Major depressive disorder: Validated treatments and future challenges

Depression is a prevalent psychiatric disorder that often leads to poor quality of life and impaired functioning. Treatment during the acute phase of a major depressive episode aims to help the patient reach a remission state and eventually return to their baseline level of functioning. Pharmacotherapy, especially selective serotonin reuptake inhibitors antidepressants, remains the most frequent option for treating depression during the acute phase, while other promising pharmacological options are still competing for the attention of practitioners. Depression-focused psychotherapy is the second most common option for helping patients overcome the acute phase, maintain remission, and prevent relapses. Electroconvulsive therapy is the most effective somatic therapy for depression in some specific situations; meanwhile, other methods have limits, and their specific indications are still being studied. Combining medications, psychotherapy, and somatic therapies remains the most effective way to manage resistant forms of depression.     

Current treatment approaches to obsessive-compulsive disorder.

The two most useful treatments in obsessive-compulsive disorder are pharmacotherapy with potent serotonin reuptake-blocking agents and behavioral techniques, such as exposure and response prevention. Based on the authors' cumulative clinical experience, it is suggested that patient education, cognitive therapy, and psychodynamic psychotherapy are helpful adjuncts during various treatment stages of obsessive-compulsive disorder. The patient's strengths and knowledge of the illness can be used by the nurse-therapist to determine the implementation and timing of these therapeutic measures. Specific behavioral and cognitive techniques that may be useful in treating specific symptoms of obsessive-compulsive disorder are highlighted. Suggestions for future nursing research are outlined.     

Psychotherapy of depression

Patients with depressive disorder are often guilty of their dysfunction and desperate of their future. In acute stage, it is most important to give patients the insight into their illness and to give them such reassurance that they will recover with treatment. Clinicians should advise the patients to take a rest. To encourage and motivate the patients to do work or other activities is often harmful. In the recovery stage, it is useful for the patients to reflect on their premorbid personality and behavioral traits that facilitate the development of depressive disorder, which may lead to their changing way of life and prevent recurrence of the illness.     

Integrating psychotherapy and pharmacotherapy for treatment of major depressive disorder. Current status and future considerations

The treatment of depression with psychotherapy and pharmacotherapy is one of the best-studied areas, yet much controversy exists about the relative merits of these treatments, singly and in combination. The author suggests that a combination of these therapies is not routinely indicated for uncomplicated major depressive disorder and provides some examples in which combined therapy can have a profound and cost- effective impact.     

Therapy of affective disorders

The key to the proper treatment of affective disorder is a correct diagnosis of the subtype of depressive illness. Thus, primary treatment recommendations include the TCAs for a depressive episode; ECT for a depressive episode with psychotic features; and MAOIs for dysthymic disorder and atypical depressive episodes. Nonresponding patients are treated with either lithium augmentation of TCA therapy, an MAOI, or ECT. Second-generation antidepressants are not usually indicated as initial treatments. They are recommended in situations in which their adverse-effect profiles offer significant advantages over TCAs in an individual patient. Second-generation antidepressants have not been extensively studied in patients who do not respond to TCAs. Maintenance antidepressant may be necessary to prevent recurrent depressive episodes. Lithium remains the mainstay of acute treatment of mania and for prophylaxis of subsequent affective episodes. In lithium-refractory or lithium-intolerant patients, carbamazepine is recommended. Valproic acid and verapamil have been useful, primarily in patients who do not respond to lithium and carbamazepine.     

The role of psychotherapy in treating psychiatric disorders

Psychotherapy has shifted from long-term to short-term approaches, which have been found to be effective for the treatment of specific psychiatric disorders. These psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been found useful in presenting an educational framework for disorders and the treatment rationale for intervention programs. Short-term and maintenance empirical data support the effectiveness of using behavior therapy and CBT as adjunctive interventions with medications for bipolar I disorder and schizophrenia. In major randomized clinical trials, psychotherapy interventions (primarily behavior therapy, CBT, and IPT) have been shown to be effective as primary treatments (treatments of choice) for the major psychiatric problems of obsessive-compulsive disorder, panic disorder, and major depression as well as several other psychiatric disorders. The combination of psychotherapy and psychotropic medications is not always additive for acute treatment effects or especially for the maintenance of treatment effects so that the combination of psychotherapy and medications is not the most effective treatment for all psychiatric disorders. Badly needed, additional randomized controlled trials of psychotherapy, medications, and their combinations are under way in large, NIMH-supported studies of the treatment of several psychiatric disorders.     

