This document provides an overview of depression and its pharmacotherapy. It defines depression as a common and serious mental health disorder. Left untreated, depression can lead to complications like suicidal thoughts and negatively impact quality of life. The document classifies depression, discusses its prevalence, risk factors, and health impacts. It causes symptoms like sadness, loss of interest, and changes in appetite and sleep. Pharmacotherapy options for depression include antidepressants, often used for mild to moderate cases. Psychotherapy combined with antidepressants can increase treatment success rates compared to medication alone.

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ISSN Print: 2278 - 2648 IJRPP | Vol. 3 | Issue 1 | Jan-April-2014
ISSN Online: 2278 - 2656 Journal Home page: www.ijrpp.com
Review article Open Access
An overview of Depression and its Pharmacotherapy
Marium Khan1
, Nasar Aqeel1
, *Atta Abbas1, 2
1
Faculty of Pharmacy, Ziauddin University, Karachi, Sindh, Pakistan.
2
Department of Pharmacy, Health and Well Being, University of Sunderland, England,
United Kingdom.
* Corresponding author: Atta Abbas.
E-mail id: bg33bd@student.sunderland.ac.uk.
Abstract
Depression is a very common mental health disorder, increasing with the socioeconomic and medical condition.
Patients experience different feelings, depending upon the severity, frequency, and duration of symptoms. If left
untreated and/or undiagnosed; can lead to complications such as suicidal thoughts etc. Patients can have an
unhealthy life; caregiver or health care provider should focus on depressed individual to improve the quality of life.
It can affect the normal daily routine, which can interfere in their daily work. Antidepressants often used for the
treatment of depression from mild to moderate depression until and unless there would be the need of
electroconvulsive therapy. Psychotherapy along with antidepressants agents can increase the success rate of
treatment and is also reported to be more effective than treating with medication alone. A pharmacist can play a
pivotal role in this regard.
Keywords: Depression; Pharmacotherapy; Psychotherapy.
Introduction
Depression is very common mental health disorder
but a serious illness.1
It is a major public health
problem and has a greater impact on the condition of
the patient or health when co morbid with a chronic
medical condition such as cancer.2
The Global
Burden of Disease 20003
found out that it was the
fourth leading cause of death in the world and affect
the patient as well as society worldwide. 4
Depression
is the most significant contributor of global burden
on disease, it affect all the communities around the
world. About 350 million people are affected by
depression. World mental health survey concluded
that every 1 in 20 person is affected by depression,
which is an alarming situation across the globe and
leading cause of other diseases.3
Patients suffering from depression experience
different feelings depending upon the severity,
frequency, and duration of symptoms. Some of the
symptoms associated with depression include
persistent sadness, anxious feelings of hopelessness
International Journal of Research in
Pharmacology & Pharmacotherapeutics

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or pessimism, guilt, worthlessness, helplessness,
irritability and or restlessness. The patients are likely
to lose interest in their activities and/or hobbies. Over
the long run it leads to fatigue, difficulty in
concentrating, memory retention, and decision
making. Associated complications of depression
include insomnia, narcolepsy, anorexia, suicidal
thoughts that sometimes become difficult to treat.1
Classification of Depression
It is classified into following types include, major
depressive disorder (MDD), depression with
melancholic or catatonic features, atypical
depression, psychotic features, bipolar depression,
single or recurrent episode, dysthymia, and seasonal
affective disorder (SAD). The differential diagnosis
for depression includes other psychiatric disorders,
CNS diseases, endocrine disorders, drug-related
conditions, infectious and inflammatory diseases, and
sleep-related disorders.5
Major depressive disorder
(MDD) was identified by the World Health
Organization (WHO) in 2001 as the fourth leading
cause of disability and premature death in world. It is
estimated that by the year 2020 MDD would be
second to ischemic heart disease in regard to disease
burden. The WHO media center published a fact
sheet in 2001 on mental and neurological disorders
which stated that 25% of individuals develop one or
more mental or behavioural disorders at some stage
in their lives, in both developed and developing
countries. A cross sectional study was conducted
which reported depression all over in Karachi,
Pakistan, and also reported an increases prevalence of
depression in society due to stress, related to socio-
economic factors. If it remains un-noticed, un-
checked and un-observed it would result in a big
disaster. It is suggested that healthy lifestyle habits
can help prevent depression, include eating properly,
sleeping adequately, exercising regularly, learning to
relax, and not drinking alcohol or using drugs.6
An epidemiological study was conducted in Pakistan
in 2007 which reported the high prevalence rates in
northern Pakistan and big urban center i.e. Karachi.
