Posted 12 October 2013 - 09:55 PM
The evidence base clearly indicates the use of an antidepressant as a first line treatment in moderate and severe major depressive episodes.
SSRI's are typically the first line treatment but with a little information certain other drugs might be choosen instead (Mirtazapine, Venlafaxine, Trazadone or Bupropion are the most likely). Typically adjuncts aren't used unless the episode is treatment resistant but in some cases, typically where there is co-morbidity this isn't always the case. Anti-epeleptics, buspirone, atypical antipsychotics, lithium, stimulants or T3 are the most common.
She needs to see a medic (qualified general medical practioner - family doctor, G.P) if she hasn't already who will order a routine blood test (thyroid, liver, full/complete blood count and maybe b 12 as well as a few others). Hypothyroidism a big cause and a risk factor for major depression and would be the most likely abnormality. On top of this he will also enquire about symptoms etc..which may point towards another disorder or a co-morbid disorder and require further invenstigation. Providing these all come back normal - which is the most likely result then she should start an antidepressant otherwise more tests and/or a referal to another medical specialty (Psychiatry, Endocrinology, Neurology, Immunology etc).
So far all I've banged on about are antidepressants. If this is a 'simple' case of moderate depression then yes, first line treatment should be an antidepressant, its likely all that she will need, although two trials may be needed to find her the correct drug.
Treatment resistance (failure of two or more antidepressants of seperate classes) should be treated with combined pharmacotherapy and CBT or IPT (interpersonal psychotherapy). 8-12 weeks of therapy is recommended as a place to start and it should be provided by a clinical or counselling psychologist or an accredited practitioner. Group therapy will be cheaper and is slightly more effective and so that remains my top recommendation psychotherapy wise.
When you say she has been having councelling it would be helpful to know what type & for how long? Is it person centered councelling? CBT? analytical psychotherapy?
While I've said the first line treatment should be medication it doesn't mean she SHOULDN'T also have CBT or IPT (or any approved psychotherapy for that matter) but typically its not needed and hence cheaper. There are also a range of interventions she can and should try to put into place herself (with or without help/encouragement). Mindfulness practice 3+ times weekly, exercise 3+ times weekly(starting from getting out of bed if she has to), good sleep hygeine and basic principles of behavioural activation. She may also like to trial hypnotherapy - its more effective for anxiety disorders but still shows an astoundingly high success rate (50-70%) - although in comparision to CBT/IPT the evidence base is much much smaller. 1-6 sessions is enough to know whether it will be of any use. It may have paticular effiacy in targeting certain symptoms (insomnia, co-morbid substance abuse/addiction, pain & anxiety). NLP (Neuro-lingustic programming) is a sham therapy with multiple trials showing lack of effiacy. It is unfortunately often practiced alongside hypnotherapy and any hypnotherapist should either not offer NLP or be specifically instructed not to use NLP.
On to choosing an antidepressant. An antidepressant should be choosen on a range of factors - not all of which I'm going to cover. The most important (focusing just on mental health) in no order are: prior success/failure with an AD in a close family memeber or themselves, side effect profile, severity of illness and symptom cluster.
If the major symptoms are fatigue, somnolence, poor concentration and apathy Bupropion MAY be choosen as a first trial. On the other hand Bupropion is not typically used as a first AD and has a weaker research base than other drugs. If she has a lot of anxiety or insomnia Bupropion should not be used.
Mirtazapine is an option when the depressive symptoms are treatment resistant, severe or if there is significant insomnia, lack of appetite and significant anxiety. Its best not used when the patient is complaining of fatigue and oversleeping/eating. The side effect profile is tolerable but not 'great' in comparison to most first line ADs and Trazadone shows equal effiacy, slightly less of an evidence base and in moderate-high doses 150mg-600mg is just as effective as Mirtazapine without as much risk of weight gain or sexual dsyfunction.
Venlafaxine is often reknown for having a severe withdrawal and very unplesant side effect profile. To an extent this is true but this is often blown out of proportion. Its about as effective as Mirtazapine and at lower doses (75mg) may be slightly sedating and increase weight gain. Higher doses tend to be more stimulanting (150mg+) and either stabilize weight or cause weight loss. Its paticually effective in severe depression and may also offer use in depression associated with fatigue, poor concentration and apathy. Duloxetine is another option and of the same class as Venlafaxine. It may have a slightly improved side effect profile and is as effective.
The SSRI's. They are for good reason grouped into one class but they all act in slightly different ways. Generally I'd only recommend three from the class as a first line therapy for depression - Sertraline, Fluoxetine and Escitalopram. Sertraline is a potent SSRI with mild but relevent dopamine re-uptake properties. It's a good choice for any set of depressive symptoms and has one of the mildest side effect profiles. Fluoxetine is an SSRI with 5ht2a/c antagonism and sigma-1 receptor agonist, its side effect profile is good and it may be slightly more effective than other SSRIs for depressive disorders with personality disordered features. Escitalopram is only an SSRI but seems to bind as an positive allosotic modulator of SERT as well - making it one of the most potent SSRIs about.
Other classes of Antidepressants relevent to first line treatments - include tricyclic antidepressants, second generation ADs, RIMA's and novel drugs. Tricyclic antidepressants should only be used as a first line therapy in severely depressed patients under careful review due to an unpleasant and rarely dangerous side effect profile and high risk of complications in overdose. The second generation antidepressants are a diverse catagory but in general have reasonable side effect profiles but shouldn't be used as first line agents. Novel drugs are also diverse including Agomelatine, Vilazodone and Vortioxetine, which are all VERY tolerable but have small evidence bases due to being so new and as such shouldn't be used as first line. RIMA's or Reversable inhibitors of Monamine oxidase - A of which the only one widely avaible is Meclobremide are very effective and well tolerated and as such they may eventually become the 'typical' first line instead of SSRIs.
And now I'm going to disagree with your and celebes suggestions. My primary reason and by far the most important reason for disagreeing with the use of supplements as treatment for depression is...a massive lack of evidence. A massive lack of evidence establishing safety and a massive lack of evidence establishing effiacy. If you compared the research combined of every single intervention you have suggested against one SSRI I am all but sure the SSRI would have at least 10x more papers establishing effiacy and safety.
The only two suggestions so far on the page with any consistent supporting evidence of effiacy are St. Johns wart and DLPA (Phenylalanine). A Cochrane review did actually suggest St. Johns wart was as effective as SSRI's with fewer side effects. They however made it clear that with out the research base coming from germany this wouldn't have been so as research in other countries consistenly show barely significant responses (much less than that of SSRIs). Further to this, with the fact that SSRI's vary quite significantly in effectiveness themselves makes it impossible to draw such a conclusion in the first place. DLPA has a very small evidence base, although it is positive - not as effective as antidepressants but it does have a significant effect.
I'm not going to go through the rest of the suggestions other than to briefly say, there are two small RCTs each for zinc and magnesium AGUMENTATION (addition to antidepressants - they have consitently been shown not to be effective alone as antidepressants) with small effect sizes. Folate has some conflicting research in the use of ante/postnatal depression but in idiopathic forms was in effective and fatty acids have in one study of 7 people shown a reduced risk of suicidal behaviour when used as an adjunct. All the other research in relation to every suggestion is of poor quality and not worth considering. Blue light therapy was shown to be no more effective than general bright light therapy, although it required reduced lux. Using a light box (10,000 lux) has shown efficay for circadian rhythm disorders and SAD but has inconsistent results in other depressive disorders. DHEA may actually worsen depression by increasing corticosteroid synthesis and increasing testosterone and estrogen activity.
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