Depression management may involve a number of different therapies: drugs, behavioral therapy, and medical equipment. Major depressive disorders, often referred to simply as "depression", are diagnosed more often in developed countries, where up to 20% of the population is affected at some stage of their lives. According to WHO (World Health Organization), depression is currently the fourth of 10 major causes of the global burden of disease; it is estimated that by 2020, depression will be ranked second.
Although psychiatric drugs are the most commonly prescribed therapy for severe depression, psychotherapy may be effective, either alone or in combination with drugs. Combining psychotherapy and antidepressants can provide "little benefit", but either antidepressants or psychotherapy alone do not differ significantly from other treatments, or "active intervention controls". Given the accurate diagnosis of major depressive disorders, in general the type of treatment (psychotherapy and/or antidepressants, alternative or other treatment, or active intervention) "is less important than depressed patients involved in active therapy programs."
Psychotherapy is the treatment of choice in those under the age of 18, with drugs being offered only along with the first and generally not as first-line agents. The possibility of depression, substance abuse or other mental health problems in the elderly should be considered and, if any and if it can help the child, the parent should be treated in parallel with the child.
Video Management of depression
Psychotherapy
There are a number of different psychotherapy for depression given to individuals or groups by psychotherapists, psychiatrists, psychologists, clinical social workers, counselors or psychiatric nurses. With a more chronic form of depression, the most effective treatment is often regarded as a combination of treatment and psychotherapy. Psychotherapy is the treatment of choice in people under 18 years of age.
As the most studied form of psychotherapy for depression, cognitive behavioral therapy (CBT) is thought to work by teaching clients to learn a range of cognitive and behavioral skills, which they can use on their own. Previous research has shown that cognitive behavioral therapy is not as effective as antidepressant drugs in the treatment of depression; However, more recent studies show that it can perform as well as antidepressants in treating patients with moderate to severe depression.
The effects of psychotherapy on patients and doctors assessed improvement as well as on the revision level continued to decline from the 1970s.
A systematic review of data comparing low-intensity CBT (such as guided self-help using written materials and limited professional support, and website-based intervention) with ordinary care found that patients initially under severe depression benefited from low intensity. intervention at least as much as patients who are less depressed.
For the treatment of juvenile depression, one published study found that CBT without treatment performed no better than placebo, and was significantly worse than antidepressant fluoxetine. However, the same article reported that CBT and fluoxetine outperformed only with fluoxetine. Combining fluoxetine with CBT does not seem to bring additional benefits in two different studies or, at most, only marginal benefits, in the fourth study.
Behavioral therapy for depression is sometimes referred to as behavior activation. Existing studies show behavioral activation to be superior to CBT. In addition, behavior activation seems to take less time and leads to more lasting changes.
Acceptance and commitment therapy (ACT), a form of awareness of CBT, rooted in behavioral analysis, also shows that it is effective in treating depression, and can be more helpful than traditional CBT, especially where depression is accompanied by anxiety and where it is resistant to CBT traditional.
A review of four studies on the effectiveness of cognitive-based cognitive therapy (MBCT), a recently developed class-based program designed to prevent recurrence, suggests that MBCT may have additional effects when given regular care in patients who have had three or more episodes of depression, although ordinary treatments do not include any antidepressant or psychotherapy treatments, and observed improvements may have reflected non-specific effects or placebo.
interpersonal psychotherapy focuses on social and interpersonal triggers that can cause depression. There is evidence that it is an effective treatment for depression. Here, therapy takes a structured course with a number of weekly sessions (often 12) as in the case of CBT; However, the focus is on relationships with others. Therapy can be used to help a person develop or improve interpersonal skills to enable him to communicate more effectively and reduce stress.
Psychoanalysis , a school of thought founded by Sigmund Freud that emphasizes the resolution of unconscious mental conflicts, is used by practitioners to treat heavily depressed clients. The more practiced technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has additional social and interpersonal focus. In a meta-analysis of three controlled trials, psychodynamic psychotherapy was found to be as effective as a drug for mild to moderate depression.
Maps Management of depression
Drug
To find the most effective pharmaceutical drug treatment, drug doses should often be adjusted, different combinations of antidepressants are tried, or antidepressants change. The response rate to the first agent given may be as low as 50%. This can take anywhere from three to eight weeks after the start of treatment before the therapeutic effect can be fully discovered. Patients are generally advised not to stop taking antidepressants unexpectedly and continue to use them for at least four months to prevent a possible recurrence.
