Information

Anti-depressants

For updates on SSRI ban see the web page 'Latest News' the link is next to the butterfly above.

The World Health Organisation now ranks depression as the world's fourth greatest public health problem.

Depressive states can range from feelings of sadness to severe illness. Accurate diagnosis is important. It is estimated that thirty to fifty percent of cases of depression in primary care and medical settings are not detected. It is important to provide more training for medical practitioners, reduce the stigma and create awareness in the general population, that help should be sought.

Free counselling should be made available and can be found by contacting the charity MIND in the UK, or by referral from your G.P. or Primary doctor.

Self help groups are run by Depression Alliance.

Bereavement counselling is widely available. From my personal experience, it allows the natural expression of pain, anguish, anger, and grief to be expressed, whereas drug treatments can block the emotions and cause further problems.

Treatment for depression
Some people benefit from a combination of drug treatment and counselling. Some may improve with counselling alone.

Of major importance is the right choice of treatment for the particular type of depression.

People with mild to moderate depression have benefited from cognitive behaviour therapy.

Anti-depressant drug treatment, may help lift the mood, but alone, will not deal with the underlying cause of the depression.

If drug therapy is recommended, referral to a specialist for advice is advisable.

EVIDENCE BASED GUIDELINES FOR TREATING DEPRESSIVE DISORDERS WITH ANTIDEPRESSANTS (a revision of the 1993 BAP guidelines) IS NOW AVAILABLE FOR PHYSICIANS AND PSYCHIATRISTS FROM THE British Association of Phychopharmacology, Cambridge, England.

Adverse drug reactions

People who are suffering from anxiety and depression may have a serious reaction to some anti-depressants. They can become agitated and suffer panic attacks. They do however need help and the following article may be of interest to sufferers and medical practitioners.

Although this seems to promote one particular medication, I have printed the article for it's value in pointing out the suicide risk for some patients who have a serious adverse reaction so some antidepressants.

Newspaper and other articles referring to the risk of suicidal ideation can be found on the links page of the APRIL web site.

The following is quoted from an article by Professor David J. Nutt MD. Ph.D. Who is the chairman of the British Association of Psychopharmacology. This was printed in the Journal of Clinical Psychiatry 1999:60 (supp[17]:23-27)

Care of Depressed Patients With Anxiety Symptoms

Anxiety frequently coexists with depression, either as a comorbid anxiety disorder or as anxiety symptoms accompanying a primary depressive disorder.

Effective therapy for the treatment of depressive illness must include a consideration of anxiety symptoms, since anxiety has been estimated to be present in up to 96% of patients with depressive illness.

Available data also indicate that depressed patients with significant anxiety may be at greater risk for suicide. Of particular clinical importance are symptoms of somatic anxiety: they are present in up to 86% of depressed patients, and the failure to treat them effectively can diminish the ability of a patient to function.

Since the overall prognosis for recovery from a major depressive episode is less than optimal in patients with significant anxiety, treatments that can provide an effective and early relief of both depressive and anxiety symptoms are of paramount importance.

When treatment is initiated, drugs with serotonin reuptake inhibition ( such as selective serotonin reuptake inhibitors [ SSRIs ] or serotonin-norepinephrine reuptake inhibitors [ SNRIs ] may produce transient increases in anxiety symptomatology presenting as:

• jitteriness,
• agitation
• insomnia,
• and gastrointestinal symptoms.

Recognition of anxiety and depressive disorders is now considered to be extremely important, since the comorbid condition of depression complicated by anxiety has a much poorer prognosis than that of depression alone.

When patients display anxiety symptoms in depression, the illness tends to be more severe at baseline and there is more psycholsocial impairment.

Moreover, response to treatment is poorer and slower, and there is a greater likelihood of chronic illness and suicide.

Although a high degree of hopelessness and complete or near total anhedonia are the most significant factors in suicide early in treatment, Sleep disturbances, severe psychic anxiety, and recent history of panic attacks are also highly significant.

Treatment-related issues that should be borne in mind while evaluating anxiety symptoms in a depressed patient include:
side effects of ongoing treatment,
inadequate treatment of a medical or psychiatric disorder, and antidepressant discontinuation syndrome.

Treatment of Anxiety symptoms in depression

The treatment options for anxiety symptoms in depression, together with their probable outcomes, are summarised in Table 3 (not included here).

Treatment of anxiety symptoms in depression with a benzodiazepine has the disadvantage of leaving the underlying depression untreated.

SSRIs have been used effectively to treat patients with depression and anxiety: however drawbacks include early side effects of agitation and anxiety.

