Depression drug therapy

Respiratory depression can be a serious event requiring administration of a respiratory stimulant. When an analeptic is administered, the nurse notes and records the rate, depth, and character of the respirations before the drug is given to provide a database for evaluation of the effectiveness of drug therapy. Oxygen is usually ordered for before and after administration of a respiratory stimulant. After administration, the nurse monitors respirations closely and records the effects of therapy. 

Assess patients for improvement of anxiety symptoms and for return to baseline occupational, social, and interpersonal functioning. With effective treatment, the patient should have no or minimal symptoms of anxiety or depression. While drug therapy is being initiated, evaluate patients more frequently to ensure tolerability and response. Increase the dose in patients exhibiting a partial response after 2 to 4 weeks on an antidepressant or 2 weeks on a benzodiazepine. Individualize the duration of treatment because some patients require up to one year of treatment.27... 

Treatment considerations for antiretroviral-experienced patients are much more complex than for patients who are naive to therapy. Prior to changing therapy, the reasons for treatment failure should be identified. A comprehensive review of the patient s severity of disease, antiretroviral treatment history, adherence to therapy, intolerance or toxicity, concomitant drug therapies, co-morbidities, and results of current and past HIV resistance testing should be performed. If patients fail therapy due to poor adherence, the underlying reasons must be determined and addressed prior to initiation of new therapy. Reasons for poor adherence include problems with medication access, active substance abuse, depression and/or denial of the disease, and a lack of education on the importance of 100%... 

Between 65% and 70% of patients with major depression improve with drug therapy. 

Indications include a wide variety of psychiatric disorders, in the first place schizophrenia, organic psychoses and other acute psychotic illnesses. However they are also of use for the manic phase of bipolar affective disorder and for psychotic depression. Under antipsychotic drug therapy patients become less agitated and restless, withdrawn and autistic patients may become more communicative, aggressive and impulsive behavior diminishes and hallucinations and disordered thinking disappear. 

An important aspect of a-methyldopa s hemodynamic effects is that renal blood flow and glomerular filtration rate are not reduced. As occurs with most sympathetic depressant drugs and vasodilators, long-term therapy with a-methyldopa leads to fluid retention, edema formation, and plasma volume expansion. While data conflict somewhat, it is generally thought that a-methyldopa suppresses plasma renin activity. 

Answer Because of sertraline s favorable side effect profile and no need for dietary restrictions, it probably should be chosen over the older agents (TCAs and MAOIs). She should be warned about nausea and possibly loose stools, anorgasmia, and insomnia before she begins therapy. It also should be explained that the medication will take at least 2 weeks to begin working and that a complete trial of the medication to assess its efficacy will take 4 to 6 weeks. Since this is her first episode of depression, she should take the medication for 6 to 12 months after her symptoms have remitted before considering discontinuation of drug therapy. 

A series of studies demonstrates a synergistic effect between drug therapies and psychodynamic talk therapies. The effectiveness of each form of therapy used independently is less than their combined use in the case of major depression. See A. Solomon, The Noonday Demon An Atlas of Depression (New York Scribner s, 2001) E. Good, Chronic Depression Study Backs the Pairing of Therapy and Drugs, New York Times (May 18, 2000) L. Altshuler et al., Treatment of Depression in Women A Summary of the Expert Consensus Guidelines, of Psychiatric Practice 7 (May 2001) 185-208. Kleinman, Rethinking Psychiatry p. ii. 

The available data indicate that patients with PMD will often respond to combination drug therapy or amoxapine at adequate doses (>200 mg/day for amoxapine or TCAs] for at least 4 weeks. However, the course of psychotic depression is often prolonged, and it may take several months of treatment before a remission is secured. 

Patients whose depression has apparently been resistant to standard antidepressant treatment often have had inadequate trials of antidepressants or have been nonadherent with drug therapy. Depression in a patient who has failed to complete an adequate trial of an antidepressant drug does not constitute treatment-resistant depression. A patient who reports a history of robust but short-lived responses to several antidepressants may be manifesting a medication-induced rapid-cycling course. Mild episodes of hypomania during the course of treatment may be overlooked, especially in a productive patient with a high level of functioning and a premorbid history of hyperthymic personality, defined as a chronic state of mild hypo-mania. In these cases, treatment with a mood stabilizer is indicated (see Chapter 5). 