Selective Serotonin Reuptake Inhibitors (SSRIs), such as sertraline (Zoloft, Lustral), escitalopram (Lexapro, Cipralex), fluoxetine (Prozac), paroxetine (Seroxat), and citalopram are the main medications considered, due to their relatively mild side effects. and widespread effects on symptoms of depression and anxiety, as well as reduced risk of overdose, compared with older tricyclic alternatives. Those who did not respond to the first SSRI tried to switch to another. If sexual dysfunction is present before the onset of depression, SSRIs should be avoided. Another popular option is to switch to atypical antidepressant bupropion (Wellbutrin) or add bupropion to existing therapy; this strategy may be more effective. Not infrequently SSRI cause or worsen insomnia; noradrenergic tranquilizers and specific serotonergic antidepressants (NaSSA) antidepressants mirtazapine (Zispin, Remeron) can be used in such cases. Cognitive Behavior Therapy for Insomnia can also help relieve insomnia without additional drugs. Venlafaxine (Effexor) may be more effective than SSRIs; however, it is not recommended as a first-line treatment because of higher side-effects, and its use is specifically not recommended in children and adolescents. Fluoxetine is the only antidepressant recommended for people under the age of 18, although, if a child or adolescent patient is intolerant of fluoxetine, other SSRIs may be considered. The evidence of SSRI effectiveness in those with a complicated depression by dementia is lacking.
Tricyclic antidepressants have more side effects than SSRIs (but fewer sexual dysfunctions) and are usually reserved for the treatment of inpatients, for whom tricyclic antidepressant amitriptyline, in particular, appears to be more effective. Different antidepressant classes, monoamine oxidase inhibitors, have historically been disrupted by questionable success (although early studies use doses that are now considered too low) and life-threatening adverse effects. They are still rarely used, although new agents of this class (RIMA), with better side effects profiles, have been developed.
There is evidence of prominent side effects of antidepressants, emotional defection, confusion with symptoms of depression itself. The study quoted, according to Professor Linda Gask is: 'funded by a pharmaceutical company (Servier) and two authors are employees of that company', which may bias the results. The authors note: "Emotional detachment is reported by nearly half of depressed patients on antidepressants and seems to be common to all monoaminergic antidepressants not just SSRIs". In addition, they note: "OQuESA scores are highly correlated with HAD depression scores; emotional abuse can not be described simply as a side effect of antidepressants, but also as a symptom of depression... More emotional humiliation is associated with more people poor quality of forgiveness... "
Augmentation
Doctors often add drugs with different mode of action to increase the antidepressant effect in case of treatment resistance; a large 2002 community study of 244,859 depressed Veterans Administration patients found that 22% had received a second agent, most often a second antidepressant. Lithium has been used to increase antidepressant therapy in those who fail to respond to antidepressants alone. Furthermore, lithium dramatically reduces the risk of suicide in recurrent depression. The addition of atypical antipsychotics when patients are not responding to antidepressants is also known to increase the effectiveness of antidepressant drugs, albeit at more frequent costs and potentially serious side effects. There is some evidence for the addition of thyroid hormone, triiodothyronine, to patients with normal thyroid function. Stephen M. Stahl, a well-known academician in the field of psychopharmacology, has declared a switch to dynamic psychostimulants, in particular, d-amphetamine is a classic augmentation strategy for refractory depression treatment. However, the use of stimulants in cases of drug-resistant depression is relatively controversial.
Setup status, efficacy and tolerability of additional treatments in depression
Medication and psychotherapy benefits
Antidepressants are statistically superior to placebo but their overall effects are low to moderate. In that case, they often do not exceed the criteria of the National Institute for Health and Clinical Excellence for a "clinically significant" effect. In particular, the effect size is very small for moderate depression but increases with severity, achieving "clinical significance" for very severe depression. These results are consistent with previous clinical studies in which only patients with severe depression benefited either from psychotherapy or treatment with antidepressants, imipramine, more than from placebo treatment. Despite similar results, the authors argue about their interpretation. One authors concluded that there is "little evidence to support prescription antidepressants for anything but the most severe depression patients, unless alternative treatments fail to deliver benefits." Other authors agree that "antidepressant glass" is far from full "but disagrees" that it is completely empty. "He pointed out that the first-line alternative to treatment is psychotherapy, which lacks superior efficacy.
