Medication

Antidepressant medication is probably the most frequently used treatment. The main types of antidepressants are tricyclic antidepressants, SSRIs, and MAOIs. They are discussed in more detail in Chapter 23.

SSRIs are widely used in general practice. However, they are probably weaker drugs in more severe depressive states; hence, by the time patients have been referred to secondary care, they have probably already failed to improve on SSRIs. There is no logic in switching from one drug to another in the same category, as the similarities between them far outweigh the differences.

Therefore, there is a strong case for the use of the previous generation of antidepressant drugs, such as the tricyclics (e.g. amitriptyline) in secondary care. The tricyclics may have more side-effects, but are probably more powerful in more severe cases.

The key point with medication is that it must be continued. The standard advice is for patients to continue with the medication until they are fully recovered, and then for a further 6 months. At this stage, if the patient has remained well, the possibility of a dose reduction can be considered.

Unfortunately, many patients stop medication as soon as they feel a bit better; this is often followed by a quick return of symptoms, and the patient may then come to feel that the condition is incurable, and that the medication is ineffective. However, the truth is the exact opposite: the drug probably is effective, and the condition probably is responsive to the drug; the symptoms would therefore probably not have recurred if the patient had carried on with the medication.

• Tricyclic antidepressants such as amitriptyline and imipramine have long been regarded by psychiatrists as the standard first-line treatment for depressive illness; they are probably the most effective drugs for severe depression. They are effective in about 70 per cent of depressed patients.

• SSRIs such as fluoxetine and paroxetine are now considered by many GPs to be the treatment of first choice, because they are safer in overdose than tricyclics and may have fewer side-effects. Others consider that SSRIs, which are more expensive, should be reserved for patients who cannot take tricyclics or have failed to respond to them.

• MAOIs such as phenelzine and moclobemide are less often prescribed but are sometimes dramatically effective when other drugs have failed.

• Lithium and other mood stabilizers are mainly used in the prevention of recurrent affective disorder, but may also useful in an established depressive episode as adjunctive treatment to one of the antidepressants listed above.

A therapeutic trial of an antidepressant drug is often required when diagnostic doubt exists. Frequent changes of drug are to be avoided, and compliance needs checking. If an effective drug is found, it should be continued at least 6 months after recovery to reduce the risk of relapse, and then gradually tapered off if the patient remains well.

Case example

A GP telephoned the psychiatrist who was responsible for her sector, and who did monthly clinics in her surgery, to discuss a 47-year-old woman who had been depressed for several months. Having benefited from a 'recent course of amitriptyline', she had now relapsed, with a full depressive syndrome, including low mood and biological symptoms such as loss of appetite and insomnia. The GP requested advice on 'a change of antidepressant and/or admission'.

On further discussion, it became clear that the patient had derived clear though partial benefit from amitriptyline 50 mg nocte; not appreciating the need for continuing medication, she had stopped the tablets when she began to feel better. The psychiatrist suggested that the patient had had the right treatment, but not enough of it for long enough, and advised restarting amitriptyline, and working up to a dose of 150 mg nocte. She offered to see the patient if needed, particularly if the GP was worried about suicide risk.

The GP was happy with this plan and, 3 weeks later, reported that the patient had restarted amitriptyline, but had been unable to go beyond 75 mg because of side-effects. Nevertheless, she was very much better. The psychiatrist strongly advised continuing medication until the patient was fully well and for 6 months thereafter, before cautiously considering reduction, and once again offered to see the patient for further education and advice about depression and its management.

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