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21.06.2015

Depression treatment options list, how to stop ringing in your ears - Review

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The most prominent symptom of major depression is a severe and persistent low mood, profound sadness, or a sense of despair.
Some people who have episodes of major depression also have episodes of relatively high energy or irritability. If a woman has a major depressive episode within the first two to three months after giving birth to a baby, it is called postpartum depression.
A primary care physician or a mental health professional usually can diagnose depression by asking questions about medical history and symptoms.
Many people with depression do not seek evaluation or treatment because of society's attitudes about depression. There is no way to prevent major depression, but detecting it early can diminish symptoms and help to prevent the illness from returning.
Regarding side effects, SSRIs are known to cause problems with sexual functioning, some nausea, and an increase in anxiety in the early stages of treatment. Although experts continue to debate the research, clinicians agree that it is important to have your treatment monitored closely and for you to report any troubling symptoms or worsening mood to your doctor immediately.
A number of psychotherapy techniques have been demonstrated to be helpful, depending on the causes of the depression, the availability of family and other social support, and personal style and preference. In some situations, a treatment called electroconvulsive therapy (ECT) can be a life-saving option. Depression is a painful and potentially dangerous illness, so you should contact a health care professional if you have any suspicion that you or a loved one is depressed. When treatment is successful, it is important to stay in close touch with your doctor or therapist, because maintenance treatment is often required to prevent depression from returning.
Treatment-resistant depression, or difficult-to-treat depression is emerging as a focus of scientific endeavor. Accurate identification of these different depressive disorder subtypes is crucial and can facilitate earlier and more effective treatment of these complex patients. In a study by Schmidt and colleagues,9 1,186 depressed patients entered a three-phase study that investigated treatment response with varying doses of fluoxetine. At this time there is no definitive evidence suggesting greater benefit for either of the two most commonly employed options, substitution or augmentation therapy.16 In general, it is believed that nonresponders may benefit from switching, and partial responders may benefit from augmentation, but more empirical evidence is needed to validate this viewpoint. Combining a TCA with an SSRI may reduce the time it takes for a patient to respond to treatment. VNS treats depression by implanting a battery device in the chest area of the patient and attaching wires to the vagus nerve.
Bright-light therapy is effective in seasonal affective disorder (SAD), particularly winter depression. Modafinil is indicated for the treatment of narcolepsy but is clinically used for medication-induced sedation. There is general evidence linking omega-3 fatty acids (polyunsaturated fatty acids [PUFAs]) with depressive illness. Double-blind maintenance studies suggest that bipolar depression is responsive to lamotrigine therapy, but there are less data on its efficacy in unipolar depression. A new medical diagnosis or drug treatment can often leave us with more questions than answers. Leaving aside the controversy over the efficacy (or lack thereof) of homeopathic treatment, data for their prescription rates would be far harder to get ahold of, as they are not prescribed under the same systems as conventional medicines.
Observing that HMGCoA reductase inhibitors are NOT blood pressure treatments, this type of result demonstrates that elevated cholesterol is common among patients with elevated blood pressure. The mood changes that occur in major depression are defined as lasting at least two weeks but usually they go on much longer — months or even years. Some people who have many episodes of major depression also have a background pattern of a milder depressed mood called dysthymia. Depression that occurs mainly during the winter months is called seasonal affective disorder, or SAD. The vast majority of people who suffer severe depression do not attempt or commit suicide, but they are more likely to do so than people who are not depressed. By definition, major depression is diagnosed when a person has many of the symptoms listed above for at least two weeks. The person may feel the depression is his or her fault or may worry about what others will think. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment.
Other identifiable causes of treatment failure are undertreatment, medical illness, and comorbid psychiatric conditions such as anxiety and personality disorder diagnosis.7 A patient suffering from medical illness, substance abuse, or personality disorder may have these problems concomitantly with TRD.
Patients with atypical depression11 or anergic bipolar patients12 seemed to respond more robustly to MAOIs.
In one small study of 15 patients,14 individuals who did not have a good response to paroxetine treatment were openly switched to imipramine treatment.14 Peselow and colleagues reported a 73% response rate with imipramine treatment. Debattista and colleagues20 examined 28 SSRI-resistant depressed patients in an open study in which bupropion sustained release (SR) 150–300 mg was added to the SSRI-based treatment regimen.


