Major
depression phases usually are not causally related to stress factors.
These factors can, however, cause revealing of successive phases of
“Major depression”.
Introduction
"Major depression” phases treated frequently,1
probably rather inappropriately, by primary medical care physicians,
usually are not causally related to stress factors. These factors
can, however, cause revealing of successive phases of “major
depression”. This phenomenon is usually independent of the season
of the year. In spite of that, it is commonly known that spring and
autumn are the seasons enhancing the development of consecutive phase
of major depression. It has been found presently that typical “old
generation” antidepressants are rather frequently of low effectiveness
and rather unsafe in the treatment of endogenous depression. Thus,
amitriptyline2 causes frequent incidence of autonomic and
circulatory adverse effects. Imipramine3 also causes rather
numerous adverse effects. A drawback of both these drugs is delayed
onset of therapeutic action, 10-14 days on the average.
On the other hand, rather beneficial is significant sedative effect
of amitriptyline.2 This helps in sleep correction and in
drug use in depression with significantly pronounced anxiety.
Imipramine3 is a drug fairly effectively potentiating psychomotor
drive which increases drug effectiveness in depression with significant
psychomotor sluggishness and inhibition and significant decrease of
activity. Amitriptyline and imipramine2,4-6 are fraught,
however, with rather many adverse effects, not only somatic but also
psychiatric which frequently limits the possibilities of their administration.
Particularly dangerous but fortunately, rather infrequent adverse
effect which could develop after both amitriptyline and imipramine
is central anticholinergic syndrome manifested as delirium. The treatment
of choice is immediate drug withdrawal, hydration of patients by parenteral
route (drip infusions), supplementation of electrolytes with infusions,
i.e. supplying mainly potassium, sodium and magnesium. Frequently,
cardiac drugs are necessary in tachycardia, and in circulatory failure
drugs from digitalis group can be useful.
Case Report
Female patient PJ aged 46 never received any psychiatric treatment.
She was hospitalized twice in surgery department where she had surgical
operation for extensive haemorrhoids, refractory to pharmacological
treatment. The patient was born after normal pregnancy and labour.
Her childhood was moderately good. The father was considerate and
warm. The mother was stand-offish, emotionally cold, peremptory, of
irascible temper, not tolerating objections, sometimes slightly abusing
alcohol. The patient has two younger brothers. The mother was burdening
the patient with caring for the younger brothers. No mental diseases
occurred in the family. Only the father is alive. The mother died
suddenly of severe cerebral stroke. In primary school and economic
secondary school the patient achieved very good results. Unfortunately,
she terminated her education after examination for secondary school
certificate, since poor economic conditions forced her to take a job
where she worked hard to help educating her younger brothers. The
patient denied any head trauma and consciousness loss. She got married
at the age of 24. Her marriage has been very successful. She has an
adult good son. The cause of intense psychiatric treatment of the
patient by the author of the paper was an extremely strong stress,
since in November 1999, under circumstances
unexplained as yet, in spite of intensive investigation, her 20-year-old
daughter had been murdered. This extreme stress released the first
typical phase of endogenous depression in the patient’s life.
In successive examinations of the patient the matter-of-fact and emotional
contact was maintained and good. The mood was very depressed. The
patient had strong groundless anxiety, with deep psychomotor sluggishness
and extreme reluctance to any activity. Transient suicidal ideation
was present but the patient was convinced that she would not undertake
any suicidal attempt, partially due to her religious outlook on life
- she is a believing and practising Roman catholic. Constant insomnia
and feeling of hopelessness of life developed. The patient had a feeling
of guilt due to her daughter’s death. She was feeling that she
deserved contempt and condemnation. She did not express any other
depressive delusions. Constant insomnia of early morning awakening
type with impossibility to fall asleep was present. Body weight drop
by 10 kg was observed over three months, with complete loss of appetite.
The worst general feeling was reported in morning hours, slightly
better during day and the best in evening hours. Detailed psychiatric
examination demonstrated typical phase of endogenous depression. The
diagnosis was confirmed by test using Hamilton scale, Montgomery-Asberg
scale and Beck Self-Assessment Inventory and also ICD-10, DSM III
and DSM IV scales. Detailed psychiatric examination and ICD-10 scale
test diagnosed the depression as medium (as the criteria of depression
intensity, minor, medium and severe depressions were taken into account).
Laboratory tests :
- basic laboratory blood and urine analyses gave normal results
- chest radiogram was normal
- ECG record: non-specific changes of the ST-T segment without clinical
importance
- EEG record was normal,
- eye fundus examinations gave normal result,
- neurological examination demonstrated no focal and meningeal symptoms,
- physical examination was normal.
Initially, the patient was treated with amitriptyline in up to 150
mg daily dose for six weeks without any therapeutic effect. Then the
patient was treated with imipramine in up to 150 mg daily dose for
six weeks without any therapeutic effect. Finally, sertraline was
administered in up to 100 mg daily dose achieving complete remission
of depression. The first symptoms of clinical improvement developed
already after 7-8 days of treatment.
