Moderate depression treatment

Various forms of psychotherapy are regarded as effective interventions in mild to moderate depression, but studies comparing the economics of psychotherapy and pharmacotherapy are few (Rosenbaum and Hylan, 1999). One study found that the total health-care costs for patients who received psychotherapy were no different from those for patients who received an antidepressant. However, no efficacy measure was used (Edgell and Hylan, 1997). A randomized, prospective study which evaluated the treatment of depression with nortriptyline, interpersonal therapy or treatment as usual, with outcomes expressed in quality-adjusted life years, found that nortriptyline but not interpersonal therapy was a cost-effective alternative to treatment as usual (Lave et al, 1998). 

Compared to antipsychotics, there are even fewer studies on the prescribing patterns of antidepressants done in Asian countries. Pi etal. (1985) conducted a survey of psychotropic prescribing practices reported by psychiatrists in 29 medical schools in 9 Asian countries. Daily dose range of tricyclic antidepressants (TCAs) such as amitriptyline, imipramine, and nortriptyline in Asian countries was comparable to the practice in USA. This is despite differences found between Asian and non-Asian populations in the pharmacokinetics of TCAs (Pi et al, 1993). A questionnaire on the practical prescribing approaches in mood disorders administered to 298 Japanese psychiatrists was reported by Oshima et al. (1999). As first-line treatment, the majority of respondents chose newer TCAs or non-TCAs for moderate depression and older TCAs for severe depression. Combination of antidepressants and anxiolytics was preferred in moderate depression, while an antidepressant and antipsychotic combination was common in severe psychotic depression. Surprisingly, sulpiride was the most favored drug for dysthymia. In a naturalistic, prospective follow-up of 95 patients with major depression in Japan, the proportion of patients receiving 125 mg/day or less of imipramine was 69% at one month and 67% at six months (Furukawa et al., 2000). 

Psychotherapy looks even better when its long-term effectiveness is assessed.17 Formerly depressed patients are far more likely to relapse and become depressed again after treatment with antidepressants than they are after psychotherapy. As a result, psychotherapy is significantly more effective than medication when measured some time after treatment has ended, and the more time that has passed since the end of treatment, the larger the difference between drugs and psychotherapy. This long-term advantage of psychotherapy over medication is independent of the severity of the depression. Psychotherapy outperforms antidepressants for severely depressed patients as much as it does for those who are mildly or moderately depressed.18... 

Optimize the dose of mood stabilizing medication(s) before adding on lithium, lamotrigine, or antidepressant (e.g, bupropion or an SSRI) if psychotic features are present, add on an antipsychotic ECT used for severe or treatment-resistant depressive episodes or for psychosis or catatonia Mild to Moderate Depressive Episode Severe Depressive Episode... 

St. John s wort, an herbal nonprescription medication containing hyperi-cum, may be effective for mild to moderate depression, but it is associated with several drug-drug interactions. Its potency, purity, and manufacture are not regulated by the FDA. As depression is a potentially life-threatening disease, all antidepressant treatments should be overseen by a trained healthcare professional. 

A multicenter trial comparing more appropriate doses of imipramine (75 mg twice daily, N = 167) and St. John s wort extract (250 mg twice daily standardized to 0.2% hypericin, N = 157) showed no difference in efficacy after 6 weeks of treatment. However, St. John s wort seemed to reduce anxiety symptoms more often than imipramine and was better tolerated (Woelk, 2000). A study including 240 participants compared St. John s wort with fluoxetine in mild to moderate depression and also concluded that efficacy of both treatments was comparable (Schrader, 2000). These results have been replicated in a smaller trial us-... 

There is no empirical evidence available for clinical use in children and adolescents. Yet, Hypericum seems to be used for the treatment of mild to moderate depression in the young (Walter et ah, 2000). St. John s wort should be avoided in young patients with severe depression and bipolar disorder (given the lack of adult data about effectiveness and risk of manic induction, respectively) and in those who have significant suicide risk. Treatments of proven efficacy (e.g., SSRIs, mood stabilisers) should be preferred in these cases. However, St. John s wort may be considered in cases of unipolar depression where conventional treatments have failed and prior to the use of combinations of drugs that have an increased risk of side effects and whose efficacy has not been demonstrated. 

Despite the diagnostic challenges that remain in trying to understand the nature of MDD in children and adolescents, advances in its treatment has progressed considerably since the last edition of this textbook. Over this interval, selective serotonin reuptake inhibitors (SSRIs) have superseded TCAs as the treatment of first choice based both on efficacy and safety considerations. As in adults, specific psychotherapies (cognitive therapy, cognitive-behavioral therapy, and interpersonal therapy) may be as effective as antidepressant medication, at least in mild to moderate depression in children and adolescents ( 111, 112). Also, evidence indicates that depression in children and adolescents may be more influenced than is depression in adults by psychosocial variables such as peers and family, as well as other environmental factors (113). 

St. John s wort (Hypericum perforatum) is a perennial wildflower indigenous to Europe, North Africa, and western Asia (Fig. 1) and has been used for medicinal purposes for over two millennia. As far back as the early 16th century, St. John s wort was used primarily to treat anxiety, depression, and sleep disorders. In the late 20th and early 21st century, St. John s wort has been recommended for the treatment of mild to moderate depression (7). In support of its use for the treatment of mild to moderate depression, a number of clinical trials have demonstrated that St. John s wort has comparable efficacy to the tricyclic antidepressants (i.e., imipramine) and selective serotonin reuptake inhibitors (e.g., fluoxetine and paroxetine) (8-13). 