TREATMENT WITH AN SSRI ALONE CAN EXACERBATE THE ANXIETY SYMPTOMS. (OUR CAPITALS).

So it is important with comorbid patients to administer a low dose and to titrate slowly, as well as to aggressively manage treatment-emergent anxiety to avoid premature discontinuation of medication.

Combined benzodiazepine and SSRI treatment is effective, but there is a potential risk of a drug-drug interaction and of benzodiazepine dependence developing.

Tricyclic antidepressants and monoamine oxidase inhibitors, although proven to be effective in treating both anxiety and depressive symptoms, have numerous adverse effects, making them second choice therapies, in addition, they are known to interact with many other pharmacologic agents.

Treatment with noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine (Rameron) shows improvement in depression with early relief from symptoms of anxiety. (We are omitting the technical details included at this point of the article.)

Choosing a Treatment Option

The rapid improvement in anxiety symptoms seen in depressed patients treated with mirtazipine could have important implications when choosing antidepressant therapy for depressed patients with significant anxiety symptoms.

Factors to consider in the choice of an antidepressant in the management of depression complicated by anxiety symptoms include the following:
Early reduction of anxiety symptoms,
Minimal side effects,
Good compliance,
Quality of Life,
and the potential for maximum dosing.

The antidepressants currently used to treat major depression with anxiety features differ in their effects upon the various neurotransmitter systems, producing both clinically beneficial and adverse effects.

Where possible, monotherapy should be attempted first with a drug capable of treating depression as well as anxiety disorders.

Mirtazapine is an effective antidepressant with anxiolytic properties that may offer a promising alternative to currently available andidepressants.

Discussion and Conclusions

Epidemiologic studies reveal that the coexistance of depression and anxiety is a common occurrence that still presents treatment challenges. In comorbid depression and anxiety, the treatment of choice is usually monotherapy with an antidepressant effective against both depression and anxiety.

However, some antidepressants currently used can have early side effects of agitation and anxiety requiring the addition of an anxiolytic or sedative-hypnotic to manage treatment-emergent anxiety.

Evidence from comparative clinical trials has shown that mirtazapine is an effective antidepressant that provides early relief of symptoms of anxiety, Moreover the effect of mirtazapine on anxiety persists throughout the course of treatment.

Since mirtazapine is effective against the symptoms of both depression and anxiety, polypharmacy is rarely needed and it shows great promise as first-line treatment for the depressed patient with symptoms of anxiety."

We have quoted from this article by Professor David Nutt, as this seemed a more positive approach, than just quoting the adverse publicity that we have all heard regarding certain antidepressants and suicide.

We must point out however that every person reacts differently to medication. Some of us have enzyme defficiencies that have an effect on the way a drug is dispersed in and out of the body. Some people seem to build up an overdose of medication due to the slow rate at which they pass out a drug. So side effects can vary according to the person's weight and metabolic rate of dispersal of the drug.

POSSIBLE SIDE EFFECTS OF MIRTAZAPINE:
based on information from the USPDI Drug Information Manual (USA)

Side effects that should be reported to your doctor immediately:Rare: convulsions (seizures) and evidence of bone marrow depression and infection, such as mouth sores, sore throat, chills or fever.

Other side effects(that may not be reversible, when the medication is stopped) should be reported to your doctor: Less common: Decreased or increased movement, mood or mental changes, shortness of breath, swelling of feet or ankles.

Other side effects that usually do not require medical attention,

some side effects may occur that are not listed. If you notice any effects check with your doctor, nurse or pharmacist.Constipation, dizziness, drowsiness, dry mouth, increased appetite, weight gain.

Less common:
Abdominal pain,
abnormal dreams,
back pain,
dizziness or fainting, when getting up suddenly from a lying or sitting position;
frequent urge to urinate;
increased sensitivity to touch and pain;
increased thirst; low blood pressure;
muscle pain; nausea;
sense of constant movement of self or surroundings;
trembling or shaking; vomiting; weakness.

Search the world wide web for more information and take a look at this site for a list of more side effects: http://www.nursespdr.com/members/database/ndrhtml/mirtazapine.html

We cannot discuss all treatments available and further information about psychiatric illness and treatments can be obtained in the UK from:

the charity MIND

DEPRESSION ALLIANCE

have self help groups and provide useful literature.
Their telephone no is 020 7207 3293
Web site: www.depressionalliance.org

Look on the APRIL links page for other related web sites and articles.

We would like to hear about your own experience of treatments for depression. Please email us: info@april.org.uk

If you have suffered a psychiatric adverse reaction to this drug please email us at reactions@april.org.uk

This page prepared August 2000.

Email us at: info@april.org.uk

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