Mood disorders are a group of disorders characterized by significant and persistent mood changes. It includes depressive episodes, manic episodes, and bipolar disorder. This group of disorders is characterized by an episodic course and a basic return to normal social function during remission. Treatment is based on medication and supplemented by psychotherapy. Except for very mild mood disorders, which can be considered not to be treated mainly with medication, it is dangerous to simply hope for psychotherapy out of the medication system. Hong Wu, Psychiatry Department, Shanghai Mental Health Center
Why do we need medication? Probably most of the people think that mood disorders are mainly caused by psychological factors. As the saying goes, “heart disease needs heart medicine”, but why do you need medication to treat it?
Well, let’s have a brief understanding of the etiology and pathogenesis of mood disorders. In fact, the etiology and pathogenesis of mood disorders are very complex and still unclear. The current view is that the etiology and pathogenesis of mood disorders are related to the following factors: (1) genetic factors; (2) neurobiochemical alterations: 5-hydroxytryptamine hypothesis, noradrenaline hypothesis, dopamine hypothesis, receptor and post-receptor signaling system; (3) abnormal neuroendocrine function: hypothalamic-pituitary-adrenal axis (HPA), excessive secretion of plasma cortisol, hypothalamic-pituitary- thyroid axis (HPT), hypothalamic-pituitary-growth hormone axis (HPGH); (4) electrophysiological changes in the brain: sleep EEG, electroencephalogram (EEG), evoked electroencephalogram (BEP); (5) neuroimaging changes: enlarged ventricles (mood disorders), atrophy of brain regions such as hippocampus, amygdala, ventral striatum (depressive episodes), reduced cerebral blood flow in the left frontal lobe and left anterior cingulate gyrus (depressive episodes). (6) Psychosocial factors: common negative events, such as widowhood, divorce, marital discord, unemployment, severe physical illness, serious illness or sudden death of a family member, poor economic status, and low social class.
Current research has not definitively identified a specific etiology for mood disorders. The prevailing view, however, is that it is a combination of causes, i.e., the individual has certain susceptible qualities that, when stimulated by external environmental factors, eventually lead to the onset of the disease.
Regardless of the cause, current science confirms that environmental, behavioral, and stressors of considerable intensity and frequency can alter human biology through relevant mediating effects, such as changes in certain neurotransmitters, changes in certain gene expression, changes in brain electrophysiology, and changes in brain imaging. And these are the mechanisms of action of drugs currently in clinical use, especially the neurotransmitter hypothesis, and the receptor and post-receptor signaling hypotheses.
Since, pharmacotherapy is so important in the treatment of mood disorders. So what are the principles and what needs to be noted? In the following, we will introduce the principles of pharmacotherapy in depressive disorder, manic episode and bipolar disorder respectively.
(1) Depressive disorder.
[Principles of pharmacotherapy].
①The principle of individualized medication.
(2) Single medication principle: single medication as far as possible, should be sufficient amount and full course of treatment.
(3) The principle of starting medication in small doses and gradually increasing the dose.
④The principle of switching and combination of drugs: switching to another class of drugs with different mechanisms of action; when switching is ineffective, the combination of two antidepressants can be considered (it is generally not recommended to combine more than two antidepressants).
⑤ Slow dose reduction principle: the dose should be gradually and slowly reduced, and should not be stopped abruptly to avoid “withdrawal syndrome” and relapse.
(6) Early detection and early treatment principle: early detection and treatment of mild depression will result in a better prognosis and shorter treatment time.
(7) The principle of full treatment: the acute phase, consolidation phase and maintenance phase, and insist on long-term maintenance treatment.
⑧The possibility of inducing mania or rapid cycling should be closely monitored during antidepressant treatment, and depressive episodes of bipolar disorder should be combined with mood stabilizers.
[Selection of therapeutic drugs
1) Classification and effects of antidepressants
According to the mechanism of action, they can be classified as 5-HT and NA reuptake inhibitors, selective NA reuptake inhibitors, selective 5-HT reuptake inhibitors, monoamine oxidase inhibitors, NEergic and specific 5-HTergic antidepressants, 5-HT receptor antagonists/reuptake inhibitors, etc.
2) Selection of antidepressants
(1) Those with significant agitation may prefer antidepressants with sedative effect.
