Indian Write-Ups

Treatment of Depression

Although depression is a common and debilitating disease, patients often don’t receive timely diagnosis or treatment. Reporting on data collected as part of the National Comorbidity Survey, Kessler and colleagues found that less than 40% of patients with a lifetime history of at least one psychiatric disorder, and less than 20% of those with a recent disorder, had received treatment from a mental health professional5. And even when patients are treated, the therapy they receive isn’t always optimal6,7. The Depression Research in European Society (DEPRES) study found that among patients with major depression who had seen a provider for the condition (69%of all subjects with major depression), 41% received drug therapy but only 18% were give an antidepressant8. Mild depressive states may require supportive therapy in the form of reassurance and family support. However, a persistent or chronic pain inspite of adequate medications, affecting the person’s sleep, appetite, mood and overall functioning, should be viewed in terms of depression and treated appropriately with medications. Among the medication options, safety and tolerability should be of prime importance apart from affectivity, of course,

Dotheipin, a relatively cardio-safe antidepressant, in appropriate dosage, is known to alleviate depressive symptoms, anxiety and also the persistent symptom of pain seen in arthritic patients. This drug is tricyclic antidepressant, which is used in the long-term treatment of depression, and is particularly useful when depression is accompanied by anxiety and insomnia. It elevates mood, increases physical activity, improves appetite and restores interest in everyday activities. Taken at night it encourages sleep and helps eliminate the need for additional sleeping drugs.

Dothiepin was shown to improve significantly the condition of patients with primary fibromyalgia syndrome. A randomized, parallel-group, double blind study was conducted in 14 general practice patients with a diagnosis of major depression. This pilot study was designed to investigate the utility of actigraphy in this patient population and to investigate possible differences between fluoxetine and dothiepin in their effects on 24-hour behavioral activity monitored for the first 10 days of treatment. Patients taking dothiepin (75 mg rising to 150 mg in the second week, nocte) were found to be significantly (p < 0.05) less active over the course of the day compared to those treated with fluoxetine (20mg, mane). This lower level of behavioral activity in the dothiepin group was particularly noticeable in the early mornig.3

In one study forty-eight female RA patients with depression and/or anxiety were randomized to receive either dothiepin (25 patients, up to 150 mg/day) or placebo (23 patients). Subjects were assessed at baseline and at 2, 4, 6, 10, and 12 weeks after commencement of the study. The Hospital Anxiety and Depression (HAD) scale was used to measure mood, the Hamilton Rating Scale (HRS) to assess depression, the visual analog scale to determine pain, and the Health Assessment Questionnaire (HAQ) to evaluate disability.

In the dothiepin group, pain was significantly reduced by week 4 and continued through the end of the study at week 12. Depression (HRS) and HAD anxiety were reduced in both groups4. Apart from this, other medication like fluoxetine, etc, could also be considered for the treatment of depression.

Conclusion

Arthritis is a chronic illness leading to disability and affects nearly 50% of persons above the age of 65 years. Depression is a common comorbid condition and 25% of all arthritic patients could be affected. Depression increases the severity of the functional disability in arthritic patients.

Early recognition of this condition and appropriate treatment definitely helps in improving the overall functional disability, alleviates symptoms of persistent pain, and hence in the overall quality of life of these patients.

References

• Health – Related Quality of Life Among Adults With Arthritis Behavioral Risk Factor Surveillance System, 11 Sates, 1996-1998. MMWR. 2000; 49: 366-369.
• Caruso I, Sarzi Puttini PC, Boccassini L, Santandrea S, Locati M, Volpato R, Montrone F, Benvenuti C, Beretta A. Double-bind study of dothiepin versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res 1987 May-39 (3): 154-9.
• Stanley N, Fariweather DB, Hindmarch I. Effects of fluoxetine and dothiepin on 24-hour activity in depressed patients. Neuropsychobiology 1999; 39(1) 44-8.
• Ash G, et al. The effects of dothiepin on subject with rheumatoid arthritis and depression. Rheumatology 1999; 38: 959-967.
• Kessler R, McGonagle KA, Zhao S. Lifetime and 12-month prevalence of DSM –III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry . 1994; 51:8-19.
• Keller MB, Lavori PW, Klerman GL, et at. Low level and lack of predictors of somatotherapy and psychotherapy received by depressed patients. Arch Gen psychiatry. 1986; 43:458-466.
• Keller MB, Klerman GL, Lavori PW, Fawcett JA, Coryell W, Endicott J. Treatment received by depressed patients. JAMA. 1982; 248:1848-1855.
• Lepine JP, for the DEPRES Steering Committee. European perspective on depression. Psychiatry. 1997; 3(Suppl 1) : s3-s6.