The study reported every third individual is expected
to suffer from depression and anxiety. Some
community based studies conducted in various
regions of Pakistan reported prevalence as high as
66% in women from rural areas to 10% in men from
urban areas. The mean overall point prevalence was
33.62%. In another study the prevalence rate of 30%
was reported from Karachi. Crude estimates for
males were 18.1% and for females 42.2%.7
These studies have found various risk factors for
depression in studied population. Rates for depressive
disorder are reported to be higher in women than
men. This is consistent with the figures from western
countries. However it was observed that significantly
higher rates in married than single females. In a cross
sectional epidemiological study carried out by N.
Haider 7
in urban middle class population of Karachi,
specifically aimed at the psychosocial risk factors,
found the close knitted family systems to be a
particular risk factor for depression. It also reported
low level of education, poverty and economic
constraints as other risk factors however the former
being the dominating one. Another important risk
factor observed for depression is socio-economic
status. It is a complex factor it comprise family
problems, income, standard of living, occupational
status, and education as sub-domains.7
Depression is one of the causes of suicide attempts.
As the suicidal death study shows that 3.5 per cent
the maximum intensity consisted only of feelings that
life was not worth and this feeling occur in
depressive patient mostly. Subjects experiencing
suicidal feelings in the last year reported more minor
psychiatric symptoms, particularly of depression,
were more socially isolated, less religious, and to a
lesser extent had experienced more stressful events
and more somatic illness. In addition to this, female
were more likely to commit suicide.8
Along with suicide, depression is one of the major
causes for provoked seizures. It was reported in a
study that depression has been shown to increase risk
for epilepsy and suicide attempts. Major depression
and attempted suicide independently increase the risk
for unprovoked seizure. The data reported from the
study suggested that depression and suicide attempt
may be due to different underlying neuro-chemical
pathways, each of which is important in the
development of epilepsy (95% CI). A history of
major depression was 1.7 fold more common among
cases than among controls (95% CI, lower 1.1 upper
2.7). A history of attempted suicide was 5.1-fold
more common among cases than among controls
(95% CI, lower 2.2 upper 11.5). Attempted suicide

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increased seizure risk even after adjusting for age,
sex, cumulative alcohol intake, and major depression
or number of symptoms of depression.9
Patients with depression need to take good care of
them to feel better, due to the symptoms, they suffer
from insomnia and restlessness. The patients may
also suffer from anorexia and lose interest in daily
activities. Due to the aforementioned factors, it leads
to detrimental health consequences.10
Major Depressive disorder MDD
Major depressive disorder, or major depression, is a
combination of symptoms that interfere with a
person's working, sleeping and normal daily routine
habits and/or activities. Some patients may
experience only a single episode in their lifetime, but
more often a person may have multiple episodes.
Dysthymic disorder or dysthymia is long-term (2
years or longer) symptoms that may not be severe
enough to disable a person but can prevent normal
functioning of the body. People with dysthymia may
also experience one or more episodes of major
depression during their lifetime.
Minor depression
Minor depression is characterized by having
symptoms for 2 weeks or longer that do not meet full
criteria for major depression. Without treatment,
people with minor depression are at high risk for
developing major depressive disorder. Some forms of
depression are slightly different, or they may develop
under unique circumstances. It is still debatable how
to characterize and define these forms of depression.
They include, psychotic depression, occurs when a
person has severe depression plus some form of
psychosis, such as having disturbing false beliefs or a
break with reality (delusions), or hearing or seeing
upsetting things that others cannot hear or see
(hallucinations).
Postpartum depression
Postpartum depression, which is much more serious
than the "baby blues" that many women experience
after giving birth, when hormonal and physical
changes and the new responsibility of caring for a
newborn can be overwhelming. It is estimated that 10
to 15 percent of women experience postpartum
depression after giving birth.