Prior to 1987, TCAs, MAOIs, and heterocyclic compounds were the only available medications for the treatment of MDD.
Lists of common augmentation agents (Table 2), their mechanisms of action (Table 3), and dosing strategies (Table 4), are provided. In a large open-label study of 560 depressed patients, not all treatment-resistant, patients received olanzapine and fluoxetine in combination for 76 weeks.
There is a double-blind, controlled 4-week trial by Levine and colleagues42 comparing SSRI and placebo to SSRI with inositol, which found no significant difference between the two treatment groups. In one retrospective chart review of 37 patients, treated with a mean dose of 112 mg lamotrigine for 40 weeks, 21% mildly improved, 40% were much improved, and 37% did not change.65 Patients with shorter duration of depressive symptoms, fewer previous failed treatment trials, comorbid chronic pain, or comorbid anxiety tended to respond better. Since depression is not a single disorder, it is likely that multiple neurotransmitter systems are involved in its pathogenesis.
DeBattista C, Doghramji K, Menza MA, Rosenthao MH, Fieve RR; Modafinil in Depression Study Group. For example, by searching “drug treatments for depression” and pressing “Show drugs” and then selecting “Generic drugs” from the available options, we can see that though Lexapro, Zoloft, and Celexa are the top three most prescribed brand-name selective serotonin reuptake inhibitor (SSRI) drugs, switching to the generic drug view indicates that escitalopram, sertaline, and fluoxetine are the top-ranked generic drugs. Currently we are working on adding more raw data to our drug treatment dataset, and we are constantly developing more tools in an effort to make exploration of all data easier. I would like to check my sister’s treatment as she suffers from fibromyalgia and the doctor has been switching her medications every couple of months. Or the person suffering major depression may not be able to take pleasure in activities that usually are enjoyable. People who have a family member with major depression are more likely to develop depression or drinking problems.
They are as effective as the newer ones and can be very useful when someone has not responded well to other treatments. Unfortunately, 30% to 60% of patients treated with the currently approved antidepressant medications do not receive adequate relief of symptoms of major depressive disorder from the initial treatment intervention.
Unfortunately, 30% to 40% of patients treated in clinical practice do not receive any significant relief of signs and symptoms of major depression disorder from the first two attempts at pharmacotherapy.1 When this occurs, the clinician must have a strategy for dealing with the difficult-to treat-patient.
Psychotic depression requires additional antipsychotic medication to avoid a very low response rate of 20%.4 Bipolar depression has typically been treated with either lithium or divalproex sodium, often with the addition of a second mood stabilizer or an antidepressant. If these additional problems are identified early in the course of treatment, their effect on the patient’s response can be minimized. Thase and colleagues15 investigated the benefits of switching individuals with chronic depression who did not respond to sertraline treatment to imipramine treatment and reported that 44% of these patients responded to the imipramine therapy. Medication options for patients who do not have an adequate response to an optimal dose of an SSRI could include bupropion, trazodone, venlafaxine, nefazodone, duloxetine, or mirtazapine treatment. The combination of fluoxetine and desipramine was studied in an open 4-week trial.18 Fourteen inpatients with major depression were given fluoxetine and desipramine in combination and were retrospectively compared with 52 similar inpatients that received fluoxetine alone.
It is not clear how long lithium augmentation should continue if the patient responds to treatment. Response and remission rates for the TRD study population were 53% and 44%, respectively.39 Only 25% of the TRD population relapsed during the 76-week period of treatment.
Furthermore, the combination treatment group experienced improvement within 1 week of therapy. Apathy was defined as a score of =31 on the Apathy Evaluation Scale (AES) and a Montgomery-Asberg Depression Rating Scale (MADRS) item 8 (inability to feel) =2.
In one retrospective chart review of 20 patients with either bipolar or unipolar depression treated with antidepressant medication and adjunctive pramipexole, 50% of the bipolar patients and 40% of the unipolar-depressed patients reported some improvement in depressive symptomatology.61 Sixty percent of patients discontinued pramipexole due to either side effects or lack of response. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression.Arch Gen Psychiatry. The efficacy and safety of a new enteric-coated formulation of fluoxetine given once weekly during the continuation treatment of major depressive disorder. Treatment of tricyclic refractory depression with a monoamine oxidase inhibitor antidepressant. Treatment of imipramine- resistant recurrent depression, IV:A double-blind crossover study of tranylcypromine for anergic bipolar depression.
Double-blind switch study of imipramine or sertraline treatment of antidepressant-resistant chronic depression. A preliminary open study of the combination of fluoxetine and desipramine for rapid treatment of major depression.
Electroconvulsive therapy vs paroxetine in treatment resistant-depression—a randomized study. Vagus nerve stimulation (VNS) for treatment resistant depression: efficacy, side effects, and predictors of outcome. Lack of a therapeutic effect of a 2-week subthreshold transcranial magnetic stimulation course for treatment-resisitant depression.
Prednisone augmentation in treatment-resistant depression with fatigue and hypocortisolaemia: a case series. A placebo-controlled comparison of lithium and triiodothyronine agumentation of tricyclic antidepressants in unipolar refractory depression.


