Treatment options for depressive symptoms (part 2) - Unipolar and bipolar depressive disorders

The main pillars of treatment for major depressive disorder are pharmacotherapy (drug treatment) with antidepressants and psychotherapy. 

Pronounced depressive states (whether pure, so-called unipolar depression or also bipolar states with phases of alternating elation and dejection or depression with delusional ideas) require specialist treatment with psychotropic drugs. Accompanying psychotherapy oriented to the individual manifestations and characteristics of the symptoms can in many cases improve the success of treatment and stabilize the outcome.  

Unipolar endogenous depression, psychotic depression and bipolar manic-depressive illness are serious mental disorders and must be treated by a specialist (psychiatrist). Drug therapy with antidepressants or antipsychotics (neuroleptics) is now considered an indispensable and effective tool. But psychotherapeutic methods, above all cognitive behavioral therapy, also have a firm place in the treatment of depression. Often, both forms of therapy are combined.1,2

It is helpful to divide the treatment into 3 phases3 :

Acute therapy (for severe depression, possibly with suicide risk), which can also take place as an inpatient and, if necessary, even in a closed psychiatric ward.

The maintenance therapy is intended to stabilize the condition that has then been achieved, and if necessary to improve it even further.

Relapse (recurrence) prophylaxis is useful for patients with recurrent (relapsing) depression. It is intended to prevent another depressive episode from occurring.  

For the treatment and prevention of depression, panic and anxiety disorders, compulsions, and post-traumatic stress disorder, so-called selective serotonin reuptake inhibitors (SSRIs) are used today. Serotonin is a messenger substance (neurotransmitter) in the signal transmission from nerve cell to nerve cell. By inhibiting the reuptake of serotonin back into the releasing nerve cell, more serotonin can be released to the next nerve cell and signal transmission in the central nervous system improves.

The corresponding drugs contain the active ingredients sertraline, paroxetine, citalopram or escitalopram, fluoxetine or fluvoxamine.

The active ingredients venlafaxine, milnacipran and duloxetine are so-called serotonin-norepinephrine reuptake inhibitors (SSNRI = selective serotonin-norepinephrine reuptake inhibitor) and have a mode of action similar to the SSRIs.

Older agents such as amitriptyline, nortriptyline, clomipramine, doxepin, imipramine, or trimipramine are called tricyclic antidepressants. They are also used to treat sleep disorders. 

The tetracyclic mirtazapine is similar to SSNRIs in its effects. It is prescribed for the treatment of depressive episodes and off-label, especially in elderly patients often also for the treatment of sleep disorders.

For the sake of completeness, the less frequently prescribed monoamine oxidase inhibitors (MAO inhibitors) should also be mentioned here: These substances inhibit the enzyme monoamine oxidase, a protein involved in the breakdown of the substances norepinephrine and serotonin. A typical MAO inhibitor is moclobemide.

Particularly when starting treatment, it should be noted that the mood-lifting effect of antidepressants only becomes noticeable after a few weeks. Side effects, on the other hand, usually occur immediately after starting treatment, but soon weaken or even disappear altogether in the course of taking the medication. If the depressive situation permits, it is therefore advisable to start with a low dose and increase it slowly to reduce the risk of side effects at the start of treatment.  

It should also be noted that the drive-enhancing effect of antidepressants usually sets in before the mood-lifting effect. Patients who are suicidal may suddenly become capable of acting due to the onset of motor agitation and actually carry out the planned suicide. Patients therefore need to be in close communication with their therapist, especially initially.

In addition, children and adolescents treated with antidepressants (especially SSRIs) are at increased risk of suicide at the beginning of treatment, even if they have not previously had suicidal thoughts.  

Antidepressants are not addictive, but they must not be discontinued abruptly. Instead, they must be "phased out" carefully by slowly reducing the daily dose over several days.  

In the case of depressive illnesses with psychotic or manic symptoms (obsessive thoughts, delusions), patients must also be treated with anti-psychotic drugs (also known as "neuroleptics").5
These active substances influence the neurotransmitter dopamine by occupying its docking sites (receptors) in the brain and thus blocking it. From the large number of available antipsychotics, only a few names are mentioned here as examples: newer active ingredients are aripriprazole, amisulpride, clozapine, quetiapine, risperidone, ziprasidone;older neuroleptics are, for example, fluspirilen, melperone, pipamperone, chlropromazine or also perazineThey are also sometimes administered as depot injections into a muscle.                         

The mode of action of these drugs, the reduction of the dopamine effect, also results in their typical side effect, the triggering of Parkinson's-like movement disorders (dyskinesias). These side effects vary in severity among the different active ingredients.  

The treatment and prevention of manic episodes in bipolar disorders is classically carried out with lithium preparations (Hypnorex, Quilonum). Lithium-Präparaten (Hypnorex, Quilonum).

Lithium influences signal transmission in the nervous system in many ways and affects, among others, the neurotransmitters serotonin and dopamine. It has a very narrow therapeutic range, which means that symptoms of intoxication can occur quickly if the ideal concentration of active substance in the blood is exceeded even slightly. To avoid lithium intoxication, the drug level must therefore be monitored closely. When therapy is discontinued, lithium must be phased out by slowly decreasing the daily dose.

As can be easily seen from the brief overview of drug treatment options for depressive clinical pictures, with the exception of the herbal sedatives mentioned in Part 1,  passionflower, valerian, hops and lemon balm, these are highly potent active ingredients whose dosage and therapy management should only be in the hands of experienced specialists. Patients should only make changes to the prescribed therapeutic regimen in consultation with their physician and never on their own authority.  

According to figures from the Robert Koch Institute, about 11% of Germans will suffer from a doctor-diagnosed depression in their lifetime; the actual rate of illness is probably much higher. For many sufferers, there is a certain inhibition threshold to recognizing and accepting their negative feelings as an illness and seeking medical help. Of the estimated four million people in Germany with depression requiring treatment, many are not in medical therapy.2