Major depressive disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mitra Chitsazan, M.D.[2]

Overview

The treatment of depression is highly individualized to the patient, based on the patient's unique combination of biological, psychological and social health factors and the severity of their condition. The three most conventional treatments for depression include medication, psychotherapy, and Electroconvulsive therapy, however new treatments and less conventional options are also available, including self help, life style changes, and vagus nerve stimulation. If there is an imminent threat of suicide or the patient is a danger to others, hospitalization is employed as an intervention method to keep at-risk individuals safe until they cease to be a danger to themselves or others. At-risk individuals may also be placed in a partial hospitalization therapy, in which the patient sleeps at home but spends most of the day in a psychiatric hospital setting. This intensive treatment usually involves group therapy, individual therapy, medication management, and is used often in the case of children and adolescents.

Medical Therapy

Pharmacologic medical therapies for Major Depressive Disorder include:

Serotonin reuptake inhibitors

• SSRIs are effective, well-tolerated medications used as a first-line treatment for MDD.
• Possible adverse effects with SSRIs: serotonergic symptoms including nausea, diarrhea, anxiety or nervousness, insomnia, sexual dysfunction, withdrawal syndrome, and hyponatremia in elderly. Most side effects are transient and self-limited; however, sexual dysfunction is usually persistent and may respond to a change in drug (for example to mirtazapine or bupropion) or dosage.
• During the early few weeks of initiation of SSRI therapy, anxiogenic effects of SSRI may aggravate suicidal ideation in patients with MDD. This can be managed by reducing the dose or adjunctive therapy with an anxiolytic, for example, a benzodiazepine.
• Co-administration with monoamine oxidase inhibitors is contraindicated due to the risk of serotonine syndrome.
• Fluoxetine (Effective dose range: 20-80mg)
  • Benefits: It is associated with a low risk of withdrawal symptoms upon tapering due to its long half-life.
  • Adverse effects: See SSRIs side effects
• Sertraline (Effective dose range: 50-200mg): has a dual mechanism of action, i.e., serotonine and dopamine reuptake inhibitor
  • Benefits: Low transplacental transmission during pregnancy; relatively low concentrations in breast milk
  • Adverse effects: Transient diarrhea during first few weeks of initiation of therapy
• Paroxetine (Effective dose range: 20-50mg)
  • Benefits: Low transplacental transmission during pregnancy; relatively low concentrations in breast milk
  • Adverse effects: higher risk of withdrawal symptoms than other SSRIs, weight gain, potential higher risk of teratogenic effects (FDA pregnancy category D)
• Citalopram (Effective dose range: 20-40mg)
  • Benefits: Few drug-drug interactions
  • Adverse effects: May prolong QTc interval, in particular at higher doses. It is not recommended in patients with congenital long QT syndrome or acute cardiac conditions (e.g. acute decompensated heart failure). It should be discontinued in patients with QTc interval >500ms. Doses of >20 mg are not recommended in the elderly or in patients with hepatic dysfunction.
• Escitalopram (Effective dose range: 10-20mg)
  • Benefits: Few drug-drug interactions
  • Adverse effects: Modest effects on QTc interval

Serotonin-norepinephrine reuptake inhibitors

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also considered first-line medications for the treatment of MDD. SNRIs have a dual mechanism of action. They may be effective in treating concomitant pain conditions.
• Adverse effects: Neuradrenergic symptoms (hypertension, dry mouth, constipation, insomnia, decreased appetite), serotonergic side effects ([[nausea, diarrhea, nervousness, insomnia, sexual dysfunction, withdrawal symptoms, and hyponatremia).
• Duloxetine (Effective dose range 60-120 mg)
  • May be effective in treating neuropathic pain and other pain condition. Smoking decreases the plasma levels of duloxetine.
• Venlafaxine (Effective dose range 75-350 mg)
  • Adverse effects: Compared to other serotonergic antidepressants, is associated with a slightly increased incidence of nausea and vomiting, higher risk of withdrawal symptoms, and hypertesnion.
• Desvenlafaxine (Effective dose range 50-100 mg)
  • Benefit: may reduce neuropathic pain
• Levomilnacipran (Effective dose range 40-120 mg)

