Medications for depression – classification and who is prescribed
Antidepressants are not addictive. However, the addiction myth is understandable. The reason is that after self-withdrawal of antidepressants, the patient feels worse than before. The presence of a withdrawal syndrome indicates an inappropriate withdrawal of the drug. Withdrawal symptoms are perceived by many as signs of addiction.
The reason is that if the artificial support for the synthesis of neurotransmitters is abruptly stopped, then their number in the body drops sharply. Patients feel this as a sharp relapse of a depressive state, increasing anxiety and suicidal danger. It is important to cancel antidepressants smoothly, combining the process with psychotherapy.
- monoamine oxidase inhibitors (MAOIs);
- inhibitors of selective uptake of serotonin (SSRIs).
The first group (tricyclic) is not a sedative. They act by inhibiting the neuronal uptake of norepinephrine, serotonin. That is, norepinephrine and serotonin are not rapidly degraded. Serotonin and norepinephrine do not evaporate in the presynaptic nerve endings. Because of this, their synthesis in the synaptic cleft increases, due to the restoration of the balance of serotonin. As a result, there is an increase in the activity of adrenergic and serotonergic transmission. Contraindications – taking other psychoactive substances, problems with the liver, kidneys, blood-forming organs. Not prescribed for patients with diabetes, severe atherosclerosis, glaucoma, pregnancy.
The second group is monoamine oxidase inhibitors (MAOI, MAOI). Monoamine neurotransmitters are responsible for regulating the processes of emotion, memory, arousal, inhibition, attention, and cognitive processes. Monoamine oxidase inhibitors slow down the leasing process, thereby increasing the accumulation of monoamines in the nerve endings. Monoamine oxidase inhibitors are divided into two groups – reversible and irreversible. MAOI-B are also used in the treatment of parkinsonism and narcolepsy. Contraindicated in patients with hypo- and hypertension, pregnant women and people whose work requires concentration.
The third group is inhibitors of selective uptake of serotonin. A short course of such drugs is prescribed to restore the normal volume of serotonin concentration. The clinical effect does not appear immediately. Plus drugs in this group – with a sharp discontinuation of the drug, there is no withdrawal syndrome. Due to the fact that the absorption of substances occurs in the liver and is excreted by the genitourinary system, they are contraindicated for use by people suffering from genitourinary diseases. Cannot be used for alcohol poisoning and in conjunction with other psychoactive substances. Contraindicated in case of risk of intestinal bleeding, glaucoma, mania, pregnancy, breastfeeding.
Antidepressants (AD) are not combined with alcohol consumption. Strong drinks increase the side effects of the medication. From a mixture of blood pressure and alcohol, depression is aggravated. In addition, in patients with depression, the risk of developing alcoholism is much higher. The combination of alcohol and blood pressure of the group of monoamine oxidase inhibitors is very dangerous. Alcohol contains tyramine, which, when combined with an antidepressant, dramatically increases blood pressure to critical levels.
There are several types of tranquilizers:
- Sedatives – normalize the condition with overexcitability of the central nervous system.
- Muscle relaxants – relaxing muscles by stopping the supply of nerve impulses to muscle tissue.
- Sleeping pills – improves the inhibition of the central nervous system at night, reduces anxiety and improves the quality of sleep. They are not used on an ongoing basis, as they quickly cause addiction.
Tranquilizers are used for violations of the process of falling asleep and awakening, anxiety, convulsive seizures. Effective as a premedication before subsequent anesthesia, in case of pathological muscle contractions. The essence of the action is to suppress the excitability of the subcortical structures of the brain. Indications for appointment:
- mild mental and behavioral disorders;
- neurotic disorders of mild severity;
- personality disorders;
- with panic attacks, phobias;
- to facilitate the state of “cancellation” for patients with alcoholism, drug addiction;
- with schizotypal disorder;
- patients with acute psychosis – in conjunction with other drugs;
- for relief of the consequences of organic lesions of the central nervous system;
- with anorexia, bulimia;
- with eczema, irritable bowel syndrome;
- to relieve asthma attacks, symptoms of hypertension, arrhythmias.
