First Glance

Treatment is aimed at reversing the underlying condition and when this can be achieved the results are very satisfactory. In drug-induced conditions, stopping the offending agent may be all that is required. Similarly treating an infectious illness with antibiotics may be sufficient to relieve all accompanying depressive symptoms. Depression also responds well to treatment.

Drug treatment of depression

Drug treatment of depression involves mainly the use of tricyclic antidepressants. Other types of antidepressants are also available but tricyclic antidepressants are the most commonly used.

When to start medications?

The decision to start antidepressants depends on the diagnosis and the nature and severity of depressive symptoms. Antidepressants are prescribed in the following situations :

• If the depression is endogenous in origin (melancholia), i.e. it is without an appropriate precipitating factor, with diurnal variation in mood, early morning awakening, low appetite and libido, loss of weight, guilt and psychomotor retardation.
• If depressive symptoms are severe and intolerable. The person feels very weepy, sleepless and is unable to do any work because of depression.
• If the person is a known case of manic depressive disorder, antidepressants should be started as soon as early changes in mood and behaviour are noticed, to cut short a full-blown episode. Similarly, sleep or appetite disturbance for a few days may be the first signs of a depressive episode and indicate the use of antidepressants.

Which antidepressant to use ?

The choice of an appropriate antidepressant requires a thorough evaluation of the patient and his depressive disorder.

• If the person has had previous episodes of depression, enquire about the previous response to antidepressants.
  Favourable response to previous antidepressants may imply that the current episode may also respond favourably to the same. Otherwise a change of antidepressant is warranted.
• If there have been previous episodes of hypomania or mania.
  Antidepressant may be used alone or in combination with Lithium. The combination with lithium may benefit by potentiating antidepressant effects as well as for future maintenance on Lithium for prophylaxis.
• In a subject with known history of epilepsy.
  Tricyclic antidepressants reduce seizure threshold and hence it is safer to use other antidepressants like mianserin, trazodone or tryptophan.
• If the subject has history of acute congestive glaucoma or prostatic enlargement.
  Drugs with minimal anticholinergic effects like fluoxetine, dothiepin, mianserin or trazodone may be used.
• If there is evidence of cardiovascular disease in the past or present.
  Drugs with minimal cardiotoxicity should be used, like fluoxetine, amoxapine, mianserin and trazodone. Among tricyclic antidepressants, doxepin and dothiepin have low cardiotoxicity.
• If there is evidence of duodenal ulcer.
  Imipramine may become the drug of choice as its ability to suppress gastric acidity is approximately as much as that of cimetidine.
• If the depression is characterised by retardation.
  Tricyclic antidepressants are useful e.g. Imipramine, amitriptyline; dothiepin.
• If the depression is characterised by anxiety, agitation or sleeplessness.
  Sedative and anxiolytic antidepressant like amitriptyline, dothiepin may be useful.
• If the depression is characterised by somatic symptoms, aches and pain, and tiredness.
  Serotinergic antidepressants like fluoxetine and amitriptyline may be beneficial.
• If the depression is associated with cancer or other physical illness.
  Antidepressant like dothiepin have been found to be better tolerated and effective.
• Depressed patients with suicidal tendencies have to be managed cautiously .
  Antidepressants with low overdose mortality like lofepramine should be used. Under such circumstances antidepressants with low side effect profile should be used. In such patients, fluoxetine may be dangerous as it has a very long half-life.