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Post  counselor on Mon Oct 15, 2012 11:18 am


The term is used to describe different forms of human experience. Its use is so extensive and referred to so many forms of subjective suffering to be determined in considerable confusion. The d. understood as a pathological condition is one of the most common psychiatric disorders in which the mental health workers are facing in their daily practice. It is, in fact, to a condition which meets the 5-15% over the existence of human beings. The d. may arise completely spontaneously, or in response to a triggering event. The reaction of the subject appears, however, disproportionate intensity and / or duration of the event itself. It is important to note that there is no depression, but there are depressions, ie a variety of depressive conditions, which manifest themselves in different ways, which are produced by different combinations of biological, psychological and social problems, which require different cures. This variety of conditions can be represented as a continuum, which leads to extremes typical two pictures: on the one hand d. more melancholic and on the other d. less anxious.

1) General Awards. In clinical practice, we encounter several depressive symptoms as they approach more or less exactly to either of these two conditions are typical, but also several paintings which have characteristics intermediate or mixed (that you have, therefore, ideally in different parts of including continuum between the two extremes).

- The d. more melancholic is characterized by the following aspects: 1) depressed mood (the subject communicates with words, facial expressions and behavior with a feeling of deep sorrow, dejection, prostration), this experience is different not only quantitatively (ie, intensity and duration), but also qualitatively (that is, by its nature) from normal sadness which any individual undergoes in unfavorable situations of his existence, and, unlike normal sadness, is insensitive to the encouragement, friendship and all ' love, 2) marked reduction or disappearance of interest and pleasure in all or almost all activities (usually all that interested in that subject and gives him pleasure - the company's partners and children, music, sport etc. - does not interest him and he does not like more, and sometimes even bothers him), 3) marked slowdown in mental and motor (the person speaks and moves little, slowly and with difficulty), 4) lack of energy and fatigue, 5) deep feelings of inadequacy, worthlessness, hopelessness, in severe cases, delusions of guilt (the subject is blaming evil acts or criminal never actually committed) or destruction (the subject is convinced that he and his loved ones are doomed to failure); 6) lack of appetite and weight loss; 7) sleep disturbance (insomnia or early morning awakening almost total) Cool thoughts of death and sometimes intentions or suicide attempts (always very determined); 9) diurnal variation of symptoms ( with worsening morning).

- The d. less anxious is characterized by the following aspects: 1) depressed mood (the subject is sad and downcast, but the depth of his experience depression is much less than in the previous form), and this experience is also quantitatively different (because more intense and lasting ), but not qualitatively from normal sadness, and may be sensitive to environmental influences in favor, 2) marked anxiety, partly somatic (ie, expressed through physical symptoms such as pain or discomfort at different location, for which he repeatedly complains and which appears to be very worried) 3) pessimism, feelings of helplessness and worthlessness (shallower than the other form; still missing delusional ideas) 4) tendency to self-pity and blame others for their condition (as in 'other form the subject blames himself) 5) motor restlessness (instead of slowing down) 6) asthenia, and fatigue, 7) insomnia (difficulty falling asleep and fragility of sleep); Cool irritability and apprehensiveness; 9) impaired concentration and feeling empty mind. There may be thoughts of death and sometimes intentions or suicide attempts (the latter, however, are generally demonstrative, that is intended to draw the attention of others on their own terms). Lacks the diurnal variation of symptoms (or the subject reported feeling a little 'worse in the afternoon and evening).

The d. are complex disorders that do not have a cause, but recognize a series of risk factors that are involved in measuring different from case to case. The more the clinical picture comes close to the prototype of d. more melancholic, the most important seem to be the familiar and triggers biological, as the clinical approaches to the prototype of d. less anxious, more significant seems to be the role of predisposing factors and triggers of a psychosocial nature.

The d. may be associated with other psychiatric disorders (schizophrenia, anxiety syndromes, dementia), be secondary to organic disease, taking medication or drugs.

