1. Treatment goals.
(1) To improve the cure rate and minimize the disability and suicide rates;
Relapse rate of 13% in patients in complete remission (HAMD≤ 17)
Partial remission patients (HAMD> 50) relapse rate of 34%;
(2) To improve the quality of survival, restore social function, and achieve a cure rather than the disappearance of symptoms;
(3) relapse prevention.
It has been reported that environment, behavior, and stress can alter gene expression. Depression relapse can affect brain biochemical processes and increase sensitivity to environmental stress and risk of relapse. Drugs follow non-etiological treatment, but can reduce relapse by reducing episodes and decreasing ascending alterations in gene activation, especially in high-risk groups with a history of previous episodes, family history, women, postpartum, chronic physical illness, heavy life burden, mental stress, lack of social support and substance dependence.
2.Treatment principles (effective rate 60~80%)
(1) Individualization;
(2) Gradually increase the dose, as far as possible in the smallest dose, is to minimize adverse reactions, improve compliance;
(3) When the small dose is not good, add to the full dose and a long enough course of treatment according to the tolerance of adverse reactions
(4) still not effective, consider changing the drug (change MAOI to 2 weeks ~ 5 weeks interval)
(5) Single medication as far as possible, if the full amount, full course of treatment and change of medication is not effective, consider the combination of two antidepressants;
(6) Active treatment of co-morbidities, such as physical illness, substance dependence, anxiety disorders
3.The concept of whole treatment.
(1) Acute phase: control symptoms and strive for recovery. 6~8 weeks for ineffective medication change, and
and recalculate the treatment time;
(2) Continuing treatment period: at least 6~8 months, the disease is most likely to fluctuate during this period, and the risk of relapse is high;
(3) Maintenance treatment period: generally tend to be 2~3 years.
WHO recommends: single attack, mild symptoms, interval > 5 years, generally do not need maintenance treatment;
Some scholars believe that: those with more than 2 relapses, especially those with more than 2 relapses in the last 5 years, should do maintenance treatment; patients with adolescent onset, with psychotic symptoms, heavy illness, high risk of suicide, and positive family history should do maintenance treatment, or even lifelong treatment.
4.Specific medication
SSRIS- Fluoxetine, paroxetine, etc.
Advantages: small anticholinergic side effects, small cardiac effects, light sedative effect, well tolerated, easy to take; fluoxetine
Convenient to take; small discontinuation reaction of fluoxetine, small drug interaction of ceteplene;
Disadvantages: Gastrointestinal side effects, headache, insomnia, sexual dysfunction, skin rash, drug interactions except cetaprotilam, risk of overdose of cetaprotilam, higher price.
SNRI- venlafaxine (5-HT/NE reuptake inhibition)
Advantages: fast-acting, effective for both depression and anxiety, effective for some refractory depression.
Disadvantages: anxiety, nausea, headache, mildly elevated blood pressure, sexual dysfunction, high price.
NaSSAs – mirtazapine (NE, specific 5-HT reuptake inhibition)
Advantages: good antidepressant and anxiolytic efficacy, fast onset of action, almost no effect on sexual function, no effect on sleep
It is effective in people with sleep disorders and anorexia, and has a lower relapse rate than amitriptyline;
Disadvantages: weight gain, sedation, rare granular deficiency, relatively high price
TCAs – doxepin, amitriptyline, promethazine, chlorpromazine
Pros: cheap, adequate supply, major depression
Disadvantages: excessive sedation, anticholinergic (prostate, glaucoma, tardive dyskinesia, heart attack, elderly
caution), postural hypotension, liver and kidney damage, cardiovascular side effects, overdose risk, contraindicated in pregnant women; epileptogenic side effects of chlorpromazine.
Tetracyclines – Maprotiline, Dulcolax, Amoxapine
Advantages and disadvantages are the same as TCAS; Deltamethrin has rare granular deficiency; Amoxapine EPS, convulsions.
NDRIS – bupropion (NE, DA reuptake inhibitor)
Advantages: less weight gain, less sexual dysfunction
Disadvantages: anorexia, insomnia, headache, tremor, hallucinations and delusions, forbidden in combination with MAOIS, fluoxetine, lithium
Combined use with MAOIS, fluoxetine, lithium is prohibited.
SARIS – Trazodone, Nefazodone (5-HT antagonist/uptake inhibitor)
Advantages: less weight gain, less sexual dysfunction;
Disadvantages: dizziness, sedation, dry mouth, nausea, postural hypotension, abnormal penile erection with trazodone
Nefazodone is contraindicated in combination with digoxin.
MAOIS-moclobemide
Advantages: effective in partial atypical depression, refractory depression, no sedative effect, no sexual dysfunction;
Disadvantages: headache, constipation, insomnia, postural hypotension, weight gain, myoclonus.
Other – Timapentine
Advantages: anxiolytic, non-sedating, no sexual dysfunction;
Disadvantages: headache, constipation, insomnia, nervousness, dizziness weight gain
-Luvotyl
Advantages: anxiolytic, insomnia; overdose safe (OTC);
Disadvantages: only for mild and moderate depression.
5.Treatment of concomitant symptoms
(1) with agitation: choose strong sedative drugs, early combination of benzodiazepines.
(2) With obsessive-compulsive: such generally poor prognosis, the dose of the selected drugs should be relatively large.
(3) With psychotic symptoms: Combine second-generation antipsychotics and use them for 1~2 months after the psychotic symptoms disappear.
(4) With somatic diseases: while effectively controlling somatic diseases, actively treating depression, choosing drugs with high safety, small doses, and slowly increasing doses.