Depressed patients depressive disorders

Treatment of Manic—Depressive Illness. Siace the 1960s, lithium carbonate [10377-37-4] and other lithium salts have represented the standard treatment of mild-to-moderate manic-depressive disorders (175). It is effective ia about 60—80% of all acute manic episodes within one to three weeks of adrninistration. Lithium ions can reduce the frequency of manic or depressive episodes ia bipolar patients providing a mood-stabilising effect. Patients ate maintained on low, stabilising doses of lithium salts indefinitely as a prophylaxis. However, the therapeutic iadex is low, thus requiring monitoring of semm concentration. Adverse effects iaclude tremor, diarrhea, problems with eyes (adaptation to darkness), hypothyroidism, and cardiac problems (bradycardia—tachycardia syndrome). 

Other agents are also used for the treatment of manic-depressive disorders based on preliminary clinical results (177). The antiepileptic carbamazepine [298-46-4] has been reported in some clinical studies to be therapeutically beneficial in mild-to-moderate manic depression. Carbamazepine treatment is used especially in bipolar patients intolerant to lithium or nonresponders. A majority of Hthium-resistant, rapidly cycling manic-depressive patients were reported in one study to improve on carbamazepine (178). Carbamazepine blocks noradrenaline reuptake and inhibits noradrenaline exocytosis. The main adverse events are those found commonly with antiepileptics, ie, vigilance problems, nystagmus, ataxia, and anemia, in addition to nausea, diarrhea, or constipation. Carbamazepine can be used in combination with lithium. Several clinical studies report that the calcium channel blocker verapamil [52-53-9] registered for angina pectoris and supraventricular arrhythmias, may also be effective in the treatment of acute mania. Its use as a mood stabilizer may be unrelated to its calcium-blocking properties. Verapamil also decreases the activity of several neurotransmitters. Severe manic depression is often treated with antipsychotics or benzodiazepine anxiolytics. 

The authors concluded that antidepressants exert a modest beneficial effect for patients with combined depressive disorder and substance use disorder. They also emphasized that antidepressants are not a stand-alone treatment for depressed alcoholic patients and that concurrent therapy directly targeting the substance use disorder is also indicated. 

Nestler EJ, Hyman SE, Malenka RC Molecular Neuropharmacology A Foundation for Clinical Neuroscience. New York, McGraw Hill, 2001 Novick DM, Pascarelli EE, Joseph H, et al Methadone maintenance patients in general medical practice a preliminary report. JAMA 259 3299—3302, 1988 Nunes EV, Quitkin EM, Donovan SJ, et al. Imipramine treatment of opiate-dependent patients with depressive disorders a placebo-controlled trial. Arch Gen Psychiatry 55 153-160, 1998... 

In summary, research on the use of antidepressants to treat cannabis dependence, particularly among individuals with comorbid major depressive disorder, although limited, offers a promising avenue for the development of pharmacological aids to assist in the treatment of cannabis withdrawal. There are clear parallels between this literature and the existing research on the use of antidepressants in the treatment of alcohol dependence comorbid with major depressive disorder (see Chapter 1, Medications to Treat Co-occurring Psychiatric Symptoms or Disorders in Alcoholic Patients). 

Schmitz JM, Averill P, Stotts AL, et al Fluoxetine treatment of cocaine-dependent patients with major depressive disorder. Drug Alcohol Depend 63 207-214,2001 Schottenfeld RS, Pakes JR, Oliveto A, et al Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse. Arch Gen Psychiatry 54 713-720, 1997... 

Einarson TR, Arikian S, Sweeney S, Doyle J (1995). A model to evaluate the cost effectiveness of oral therapies in the management of patients with major depressive disorders. Clin Ther 17, 136-53. 

Evaluation of the economics of mental illness in primary care is an ongoing initiative of the UK Department of Health (Lloyd and Jenkins, 1995). A similar American study in Washington State included sub-threshold anxiety or depression, but these imposed relatively little economic load compared with disorder-level anxiety or depression (Simon et al, 1995). Mental health treatment accounted for only a small part of overall utilization, approximately 5%. Nevertheless, most patients with anxiety or depressive disorders showed considerable improvement. This was accompanied by only modest reductions in cost. 

Honorary Consultant at the Maudsley Hospital and sees patients with anxiety, sleep and depressive disorders. He is on the advisory boards of about 25 international scientific journals. 

It is not uncommon for a patient to experience only a single major depressive episode, but most patients with major depressive disorder will experience multiple episodes. 

Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000 157(4 suppl) lM5. 