Behnke K, Jensen GS, Graubaum HJ, Gruenwald J. Hypericum perforatum versus fluoxetine in the treatment of mild to moderate depression. Adv Ther 2002 19(l) 43-52. 

Philipp M, Kohnen R, Hiller K. Hypericum extract versus imipramine or placebo in patients with moderate depression randomised multicentre study of treatment for eight weeks. Br Med J 1999 319 1534—1538. 

The most recent systematic review and meta-analysis involved 37 randomized, double-blind, controlled trials (26 compared St. John s wort to placebo, 7 to tricyclic antidepressants, and 7 to selective serotonin reuptake inhibitors [SSRIs]). St. John s wort was reported to be more efficacious than placebo and equivalent to prescription reference treatments including the SSRIs for mild to moderate depression. Most trials used 900 mg/d (for mild to moderate depression) of St. John s wort for 4-12 weeks. 

Other CYP3A4 inducers have also been reported to exert a pronounced effect on oral midazolam AUC (78), presumably through induction of intestinal and hepatic CYP3A4. For example, administration of phenytoin and carba-mazepine led to a 94% reduction in midazolam AUC compared with an untreated control population. Induction of CYP3A by St. John s wort, a widely used herbal supplement for the treatment of mild to moderate depression, has also attracted considerable interest. The major bioactive ingredient of St. John s wort, hyperforin, is a very potent in vitro activator of hPXR (79,80). Several groups have investigated induction of midazolam clearance by St. John s wort (81-83). As in the case of rifampin, clearance of oral midazolam... 

Bipolar disorder is a lifetime condition, and accordingly, treatment must be given for the duration of the patient s life. The purpose of maintenance treatment includes full and partial breakthrough episode relapse prevention, suicide prevention, mood stability, and improved functioning. In particular, low-grade symptoms, like mild to moderate depressive symptoms and unpredictable mood fluctuations, can have noticeable effects on functioning. 

A number of studies have suggested St. John s wort as a viable treatment for depression. In one study of more than 3,000 patients with mild to moderate depression, over three quarters showed improvement after four weeks of using the herb. In another study, patients who received St. John s wort showed significantly more improvement than patients who received a placebo. Although St. John s wort may provide benefits to individuals with milder forms of depression (Lawvere Mahoney, 2005), recent studies have indicated that it is not effective in the treatment of major depression (Hypericum Depression Trial Study Group, 2002 Shelton et al., 2001). 

St. John s wort is used most often for the treatment of mild to moderate depression. It is also used to treat anxiety, sleep disorders, seasonal affective disorders (SADs), and wound healing (1,4,5). 

Increasingly, consumers are choosing alternative forms of therapy, such as herbal medications including St. John s wort." " Some evaluations have found that the active ingredient in St. John s wort, hypericum, is a safe and effective treatment for mild to moderate depression" " when compared with placebo, TCAs, and fluoxetine." " In most cases, side effects appear to be mild. St. John s wort is available as an over-the-counter medication. Although this... 

I Psychotherapeutic interventions, particularly cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) are effective in the treatment of many children and adolescents with depressive symptoms and mild-to-moderate depressive episodes and should probably be considered first-line treatment. 

B. Lymphocyte levels between 1000 and 1500/ mm3. The patient may require treatment for moderate depression in granulocytes and platelets within 3 weeks. 

The drug contains peculiar chemical constituents such as naphtodianthrones (hypericins), acylphloroglucinols (hyperforins), flavonol glycosides (quercetin derivatives) and biflavones [9] and all the metabolites as a whole seem to contribute to its pharmacological activity. Current use of St. John s Wort is mainly for the treatment of mild to moderate depression [10,3] and drug extracts for antidepressant applications have become increasingly popular. 

Herbal preparations from the dried aerial parts of H. perforatum are currently used for the treatment of mild to moderate depression [4,5]. The antidepressant effectiveness of the plant is well documented by several studies [3,10,85-87], which also indicate that the drug has advantages compared to synthetic antidepressants. 

ABSTRACT Hypericum perforatum L., St. John s Wort, has become one of the most important medicinal plants of nowadays. This is a result of extensive research on the chemical constituents of this plant, and of increasing efforts for pharmacological and clinical profiling of St. John s Wort extracts and of their individual components. To date, these studies provide a solid basis for the the therapeutic use of St. John s Wort in the treatment of mild to moderate depressions. 

Witte. Harrer, Kaptan, Podzuweit, and Schmidt 1995 97 (33 mJ64 f) moderate depressive Episode (HAMD >16) [ICD-10 F32.1] Psychotonin forte 2 x 100-120 mg 6 weeks A 88 patients with at least 4 weeks treatment (last value carried forward) (Hyp 43, Pic 45) R HAMD response rate (decrease in total score >50% or total score <10) 79% (placebo 56%). p<0.02 (Chi-square test), decrease in mean total score from 24,6 to 7,9 (placebo approx. 23 to 11) D-S (self-rating scale) decrease in mean total score from approx. 25 to 7 (placebo approx. 22 to 11) CGI change 67% of patients "vety much improved (placebo 30%), p<0.005 (Chi-square test) Patient s global impression full remission in 44% of patients, improvement in a further 36% (placebo 3% and 63%, respectively) STAI mean decrease in XI score 38% and in X2 score 39% (placebo 19% and 20%, respectively)... 

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