Seasonal affective disorder SAD
Seasonal affective disorder (SAD) the onset of
depression during the winter months, when there is
less natural sunlight. The depression generally lifts
during spring and summer. SAD may be effectively
treated with light therapy, but nearly half of those
with SAD do not get better with light therapy alone.
Antidepressant medication and psychotherapy can
reduce SAD symptoms, either alone or in
combination with light therapy.
Bipolar disorders
Bipolar disorder, also called manic-depressive illness,
is not as common as major depression or dysthymia.
It is characterized by mood swings. Some other
associated illnesses may come on before depression,
cause it, or be a consequence of depression. But
depression and other illnesses interact differently in
different individual.
Chronic depression
Chronic depression is illness which last for 2 years or
more and comprises of 4 subtypes of depressive
illness i.e. chronic major depressive disorder,
dysthymic disorder, dysthymic disorder with major
depressive disorder “double depression” and major
depressive disorder with poor inter-episodic
recovery.11
Anxiety disorders, such as post-traumatic stress
disorder (PTSD), obsessive-compulsive disorder,
panic disorder, social phobia, and generalized anxiety
disorder, often associated with depression PTSD can
occur after a person experiences a terrifying event or
suffering, such as a violent assault, a natural disaster,
an accident, terrorism or military combat. Alcohol
and other substance abuse or dependence may also
co-exist with depression. Studies have shown that
mood disorders and substance abuse have been
observed to co-exist with latter complementing the
former. Depression is also reported to be associated
as co-morbidity with other major and serious
illnesses like heart disease, stroke, cancer,
HIV/AIDS, diabetes, and Parkinson's disease and its
adequate treatment can also help improve the
outcome of associated co-morbidities.

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Risk factors of depression
Most likely, depression is caused by a combination of
genetic, biological, environmental, and psychological
factors. Studies reported imbalance of important
neurotransmitters NT in depression. But it is difficult
to prove if depression is the solitary reason for such.
It is also evident from some studies that depression
tends to run in families i.e. the genetic predisposition.
But at the same time depression can occur in people
without having family histories. Some researches
indicate that risk for depression results from the
influence of several genes acting together with
environmental or other factors. In addition, trauma,
loss of a loved one, a difficult relationship, or any
stressful situation may trigger a depressive episode.
Research indicates that depressive illnesses are
disorders of the brain.1,12
In the case of cancer patient it was observed in a
study these patients experience less common
depression and anxiety, but mood swings in 30-40%
hospitalized patients without a significant difference
in palliative and non-palliative care settings and
concluded that the clinicians should be vigilant for
mood disturbance along with episodes of
depression.13
Diagnosis of depression
The widely used criteria for diagnosing depressive
conditions in depressive individuals are found in the
American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders DSM-IV-TR14
and the World Health Organization’s International
Statistical Classification of Diseases and Related
Health Problems ICD-10. There is no clinical
laboratory test for major depression and both the
DSM-IV-TR and ICD-10 identify specific depressive
symptoms. The ICD-10 banks upon three typical
depressive symptoms i.e. depressed mood, anhedonia
and fatigue as biomarkers of depression, two of
which needed to be present to determine depressive
disorder diagnosis. According to the DSM-IV-TR,
there are two biomarkers i.e. depressed mood and
anhedonia, one of which must be present to
determine diagnosis of a major depressive episode,
and five symptoms out of the following such as
depressed mood, anorexia, insomnia, psychomotor
agitation, fatigue, guilt or worthlessness, difficulty in
concentrating and suicidal thoughts must be present
daily or for at least last 2 weeks.15
Health awareness would be helpful in developing the
understanding of the mental disease which will in
turn help in understanding the condition of the patient
and eventually lead towards management of the
treatment.16
Antidepressants are often used for the
treatment of depression from mild to moderate
depression until and unless there would be a need for
electroconvulsive therapy.14
Primary care physician
are consulted before obtaining the services of mental
health care provider, when patients suffers from
depression. Depressed patients often deny, oversight
their particulars somatic and cognitive/behavioural
symptoms, undervalue symptoms severities. Elderly
patients suffering from depression have an
approximate prevalence between 5%-50%, increase
in age result in more suicidal thoughts and attempts.