2) Therapy. The treatment of the d. can not be the same in all cases, but should be individualized on the basis of: the characteristics of the clinical picture, the information available regarding the role of the various predisposing factors, triggers and protective in this case, the current physical condition of the depressed person, the response that the patient has had any previous treatments. In principle, the more the clinical picture comes close to the prototype of d. more melancholic, the more central is the role of drugs, as the clinical approaches to the prototype of d. less anxious, the more important is the role of psychotherapy (Table 1).

Table 1

Therapeutic interventions in depression
Pharmacotherapy Tricyclic antidepressants (ADT)
Selective serotonin reuptake inhibitors (SSRIs)
Reuptake inhibitors of serotonin and norepinephrine reuptake inhibitors (SNRIs)
Antidepressants specific noradrenergic and serotonergic (NaSSA)
Antidepressants with predominantly noradrenergic activity (NARI)
MAO inhibitors (MAOIs), MAO-A (RIMA)
Other antidepressants
For cognitively oriented psychotherapy

Oriented interpersonal

A psychodynamic approach

3) drug treatment. The pharmacological treatment of the depressive episode, regardless of the choice dell'antidepressivo, includes three phases.

- Acute phase: the goal is the resolution of depressive symptoms and the restoration of social and occupational functioning. The optimal dosage of the drug must be reached within 10-12 days, always starting with low doses and fractionated during the day. In the elderly, on average, lower doses should be used (30-50). In order to avoid suspension of early treatment is important to remember that the latency of action of antidepressants is variable between 7-15 days, and that the remission of symptoms is usually obtained in the 4-6th week of treatment. In the absence of side effects, the treatment should not be discontinued before 6-8 weeks (late responses).

- Continuation phase: aims to reduce the likelihood of relapse (ie, return of symptoms of the current episode within six months after remission) and uses, if there are no problems or side effects of compliance, the same doses used in the acute phase. The continuation phase must be continued for at least 4-6 months of remission of the depressive symptoms. In the event that it becomes necessary, the suspension of the treatment should be carried out always in a gradual manner (reduction of about 25-30 1081344000el dosage / day per week) in order to avoid the appearance of withdrawal symptoms.

- Maintenance phase: the objective is to prevent the onset of a new depressive episode (relapse). Candidates for the maintenance treatment are especially patients with a history of three or more previous episodes of depression, a history of previous relapse within one year after treatment and depressive episodes characterized by high intensity and high suicide risk. In these cases it is suggested to continue treatment with the same drug used in the continuation phase, for a period longer than 12-24 months. It is possible to climb a reduction of the dose used in the acute phase (up to 50).

The data in the literature indicate that about 25 664532ei depressed patients not responding satisfactorily to antidepressant drugs. If the patient did not respond at all or showed minimal symptomatic response to pharmacotherapy after 6 weeks, you need to: 1) review the correctness of the diagnosis, two) re-evaluate the adequacy of treatment (dosage, compliance). In cases where the treatment was conducted in an appropriate manner will be useful to consider one of the options shown in Table 2.

Table 2

Strategies to be used in patients
depression who do not respond to
antidepressant treatment
1. Replacing dell'antidepressivo with another compound of different category (for example, ADT with SSRIs)
2. Enhancement of the antidepressant effect by the addition of:

- Salts of lithium or other mood stabilizers

- Thyroid hormones

- Pindolol

- Tryptophan

3. Combination with antidepressants of the same class or different class (ADT + SSRI, SSRI + SSRI).

The choice dell'antidepressivo should take into account patient characteristics (age, gender, somatic conditions, other drug treatments in place, response to previous treatments) and clinical (presence of special events in symptoms, severity, course). It is also important to an assessment of tolerability (side effects, toxicity) dell'antidepressivo to use. For all classes of antidepressants, often identifying the most appropriate drug in a particular case requires several attempts. Be distinguished, in this sense, as follows.