For children, drugs are prescribed for behavioral disorders. Tranquilizers are not prescribed for alcohol, drug and medical poisoning. Cannot be used by people whose work is associated with increased concentration of attention (driving a car, operating dangerous machinery, etc.).
To prevent withdrawal symptoms, discontinuation of the drug occurs gradually, reducing the dose. To prevent getting used to addictive to the drug, a long course of treatment is carried out fractionally, with interruptions. Not recommended for pregnancy and lactation.
Tranquilizers eliminate fears and phobias of a non-psychotic nature. They facilitate adaptation to stress, do not disrupt cognitive activity. Many drugs from this group are used as sleeping pills, when you have difficulty falling asleep, when you wake up early, when you feel tired after sleep. In the treatment of psychosis, tranquilizers are used only as an additional tool that relieves psychomotor agitation and helps to avoid side effects from antipsychotics.
Tranquilizers, like any drugs, have side effects. They are expressed in drowsiness (during the day), lethargy, muscle relaxation. Sometimes patients have slightly impaired concentration and short-term memory. The speed of mental reactions slows down. Vegetative disorders, possible after tranquilizers – constipation, low blood pressure, nausea, problems with urination, a drop in libido. Tranquilizers can be addictive (both mental and physical), so they are prescribed in short courses.
The worst consequence is irreversible mental deterioration.
When trying to classify antipsychotics, scientists first of all start from their chemical structure:
- aliphatic phenothiazines – drugs in which antipsychotic activity is weak, they are aimed at sedation (soothe, help to fall asleep);
- butyrophenones (popular haloperidol) – powerful antipsychotics, which have almost no sedative effect, they stop hallucinations and delusions;
- benzodiazepines are characterized by weak side effects, are better combined with other drugs, but have almost no sedative effect, aimed at stopping psychotic manifestations;
- derivatives of phenothiazine relieve pain, are prescribed for damaged vessels, thrombophlebitis.
Antipsychotics or antipsychotics are atypical or typical, prolonged or non-prolonged. Typical antipsychotics are outdated drugs that do an excellent job of relieving psychotic symptoms, but have a high likelihood of side effects. Atypical – a modern version of antipsychotics, which allows you to reduce the risk of side effects to a minimum. Sustained-release antipsychotics have a long-term effect, their effect is noticeable for 20-30 days. They are not taken daily.
Antipsychotics eliminate strong fear, anxiety, agitation, and improve sleep. They are used for severe psychotic depression, the dosage is low. Antipsychotics are prescribed more often to patients with psychoses, combined with psychomotor agitation. Less commonly used for apathy, lethargy.
Prescribing antipsychotics to children is a controversial issue in psychiatry. There is a lack of evidence-based medicine data on this issue. Therefore, antipsychotics are prescribed for pediatric patients, but rarely, with caution and in small dosages.
Nootropics are drugs that have a positive effect on the functionality of the higher integrative parts of the brain. That is, they have a positive effect on mental abilities, increase the activity of cognitive functions. A person becomes more learnable, his memorization processes and resistance to distress improve. There are several groups of nootropics:
- “true” nootropics, the action of which is focused on improving mnestic functions;
- a group of neuroprotectors – a secondary mnestic effect, a mixed effect on the central nervous system (anticonvulsant, muscle relaxant, antihypoxic);
- primary action nootropics – directly affect nerve cells;
- secondary action – improve cerebral blood flow, microcirculation, are distinguished by pronounced antiplatelet and antihypoxic effects;
- neurodynamic or neuroregulatory – primarily aimed at stimulating metabolic processes in nerve tissues, are prescribed to patients with anoxia, ischemia, intoxication, trauma.
Nootropics affect the processes of metabolism and bioenergetic metabolism in the nervous tissue, they interact with the neurotransmitter sphere of the brain. Children are prescribed with caution, in small dosages.
