physical status, severity of disorder including self harm, patient preference & nature of any associated illnessQ In recurrent depression, continuation treatment of choice will be which ever (any) antidepressant has been effective & well toleratedQ. Guidelines for medical management of (unipolar) major depression Objective of treatment is remission of symptoms, not just symptom reduction as patients with residual symptoms are more likely to experience relapse or recurrence. Significant therapeutic effect may take 3-4 weeks although some may be seen earlier. Most common mistake 1/t unsuccessful trial is the use of too low a dosage for too sho time. An antidepressant need to be continued for a minimum duration of 6 weeks (oxford) /4-5 weeks (kaplan) at adequate or high dose before being considered as unsuccessful. If not responding, plasma conc. of drug is obtained at 2 or 3 weeks to find out non compliance or unusual pharmacokinetics. There is no ideal antidepressant. First choice is determined by side effect profile least objectionable to patient's physical status, severity of disorder including self harm, patient preference & nature of any associated illnessQ Since SSRIs are comparatively free of side effects and are not costly, they are generally recommended as first choice antidepresantsQ. Where there is a previous h/o response to a specific drug or class, the best first choice is that antidepressantQ. Symptom pattern and therapeutic use of side effects (such as sedating amitriptyline for more anxious and more activating desipramine for psychomotor retardation) is not a good guide to treatment. Despite widespread use of SSRIs, there is no evidence that this class is more efficacious than TCA. Selecting second option: Switching to a new single treatment rather than augmenting is preferred after initial medication failure. Whereas augmentation is helpful with patients who have gained some benefit from initial treatment but who have not achieved remission. Switch should be to an antidepressant of a different class or to broad action SNRI. Lithium > thyroid hormone are best documented augmentations. For non responsive & resistant cases not responding to Li or thyroid hormone variety of other augmenters such as tryptophan, pindolol, buspirone, and combinations of antidepressants such as SSRIbupropion (widely used), SNRI-mitrazepine, TCA-MAOI may be tried. ECT is an alteranative 2^d choice in very severe depression or for repeatedly non responsive cases. Begin new medication at 1/3 to 1/2 target dose if drug is TCA, bupropion, venlafaxine or mitrazapine, or full dose as tolerated if drug is an SSRI. For sedative ADD, administration of 2/3 of drug dose at night may avoid hypnotic. Bed time doses of stimulant anti depressant (ADD) such as SSRIs and older MAOIs should be avoided. ECT may be used as 1s, choice treatment in severe depression with psychomotor retardation or mood congruent depressive delusions, or where an antidepressant has failed, and for moderately severe depressions which have not responded to 1 or 2 courses of AD.UK-NICE recommend its use only to achieve rapid improvement where other treatment has failed or the condition is potentially life threatening, in severe depression, catatonia & prolonged or severe mania. Antidepressant or Li are advisable after ECT. Patient should be completely free of residual symptom for atleast 4 months before AD is withdrawn. Withdrawal should be slowly over 2-3 months, to minimize the risk of relapse & withdrawal symptoms (oxford). AD treatment should be maintained for atleast 6 months or length of previous episode, whichever is greater. Prophylactic treatment is effective in reducing the number & severity of recurrences. (Kaplan). Continuation treatment for 9-12 months should be routine following response to acute treatment. Full dose should be resumed, f/b continuation for fuher 912 months if depressive symptoms return (relapse). Several recurrences (>2 in last 2 years or >3 in 5 yrs) require maintenance treatment for 2 to 5 years or even life long where 2 or 3 attempts to withdraw have been followed by another episode within year Maintenance treatment of choice will be whichever antidepressant has been effective and well toleratedQ Condition Preferred antidepressants (AD) Atypical depression (hysteroid dysphoria) MAOIs or SSRIs or bupropion Melanocholic AD with dual action on both depression serotonin & noradrenergic receptors (SNRIs) Psychotic - Antidepressant SNRIs or TCA (delusion) rather than SSRIs and an depression atypical antipsychotic combinationQ - ECT is perhaps more effective than pharmacotherapy - Antipsychotic alone is not adequate and it is refractory to psychotherapy Seasonal Light (photo) therapyQ Winter depression Suicidal risk Requires consideration of lethality of AD in over dose. So SNRIs & TCA should be avoided. SSRIs & most new drugs are comparatively safe in overdose, with careful monitoring for increased risk early in treatmentQ Elderly SSRIs & newer AD are preferable to TCAQ Children & adolescents AD are not first choice, psychological therapy is preferred. In non improving & severe depression, SSRIs (fluoxetine is best) preferred. For adolescents, combination of SSRIs with CBT is useful. Pregnancy & TCA is safe. Lithium & Lactation anticonvulsants carry risk of foetal malformation & are contraindicated in the early months of pregnancy. Cardiac SSRI or other new non TCA? problems non-SNRI antidepressant is indicated. MAOIs lower BP as dose related effect & should be avoided. T/t of depression after MI enhance survival Epilepsy Only AD established not to be epileptogenic are older MAOIs Depression SSRIs, SNRIs or clomipramine with OCD are preferable to noradrenergic AD Depression with panic disorder TCA and SSRIs Depression Abstinence often results in with remission in substance induced substance abuse mood disorder
Imipramine
Carbazepine
None
Na valproate