Depression treatment – treatment regimens, selection of antidepressants

Important : The basis for treating depression is confidential supportive conversations with your doctor (“supportive psychotherapy”).

Most patients first seek help from their family doctor. He must make a diagnosis, decide whether he can manage the patient on an outpatient basis, and if not, then refer him to a specialist or send him for inpatient treatment.

Signs that determine the direction of inpatient treatment or to a specialist doctor for depression: a) Referral to a specialist doctor : • Uncertainty in the diagnosis • Delusional / psychotic depression • Suicide risk not reliably identified • Psychoneurological comorbidity • Lack of appropriate competence • Indications • Prevention of relapse

b) Referral to inpatient treatment : • Acute suicidality • Depressive stupor • Resistance to therapy, transition of the disease to a chronic form • Negative compliance • Special treatment measures • Lack of medical care • Acute mania (switching / inversion

Drawing up a single treatment plan : the essence of therapeutic measures is focused on the clinical picture and the ongoing development of the disease.

The basics of psychotherapy for depression :
• “Calming confidence” (the patient is not an isolated case, the disease has been studied)
• Empathy, there is always time for the patient (!)
• Distraction, employment
• “Relief”, discharge
• Do not force the patient to make decisions!
• The principle of small steps (the gradual establishment of previous functions)
• Informing loved ones and relatives and involving them in the therapeutic process

Three phases of treatment :
I. Emergency care
II. Supportive treatment (6-8 months)
III. Relapse prevention (disruption protection)

Initially, the question arises whether the treatment will be outpatient or inpatient. The key to resolving this issue is the assessment of suicide. The next step is to determine the severity of depression:

Slight depressive disorder (ICD-10 F32.0): supportive psychotherapy, as an additional means perhaps use phytotherapeutic preparations (Gypea-ricin)

The more severe and deeper the depressive symptoms, the more important the role of drug treatment with antidepressants

Clinical and pharmacological classification of antidepressants by action

Important : The doctor should consider that the additional intake of benzodiazepines or light antipsychotics is always recommended, since antidepressants have a slow effect, which occurs within 2-4 weeks. This should definitely pay special attention to the patient.

I. Emergency care for depression

• Biological / Drug Therapy for Depression . An overview of antidepressants is presented in the table above. – the criteria for choosing an antidepressant are as follows: a) a retrospective determination of the history of an effective antidepressant (response at an earlier stage of the disease) b) cross-sectional results of a psychopathological examination / status presents (sleep disorder, anxiety, obsessive symptoms, etc.) c) profile of adverse events action, contraindications, toxicity (anticholinergic effects, excessive activation / inhibition, the patient is at risk, a high risk of overdose) g) severity e) treatment costs (financial costs) is important A : Organized regular medication is extremely important.

Treatment of specific forms of depression :
• Delusional depression: trimipramine or “double therapy” antidepressant + antipsychotic; electroconvulsive therapy
• The so-called atypical depressions: classic or reversible: MAO inhibitors
• With the so-called seasonal depressions (autumn-winter depressions), light therapy can be used (course dose of 2000-10 000 lux).

The severity of the response to antidepressant treatment (response rating: more than 50% reduction in the severity of the main symptoms according to rating scales, for example, HAMD); the remission level is about 65% (remission = HAMD-17 <7, HAMD-7 <3, MADRS <10); makes up about 45%.

The corresponding response rates when using placebo are up to 45% and up to 25%, respectively, so in this case we can talk about the obvious effectiveness of antidepressants (confidence level A). The placebo response rate for confirmed deep “endogenous” (non-psychogenic reactive) depressions is significantly lower.

Important :
• Depression in the elderly (involutional) often lasts longer and tends to become chronic.
• In patients with a high body mass index (obesity), the response to the use of antidepressants is much worse.

Treatment approaches for treatment-resistant depression :
• Occurrence rate of 30%!
• Adequate dosing / determination of plasma concentration (many patients receive treatment in insufficient doses!)
• Compliance control
• Infusion therapy with antidepressants
• Switching to the next antidepressant with a different neurobiochemical mechanism of action
• Additionally, treatment of insomnia
• Use of lithium salts
• Electroconvulsive therapy

• Depression psychotherapy – cognitive behavioral therapy: a) correction of negative assessments of reality and negative self-esteem b) step-by-step construction of different types of activities according to the principle of reinforcement c) assistance in building self-confidence and social skills d) training in coping with (inevitable) everyday and life problems

Behavioral therapy for depression :
• Strict adherence to the daily routine
• Building positive types of activity
• Reducing the activities that have a depressing effect (thinking, sobbing)
• Enhancing self-confidence

Cognitive Behavioral Therapy (Beck) for depression :
• Erroneous, illogical interpretations
• Step-by-step correction of judgments
• Replacement of dysfunctional disorders with corrected concepts, interpretations

Cognitive behavioral therapy for depression :
• Analysis of mental distortions and erroneous conclusions
• Development of models of the relationship “thoughts-feelings-behavior”
• Exercises to verify the conformity of inferences of reality (keeping a diary)
• Development of positive self-esteem and alternative conclusions
• Involvement of relatives and relatives

Elements of cognitive behavioral therapy for depression :
1. Main elements : • Interacting working union • Structurality, problem orientation 2. Building activities : • Increasing ways to get pleasant practical experience • Reducing burdensome practical experience 3. Improving competence : • Training social perceptions • Skill training 4. Change in the cognitive sphere : • Detection of absurd depressive inferences • Socratic dialogue • Verification of reality • Re orientation 5. Stabilization : • Preparing for possible crises • Testing in everyday life

– Interpersonal psychotherapy ( IPT ): among other things, the therapeutic effect of the interaction of a depressed patient with his immediate environment

Mistakes in communicating with patients with depression (according to Hell) :
• Mild behavior, custody
• Irritability, impatience, excessive activity
• Encouragement, comfort

• Psychotherapy based on depth psychology or psychoanalytic psychotherapy : while maintaining psychodynamic conflicts after the disappearance of acute symptoms

II. Supportive Treatment for Depression

After the disappearance of depressive symptoms, it is usually recommended for 6-18 months. continue maintenance drug therapy with antidepressants, while maintaining the necessary dosage of drugs in full, since it is during this period of time that there is a high risk of relapse.

III. Preventive anti-relapse treatment for depression

The indication for the appointment of preventive anti-relapse treatment is the presence of 3 or more depressive episodes. According to meta-analysis of controlled long-term studies, the risk of relapse when using placebo is more than 41%, when taking the active / active substance – up to 18%.

Thus, with placebo, the risk of relapse increases by 2–3 times, and with the use of antidepressants, the probability of relapse is reduced by 70% (confidence level A). Procedure:

• Continued use of an effective antidepressant that relieves acute conditions, or prophylaxis with lithium preparations.

The Commission of the German Medical Society for Medicines and the working group for the treatment of depression and the World Union of Biological Psychiatry developed recommendations for the treatment of primary forms of the disease and preventive anti-relapse treatment, presented in the diagram below.

Important : In recent years, antidepressant treatment in combination with cognitive psychotherapy has gained recognition .