Antidepressants are generally as effective as psychotherapy for severe depression, and these conclusions apply to mild and mild forms of MDD. In contrast, the drug provides better results for dysthymia. The SSRI subgroup may be a little more potent than psychotherapy. On the other hand, significantly more patients withdraw from antidepressant medications than from psychotherapy, possibly because of the side effects of antidepressants. Successful psychotherapy appears to prevent recurrence of depression even after being discontinued or replaced by an occasional "booster" session. The same level of prevention can be achieved by continuing antidepressant treatment.
Two studies have shown that a combination of psychotherapy and treatment is the most effective way to treat depression in adolescents. Both TADS (Treatment of Adolescents with Depression Study) and TORDIA (Treatment of Resistant Depression in Adolescents) showed very similar results. TADS resulted in 71% of adolescent subjects having "many" or "very many" mood elevations above 60.6% with medication alone and 43.2% with CBT alone. Similarly, TORDIA showed an increase of 54.8% with CBT and 40.5% versus drugs with drug therapy alone.
Treatment resistance
Risk factors for drug-resistant depression are: the duration of episodes of depression, the severity of episodes, if bipolar, lack of symptom improvement in the first few weeks of treatment, anxiety or avoidance and borderline comorbidities and old age. Treatment-resistant depression is best treated with a combination of conventional antidepressants along with atypical antipsychotics. Another approach is to try different antidepressants. Unconvincing which approach is superior. Treatment-resistant depression may be misdiagnosed if antidepressant antidepressant doses are the case, noncompliance, unacceptable side effects or thyroid disease or other conditions misdiagnosed as depression.
Experimental treatment
Ketamine
Research on the effects of antidepressant infusion of ketamine at subanaesthetic doses consistently showed a rapid response (4 to 72 hours) of a single dose, with a substantial increase in mood in most patients and remission in some patients. However, these effects are often short-lived, and attempts to prolong the effects of antidepressants with repeated doses and extended treatment ("maintenance") yield little success.
Creatine
Creatine amino acids, commonly used as a supplement to improve the performance of bodybuilders, have been studied for potential antidepressant properties. A double-blinded, placebo-controlled trial focused on women with major depressive disorder found that daily supplementation of creatine in addition to escitalopram was more effective than escitalopram alone. Studies in rats have found that the antidepressant effect of creatine can be blocked by drugs acting against dopamine receptors, suggesting that the drug works on dopamine pathways.
Dopamine receptor agonist
Some studies suggest dopamine receptor agonists may be effective in treating depression, but little research and outcomes are preliminary
SAMe
S-Adenosyl methionine (SAMe) is available as an antidepressant prescription in Europe and an over-the-counter dietary supplement in the US. Evidence from 16 clinical trials with a small number of subjects, reviewed in 1994 and 1996 suggested to be more effective than placebo and as effective as standard antidepressant drugs for the treatment of major depression.
Tryptophan and 5-HTP
Tryptophan amino acid is converted into 5-hydroxytryptophan (5-HTP) which is then converted into serotonin neurotransmitter. Since serotonin deficiency has been recognized as a possible cause of depression, it has been suggested that the consumption of tryptophan or 5-HTP can improve the symptoms of depression by increasing serotonin levels in the brain. 5-HTP and tryptophan are sold on the table in North America, but need a prescription in Europe. Small studies have been conducted using 5-HTP and tryptophan as additional therapy in addition to standard treatment for depression. While some studies have positive results, they are criticized for having methodological deficiencies, and newer studies do not find sustainable benefits from their use. The safety of these drugs has not been well studied. Due to the lack of high-quality research, the early nature of studies showing effectiveness, lack of adequate studies on their safety, and reports of Eosinophilia-myalgia syndrome associated with the use of tryptophan, the use of tryptophan and 5-HTP is not highly recommended or considered clinically useful.
Inositol
Inositol, the alcohol sugar found in fruits, seeds and nuts may have high-dose antidepressant effects. Inositol can exert its effect by altering intracellular signaling.
