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MEN’S
HEALTH
continued from page 16
Depression can be significant in other psychiatric disorders in-
cluding post-traumatic stress disorder, bipolar disorders, schizophre-
nia, panic disorders. Often a time, Bipolar Disorder type II with
depression gets misdiagnosed as Major Depression Disorder. Pa-
tients are prescribed antidepressants, especially SSRIs (Selective
Serotonin Reuptake Inhibitors) which are counterproductive and
may precipitate a manic episode; long term use of these SSRIs may
even cause them to be rapid cyclers between mania and depression.
These groups of patients are very difficult to treat. When a patient
presents with the complaint of depression, always rule out any his-
tory of mania. In spite of treatment with pharmacotherapy and psy-
chotherapy remission rate after an episode of depression is only
about 33 percent.
Current mode of treatment for Major Depression
Antidepressants — SSRIs, SNRIs
ECT
Psychotherapy supportive, cognitive behavioral
Electroconvulsive therapy was first introduced by Cerletti and
Bini in 1938, and was tried for various patients with affective dis-
order and schizophrenia. Now it is generally recognized as one
of the effective treatment modalities for major depression. ECT
may be the treatment of choice where rapid actions are required:
examples include psychotic depression, post-traumatic depression
and depression with very high suicidality, elderly patients with
multiple organ system problems and taking a large amount of
medicines and poor tolerance/response to antidepressants. There
is also maintenance ECT with treatment once monthly or so for
relapse prevention.
Research studies show no significant advantage between different
SSRIs. They vary only in their Behavioral Therapy (CBT) and in-
dividual psychotherapy being beneficial.
Labs
There is no specific lab test to diagnose depression, however basic
metabolic panel, blood count, urine analysis and thyroid studies are
routine to rule out other causes.
Neuro Imaging
Anatomical changes of decreased prefrontal cortex, especially
left side.
Functional impairment of increased activity in amygdala and de-
creased blood flow and glucose metabolism (found in pet studies).
Genetics:
1. Affective Disorder concordance among monozygotic twins
is 40 percent and among dizygotic twins is 11 percent.
2. Depression starting in younger age, alcoholism and sociopa-
thy among the relatives of patients with major depression.
3. Associations between mood and monoamines, serotonin, and
norepinephrine were first discovered in the 70’s (James Maas-
18 San Antonio Medicine • December 2015
Biogenic amines and depression 1975) serendipitously by the
mood altering effects of isoniazid (anti tuberculosis medi-
cine) which is a monoamine, oxidase inhibitor. Now we
know that all anti-depressants affect post synaptic signaling
of serotonin and no-epinephrine or both at the post synaptic
membrane. This led to the hypothesis that depression is
caused by a neurotransmitter deficiency and anti-depressants
treat this imbalance.
4. Homocysteine hypothesis
Lack of co-enzymes that are necessary for monoamine pro-
duction among genetically predisposed individuals. These
patients have elevated Homocysteine which reduces the
monoamine production causing depression.
Hence depression is a medical illness, not a character weakness.
Recovery with proper treatment is the rule not the exception. The
risk of recurrence is 50 percent after one episode, 70 percent after
two episodes, 90 percent after three episodes. Patients who expe-
rience residual subthreshold depressive symptom – painful somatic
symptom are likely to relapse three times more and they have had
shorter duration of time to relapse, than asymptomatic patients
with full remission. However primary mode of treatment is psycho
pharmacological.
Most patients with depression present themselves to their primary
care physician, OBGYN, neurologists and internists, because there
is still a great deal of stigma in the society about mental illness and
“being a mental patient.” A thorough physical exam, mental status
exam, family history and previous history of depression/suicidality,
previous history of treatments are a must.
Depression is a biological event with superimposed psycho-social
stressors that aggravate the condition. It is recommended that phar-
macological treatment should continue for at least 6-8 months after
full remission in order to reduce the relapse rate.
Treatment approach should address
Bio-psycho-social aspect of the disease
Anti-depressants
Psychotherapy
ECT
Enhance support system
Life style changes
Most patient’s fair well with combined treatment approach.