Discussion
Sertraline2 is a selective serotonin reuptake inhibitor
recently in Germany. The drug7 increases serotoninergic
transmission-this property explains the antidepressant activity of
the drug. The results2 of several placebo-controlled studies
performed by double blind method evidently demonstrated antidepressant
activity of sertraline. Many authors2,3 confirmed the therapeutic
effectiveness of sertraline in endogenous depressions refractory to
other drugs, described in the present case report. Sertraline exerts
more rapid therapeutic effect than that of many tricyclic antidepressants.
It has been noted that, typically, the first manifestations of clinical
improvement in endogenous depression occur usually already after seven
days of treatment with sertraline. Similar situation was observed
in the above reported case. Fairly numerous authors regard sertraline
as the drug of choice in the treatment of “major depression”.1,4-16
References
1. Luketos GG, Taragano F, Freishman GJ. Major depression and
its response to sertraline in primary care vs. Psychiatric office
practice patients, results of an open-label trial in Argentia. Neuropsychiatry
and Memory Group, John Hopkins University, Baltimore, MD, USA.
2. Moller HJ, Gallinat J, Hegerl U. Double-blind, multicenter comparative
study of sertraline and amitriptyline in hospitalized patients with
major depression. Pharmacopsychiatry 1980; 31 (6) : 170-7.
3. Kirli S, Caliskan M. A comparative study of sertraline versus imipramine
in postpsychotic depressive disorder of schizophrenia. Schizophrenia
Research 1998; 33 (1-2).
4. Hirschfeld RM, Russell JM, Delgado PL. Predictors of response to
acute treatment of chronic and double depression with sertraline or
imipramine. Journal of Clinical Psychiatry 1998; 59 (12) : 669-75.
5. Davis SM, Harrison WM, Keller MB. The treatment of chronic depression,
part 3: psychosocial functioning before and after treatment with sertraline
or imipramine. Journal of Clinical Psychiatry 1998; 59 (11) : 608-19.
6. Keller MB, Gelenberg AJ, Hirschfeld RM. The treatment of chronic
depression, part 2 : a double-blind, randomized trial of sertraline
and imipramine. Journal of Clinical Psychiatry 1998; 59 (11) : 598-607.
7. Murdoch D, McTavish D. Sertraline a reveiw of its pharmacodynamic
and pharmacokinetic properties, and therapeutic potential in depression
and obsessive compulsive disorder. (Review) (72 refs) Drugs 1992;
44 (4) : 604-24.
8. Croft H, Settle EJr, Houser T. A placebo-controlled comparison
of the antidepressant efficacy and effects on sexual functioning of
sustained-release bupropione sertraline. Clinical Therapeutics 1999;
21 (4) : 643-58.
9. Shapiro PA, Lesperance F, Frasure-Smith N. An open-label preliminary
trial of sertraline for treatment of major depression after acute
myocardial infarction. Department of Psychiatry, Columbia University
College of Psysicians and Surgeons, New York, NY 10032, USA.
10. Rush AJ, Koran LM, Keller MB. The treatment of chronic depression,
part 1 : Study design and rationale for evaluating the comparative
efficacy of sertraline and imipramine as acute, crossover, continuation
and maintenance phase therapies. Journal of Clinical Psychiatry 1998;
59 (11) : 589-97.
11. Keller MB, Kocsis JH, Thase M. Maintenance phase efficacy of sertraline
for chronic depression: a randomized controlled trial. JAMA 1998;
20 (19) : 1665-72.
12. Preskorn SH, Lane RM. Sertraline 50 mg daily: the optimal dose
in the treatment of depression. (Review) (55 refs) International Clinical
Psychopharmacology 1996; 10 (3) : 129-41.
13. Keller MB, Harrison W, Fawcett JA. Treatment of chronic depression
with sertraline or imipramine: preliminary blinded response rates
and high rates of undertreatment in the community. Psychopharmacology
Bulletin 1995; 31 (2) : 205-12.
14. Bennie EH, Mullin JM, Martindale JJ. A double-blind multicenter
trial comparing sertraline and fluoxetine in outpatients with major
depression. Journal of Clinical Psychiatry 1995; 56 (6) : 229-37.
15. Oinan TG. Lithium augmentation in sertraline - resistant depression:
a preliminary dose - resposne study. Psychiatrica Scandinavica 1993;
88 (4) : 300-1.
16. Aguglia E, Casacchia M, Cassano GH. Double-blind study of the
efficacy and safety of sertraline vesus fluoxetine in major depression.
International Clinical Psychopharmacology Fall 1993; 8 (3) : 197-202.
TOPICAL
CAPSAICIN MAY BE A USEFUL ADJUNCT IN CHRONIC PAIN
Capsaicin is better than placebo for treating neuropathic and
musculoskeletal pain. Analysing data from nine trials including
more than 1000 patients, Mason and colleagues found that the
number needed to treat for patients with neuropathic pain was
six for benefit eight weeks after treatment with capsaicin,
and eight for patients with musculoskeletal pain after four
weeks of treatment. A third of treated patients experienced
local adverse effects. The authors conclude that, although topical
capsaicin has moderate to poor efficacy, it may be useful for
a small number of patients who are unresponsive to, or intolerant
of, other treatment.
BMJ, 2004; 328 : 991. |
Central University Teaching
Hospital with Polyclinic, Armed Forces School of Medicine, Independent
Public Health Care Institution.
|