Adult ADHD: evaluation and treatment in family medicine

Attention-deficit/hyperactivity disorder (ADHD) affects 30 to 50 percent of adults who had ADHD in childhood. Accurate diagnosis of ADHD in adults is challenging and requires attention to early development and symptoms of inattention, distractibility, impulsivity and emotional lability. Diagnosis is further complicated by the overlap between the symptoms of adult ADHD and the symptoms of other common psychiatric conditions such as depression and substance abuse. While stimulants are a common treatment for adult patients with ADHD, antidepressants may also be effective. Cognitive-behavioral skills training and psychotherapy are useful adjuncts to pharmacotherapy.     

Psychogenic amnesia

Psychogenic amnesia is a psychiatric disorder characterized by sudden loss of memory in the absence of organic lesion or disease. The disorder most frequently occurs in association with a severe stressor, such as a natural disaster or military conflict. To facilitate effective treatment and an accurate prognosis, psychogenic amnesia must be differentiated from amnesia of structural or pharmacologic origin. Treatment may involve supportive psychotherapy, behavioral modification or pharmacotherapy. Prognosis for complete recovery is generally good.     

Primary care treatment of post-traumatic stress disorder

Post-traumatic stress disorder, a psychiatric disorder, arises following exposure to perceived life-threatening trauma. Its symptoms can mimic those of anxiety or depressive disorders, but with appropriate screening, the diagnosis is easily made. Current treatment strategies combine patient education; pharmacologic interventions, such as selective serotonin reuptake inhibitors, trazodone and clonidine; and psychotherapy. As soon after the trauma as possible, techniques to prevent the development of post-traumatic stress disorder, such as structured stress debriefings, should be administered. A high index of suspicion for post-traumatic stress disorder is needed in patients with a history of significant trauma.     

The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update

Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.     

Generalized anxiety disorder

Patients with generalized anxiety disorder experience worry or anxiety and a number of physical and psychologic symptoms. The disorder is frequently difficult to diagnose because of the variety of presentations and the common occurrence of comorbid medical or psychiatric conditions. The lifetime prevalence is approximately 4 to 6 percent in the general population and is more common in women than in men. It is often chronic, and patients with this disorder are more likely to be seen by family physicians than by psychiatrists. Treatment consists of pharmacotherapy and various forms of psychotherapy. The benzodiazepines are used for short-term treatment, but because of the frequently chronic nature of generalized anxiety disorder, they may need to be continued for months to years. Buspirone and antidepressants are also used for the pharmacologic management of patients with generalized anxiety disorder. Patients must receive an appropriate pharmacologic trial with dosage titrated to optimal levels as judged by the control of symptoms and the tolerance of side effects. Psychiatric consultation should be considered for patients who do not respond to an appropriate trial of pharmacotherapy.     

Electroconvulsive therapy plays an irreplaceable role in treatment of major depressive disorder

Major depressive disorder is a serious and common neuropsychiatric disorder that affects more than 350 million people worldwide. Electroconvulsive therapy is the oldest and most effective treatment available for the treatment of severe major depressive disorder. Electroconvulsive therapy modifies structural network changes in patients with major depressive disorder and schizophrenia. And it can also affect neuroinflammatory responses and may have neuroprotective effects. Electroconvulsive therapy plays an irreplaceable role in the treatment of major depressive disorder.     

Proper use of antidepressants in the acute and maintenance phase treatment of depression

In spite of their different pharmacological profiles, a number of meta-analyses have shown that all antidepressants are equally effective in the treatment of major depression. However, there is the discordance between efficacy data and clinical observation. So then, how should we use antidepressants properly in the clinical setting? Toward rational pharmacotherapy, the selection of antidepressant medications will be based on their pharmacological profiles, clinical features of the patient, the anticipated side effects, and clinical trial data regarding the medication. During about 6 months following remission, the treatment that was effective in the acute phases should be used in the maintenance phase to prevent relapse.     