Prien RE, Kupfer DJ Continuation drug therapy for major depression episodes how long should it be maintained Am J Psychiatry 143 18—23, 1986... 

S. M. Stahl, L. Palazidou (1986). The pharmacology of depression studies of neurotransmitter receptors lead the search for biochemical lesions and new drug therapies. Trends Pharmacol. Sci. 7 349-354. 

If an antidepressant is discontinued too early, rapid and serious relapse may result. This indicates that, whereas antidepressants may shorten or curb a depressive episode, they cannot definitely end and hence cure it. The attenuation of depressive symptoms is thus not a sufficient criterion for withdrawing drug therapy (Chapter 8). The decision as to when an antidepressant may be discontinued is often difficult and also dependent on the chronicitv of the patient s depression and the number of episodes of depression experienced. 

The drug therapy of depression differs in a number of critical points from that given to schizophrenics. Depressions are phasically occurring deviations from the norm that, in the majority of cases, show spontaneous remission, although this often may be only after a period of some months. The majority of depressives can be treated as outpatients a fact that explains why the illness generally does not make as severe an encroachment into the family and social surroundings of the patient as does schizophrenia. Outsiders are able to imagine what a depression must be like, or at least believe that they can everyone is occasionally sad. disappointed or devoid of hope. In the eyes of his fellow men and women a depressive consequently tends to be a person to be pitied but not one who is necessarily mad. 

Numerous investigations have been published concerning the question of the contributions that psychotherapy and drug therapy can make to the treatment of depressions, which psychotherapeutic procedures are particularly suitable for depressions and whether combined drug therapy and psychotherapy is sensible for depressions. 

In all, this study suggested the suitability of CT in mild to moderately severe depressions and tended to speak against the drug treatment of patients whose mental illness is conditioned primarily by their life situation. The study also confirmed that drug therapy and non-drug treatments can be combined in depressions. 

In all, and despite the considerable differences between the cited studies, these results suggest that CT is an effective therapeutic procedure for ambulatory patients with mild to moderately severe depressions. It also appeal s that CT and drug therapy may have similar efficacy in these cases, although the small numbers typical of these trials leave the possibility of type 2 errors open. It remains to be determined whether a combination of CT with an antidepressant provides a significant additional benefit, and it is also unclear what the precise indications are for the two forms of therapy (see Hollon et al., 1991). Two more recent studies also have not provided definitive answers to these questions ... 

Endogenous depressives responded best to a combination of drug and psychotherapy. Drug therapy alone was only marginally better than free appointments. Psychotherapy alone was less effective than free appointments. 

In the case of situative depressives. psychotherapy and combined drug and psychotherapy achieved approximately the same result and both were markedly better than drug therapy alone, which in turn was better than free appointments. 

Viewed as a whole, this investigation supports the view that tricyclic antidepressants are particularly effective in cases of endogenous depression, whereas psychotherapy, possibly in conjunction with drug therapy, constitutes the best solution in cases of situative depression (which would probably be termed reactive depression in the terminology used hitherto). It is interesting to note that the combination of drug therapy with psychotherapy provided additional benefit in patients with endogenous depression. It must, however, be stated that this final conclusion is only based on a fairly small subsample. 

Concluding Comments on Drug Therapy and Psychotherapy of Depressions... 

As Weissman et al. (1987) emphasized in a review some years ago, the utility of several psychotherapeutic procedures in the treatment of unipolar non-psychotic depressions has been shown convincingly in a number of independent, controlled studies. Clearly structured procedures with time limits, such as CT. IPT and SST, represent valuable alternatives or a supplement to drug therapy with antidepressants, especially in outpatients. This view is supported by the large, carefully controlled study by Keller et al. (2000, see above), which resulted in very similar response rates for drug treatment and... 

Friedman, AS. Interaction of drug therapy with marital therapy in depressive patients. Arch. Gen. Psychiatry 32, 619-637, 1975. 

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