Nootropics are not recommended for use during pregnancy and lactation, with gastric ulcer, with fever, liver and kidney problems. Nootropics are not prescribed for patients with sensitivity to components, with epilepsy. During the application, it is recommended to take a blood and urine test in a timely manner to assess the results of the course of nootropics.
Best drug for the treatment of acute bipolar depression
Canadian researchers compared the efficacy and tolerability of pharmacological treatments for acute bipolar depression in a systematic review and meta-analysis.
The researchers analyzed medical databases to select double-blind, randomized controlled trials that included patients with acute bipolar depression.
Treatment response and remission were selected as the primary efficacy endpoint. The final point of safety was the refusal of therapy due to the development of undesirable phenomena.
- The final analysis included 50 clinical trials with 11,448 patients.
- The average follow-up time for patients was 8 weeks.
The following drugs were more effective than placebo (ranked from more effective to less effective drug)
- antipsychotics: lurasidone, quetiapine, olanzapine
- antidepressants: tranylcypromine, venlafaxine, fluoxetine, imipramine
- mood stabilizers: valproate, lamotrigine.
Compared to placebo, the following drugs were found to be ineffective:
- antipsychotics: aripiprazole, ziprasidone
- antidepressants: paroxetine, moclobemide, escitalopram, sertraline
- mood stabilizers: lithium preparations, gabapentin, and carbamazepine.
The olanzapine / fluoxetine combination was more effective than olanzapine but less effective than fluoxetine.
Quetiapine was found to be more effective than placebo in reducing the incidence of affective switchings (manic or mixed) in the treatment.
Aripiprazole therapy was associated with a higher rate of withdrawal due to the development of side effects compared with placebo.
A systematic review and meta-analysis demonstrated the efficacy of various drugs (antipsychotics, antidepressants, and mood stabilizers) compared with placebo in patients with acute bipolar depression.
How does the age of depressed patients affect the effectiveness of psychotherapy?
A new systematic review and meta-analysis is devoted to determining the relationship between the effectiveness of psychotherapy in patients with depression and the age of patients.
Research searches were conducted in PubMed, Embase and Cochrane databases. Randomized trials compared psychotherapy with controls in depressed patients. The researchers included patients of all ages in the analysis.
The main endpoint of the study was depression symptoms at the end of psychotherapy.
After reviewing 2608 full-text publications, the final analysis included 366 studies (36 702 patients) with 453 comparisons of psychotherapy with controls, including 13 (3.6%) in children (13 years and younger), 24 (6.6%) in adolescents (≥13-18 years old), 19 (5.2%) in young adults (≥18-24 years old), 242 (66.1%) in middle-aged adults (≥24-55 years old), 58 (15, 8%) in elderly adults (≥55-75 years old) and 10 (2.7%) in elderly people (75 years and older).
The average effect of therapy in all age groups was g = 0.75 (95% confidence interval (CI), 0.67-0.82), very high heterogeneity was noted (I2 = 80%; 95% CI: 78-82).
The average effect of therapy in terms of symptoms of depression was significantly less in children (g = 0.35; 95% CI, 0.15-0.55) and adolescents (g = 0.55; 95% CI, 0.34-0, 75), compared with patients ≥24-55 years old (g = 0.77; 95% CI, 0.67-0.87).
No significant differences were found between persons aged ≥55-75 years (g = 0.66; 95% CI, 0.51-0.82) and older patients (g = 0.97; 95% CI, 0, 42-1.52).
The effect of psychotherapy in depressed patients varies with age. The effect is small in children and adolescents compared to adults.
There were no significant differences in the effect of psychotherapy in persons ≥24-55 years old, ≥55-75 years old, and 75 years old and older.
Pim Cuijpers, Eirini Karyotaki, Dikla Eckshtain, et al. JAMA Psychiatry. Published online March 2020.
Anees Bahji, Dylan Ermacor, Callum Stephenson, et al. J Affect Disord 2020 May 15; 269:154-184.