The bachelor of medicine, the bachelor of surgery, member of Royal board of doctors of the general practice, member of Royal board of psychiatrists, London
Campaign for struggle against depression recommends to doctors of the general practice holistic the approach to treatment of this disease: the benevolent relation to the patient in a combination to various variants of psychotherapy, both orthodox, and additional. The special attention at a prescription of medicines should be turned on alarm, mood change, phobic and panic symptoms.
It is useful to remind signs of depression (tab. 1). Their knowledge helps to diagnose, define gravity of depression and to estimate risk of a suicide.
As to medicinal therapy diagnosing of the deployed episode of depression means, that 70-80 % of such patients with success will receive medical treatment modern antidepressants, rather safe even at an overdosage.
The most widespread antidepressants. They share on four basic groups: tricyclic the antidepressants new tricyclic and related antidepressants; selective antidepressants and monoaminoxidase inhibitors (OIMAO), including new reversible inhibitors of a monoaminoxidase (OIMAO).
Table 1. Diagnostic criteria of affective disorders
- Five of reducible below conditions Should take place at least
- Depressive mood within more than two weeks
- Loss of interest to any activity
- Bad appetite or weight loss
- The Sleeplessness or the hypersomnia
- Psychomotor excitation or inhibition
- Loss of sexual inclination
- Weariness or energy loss
- The Lowered ability to concentration
- Constantly coming back thoughts on death/suicide, desire to die or suicidal attempt
This year to the list from 31 most widespread antidepressants has increased two new groups. Both of them belong to new, selective type, but influence various receptors – actually the group of selective antidepressants is sectioned into four subgroups.
The term “selective” is key in understanding of this new group of antidepressants. They possess very high affinity or to noradrenaline (NA), or to serotonin (S) synaptic to receptors and very low – to other receptors, such as acetylcholine, influence on which causes most often observable by-effects in the patients accepting tricyclic antidepressants.
At described below depressive disorders following groups of antidepressants are applied.
Serotonin antidepressants are prescribed as additional agents at disturbing conditions and obsessional compulsive disorders, as a serotonin – the transmitter immediately bound to alarm and repeating behaviour, for example notions of compulsion.
Noradrenalinum – the transmitter which is responsible for motivation. Are especially effective On-energizers at depressions where a leading symptom is retardation of motivation and, as consequence, behaviour.
Inhibitors MAO and IOMAO can be very effective in the absence of effect from other antidepressants. OIMAO diet keepings do not demand, but interaction with sympathomimetics remains. The list of indications includes phobias (in particular social), a hypochondria and somatic implications. New in a prescription of antidepressants. In 1997 has appeared five important innovations in the medical approach to treatment by antidepressants.
First, it is proved, that the effect from the prescribed dose of an antidepressant develops not at once – at least within eight weeks. Practically it means, that the doctor can wait long time before to change a dose or antidepressant type.
Secondly, there are bases to believe, that for treatment of the majority sick of depression enough an initial dose of selective inhibitors of return capture of a serotonin (SIRCS). However in some cases for SIRCS early generations of an initial dose can be insufficiently and it it is necessary to enlarge (tab. 2 ).
Table 2. A standard dose of antidepressants of type SIRCS at initial therapy of depression
Antidepressant the Dose (mg/day) of %* the Dose (mg/day) of % *
Fluvoksamin 50/31,70 100/48,74
Sertraline 50/49,30 100/44,95
* % from an prescribed dose for each antidepressant
Thirdly, today it is considered to be, that the the patient is more senior, the the large concentration of an antidepressant is reached at it in blood, therefore to older persons smaller doses of preparations are required.
Fourthly, though doctors are assured that at the newest antidepressants is less than the by-effects, many patients refuse to accept them. The analysis has shown, that 30 % of patients have stopped to accept tricyclic antidepressants whereas SIRCS  accept 27 %. The quantity of refusals of preparations only because of by-effects has made 20 % for трициклических antidepressants and 15 % for SIRCS.
Some of early antidepressants, namely tricyclic antidepressants of the second generation, possess the same efficiency and safety, as well as selective antidepressants, and smaller anticholinergic by-effects in comparison with earlier antidepressants.
Fifthly, today by-effects of the selective antidepressants influencing on serotonin receptors are summarised. The Serotoninergichesky syndrome is caused by direct influence on not protected постсинаптические serotonin brain and intestine receptors. By-effects include a nausea, a sleeplessness, nervousness and excitation, extrapyramidal disorders, headaches and sex dysfunction. The Serotoninergichesky syndrome is similar to the well-known anticholinergic syndrome developing when taking TCAs.
Suicidal risk. On the recommendation of the Committee on struggle against depression of patients it is necessary to ask on suicidal ideas/thoughts/intentions/impulses/plans in the benevolent and sparing form, it facilitates mutual understanding. Practically it means, that the doctor should achieve first of all a trust establishment between it and the patient – too early intervention leads to refusal of the patient to communicate with the doctor while the timely conversation helps to achieve from the patient of frankness.
Campaign for a safe prescription of medicines at suicidal risk has been begun by the London unit of the poisonings which last research is dated 1995. According to data of this research, in 1995 approximately 300 persons were lost from antidepressants, basically at the expense of cardiotoxic effects of amitriptyline and dothiepin .
Ineffective treatment. Check up once again the diagnosis and be convinced, that the patient accepts the ordered medicines in the necessary doses.
