4. DEFINITION
“An affective disorder characterized by loss of interest or
Pleasure in almost all a person’s usual activities or
Past times.”
It may be an unipolar or biopolar disorder in which
cycles of mood swings from mania to depression occurs
over time.
SYMPTOMS:
• Sadness, Despair, Guilt
• Decrease in energy
• Decrease in sex drive
• Insomnia and fatigue
• Thoughts of death and suicide
• Mental slowing, lack of concentration
10. Mostly used.....
•The most widely prescribed medications for
depression are drugs in the SSRI category, such
as fluoxetine (Prozac), citalopram (Celexa), and
sertraline (Zoloft)
•These drugs correct chemical imbalances by
increasing the level of serotonin, a
neurotransmitter that affects mood, to the brain
•SSRIs are now considered to be frontline
pharmaceutical treatment for depression.
11. Drug Used In Depression
Sr.no Name of drug Class Dose and dosage
form
1 CYMBALTA
(Duloxetine HCl)
SNRI
(2004)
Tab, Cap:20-60 mg/day
2 LEXAPRO
(escitalopram oxalate)
SSRIs
(2002)
Tablets:5-20mg
oral solution:5mg/5mL
3 ZOLOFT
(sertraline HCl)
SSRIs
(1991)
Tab ,film coated:50-
200mg/day
4 PROZAC
(fluoxetine HCl)
SSRIs
(1986)
Tab:10-90mg/day
Oral:20mg/5mL
5 CELEXA
(Citalopram HBr)
SSRIs
(1998)
Tab:20-60mg/day
6 Xanax
(alprazolam)
Benzodiazepines
(1981)
Tab:0.25-4mg/day
12. TRIPLE REUPTAKE INHIBITORS
New class of psychoactive medications which
inhibit neuronal reuptake of 5-HT,NE and
dopamine.
These TRI’S may also have efficacy in obesity,
addiction and pain syndromes
TRI’s exert their activity by treating more
symptoms of MD and/or attenuate some side
effects observed for the traditional antidepressants
EXAMPLE:
BICIFADINE (approved tri)
13. St. Johns Wort
St. John’s Wort or Hypericum perforatum is a plant
which grows in the wild and is widely prescribed for
depression in Europe
Mechanism of action :
Partially understood but is similar to that of SSRI’s
• Clinical trials carried out have found it as
effective as a commonly prescribed antidepressant
• Combining antidepressants and SSRI’s leads to
serotonin syndrome
• It can induce metabolism of drugs like:
Cyclosporine, Digoxin, Warfarin, Birth control pills
,Indinavir etc.
15. A DRUG WHICH ACTS THROUGH
NON-MONOAMINERGIC SYSTEM
AGOMELATINE:
•In depression, sleep is greatly disturbed.
•Melatonin produced by the pineal gland is an
important regulator of circadian rhythms/sleep
cycle Chemically melatonin is N-acetyl-5-
methoxytryptamine.
•Agomelatine(naphthalene derivative of melatonin)
acts on both the melatonergic(MT1 and MT2)and
5HT2C receptors co-localized in the SCN of the
brain.
16. According to a recent study:
"The rate of treatment response following first-line
treatment with SSRIs is moderate, varying from 40
to 60 percent; remission rates vary from 30 to 45
percent. Up to one third of persons taking
antidepressant medications will develop recurrent
symptoms of depression while on therapy."
