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Severe depression
Severe depression: is there a best approach?
by
Sonawalla SB, Fava M.
Depression Clinical and Research Program,
Massachusetts General Hospital,
Harvard Medical School, Boston, Massachusetts, USA
CNS Drugs 2001;15(10):765-76
severe depression
ABSTRACT
A major depressive episode can be categorised as severe based
on depressive symptoms, scores on depression rating scales,
the need for hospitalisation, depressive subtypes, functional
capacity, level of suicidality and the impact that the depression
has on the patient. Several biological, psychological and
social factors, and the presence of comorbid psychiatric or
medical illnesses, impact on depression severity. A number
of factors are reported to influence outcome in severe depression,
including duration of illness before treatment, severity of
the index episode, treatment modality used, and dosage and
duration of and compliance with treatment. Potential complications
of untreated severe depression include suicide, self-mutilation
and refusal to eat, and treatment resistance. Several antidepressants
have been studied in the treatment of severe depression. These
include tricyclic antidepressants (TCAs), selective serotonin
reuptake inhibitors (SSRIs), serotonin-noradrenaline (norepinephrine)
reuptake inhibitors, noradrenergic and specific serotonergic
antidepressants, serotonin 5-HT(2) receptor antagonists, monoamine
oxidase inhibitors, and amfebutamone (bupropion). More recently,
atypical antipsychotics have shown some utility in the management
of severe and resistant depression. Data on the differential
efficacy of TCAs versus SSRIs and the newer antidepressants
in severe depression are mixed. Some studies have reported
that TCAs are more efficacious than SSRIs; however, more recent
studies have shown that TCAs and SSRIs have equivalent efficacy.
There are reports that some of the newer antidepressants may
be more effective than SSRIs in the treatment of severe depression,
although the sample sizes in some of these studies were small.
Combination therapy has been reported to be effective. The
use of an SSRI-TCA combination, while somewhat controversial,
may rapidly reduce depressive symptoms in some patients with
severe depression. The combination of an antidepressant and
an antipsychotic drug is promising and may be considered for
severe depression with psychotic features. Although the role
of cognitive behaviour therapy (CBT) in severe depression
has not been adequately studied, a trial of CBT may be considered
in severely depressed patients whose symptoms respond poorly
to an adequate antidepressant trial, who are intolerant of
antidepressants, have contraindications to pharmacotherapy,
and who refuse medication or other somatic therapy. A combination
of CBT and antidepressants may also be beneficial in some
patients. Electroconvulsive therapy (ECT) may be indicated
in severe psychotic depression, severe melancholic depression,
resistant depression, and in patients intolerant of antidepressant
medications and those with medical illnesses which contraindicate
the use of antidepressants (e.g. renal, cardiac or hepatic
disease).
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