Depressive disorder occurs at any stage of life,
percentage of major depression has been elevated as
already discussed in the beginning. Pharmacological
treatment and non-pharmacological treatment such as
cognitive and psychotherapy have observed to
increase benefits in depressive patients.
Pharmacotherapy for depression
Pharmacotherapy of depression is a process which
includes thoughtful insight to medication side effects,
adverse effect and patient specific factors.17
The outcome is not immediately seen as weeks are
needed to get the desired response. Medicines
prescribed must comply with the patient appropriate
condition. For this targeted response patient
adherence to the medications must be important
factor in order to get relief from symptoms. A clinical
pharmacist can come in handy is drug selection,
optimization and medication adherence. In addition
to this, improvement in symptoms and quality of life
are normally the goals of therapy. A combination of
pharmacotherapy and psychotherapy are beneficial
rather giving monotherapy.18
Psychotherapy along with antidepressants agents can
increase the rate of treating patients correctly. This
can also be associated with higher improvement rate
than medications alone. It also increase medication
adherence by patient which in turn would lead to
better outcomes. However, evidence on medication
adherence-enhancing effects of psychological

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intervention was reported in a study in which two
groups were studied with one being treated with
pharmacotherapy in combination with psychotherapy
and the latter with pharmacotherapy alone. Therefore,
psychotherapy is considered best along with
pharmacological treatment with objectives of
improving quality of life, enhance patient’s social
functioning, promote adherence to medication and
prevent recurrence.19
The American Psychiatric Association (APA)
emphasizes the need to customize a treatment plan
for each patient based on a careful assessment of
symptoms, including rating scale measurements, as
well as an analysis of therapeutic benefits and side
effects. The treatment would be based on the various
biomarkers such as clinical assessment, co-
mobidities, stressors analysis, patient preferences and
results of previous treatment.5
Medications used to
treat depression include selective serotonin reuptake
inhibitors SSRIs, serotonin-norepinephrine reuptake
inhibitors SNRIs, monoamine oxidase inhibitors
MAOIs, tricyclic antidepressants TCAs, central
alpha2-receptor antagonists, and norepinephrine and
dopamine reuptake inhibitors. Antidepressants
influence the overall balance of the three
neurotransmitters in the brain that regulate emotion,
reactions to stress, sleep cycles, appetite, and
sexuality. Side effects to monitor for sudden
behavioural changes include worsening of
depression, withdrawal from normal social situations,
agitation, irritability, anxiety, panic attacks, insomnia,
aggressiveness, impulsivity, and increased thoughts
of suicide.15
Psychotherapy and pharmacotherapy
does decrease the rate of treatment failure. Choice of
psychiatrist decreases the likelihood of treatment
failure, independent to the number of psychotherapy
sessions and antidepressant prescriptions. The effect
of health care provider on treatment failure could be
due to the differences in follow-up or clinical skills.
Managed care plans do not appear to reduce the
intensity or severity of depression treatment, case
management do escalate the likelihood for failure of
treatment.20
The primary goal of management of
depression is to improve the overall mood of the
patient and relieve depression and its symptoms i.e.
suicidal thoughts. The secondary target is to find out
the underline cause and eliminate or reduce it. The
management and treatment of depression is a two
way approach as discussed earlier i.e. treatment by
pharmacotherapy and psychotherapy.21
Monitoring is
required for sudden mood changes, suicidal
tendencies. The care plan for depression will be
directed towards pharmacologic treatment initially
followed by an assessment of the condition after
some period of time. Finding the underline cause and
its treatment is essential as the condition is normally
the outcome of an underlining cause. Major
depression needs pharmacotherapy and psycho
therapeutical approach. It will be helpful to educate
the patient and care givers about the condition and
how to cope with it along with effective
pharmacological therapy for the problem.21
Conclusion
In a nutshell, further researches on depression can
help the health care professionals to deal with it, as
well as studies on pharmacotherapy options will help
the health care providers to select the treatment
options such as pharmacological approach and
psychotherapy which will prevent the recurrence of
depression. A pharmacist can play an important role
not only in spreading health awareness about
depression but also in the selecting the
pharmacotherapy and performing educational
interventions such as patient counseling.
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