Depression

Recurrent Depressive Disorder is the most common mood disorder and approximately 8 percent of the population will experience at least one episode of depression over a lifetime. People that have depression will tend to have some family history. Depressive episodes can occure either on their own or in reaction to life events. These issues are not particularly predictive as to whether a person will benefit from medication or not. Whichever anti-depressant is used initially, it is likely to have about a 65 percent change of relieving symptoms. If it is necessary to try a second agent, it again has about a 65 percent likelihood of being able to relieve symptoms.

Selective Serotonin Reuptake Inhibitor anti-depressants (SSRI) include Prozac, Paxil, Zoloft, Celexa, Lexapro and Luvox. These drugs have a low incidence of side effects, which include gastrointestinal disturbance in the first few days of taking the medication and some people will experience some sexual side effects, which typically are most useful to discuss at the follow-up visit. Less commonly, some people will experience some agitation while using these medications. If that hasn’t cleared within a few days, it is frequently a reason to discontinue the medication. Of these drugs, Luvox is generally dosed at bedtime. The others are generally dosed in the morning. It is frequently recommended to take these medications with food to help mitigate any stomach upset. Prozac is a very long-acting medication and Paxil is a relatively short-acting medication. As it relates to this characteristic, often when people are stopping Paxil they experience a serotonergic withdrawal syndrome and so, it may be necessary to taper the drug gradually.

Wellbutrin is an anti-depressant that works on dopamine and may have some stimulating qualities and at worst, will produce some anxiety and/or agitation. This drug is associated with a loss of taste for cigarettes as well. At the top of its dose range, there is a slight increase risk of having seizures and so this drug is contraindicated in people who have a seizure disorder or have had an eating disorder.

Tricyclic anti-depressants were first introduced in the 1960’s. The ones that I would particularly mention are Desipramine and Nortriptyline for which blood levels are available. These drugs have what are called “anti-collinergic” side effects in which people commonly get dry mouth and sometimes get problems of constipation.

There are other anti-depressants worth mentioning. Remeron is particularly helpful for anxiety and insomnia, but has had the side effect of increased appetite and weight gain. Effexor works on both norepinephrine and serotonin, but usually requires an extended discontinuation to mitigate serotonin withdrawal syndrome. Missing doses may trigger nausea. Cymbalta also works on both of these neurotransmitters. EMSAM (selegiline patch) is a monoamine oxidase inhibitor (MAO-I) anti-depressant without dietary restriction for its 6 mg. dose. It works on dopamine as well as serotonin and norepinephrine.

An augmentation strategy is sometimes necessary in anti-depressant treatment. Buspar is frequently added to an SSRI type anti-depressant. Lithium or other mood stabilizing agents have at times been helpful to produce an enhanced anti-depressant response. At times, stimulants are added such as Ritalin (Methylphenidate) or Dextroamphetamine. There are times when thyroid may be added to a patient’s regime even though they are not hypothyroid and that may, as well, enhance a person’s response to anti-depressants. Some second generation anti-psychotic medications may also be used for augmentation. In addition to recurrent depressive disorder, there are depressions that are chronic in nature and respond to the aforementioned treatments.

There are times when people will have a protracted grief reaction in which they will respond well to anti-depressant treatment and there may be other adjustment disorder situations in which people have fairly intense depressive symptomotology. Again, these merit treatment with the aforementioned strategies. There is an unusual condition call Brief Recurrent Depression which seems to only respond to Lithium. Dysthymic Disorder has episodic bouts of depression that are usually triggered by conflict. It responds best to psychotherapy.

Feeling Good by David Burns, M.D. is very helpful for its cognitive behavioral approaches.