Ziprasidone augmentation of selective serotonin reuptake inhibitors (SSRIs) for SSRI-resistant major depressive disorder. Olanzapine in the treatment of apathy in previously depressed participants maintained with selective serotonin reuptake inhibitors: an open label, flexible dose study.
Double-blind controlled crossover trial of inositol vs fluvoxamine for the treatment of panic disorder. Venlafaxine augmentation with methylphenidate for treatment refractory depression: a case report. Combined treatment with methylphenidate and citalopram for accelerated response in the elderly: an open trial. Adjunct modafinil for the short term treatment of fatigue and sleepiness in patients with major depressive disorder: a preliminary double blind, placebo controlled study. Lack of efficacy of estradiol for depression in postmenopausal women: a randomized, controlled trial. Omega-3 fatty acids in major depressive disorder: a preliminary double-blind, placebo-controlled trial.
A double-blind placebo-controlled study of the omega-3 fatty acid docosahexaenoic acid in the treatment of major depression.
Pramipexole augmentation in the treatment of unipolar and bipolar depression: a retrospective chart review.
A double-blind, randomized, placebo-controlled trial of augmentation with lamotrigine or placebo in patients concomitantly treated with fluoxetine for resistant major depressive episodes. Lamotrigine as adjunct to paroxetine in acute depression: a placebo-controlled, double-blind study. For example, “hypertension drug treatment”, initially shows us that, of all the patients diagnosed with hypertension, 25% were prescribed angiotensin converting enzyme inhibitors, 22% HMG-CoA reductase inhibitors, 21% cardioselective beta blockers, 19% antihypertensive combinations, and 16% calcium channel blocking agents.
This is interesting because if we switch back to the brand-name list, escitalopram (generic for Lexapro) and sertraline (generic for Zoloft) remain at the top two positions, but citalopram (generic for Celexa) drops off the top three and is replaced by fluoxetine (generic for Prozac).
Therefore family members or friends may need to encourage the depression suffer to seek help. In fact, only approximately 35% of patients in rigorously-controlled clinical research studies (those having a score of <8 on the Hamilton Rating Scale for Depression) benefit enough from initial treatment to be classified as fully remitted. Current thinking is that these factors increase the likelihood that the response to treatment will not be straightforward.
One week after treatment, the Hamilton Rating Scale for Depression (HAM-D) score change was 42% in the combination treatment group and 20% in the fluoxetine-alone group. However, interest in augmentation research diminished with the advent of SSRIs, which were thought to be safer, better tolerated, and potentially more effective for certain types of depression. At the end of treatment, the estrogen-fluoxetine combination was the most effective, followed by fluoxetine alone, and the estrogen patch.53 The use of estrogen alone as an antidepressant agent has not proved to be helpful. There are multiple modalities of treatment that range from somatic to psychotherapeutic to pharmacologic and combined treatment. For example, the angiotensin converting enzyme inhibitor Lisinopril is more commonly prescribed to male hypertension patients than females, but looking further down the list, we can see that female patients are more commonly prescribed Enalapril than are males. Many types of practitioners with differing levels of expertise treat depression: general internists, nurse practitioners, psychiatrists, obstetricians, neurologists, and others.
Thus an SSRI-to-SSRI switch may be conceptualized as not representing any form of treatment alternative to continuing on the initial SSRI.
It is not known how long a patient that responds to treatment should be maintained on T3, though, in most of the studies, maintenance lasted 2–3 weeks. Among the pharmacologic treatments, the antidepressants and augmentation agents have differing mechanisms of action so that in cases of partial response, or failure of response, the clinician has a variety of alternative approaches to employ.
Similar to the logic behind the switch from an SSRI to a TCA, the theoretical rationale for the switch is to recruit additional or different neurotransmitter system interactions into the attempt to treat the depressive disorder.
As previously discussed, only 40% to 70% of patients respond well to initial treatment with these agents, and only approximately 35% actually achieve remission.28 This led to a re-emergence of interest in treatment augmentation research. This study found no difference between placebo and DHA for depression; the response rates were 27% and 23% for DHA and placebo, respectively. ECT is the quickest and most effective treatment for the most severe forms of depression, and in most people, it is not more risky than other antidepressant treatments. Depressive disorders are not alike, so variations in patient presentation further complicates our ability to unambiguously define a patient as suffering from TRD.
Mirtazapine 15–30 mg QHS was added to the current antidepressant regimens of 20 patients with persistent symptoms of major depressive disorder (MDD) or dysthymia.
Four weeks after treatment, 11 out of 20 patients (55%) responded, 6 out of 20 (30%) did not respond, and 3 out of 20 (15%) did not tolerate the weight gain, sedation, or fatigue effects. It is apparent that mood regulation involves multiple neurotransmitter systems, and this widens the potential for chemical manipulation and, thus, treatment options.



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