treatment of depression a glimpse

1. Treatment Of Depression
Pharmacological and Behavioural
Therapy

2. Considerations before developing a treatment
plan
• Lethality of patient
• Past treatment
• Need for hospitalization:
– Risk of suicide
– Depressive stupor
– Depression with agitation or panic attacks
– Concomitant physical or psychological problems(eg: drug
abuse)
– Non responders to drugs
– Poor support system

3. Treatment of depression
• Pharmacotherapy-
– I) Antidepressants-
TCA MAO inhibitors
Newer antidepressant- SSRI, SNRI, SDRI
• Psychosocial therapies
• ECT

5. MOA of Anti depressants
• Most antidepressant drugs
potentiate, either directly or
indirectly, the actions of
norepinephrine and/or
serotonin in the brain.
• Atypical antidepressants have
actions at different sites. Not
more efficacious than the
TCAs or SSRIs, but their side
effect profiles are different.

6. Response to treatment
• Down-regulation of
inhibitory receptors
permits greater synthesis
and release of
neurotransmitters

7. SSRI
• specifically inhibit serotonin reuptake
• SSRIs have little blocking activity at
muscarinic, α-adrenergic, and H1
receptors.
• Relatively safe in overdose
• Discontinuation syndrome

8. SNRI
• Inhibit the reuptake of both serotonin and nor-
epinephrine
• Used in patients not responding to SSRI
• Dual actions of inhibiting both serotonin and
norepinephrine reuptake, are sometimes
effective in relieving physical symptoms of
neuropathic pain
• Venlafaxine, desvenlafaxine, duloxetine

9. TCA
• Block norepinephrine and serotonin reuptake
• TCAs also block serotonergic, α-adrenergic,
histaminic, and muscarinic receptors
• Overdose can be lethal

10. MAO INHIBITORS • Used in depressed
patients who are
unresponsive or
allergic to TCAs or
who experience
strong anxiety.
Patients with low
psychomotor
activity also
benefit.
• drug-food and
drug-drug
interactions
• Cheese
reaction,serotonin
syndrome.

11. ATYPICAL ANTIDEPRESSANTS
• Bupropion:
- This drug acts as a weak dopamine and norepinephrine
reuptake inhibitor
- Side effects: dry mouth, sweating, nervousness, tremor, a
very low incidence of sexual dysfunction and an increased
risk for seizures at high doses.
• Mirtazapine
- Enhances serotonin and norepinephrine neurotransmission
via blockage of presynaptic α2 receptors.Some ability to
block 5-HT2 receptors.
• Nefazodone and Trazodone:
- Block postsynaptic 5-HT2A receptors and mild to moderate
α1-receptor antagonism

12. Psychotherapy
• Interpersonal therapy
• Cognitive behaviour therapies: to modify
patient’s faulty ways of thinking about life
situations
• Behavioural therapies:
– Social skills training
– Problem solving skills

13. Interpersonal Therapy
• Emphasizes use of personal interactions and
psychosocial environments
– Aims to alleviate depressive symptoms and aid
patient in developing more effective skills for
coping with social and interpersonal relationships
• Short term therapy lasting for 12-16 weeks
with one session per week
• Usually on an OP basis

14. Interpersonal Therapy
• Improve current interpersonal skills
• Techniques:
– Reassurance
– Clarification of feeling state
– Improve interpersonal communication and skills
– Testing perceptions

15. CBT
• Identify maladaptive thoughts and distorted
beliefs that lead to depressive moods.
• Learn strategies to modify these beliefs and
practice adaptive thinking patterns.
• Use a systematic approach to reinforce
positive coping behaviours

16. Cognitive disorders in depression
• Intrusive Thoughts
• Cognitive disorders
– Arbitrary inference
– Selective abstraction
– Over generalization
– Magnification or minimisation
– Personalization
– Dichotomous thinking

18. Cognitive techniques
• Activity schedule
• Identify depressive thoughts
• Answering negative thoughts
• Problem solving

19. Electroconvulsive Therapy
• Indication:
– Depression with suicidal ideation
– Depression with psychotic symptoms (like delusions)
– Resistant depression- not responding to various drug
combinations in full doses
– Rapid cycles of mania and depression
• Frequency & number of treatments:
– First 3 treatment on alternate day then twice a week
– 6-12 depending upon response

20. Sleep Deprivation
• Mechanisim:
– Not clear, probably due to accumulation of excitatory
sleep factor or influence of altered circadian rhythm on
sensitivity of some neurotransmitters
• REM Deprivation: builds up REM pressure
– 30-60% show improvement
• Total sleep deprivation:
– Studies showed 30% cases having rapid clinical
improvement

21. High Intensity Light
• Indicated in seasonal affective disorder (
depression in winter with remission in
summer)
• Such patient’s responded poorly to drugs
• Improvement seen with exposure to bright
artificial light of 2500 lux during the short days
of winter

22. Trans cranial Magnetic Stimulation
(TMS)
• Non invasive method of stimulating nerve cells
in superficial areas of the brain.
Deep Brain Stimulation
• Surgical technique involving implantation of a
brain pacemaker
• Considered in severe forms of TRD

23. Lifestyle Changes
• Recommend lifestyle management for all patients
with depression
• Regular exercise
• Healthy regular meals
• Stress management strategies
• Sleep hygiene
• Engaging in at least one pleasurable activity a day
• Avoiding substance use
• Keeping a daily mood chart

24. Monitoring
• Assess and discuss self-management goals, challenges and
progress.
• Review treatment plan and modify if no response to
antidepressants after 3-4 weeks
• At least three follow-up visits in first 12 weeks of
antidepressant treatment.
• Continued antidepressant treatment for 6 months after
remission, at least 2 years for those with risk factors.
• Encourage adherence to continued treatment even and
especially after remission.
• Discuss relapse risk factors, symptoms and prevention.
• Discuss and plan gradual discontinuation of antidepressants.
• Discuss need for social network of family, friends and
community.

25. THANK YOU