- Tricyclic antidepressants (ADT). ADTs are still the most widely used drugs in the treatment of d. more melancholic. Inhibit the reuptake of serotonin, norepinephrine, and to a lesser extent dopamine at the synaptic level. The effectiveness of the various ADT is substantially equivalent to the treatment plan. Some ADT (amitriptyline, trimipramine) have a greater depressant, probably due to increased activity á1-adrenolytic and antihistaminic, and can be used in depressive symptoms where component prevails anxiety and / or insomnia. ADTs have some common side effects and annoying (Table 3), can lower the seizure threshold, cause reduction in blood pressure and cardiac conduction disturbances (bundle branch block and AV), weight gain and are dangerous in overdose. These effects are related mainly to the blockade of central and peripheral cholinergic receptors, receptor-adrenergic and histaminergic á1. The ADT prostatic hypertrophy are contraindicated in narrow-angle glaucoma, in myocardial infarction recent and severe cardiac conduction disturbances. Should be used with caution in patients with severe liver disease, in patients with epilepsy and the elderly.

- Monoamine oxidase inhibitors (MAOIs). Despite their antidepressant efficacy, MAOIs are currently little used, especially due to their poor tolerability and handling. These drugs inhibit the enzyme systems irreversibly Members of the catabolism of biogenic amines (MAO-A and MAO-B), which increases the intracellular concentrations. The restoration of the activity will occur only when the enzyme is synthesized again, which implies the need of a wash-out 7-8 days before being able to undertake other therapies. In addition, these drugs can not be combined with other antidepressants and foods high in tyramine (aged cheese, liver, sausage, smoked fish, red wine, yeast extract), as its inactivation intestinal failure could result in serious hypertensive crisis . A new class of MAOIs is represented by reversible inhibitors of MAO-A (RIMA), whose parent is the moclobemide. It is a drug with a better tolerability and handling, even if the antidepressant efficacy appears to be minor.

- Inhibitors Selective serotonin reuptake inhibitors (SSRIs). Are antidepressants, most recently introduced that act selectively on the serotonergic system. The antidepressant efficacy is comparable to that of ADT and substantially equivalent among the various compounds included in this class. The latency of action of SSRIs is 7-8 days. Compared to ADT are better tolerated, as almost totally devoid of anticholinergic activity, adrenolytic and antihistamine at both central and peripheral. The most frequently reported side effects are nausea, vomiting, diarrhea, irritability, tremors, insomnia, headache, dizziness, decreased libido and anorgasmia. The tolerability of SSRIs has made them easier to take and increased patient adherence to therapy, making them inappropriate for long-term treatments.

- Reuptake Inhibitors Serotonin and norepinephrine (SNRIs). SNRIs are a new class of antidepressants whose parent is venlafaxine, used at a daily dose of 75-150 mg / day. Venlafaxine has a low incidence of side effects due to the poor affinity for cholinergic muscarinic, histamine and á-adrenergic receptors. A peculiar aspect of his action would be represented by a rapid induction of down-regulation of b-adrenergic receptors, resulting in a more rapid onset of antidepressant. The side effects most frequently reported side effects are nausea and vomiting, headache, dizziness and insomnia.

- Specific noradrenergic and serotonergic antidepressants (NaSSA). Progenitor of NaSSA is mirtazapine, which acts by enhancing noradrenergic transmission through blockade of the autoreceptors á2-adrenergic and serotonergic that through a mechanism of post-synaptic stimulation of 5HT1 receptors and inhibition of those 5HT2 and 5HT3. Has also high affinity for the H1-histamine receptors, which influences the profile of the side effects (Table 3).

- Antidepressants with predominantly noradrenergic activity (NARI). In this category, the mianserin, with a marked adrenolytic and antihistaminic action, which explains its strong sedative and anxiolytic activity. It is recommended as a single dose at night. Especially useful in the treatment of d. anxious, especially if resistant to treatment with ADT, and the elderly. To this category belongs also reboxetine, active receptors is á1 - and b-adrenergic receptors. Possesses a good tolerability profile, presents no interference with the cytochrome P-450 and, therefore, is easier to handle when used in combination with other drugs. It does not give sedation or sleepiness, and would seem to have an effect method for societal reintegration.