Medical devices
A variety of medical devices are being used or are being considered for depression treatments including devices that offer electroconvulsive therapy, vagus nerve stimulation, recurrent transcranial magnetic stimulation, and cranial electrotherapy stimulation. Use of such devices in the United States requires approval from the US Food and Drug Administration (FDA) after field trials. In 2010 the FDA advisory panel considered the question of how field trials should be managed. Factors to consider are whether the drug has been effective, how many different drugs have been tried, and what tolerance for suicide should be in field trials.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is a standard psychiatric treatment in which electrical spasms are induced in patients to provide relief from psychiatric illness. ECT is used with informed consent as the last line of intervention for major depressive disorder.
One round of ECT is effective for about 50% of people with severe depression who are resistant to treatment, whether unipolar or bipolar. Treatment follow-up is still poorly studied, but about half of people respond, recurring with twelve months.
In addition to effects in the brain, the general physical risk of ECT is similar to the general short anesthesia. Immediately after treatment, the most common side effects are confusion and memory loss. ECT is considered one of the most innocuous treatment options available for pregnant women with severe depression.
Usually ECT involves a lot of administration, usually given two or three times per week until the patient no longer suffers the symptoms of ECT given under anesthesia with muscle relaxants. Electroconvulsive therapy may differ in its application in three ways: electrode placement, maintenance frequency, and the electrical waveform of the stimulus. These three forms of application have significant differences in both side effects and remission of symptoms. After treatment, drug therapy is usually continued, and some patients receive ECT treatment.
ECT seems to work in the short term through most anticonvulsant effects in the frontal lobe, and long-term through neurotropic effects especially in the medial temporal lobes.
Brain stimulation in
Support for the use of deep brain stimulation in drug-resistant depression originated from several case studies, and this treatment is still in the very early stages of investigation. In this technique the electrodes are implanted in a specific area of ​​the brain, which then continues to be stimulated. A systematic review of March 2010 found that "about half the patients showed dramatic improvement" and that side effects were "generally trivial" given the younger population of psychiatric patients compared with movement disorders. In-brain stimulation is only available experimentally in the United States; there is no FDA approved system for this use. It is available in Australia.
Repetitive transcranial magnetic stimulation
Transcranial magnetic stimulation (TMS) or deep transcranial magnetic stimulation is a noninvasive method used to stimulate small areas of the brain. During the TMS procedure, magnetic field generator, or "coil" is placed near the head of the person receiving the treatment. The coil produces a small electric current in the brain region just below the coil via electromagnetic induction. The coil is connected to the pulse generator, or the stimulator, which gives an electric current to the coil.
TMS was approved by the FDA for major drug-resistant depressive disorders in 2008 and in 2014 clinical evidence supports this use. The American Psychiatric Association, the Canadian Network for Mood and Anxiety Disorders, and the Royal Australia and New Zealand College of Psychiatrists have authorized the rTMS for trmDD.
Vagus nerve stimulation
Vagus nerve stimulation (VNS) uses an electrode and an implanted generator to transmit electrical pulses to the vagus nerve, one of the main nerves originating in the brain. This is an approved therapy for drug-resistant depression in the EU and the US and is sometimes used as an adjunct to the treatment of existing antidepressants. Support for this method mainly comes from open label trials, which suggests that a few months may be necessary to see the benefits. The only major double-blind trials conducted lasted only 10 weeks and produced inconclusive results; VNS fails to show superiority over false treatment in primary efficacy outcomes, but results are more favorable for one secondary outcome. The authors conclude "This study did not produce definitive evidence of short-term efficacy for adjuvant VNS in drug-resistant depression."
Stimulation of skull electrotherapy
A Cochrane 2014 review found insufficient evidence to determine whether the stimulation of Cranial electrotherapy with alternating current is safe and effective for treating depression.
Other treatments
Light light therapy
A light meta-analysis of light therapy commissioned by the American Psychiatric Association found a significant reduction in the severity of depressive symptoms associated with bright light treatments. Benefits are found for both seasonal affective disorder and for non-elderly depression, with measures of effect similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to standard antidepressant treatment is not effective. A meta-analysis of light therapy for the non-seasonal depression performed by Cochrane Collaboration, studied a series of different trials, in which light is widely used in combination with antidepressants or wake-up therapy. A statistically significant moderate effect of light therapy was found, with a significantly better response than control treatment in high-quality research, in studies that applied morning light therapy, and with patients who responded to total or partial sleep deprivation. Both analyzes noted the poor quality of most studies and their small size, and insisted cautiously in the interpretation of their results. The shortest 1-2 weeks duration of most trials makes it unclear whether the effects of light therapy can be sustained over the long term.