19. Advance therapy of depression
• AUGMENTATION
THERAPY:
• PSYCHOLOGICAL
THERAPY:
-Supportive Therapy
-Interpersonal Therapy
-Cognitive Behavioral Therapy
(CBT):
a. Cognitive Therapy
b. Behavioral Therapy
-Dialectical Behavior Therapy
-Family Focused Therapy
-Psychodynamic Therapy
-Light Therapy
-Transcranial Magnetic
Stimulation (TMS)therapy
• CAM(COMPLEMENTARY
AND ALTERNATIVE
MEDICINE):
-Mediation For Stress
Managements (Yoga)
-Dietary Guidelines, Exercise,
Nutritional Supplements
-Expressive Or Creative Therapy
-Animal Assisted Therapy
-Play Therapy
20. New drug in depression
REXULTI(BREXPIPRAZOLE)(2015)
BRINTELLIX(VORTIOXETINE)(2013)
FETZIMA(LEVOMILNACIPRAN)(2013)
VIIBRYD (VILAZODONE HYDROCHLORIDE)(2011)
OLEPTRO (TRAZODONE HYDROCHLORIDE) (2010)
21. Rexulti(brexpiprazole)
Rexulti (brexpiprazole) is an atypical antipsychotic.
Rexulti is specifically indicated for the adjunctive
treatment of major depressive disorder and the
treatment of schizophrenia.
Rexulti is supplied as a tablet for oral administration
22. MOA
Rexulti (brexpiprazole) is an atypical
antipsychotic. The mechanism of action of
brexpiprazole in the treatment of major depressive
disorder or schizophrenia is unknown. However, the
efficacy of brexpiprazole may be mediated through a
combination of partial agonist activity at serotonin 5-
HT1A and dopamine D2 receptors, and antagonist
activity at serotonin 5-HT2A receptors.
23. Brintellix(vortioxetine)
Brintellix (vortioxetine) is a serotonin modulator and
stimulator. It belongs to a psychotropic class of
chemical compunds known as bis-aryl-sulphanyl
amines.
Brintellix is specifically indicated for Major
Depressive Disorder.
Brintellix is supplied as a tablet for oral
administration. The recommended starting dose is 10
mg administered orally once daily without regard to
meals. The dose should then be increased to 20
mg/day, as tolerated.
.
24. MOA
The mechanism of the antidepressant effect of
vortioxetine is not fully understood, but is thought to
be related to its enhancement of serotonergic activity
in the CNS through inhibition of the reuptake of
serotonin (5-HT). It also has several other activities
including 5-HT3 receptor antagonism and 5-HT1A
receptor agonism.
25. Fetzima(levomilnacipran)
fetzima (levomilnacipran) is an extended release
selective norepinephrine and serotonin reuptake
inhibitor.Fetzima is specifically indicated for the
treatment of Major Depressive Disorder.
Fetzima is supplied as a capsule for oral
administration. The recommended dose is 40 mg to
120 mg once daily with or without food. Initiate dose
at 20 mg once daily for 2 days and then increase to
40 mg once daily. The dose should be increased in
increments of 40 mg at intervals of 2 or more days.
The maximum recommended dose is 120 mg once
daily. The capsules should be swallowed whole.
26. MOA
Fetzima (levomilnacipran) is an extended release
selective norepinephrine and serotonin reuptake
inhibitor. The exact mechanism of the antidepressant
action of levomilnacipran is unknown, but is thought
to be related to the potentiation of serotonin and
norepinephrine in the central nervous system,
through inhibition of reuptake at serotonin and
norepinephrine transporters. Non-clinical studies
have shown that levomilnacipran is a potent and
selective serotonin and norepinephrine reuptake
inhibitor (SNRI).
27. VIIBRYD (VILAZODONE HYDROCHLORIDE)
Viibryd (vilazodone hydrochloride) is a selective
serotonin reuptake inhibitor and a 5HT1A receptor
partial agonist. The mechanism of the antidepressant
effect of vilazodone is not fully understood
Viibryd is specifically indicated for the treatment of
major depressive disorder.
The recommended initial dose of Viibryd is 40 mg once
daily. Treatment should be titrated, starting with an
initial dose of 10 mg once daily for 7 days, followed by
20 mg once daily for an additional 7 days, and then an
increase to 40 mg once daily.