(ii) SSRIs and clomipramine may be preferred for those with obsessive-compulsive symptoms.
(iii) Amoxapine is preferred to bupropion for those with psychotic symptoms, and bupropion is not appropriate, and often requires the combination of antipsychotics such as sulpiride, risperidone, and olanzapine with antidepressants.
④TCAs are appropriate for those with significant insomnia and anxiety symptoms, and benzodiazepines may also be used in combination.
(⑤ For those with significant psychomotor retardation, mipramine and moclobemide are preferable.
(6) MAOIs and SSRIs for atypical depression.
(vii) Those with physical illnesses and elderly patients may prefer drugs with high safety, few adverse effects and good tolerability.
(8) Past medication history is particularly important for the selection of relapsing patients: most of the relapsing patients whose treatment was once effective and was later reduced or discontinued are still effective with the original medication.
(3) Treatment staging can be divided into acute treatment period, consolidation treatment period and maintenance treatment period.
Acute treatment period: the main purpose is to control the symptoms, usually need 6~8 weeks of adequate antidepressant treatment.
Consolidation treatment period: The main purpose is to prevent the recurrence of symptoms.
Maintenance treatment period: The main purpose is to prevent relapse.
(2) Manic episode
[Principles of medication].
The drug treatment of manic episode is mainly based on mood stabilizers, and if necessary, antipsychotics or benzodiazepines can be used in combination. Follow the principles of individualized medication, small dose, gradually increasing dose and whole treatment.
Selection of therapeutic drugs
1) Classification and effects of therapeutic drugs
Mood stabilizers, also known as antimanic drugs, are a class of drugs that treat mania and prevent manic or depressive episodes of bipolar disorder, and do not cause manic or depressive transitions.
The mechanism of action of lithium salts is not yet fully elucidated, and it may work by affecting the distribution of Na+, K+, Ca2+, and Mg2+ inside and outside the nerve cells, inhibiting the release of NE and DA in the brain and promoting their reuptake, promoting the release of 5-HT, and inhibiting the reactions mediated by adenylate cyclase and phospholipase C.
The mechanism of action of antiepileptic drugs as mood stabilizers has not yet been elucidated.
2) Choice of therapeutic drugs
Lithium salt: Lithium salt is the drug of choice for the treatment of manic episodes, and can be used for both acute episodes of mania and maintenance treatment in remission, with an efficiency of about 80%.
Anti-epileptic drugs: These drugs can be used when lithium carbonate is not effective or cannot be tolerated.
Antipsychotics: For patients with acute severe mania or mixed seizures with severe excitement, agitation, aggression or with psychotic symptoms, antipsychotics can be applied in combination for a short period of time in the early stage of treatment.
First-generation antipsychotics are effective for manic episodes and are more effective than lithium for motor agitation.
The second generation antipsychotics have the effect of stabilizing emotion, and all of them can effectively control manic episodes with better efficacy.
Benzodiazepines: control acute symptoms such as excitement, agitation and aggression, and improve insomnia.
[Adverse drug reactions and prevention]
Lithium carbonate.
(1) gastrointestinal reactions; (2) neurological reactions; (3) endocrine system reactions; (4) renal reactions; (5) acute poisoning.
(3) Bipolar disorder
Principles of drug treatment
(1) The principle of basic use of mood stabilizers: what clinical type of bipolar disorder, the choice of mood stabilizers.
② Combined medication treatment principle: according to the need of the disease can be timely combined medication.
③Long-term treatment principle: adhere to the principle of long-term treatment.
④The principle of regular monitoring of blood concentration: regular monitoring of blood concentration of lithium salt, valproate and carbamazepine.
[Selection of therapeutic drugs
(1) For bipolar disorder, the treatment of manic episodes is generally preferred to lithium treatment.
(2) For the treatment of bipolar disorder with depressive episodes, lithium and lamotrigine can be used as the first-line drugs.
(3) For the treatment of bipolar disorder with mixed episodes or rapid cycling episodes, lithium is less effective. Valproate or carbamazepine should be preferred.
In conclusion, pharmacotherapy plays a pivotal role in the treatment of mood disorders. For patients, it is crucial to follow medical advice and use medication under the guidance of a physician. Patients should also provide their medical history, past medication history, adverse reactions, physical condition, medication use, and financial situation to the doctor so that the doctor can develop an appropriate treatment plan.