Horton / Katona Biological Aspects of Affective Disorders

1. Auflage 2013
ISBN: 978-1-4832-8868-0
Verlag: Elsevier Science & Techn.
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, Band Volume 1, 384 Seiten

Reihe: Neuroscience Perspectives

Biological research in the affective disorders has been an international growth industry for several years. Biological Aspects of Affective Disorders is a comprehensive introduction to the biochemical, pharmacological, and genetic aspects constituting the abnormalities that may underline the diseases of depression and mania, together with the current understanding of the clinical features and management of affected patients.It will be of great value especially to young researchers from all disciplines contributing to this area and to trainee psychiatrists.

Autoren/Hrsg.

Horton, R. W.

Katona, Cornelius

Leseproben

CHAPTER 2 PHYSICAL TREATMENTS FOR DEPRESSION
Stephen Merson and Peter Tyrer,     Stephen Merson, MRCPsych., Clinical Research Fellow & Honorary Registrar. Peter Tyrer, MD., MRCP., FRCPsych., Senior Lecturer in Community Psychiatry, St Charles’ Hospital, London W10 6DZ, UK Publisher Summary
This chapter discusses the physical treatments for depression. Physical treatment is a rather unfortunate description that implies marked personal activity when it is in fact a very passive process. It covers the range of treatments that are given to correct some presumed physical, or organic, abnormality in the patient. The indications for physical treatment can be summarized under a series of headings, all beginning with the letter “s”: specific symptoms, severity, suicide, stupor, and speed. They make a major contribution toward the continuum of symptomatology in depression. This continuum of symptomatology reflects the relative indications for psychological and physical treatments that follow opposite exponential curves with varying degrees of overlap, particularly, marked in the middle range. For patients with severe depression, there is no difficulty in deciding that physical treatment is currently the most appropriate form of management. There is much greater difficulty in selecting the physical therapy mode when the severity of the depression is moderate because, under these circumstances, psychological treatments can be regarded as equally appropriate. Table of Contents 2.1 Indications for Physical Treatment 2.1.1 Specific symptoms 2.1.2 Severity and stupor 2.1.3 Suicide 2.1.4 Speed 2.2 Assessing the Need for Physical Treatment 2.3 Drug Treatments 2.3.1 Tricylic antidepressants 2.3.2 Monoamine oxidase inhibitors 2.3.3 New antidepressants 2.3.4 Lithium salts 2.3.5 Other drugs with antidepressant properties 2.4 Electroconvulsive Therapy (ECT) 2.5 Psychosurgery 2.6 Practicalities of Treatment 2.6.1 Drug dosage 2.6.2 Delay in therapeutic effect of drugs 2.6.3 Drug withdrawal 2.6.4 Adverse effects 2.6.5 Drug interactions 2.6.6 Lithium salts 2.6.7 Electroconvulsive therapy 2.6.8 Psychosurgery 2.7 Treatment of Resistant Depression 2.7.1 Change to another antidepressant 2.7.2 ECT and other treatments 2.7.3 Combined antidepressant treatment Much of the interest in depression shown by basic scientists and clinicians in the last 40 years has flowed from evidence that physical treatments for depressive illness are not only effective but in many cases the preferred therapy for the disorder. Thus, changes in the classification of depression (see Chapter 1), the burgeoning interest in the biochemistry of depression, and the epidemiology of depressive disorders and their causal influences (exemplified by studies of life events), all owe at least some of their inspiration to the development of successful physical treatments. This may tempt contradiction, but it is worth reminding ourselves that for the first 30 years of this century depressive disorders were virtually forgotten diagnoses. Aubrey Lewis (1934) rescued them from obscurity by clinical description and Cerletti and Bini (1938) began the era of physical treatments by their introduction of electroconvulsive therapy (even though depression was not the original indication for the treatment). 2.1 Indications for physical treatment
‘Physical treatment’ is a rather unfortunate description which implies marked personal activity when it is in fact a very passive process. It covers the range of treatments that are given in order to correct some presumed physical, or organic, abnormality in the patient. In the case of depression the distinction is often made between understandable sadness and unhappiness in response to an event, usually a loss, which is considered unsuitable for physical treatment and, at the other extreme, a condition manifest by severe depressive symptoms and psychomotor changes in the absence of obvious precipitants (at least immediate ones) and which is presumed to be caused by a biochemical abnormality requiring reversal by pharmacological treatment or electroconvulsive therapy (ECT). This explains the attraction of a dichotomous classification of depression for psychiatrists; it has face validity and can be a useful guide to practice. Unfortunately the decision to give treatment is often made before adequate assessment so that diagnosis becomes a tautologous exercise that justifies rather than indicates the treatment. The indications for physical treatment can be summarized under a series of headings, all beginning with the letter ‘s’: specific symptoms, severity, suicide, stupor and speed. They are worth discussing separately but together they make a major contribution towards the continuum of symptomatology in depression. This continuum also reflects the relative indications for psychological and physical treatments which follow opposite exponential curves with varying degrees of overlap, particularly marked in the middle range (Figure 1). Figure 1 Scope of physical and psychological treatment of depressive illness. 2.1.1 Specific symptoms
There is a popular belief that certain symptoms of depression, particularly certain ‘somatic’ symptoms, are specific indicators for physical treatment in depression (Table 1). These symptoms include marked anorexia, weight loss, loss of libido, a characteristic pattern of sleep disturbance with waking in the early morning, and a diurnal mood swing. These symptoms, which are perhaps better described as ‘endogenomorphic’ (Klein, 1974) rather than ‘somatic’, because they cover more than bodily symptoms, are often found in more severe depressive illness and it is difficult to know whether they should be regarded as specific indicators for physical treatment independent of severity. Studies of antidepressant drugs have shown that all symptoms of depression respond to antidepressants (Morris and Beck, 1974; Bielski and Friedel, 1976) and the relative specificity of somatic symptoms may be spurious, as these, being marked in severe depression, may be the first to improve when clinical response begins. Table 1 Depressive symptoms indicating response to physical treatment. There have also been several studies of psychological treatments, particularly cognitive therapy, suggesting that they are effective in the treatment of relatively severe depression (Rush et al., 1977; Blackburn et al., 1981; Teasdale et al., 1984). The recently completed large-scale study of depression carried out by the National Institute of Mental Health in the USA also showed that cognitive therapy and interpersonal psychotherapy were both as effective as imipramine in treating moderate depressive illness (Weissmann et al., 1987; Klerman, 1988). However, it would be wrong to infer from this that cognitive therapy and other psychological treatments are effective against the whole range of depressive symptoms because these treatments have not been tested in the most severe forms of depression. Similar suggestions have been made with the regard to the outcome of ECT (e.g. Hobson, 1953) but, again, in the absence of comparable control groups with similar symptoms it is impossible to be certain whether these symptoms do indeed respond specifically to ECT or whether they have the best outcome irrespective of the nature of treatment. 2.1.2 Severity and stupor
As indicated in Figure 1, the more severe the depressive illness the greater the indication for physical treatment. This is shown at its most extreme in the now relatively rare condition of depressive stupor, in which psychomotor retardation is so pronounced that the sufferer is fixed in immobility despite being fully conscious. States in which there are depressive delusions (e.g. of hopelessness, unworthiness and guilt) and hallucinations (usually auditory and of a derogatory nature) are also such strong indications for physical treatment that this treatment could be regarded as mandatory, if only because in these cases there is little or no insight and all forms of psychological treatment are largely ineffective. 2.1.3...