28. MOA
Viibryd (vilazodone hydrochloride) is a selective
serotonin reuptake inhibitor and a 5HT1A receptor
partial agonist. The mechanism of the antidepressant
effect of vilazodone is not fully understood but is
thought to be related to its enhancement of
serotonergic activity in the CNS through selective
inhibition of serotonin reuptake. Vilazodone is also a
partial agonist at serotonergic 5-HT1A receptors;
however, the net result of this action on serotonergic
transmission and its role in vilazodone’s
antidepressant effect are unknown.
29. Oleptro (trazodone hydrochloride)
Oleptro (trazodone hydrochloride) is an anti-depressant that
acts as a dual serotonin agonist and serotonin reuptake
inhibitor. Although the exact mechanism of action is unknown,
trazodone appears to increase serotonin activity via three
mechanisms: the activation of neuronal serotonin receptors; the
inhibition at the neuronal serotonin receptors of the feedback
system which regulates the action of serotonin; and the
inhibition of the re-uptake of serotonin.
Oleptro is specifically indicated for the treatment of major
depressive disorder in adults.
Oleptro is supplied as an extended-release tablet designed for
oral administration. The recommended initial dose of Oleptro is
150 mg once daily. The dose may be increased by 75 mg/day
every three days. The maximum daily dose should not exceed
375 mg.
30. MOA
It is an anti-depressant that acts as a dual serotonin
agonist and serotonin reuptake inhibitor. Although
the exact mechanism of action is unknown,
trazodone appears to increase serotonin activity via
three mechanisms: the activation of neuronal
serotonin receptors; the inhibition at the neuronal
serotonin receptors of the feedback system which
regulates the action of serotonin; and the inhibition
of the re-uptake of serotonin.
32. AUGMENTATION THERAPY
In case of inadequate response to conventional
antidepressant therapy
Augmentation therapy is includes combining of
an augmenting agents along with the conventional
antidepressant
Augmentation therapy, can avoid patients from
unnecessary switching between antidepressants
which may jeopardize the remission rates and even
aggravate existing side effects augmentation: the
action or process of making or becoming greater in
size or amount
33. Medication Data supporting efficacy as augmentation agent
Lithium Positive RCTs with TCAs, limited RCTs with SSRIs,
comparable to T
Thyroid
Hormones
Positive RCTs with TCAs, limited RCTs with SSRIs,
comparable to lithium
Bupropion Open –lable trials comparable to buspirone ,no RCTs
Mitazapine Multiple Positive RCTs and comparable to MAOI
Pinolol Negative RCTs
Sex Hormones Mixed data most convincing for testosterone in men
with low or borderine- low testosterone levels
Aripiprazole 3 large Positive RCTs
Ofanzapine 2 Positive RCTs And 3 Negative RCT
Omega -3 Fatty
Acids
Increases small positive RCT
Creatine Increases positive RCT in woman
SAMe Increases small positive RCT RCT- randomized controlled trial
T-tridothyronine
36. Supportive Therapy
•Long term therapy with various attempt by a therapist by
any practical means whatever to help patients deal with
their emotional distress and problems in living.
•Most mature people lose their ability to provide support
from within when they are excessively scared or in pain.
ROLE OF THERAPIST IN SUPPORTIVE THERAPY
• Educate him to the unwritten but crucial rules that
govern all social interaction.
• Encourages his patient to expand his/her interests in
the world by making friends, or by going to school or to
work.
• Encourage participation in sports or hobbies
37. Interpersonal Therapy
Based on the idea that
improving communication
patterns
The ways people relate to
others will effectively treat
depression. IPT helps identify
how a person interacts with
other people.
Help patients adopt regular
daily routines and sleep/wake
cycles, stick with medication
treatment, and improve
relationships.
Research has found that
when ipsrt is combined with
medication, it is an effective
38. Cognitive Behavioral Therapy (CBT):
•At the heart of cognitive therapy is
the idea that our thoughts can
affect our emotions.
• Cognitive behavioural therapy
(CBT) developed out of behaviour
modification, cognitive therapy,
and rational emotive behaviour
therapy, and combines cognitive
and behavioural techniques.
•Cognitive therapies for suicide
prevention, and schizophrenia and
other psychopathologies.