Exercise
Cochrane Collaboration 2013's review of physical exercise for depression notes that, based on limited evidence, it is quite more effective than control interventions and is comparable to psychological or antidepressant medications. Smaller effects are seen in more rigorous and meticulous studies. The following three systematic reviews that include Cochrane's review in their analysis conclude with similar findings: one indicates that physical exercise is effective as an adjunctive treatment with antidepressant drugs; two others indicated that physical exercise had marked the antidepressant effect and recommended the inclusion of physical activity as an adjunctive treatment for mild-moderate depression and general mental illness. These studies also found a smaller effect size in a more meticulously methodological study. All four systematic reviews call for further research to determine the effectiveness or intensity of optimal exercise, duration, and modalities. The evidence for brain-derived neurotrophic factors (BDNF) in mediating some of the neurobiological effects of physical exercise is noted in a review hypothesized that increased BDNF signaling is responsible for the effects of antidepressants.
A review of clinical evidence and guidelines for depression management with exercise therapy was published in June 2015. It noted that the available evidence on the therapeutic efficacy of exercise for depression suffers from some limitations; Nonetheless, it states that there is clear evidence of efficacy in the reduction of symptoms of depression. The review also notes that patient characteristics, types of depressive disorders, and the nature of the exercise program all affect the antidepressant properties of exercise therapy.
Meditation
Mindfulness meditation programs can help improve symptoms of depression, but they are no better than active treatments such as medication, exercise, and other behavioral therapies.
Music therapy
A 2009 review found that 3 to 10 music therapy sessions resulted in marked improvement in depressive symptoms, with better improvement after 16 to 51 sessions.
St John's wort
A Cochrane Collaboration 2008 meta-analysis concluded that "Available evidence suggests that hypericum extract tested in a trial) is superior to placebo in patients with severe depression, b) as effective as standard antidepressants c) and has fewer sides , the effects of standard antidepressants, associations of countries of origin and precision with effect sizes complicate interpretation. "The American National Center for Complementary and Integrative Health advice is that" St. John's wort may help some types of depression, similar to the treatment with standard prescription antidepressants, but the evidence not sure." and warned that "Combining St. John's Wort with certain antidepressants can lead to an increase in serotonin, a brain chemical targeted by antidepressants.St John's wort may also limit the effectiveness of many prescription drugs."
Sleep
Depression is sometimes associated with insomnia - (difficulty sleeping, getting up early, or waking up in the middle of the night). The combination of these two results, depression and insomnia, will only worsen the situation. Therefore, good sleep hygiene is important to help break this vicious cycle. This will include measures such as regular bedtime routine, avoiding stimulants like caffeine and sleep disorder management such as sleep apnea.
Smoking cess
Smoking cigarettes is associated with decreased depression and anxiety, with the effect of "equal or greater than" those of antidepressant treatments.
Total/partial sleep deprivation
Sleep deprivation (missed sleepless nights) has been found to improve symptoms of depression in 40% - 60% of patients. Lack of partial sleep in the second half of the night may be as effective as a sleep deprivation session all night. The increase can last for weeks, although most (50% -80%) recur after sleep restoration. Shifts or reduction of sleep time, light therapy, antidepressant drugs, and lithium have been found to potentially stabilize the effects of sleep deprivation.
Essential Fatty Acids
Cochrane Collaboration 2015 reviews find insufficient evidence to determine whether omega-3 fatty acids have an effect on depression. A 2016 review found that if experiments with formulations containing eicosapentaenoic acid (EPA) were largely separated from experiments using formulations containing docosahexaenoic acid (DHA), it appears that the EPA may have an effect while DHA may not, but there is insufficient evidence to ascertain.
Co-treatment, when primary doctors and specialists have joint management of individual health care, have been shown to reduce depression outcomes.
See also
- Antidepressants work fast
References
External links
- Media related to Depression Treatment on Wikimedia Commons
Source of the article : Wikipedia
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