Other antidepressants

• Bupropion XR (Effective dose range 300--450 mg)
  • Atypical antidepressant
  • A noradrenergic, dopaminergic drug with stimulat-like effects
  • Approved for smoking cessation
  • Benefits: Weight neutral, minimal to no risk of sexual dysfunction, minimal withdrawal symptoms.
  • Adverse effects: Lowers seizure threshold, particularly at higher doses.
• Mirtazapine (Effective dose range 15-45 mg)
  • Atypical antidepressant
  • Benefits: faster onset of action than SSRIs, minimal sexual dysfunction, minimal withdrawal symptoms.
  • Adverse effects: increased appetite and sleep (may be beneficial in patients with reduced appetite and insomnia as symptoms of MDD), higher risk of weight gain
• Trazodone
• Vilazodone (Effective dose range 10-40 mg):
  • Serotonin partial agonist and reuptake inhibitor.
  • Benefits: May have a lower risk of [[sexual dysfunction[]] than other serotonergic antidepressants
  • No generic formulation is currently available.
• Vortioxetine (Effective dose range 10-20 mg):
  • Serotonin reuptake inhibitor and serotonin modulator
  • Benefits: May have a lower risk of sexual dysfunction than other serotonergic antidepressants. A long half-life may reduce the risk of withdrawal symptoms upon tapering.
  • Adverse effects: Despite 5-HT3 receptor antagonism, it has high rates of nausea.

Tricyclic antidepressants

• Tricyclic antidepressants (TCAs) are considered second-line or third-line medications in the treatment of MDD due to greater side effects compared to SSRIs and SNRIs, in particular in the elderly.
• they work by inhibiting serotonin and norepinephrine reuptake.
• Common side effects of TCAs include sedation, orthostatic hypotension, anticholinergic effects, GI distress, weight gain, cardiac arrhythmias, and QTc prolongation.
• TCAs include:
• Amitriptyline
• Nortriptyline
• Imipramine
• Desipramine
• Clomipramine
• Doxepin
• Amoxapine

Monoamine oxidase inhibitors

• Monoamine oxidase inhibitors (MAOIs) are considered second-line or third-line medications in the treatment of MDD due to greater side effects compared to SSRIs and SNRIs, in particular in the elderly.
• Combination of MAOIs with other serotonergic drugs, i.e., TCAs, SSRIs, or SNRIs are contraindicated due to increased risk of serotonin syndrome.
• MAOIs include:
  • Phenelzine
  • Tranylcypromine

Clinical Hints

• Initiation of SSRIs may be associated with early transient anxiety, aggravating suicidal ideation. Reducing the dose or adding a benzodiazepine may be helpful in these patients.

In MDD patients with insomnia, benzodiazepines, zolpidem, trazodone, or mirtazapine are helpful.

• In addition, when depressed patients begin to clinically improve, their physical energy also improves, enabling them to carry out suicidal acts that they did not have the power to perform before. This is known as paradoxical suicide.
• Antidepressants may take as long as 6-8 weeks to take effect.
• The goal of treatment is achieving complete remission of symptoms and return to normal functioning.
• In patients who fail to respond to an SSRI, or experience intolerable side effects, another medication in this class may be tried. However, some physicians prefer to switch to another medication with a different mechanism of action.
• Psychotherapy may be added in the treatment of patients with a partial response to pharmacotherapy alone.
• In patients with first episode of major depression, maintenance treatment for at least months may be helpful in preventing relapse. In patients with recurrent major depressive episodes, long-term treatment may be beneficial.
• In patients experiencing intolerable sexual side effects with SSRIs, bupropion or mirtazapine may be considered.
• Bupropion may be beneficial in patients with anergy and psychomotor retardation due to its stimulant-like effects.
• Hospitalization may be considered in patients with significant suicidal ideation or intent without adequate family support or safe-guards at home. Patients who express intent to hurt others or those who are not able to care for themselves may also be hospitalized.