4) Drug interactions of antidepressants. Antidepressants are involved in numerous drug interactions. In fact, are metabolized by various isoenzymes of liver microsomal P-450 (CYP) of which can also be competitive inhibitors, resulting in additive or synergistic pharmacological effects with the result of an increase in the action of either drug. Patients at risk of drug interactions are especially those with medical conditions being treated with more than one drug, in particular those which inhibit multiple pathways; the elderly and debilitated; subjects with liver disease and / or renal dysfunction. The most significant interactions you may have with ADT drugs with anticholinergic and sedative strengthening of their actions, and MAOIs due to the risk of serotonin syndrome. Also appears to be significant association with clonidine, to inhibition of the anti-hypertensive latter, with the ephedrine and all drugs with á-adrenolytic. Some NSAIDs and anticoagulants can give some phenomena of displacement and thus result in increased plasma levels of ADT. SSRIs is contraindicated for use in combination with alcohol, sedatives, antihistamines, anticholinergics, MAOIs and tryptophan (to the risk of serotonin syndrome), propranolol, theophylline, digoxin, warfarin (increased PT), cimetidine (increased first- pass effect). In particular, for fluoxetine caution must be used in the association with the ADT, neuroleptics butirrofenonici and phenothiazine, carbamazepine, valproic acid, oxidized benzodiazepines such as diazepam and alprazolam, for the inhibition of CYP2D6 and the consequent increase of plasma levels.

5) toxicity in overdose. All ADT drugs are considered high index of fatal toxicity. Acute intoxication by accidental overdose or voluntary particularly interested in the heart and central nervous system, with the possible appearance of the triad characterized by coma, convulsions and severe arrhythmias. The cardiac effects are represented by atrial fibrillation or flutter or ventricular arrhythmias, AV block from complete or incomplete, ectopic rhythms, from asystole. An early clinical indicator of intoxication is the prolongation of the QRS over 100 msec. The effect on the CNS include agitation, confusion, slurred speech, convulsions, respiratory paralysis, and coma. Other symptoms of peripheral anticholinergic activity are the pupillary areflexia and mydriasis, scleral hyperemia, dry skin and hyperemic, the reduction in mucous secretions, urinary retention and bowel paralysis. Physostigmine salicylate is the drug of choice for the control of symptoms associated with anticholinergic action of ADT. In the case of generalized seizures is indicated intravenous administration of diazepam. For the control of cardiac arrhythmias are indicated propanol and lidocaine. The treatment must be carried out in an intensive care unit. MAOI and RIMA in intoxication from the symptoms most frequently are psychomotor agitation, confusional states, hallucinatory phenomena, violent headache, hyperthermia, changes in pressure, convulsions, lockjaw and coma. SSRIs are drugs with a narrow acute toxicity and the few cases with fatal outcome reported in the literature concerning the subjects who took SSRIs with other drugs and / or with large quantities of alcohol. A toxic condition acute, sometimes with fatal outcome, described in patients taking SSRIs concomitantly with other drugs with serotonergic activity (eg other SSRIs or MAOIs) is known as serotonin syndrome. This is characterized by abdominal cramps, bloating, diarrhea, hyperthermia, tremor, dysarthria, myoclonus, euphoria, cardio-circulatory collapse, hypertension, tachycardia, confusion to coma.

6) Psychotherapy. Psychotherapies now used in d. are essentially of three types:

- Oriented cognitive psychotherapies seek to identify and correct thought patterns of the person (negative view of self, the world and the future) that may have contributed to produce the depressive condition;

- Oriented interpersonal psychotherapies aim to identify and correct problems in interpersonal relationships that may have precipitated the current depressive condition;

- Psychodynamic psychotherapy-oriented aim to reconstruct the events and conflicts of standing that may have predisposed the individual to depression.

The cognitive and interpersonal psychotherapy-oriented are shorter and their effectiveness is documented by research. Psychotherapies a psychodynamic approach are longer and their efficacy is currently not documented scientifically. Psychotherapy and medications should not be seen as antagonistic, but rather as compatible and complementary. The drugs are rapidly effective on depressive symptoms, and psychotherapeutic interventions can help patients to modify aspects of the ways of thinking and relating to others that make them vulnerable to depression.

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