A review of combined psychotherapy and pharmacotherapy in the treatment of depression

The effectiveness of combined psychotherapy and pharmacotherapy for depression is a clinical issue of increasing importance. Using a box score approach, the authors review the 17 available studies in the literature, provide a methodological critique, summarize results, and suggest directions for further research and for clinical practice. Overall, given methodological limitations in the existing literature, it appears that combined treatment is no less effective than psychotherapy or pharmacotherapy alone and may have specific advantages for subpopulations of depressed patients.     

Depression in post-acute myocardial infarction patients

PURPOSE: To identify strategies for nurse practitioners to diagnose and treat depression following acute myocardial infarction (AMI) and prevent subsequent cardiac events. DATA SOURCES: Selected articles in the medical and psychiatric literature and government consensus guidelines. CONCLUSIONS: Between 8% and 45% of patients who have suffered an AMI exhibit symptoms of major depression. Depression is an independent risk factor for cardiovascular disease and causes higher morbidity and mortality rates among patients with coronary artery disease. IMPLICATIONS FOR PRACTICE: Early diagnosis and aggressive treatment are crucial to reducing cardiac related morbidity and mortality. Cardiac rehabilitation programs, psychotherapy and counseling, and pharmacotherapy are effective in the management of AMI depression.     

Psychogenic urinary retention in women.

There appears to be a spectrum of psychogenic urinary retention that is seen mostly in women. The degrees of psychiatric disorder and bladder disorder do not necessarily coincide. Some patients with psychogenic retention may have one acute episode temporally related to psychologic trauma. Others may present with problems related to large residual volumes such as recurrent urinary tract infection or incontinence. All patients require complete neurologic, urologic, and psychiatric evaluation. Permanent urethral catheterization is avoided if possible. Intermittent self-catheterization should be used during periods of psychotherapy and bladder training. Patients with neurogenic bladder, as determined by urodynamic studies, should be managed by bladder training and the use of pharmacologic agents when indicated.     

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders

Objective To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting. Methods In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow‐up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF‐36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence. Results Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF‐36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF‐36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06–1.71). No significant differences were found within socio‐demographic variables, co‐morbidity and the scores on the BSI subscales between the adherence groups. Conclusions We found that patients with low scores on the vitality subscale of the SF‐36 were at the highest risk to receive low guideline‐concordant care. Understanding factors that affect treatment adherence may help to prevent non‐adherence and increase the quality of care as well as cost‐effectiveness.     

Management of acute,severe asthma in children

OBJECTIVE: To briefly present the current options available for the treatment of acute, severe asthma in children, with a special focus on emergency department and inpatient treatment, and to describe newer therapies that may aid treatment in the future. DATA SOURCES AND STUDY SELECTION: A MEDLINE search (1966-May 2001) of the English-language literature pertaining to drug therapy of acute asthma was performed. Key word searches included acute asthma, albuterol, ipratropium, corticosteroids, magnesium, and theophylline. Additional articles from these sources and published national guidelines were identified. Relevant studies pertaining to current therapy of acute asthma in pediatric patients were selected; if there were minimal pediatric data, adult data were included. DATA SYNTHESIS: Asthma is a chronic, inflammatory disorder of the airways. Acute exacerbations can occur and are challenging to manage. Albuterol, ipratropium, and systemic corticosteroids have been shown to be effective in acute asthma exacerbations. Because some patients do not respond to maximal therapy, older therapies such as magnesium and theophylline are being reevaluated. Theophylline may have some therapeutic effect, but given its toxicity profile, it is unclear whether it offers any advantage over maximal beta(2)-agonist therapy. There are only minimal published data evaluating the use of magnesium in pediatrics, and most are small trials or case reports. Newer therapies such as ventilation strategies with heliox and intravenous leukotriene modifiers currently being evaluated may or may not prove to be beneficial in the future. CONCLUSIONS: beta(2)-agonists, ipratropium, and corticosteroids remain the most useful therapeutic agents for acute asthma exacerbations in pediatric patients. However, these agents are not ideal in all patients and, given the existing questions regarding safety and/or efficacy of available alternatives, more effective options are needed.