TRENDS IN PHARMACY AND PHARMACEUTICAL CARE
An ongoing CE program of
The University of Mississippi School of Pharmacy and DRUG TOPICS
Depression has one of the most established biological bases of any of the psychiatric disorders. The central dogma of depression postulates that depressed patients have abnormalities in serotonin (5-HT) and/or norepinephrine (NE), two of the most prominent neurotransmitters in the central nervous system (CNS). A variety of data from both animal and human studies, including postmortem brain studies from suicidal patients, support this theory. Although the exact physiological basis of depression has been elusive, the presumed involvement of 5-HT and NE has provided a stimulus for development of drugs effective in its treatment. Hence, most of the available antidepressants alter the activity of one or both of these neurotransmitters.
Major depression is a serious illness that frequently requires hospitalization. The mortality from suicide associated with depression in the United States may be as great as 70,000 people annually. The illness is recurrent for most people; therefore, careful documentation of symptom presentation may aid in subsequent therapy. To determine if there is a genetic predisposition to development of depression, a patient's family history of illness is an important component of patient evaluation.
Major depression is accompanied by both cognitive and physical symptoms. A dysphoric mood is an essential feature, with feelings of profound sadness and a sense of hopelessness about the future. This may be accompanied by suicidal thoughts and attempts. The activities, people, and ideas that usually give the person pleasure become seemingly hollow.
Pessimistic thinking is customary with low self-- esteem. There is a lack of motivation to accomplish everyday activities. Physical symptoms are often prominent. Anorexia leading to weight loss is frequent, as are sleep disturbances and loss of libido.
The symptoms of depression usually develop over a period of days to weeks. When five or more symptoms are present for a sustained two-week period, accompanied by a loss of functioning, most experienced clinicians would consider a major depressive episode to be present.
Depression can occur at any age. If left untreated, a major depressive episode may last for six months or longer until the symptoms resolve. For perhaps 20% to 30% of patients, some symptoms may persist for months to years. The results of epidemiologic studies have recently documented that the experience of each depressive episode is a strong predictor that the person will experience subsequent episodes of depression in the future. Thus, it has become extremely important to effectively treat or index the initial episode of depression and to maintain treatment for a sufficient time after symptoms have resolved in an attempt to ensure that further episodes will not occur.
It is becoming increasingly clear that depression coexisting with medical illness is not a chance occurrence. After experiencing a heart attack, nearly 18% of patients will have depressive symptoms severe enough to be diagnosed as depression. In the elderly, depression has been highly associated with myocardial infarction, stroke, and hip fracture. Anxiety is a frequent symptom of depression. Anxiety disorders (e.g., panic disorder) may coexist with depression, or anxiety may be one of the initial symptoms of an impending episode of depression. Fortunately, the newer antidepressants that have become available in recent years have prominent anxiolytic effects. Several antidepressants are approved for treatment of one or more of the major anxiety disorders (panic disorder, obsessive compulsive disorder, generalized anxiety disorder, and/or posttraumatic stress disorder). The effectiveness of these newer drugs has clearly improved the overall treatment of depression and its associated symptoms. …