In our practice cases of the latent reception of alcohol are very prevalent. Check up, whether the patient any stresses worries now and whether there are no they in the anamnesis. It can appear, that deterioration is caused by an exacerbation of posttraumatic stress.
At the disposal of the doctor there are various information booklets, audio-and videorecordings with which it can supply the patient.
Consultation can help with finding-out or the problem decision. The certain help is rendered sometimes cognitive therapy though its role still definitively is not found out, – it especially approaches in cases of chronic and moderately serious depressions.
Table 3. The facts which are useful for knowing
- During campaign for struggle against depression criteria of diagnostics and principles of treatment of depression for doctors of the general practice have been defined
- This widespread disease – one of each three adults worries a depression episode at least time throughout a life; it every sixth of again taped patients in the general practice suffers
in general for adults prevalence of depression makes 5 %, being enlarged to 15 % among mothers within first eight months giving birth
- Though depression is considered disease of people of middle age, it is extended in all age groups – teenage, among youth and old men, thus its implications in these groups can be atypical
- At research of the patients, suffering fixing serious diseases, such as seizure, to illness of cardiovascular system and a pseudorheumatism, it is proved, that among them widespread associated depression
- Such co-presence depressions meets at 15-60 % of patients. This condition accompanies many psychiatric illnesses, especially schizophrenia, alcoholic and narcotic dependence, enlarging level of suicides in this group of patients
It is necessary to pay attention to a sleeplessness, alarm, a panic, phobias, psychotic disorders, each of which can dominate in an illness picture as independent disease.
Additional appointment of sedative therapy as selective antidepressants do not possess collateral sedative action can be necessary. So, in the treatment beginning soporific or a day relaxant, for example tioridazin or diazepam can be necessary. Relaxation therapy, additional methods of treatment also have salutary influence.
The group of patients difficultly giving in to treatment is made by patients with somatic disorders. As a rule, they with mistrust concern the diagnosis, badly give in on arrangements to accept medicines, and having agreed, find out a hypersensibility to by-effects. In this group it is possible to prescribe the low doses of preparations which even are considered subtherapeutic with success.
The more term of the depression proceeding prior to the beginning of treatment, the more time is required on its treatment.
Direction in Association of mental health or to the psychiatrist of the secondary help for consultation and the therapeutic help. If suicide possibility is not excluded, longer consultations, helping to take out despair and suicidal hopelessness are necessary. Recently the organizer of psychotherapeutic courses for doctors of the general practice in this occasion has noticed: “If it is possible to let to the person know, that we care of it, hopelessness there and then leaves and recovery process” begins.
One of researches has shown, that early the begun adequate therapy by antidepressants allows to lower essentially number of secondary directions to the expert, necessity of hospitalisation and frequency of cases of a suicide.
Steady depression. Sometimes there is a necessity for an additional prescription of medicines, augmentation of a dose of an accepted antidepressant or its replacement.
To an antidepressant it is possible to add lithium. Safety of this agent is checked up in practice, but patients are necessary for informing on its nature and action mechanisms.
Lithium should be prescribed unitary to night. In order to avoid possible differences in bioavailability it is necessary to prescribe only qualitative preparations.
Before treatment necessarily carry out research iron-binding abilities of blood, define function of kidneys and a thyroid gland. Within the first month of treatment define concentration of a preparation in bloods and electrolytic balance each 7-14 days, then monthly, time in three months and, at last, time in half a year. It is better, if lithium level is rather low, about 0,4 mmol/l (in comparison with 0,8 mmol/l). Duration of treatment makes eight weeks.
Duration of treatment. Depression is a relapsing disease, and the main prognostic factor of relapse is last episode of depression. It is possible to be guided with success following data: at a unique episode of depression the probability of relapse makes 50 %, at the second – 70 %, and at the third – 90 %.
After a unique episode it is possible to prevent relapse development, but there is no common opinion how longly it is necessary to give antidepressants.
Some doctors stand up for carrying out of three – four – six-or even nine-monthly courses of therapy. The world organisation of public health services recommends to prescribe an antidepressant in a full dose to two, three or four months, and then some more months the patient accepts half of dose of a preparation. This approach demands additional studying and observation.
To patients at whom the alarm is observed, obsessional and phobic implications, it is necessary to accept longly antidepressants though in the general practice frequently happens difficultly to persuade patients even to begin their reception.
There is an impression, that in process of improvement of a condition the patient becomes more sensitive to by-effects. In practice it makes sense to define, it is necessary to prescribe an antidepressant to what time, being guided by on depression at the moment of the treatment how many was serious.
I always warn patients about possibility of relapse and I advise to them to renew reception of antidepressants as soon as it becomes worse, – even before they can get to me on reception. As a rule, the more relapses at the patient in the anamnesis, longer the necessary course of treatment.
Patients of advanced age are more subject to the serious lingering depressions, lasting by years. In this group the appreciable share of the morses bound to depression is observed, therefore at such patients often it is necessary to spend long courses of treatment by antidepressants. In the same way it is necessary to treat any patient with fixing serious returnable depression, irrespective of age.
Reaction of cancellation of an antidepressant differs from relapse of depressive disorder. It can develop at application of any antidepressant, but only after the lapse of 6-8 weeks of therapy, that, probably, specifies in involving of adaptive processes CNS .