ADHD is rarely encountered without comorbid conditions and often is underdiagnosed. Between 40% and 75% of patients with ADHD will have one or more comorbidities (e.g., learning disabilities, oppositional defiant conduct, anxiety, or depressive disorders).10 It is important to identify other coexisting conditions in patients with ADHD to assist in initial and ongoing selection of treatment. 

Yoshida, K. et al. (2002). Monoamine oxidase a gene polymorphism, tryptophan hydroxylase gene polymorphism and antidepressant response to fluvoxamine in Japanese patients with major depressive disorder. Prog. Neuropsychopharmacol. Biol. Psychiatry, 26, 1279-83. 

Sato, K., Yoshida, K., Takahashi, H. etal. (2002). Association between -1438G/A promoter polymorphism in the 5-HT(2A) receptor gene and fluvoxamine response in Japanese patients with major depressive disorder. Neuropsychobiology, 46, 136-40. 

Currier, M. B., Molina, G. 8c Kato, M. (2004). Citalopram treatment of major depressive disorder in Hispanic HIV and AIDS patients a prospective study. Psychosomatics, 45, 210-16. 

Lewis-Fernandez, R., Blanco, C., Mallinkcrodt, C. H., Wohlreich, M. M. et al. (2006). Duloxetine in the treatment ofmajor depressive disorder comparisons of safety and efficacy in US Hispanic and majority Caucasian patients. /. Clin. Psychiatry, 67, 1379-90. 

The median values of REM sleep latency, total time asleep, and SWS (in minutes and as a percentage of total time asleep) were lower, and REM sleep (percent) values were found to be higher, in depressive disorders than in all other psychiatric conditions. However, the statistical differences between depressed patients and other psychiatric categories were far less evident. Indeed, no sleep variable reliably distinguished depressed patients from those with other psychiatric disorders. The investigators concluded that sleep disturbances are associated with most psychiatric disorders, although the most widespread and most severe disturbances are found in patients with depressive disorders (Van Bemmel 1997). 

The positive symptoms are the most responsive to antipsychotic medications, such as chlorpromazine or halo-peridol. Initially, these drugs were thought to be specific for schizophrenia. However, psychosis is not unique to schizophrenia, and frequently occurs in bipolar disorder and in severe major depressive disorder in which paranoid delusions and auditory hallucinations are not uncommon (see Ch. 55). Furthermore, in spite of early hopes based on the efficacy of antipsychotic drugs in treating the positive symptoms, few patients are restored to their previous level of function with the typical antipsychotic medications [2]. 

The typical antipsychotic drugs, which for 50 years have been the mainstay of treatment of schizophrenia, as well as of psychosis that occurs secondary to bipolar disorder and major depressive disorder, affect primarily the positive symptoms[10]. The behavioral symptoms, such as agitation or profound withdrawal, that accompany psychosis, respond to the antipsychotic drugs within a period of hours to days after the initiation of treatment. The cognitive aspects of psychosis, such as the delusions and hallucinations, however, tend to resolve more slowly. In fact, for many patients the hallucinations and delusions may persist but lose their emotional salience and intrusiveness. The positive symptoms tend to wax and wane over time, are exacerbated by stress, and generally become less prominent as the patient becomes older. 

Major depression is characterized by one or more episodes of major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (Table 70-1). Symptoms must have been present nearly every day for at least 2 weeks. Patients with major depressive disorder may have one or more recurrent episodes of major depression during their lifetime. 

The efficacy of psychotherapy and antidepressants is considered to be additive. Psychotherapy alone is not recommended for the acute treatment of patients with severe and/or psychotic major depressive disorders. For uncomplicated nonchronic major depressive disorder, combined treatment may provide no unique advantage. Cognitive therapy, behavioral therapy, and interpersonal psychotherapy appear to be equal in efficacy. 

Some failures will be due to the presence of variants in drug handling. Patients who are rapid acetylators of isoniazid have a slower antituberculous response than slow acetylators (Evans and Clarke, 1961). Asthmatics who do not respond well to (32-agonist bronchodilators may have fewer functioning p2-adrenergic receptors (Drysdale et al., 2000). Variations in the synthesis or structure of the serotonin transporter protein, which is involved in selective reuptake of serotonin by presynaptic neurons, may explain why some patients with depressive disorders respond to selective serotonin reuptake inhibitors and others do not (Steimer et al., 2001). 

US National Institute of Mental Health, anxiety (in particular generalized anxiety disorder or GAD) and depression are the most prevalent mental illnesses. In the United States alone, an estimated 4 million adults suffer from GAD and nearly 19 million adults are affected by depressive disorders. As GAD and depression are often present together, most patients suffering from these disorders are treated with the same drugs [1]. 

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