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In Transition

On The Treatment of Mood Disorders - Part 1

by

Dr. Peter Melgaard Thompson

We have been discussing what is a mental illness. In this column I will move the focus to treatment of depression. In technical lingo there are several types of depression, Major Depression, Dysthymia, depressed phase of Bipolar (manic depression) Disorder, and depression as part of an Adjustment Disorder. Twenty years ago the only treatment option was psychotherapy. Now with the development of medications there are many more options.

How do you know when to use psychotherapy or when to use medication? This is not an easy question and the answer is complicated. However, one approach is to try psychotherapy if you are uncomfortable about taking medication or you have a little depression. In a future column we will discuss the different types of psychotherapy and their uses. If you are more inclined to use medication rather than talk therapy or if your depression is more severe, then medication should be the treatment. Before we get into the specifics lets talk a little about the history of antidepressant medication.

It has been know for many years that stimulants have mood elevating properties. In the late l950's physicians noticed that depressed tuberculosis patients treated with a medication called iproniazid were not so depressed. This lucky observation led to the development of the first generation of medication made specifically for the treatment of depression. As with most discoveries, there have been refinements in the following generations. Currently, antidepressants are forth generation. These medications have the same effectiveness as the first generation but with many less side effects.

The effectiveness of antidepressants ranges, but most experts agree that between 70% - 80% of uncomplicated major depressions will respond to antidepressant treatment. For those that do not respond, 50%-60% will respond to a second medication. This rate of treatment response is equal to most other treatments of medical problems, e.g. diabetes and hypertension.

As with any medical treatment, there are side effects. It is not a question of whether there will be side effects but rather which ones will be present and in what severity. From both the patient's and doctor's points of view the use and taking of medication is a balance between potential benefits and side effects. When the potential benefits of a medication are greater than the potential side effects, then the medication should be taken and the side effects dealt with. However when the side effects are worse than the benefits, the medication should not be taken. Given these guidelines let me talk about one specific class of antidepressants - the selective serotonin reuptake inhibitors (SSRI's).

In the United States fluoxetine (Prozac) was the first marketed SSRI. Within a short time four others were being marketed, paroxetine (paxil), sertraline (zoloft), fluvoxamine (luvox) and nefazodone (serzone). They all basically do the same thing with the exception of nefazodone. For this discussion we group them together.

This group of medications all raise the level of the brain neurotransmitter serotonin. The result is that for most people there will he a reduction of depressive symptoms. These are not happy pills. They do not make happy people happier. Nor, if nothing good is going on in one's life, will they change that either. What they will do is allow people to respond positively to good events happening in their lives. They also help people tolerate their life situation. That is the up-side. The down-side is that these medications all have some minor side effects. These side effects range from nausea, drowsiness, irritability to decreased libido. In general the side effects are minor and the benefits are great. One final point: how long do you take them? At this point the field recommends taking medication for one year after the first depression and for two years after the second depression.