How to choose an antidepressant to treat depression?

Existing recommendations on the antidepressants use in patients with depression are based on data coming from various sources. One of them is the results of clinical trials of drugs meeting the highest methodological standards. Thus, patients are selected according to strict diagnostic criteria or scales. The study is necessarily of a comparative nature. The antidepressant is compared with a biologically neutral substance (placebo) or another known psychotropic drug of the same class. And neither the doctor nor the patient himself is aware of what they are prescribing (study drug, placebo, antidepressant comparison) or receive (respectively). To do this, all tablets (containing the drug or placebo) are made the same. Patients are divided into groups receiving the study antidepressant, placebo or drug comparison randomly (randomization). Finally, the effectiveness and safety of treatment are recorded using standardized scales or questionnaires.
It would seem that we have a very reliable data source that allows us to formulate recommendations on the antidepressants use in patients with depression. However, the clinical trials results of drugs, and, consequently, judgments based on them on the medicines effectiveness in question are increasingly generating distrust and even rejection. At the same time, they emphasize that in 96% of such works, at least one of its direct participants is associated with a pharmaceutical company that produces an antidepressant. It is pointed out that it’s quite easy for the doctor performing the research, despite all the precautions described above, to understand what exactly is taking him sick. After all, any antidepressant has a characteristic marker – side effects. They aren’t only related to the mechanism of action of the drug, but also arise at the very beginning of therapy, leaving patients on the condition quite licked “fingerprints.” Placebo, being a biologically neutral substance, has no side effects. How the doctor will act by revealing the “research code” paid by a pharmaceutical company is known only to himself.
More recently, a new concept of a rational choice of antidepressants has been proposed. It is based on the two types differentiation of depression symptoms: with hyperesthesia (positive affectivity) and anesthesia (negative affectivity), which are combined into appropriate target syndromes. The first of them includes depressive hyperesthesia signs (melancholy, vital anxiety, low value ideas, sinfulness, damage, suicidal thoughts, hypochondriacal ideas). The second combines signs of depressive hypo- or anesthesia (painless insensitivity, moral anesthesia phenomena, depressive devitalization, apathy, anhedonia, asthenia).
It is assumed that in depression with depressive hyperesthesia all antidepressants are effective, regardless of their mechanism of action (drugs affecting serotonergic, brain noradrenergic structures, double action, etc.), taking into account the only limitation: the drugs choice depends on the severity of the condition. In severe depression, TCAs are preferred, whereas for mild-to-moderate patients, modern drugs are preferred. They are also effective in the treatment of depressive states with depressive hypo- or anesthesia.
Unfortunately, the concept under consideration is also not devoid of shortcomings. First, it is not entirely clear why some pathological ideas reflecting the content of the self-awareness of a depressed patient are considered as plus- and other minus signs. For example, persistent reflections on one’s own worthlessness, depravity with a negative reassessment of the past, present, future prospects refer to depressive hyperesthesia, and the painful feeling of one’s own altered and emotions loss – to hypesthesia. Secondly, it is not clear why the antidepressants therapeutic effects in any way don’t depend on their mechanisms of action. It turns out that the patient isn’t a medication, but the fact of admission? In other words, the drug has no thymoanaleptic properties, but rather a placebo effect. Thirdly, does the choice of an antidepressant depend on the target syndrome? It is easy to see that to a large extent it is associated not so much with hyper- and hypoesthesia as with the severity of depression. So, the most severe depressive conditions are the target for TCAs. The application sphere of other antidepressants are all other depressions.
Thus, the presented data clearly demonstrate the need to search new data modern recommendations development sources for the rational antidepressants use in clinical practice. In particular, for the search target syndromes, the achievements of so-called functional psychopathology can be used. Within this clinical psychiatry area, significant relationships are established between the mental disorder and the violation symptom of the neurotransmitters exchange in the central nervous system. So, with the dopamine excess in the nucleus accumbence, the delirium and hallucinations occurrence is associated. A significant number of symptoms are associated with so-called monoamine deficiency syndrome.

The Author of this article, Thomas Vendor is an expert analyst writing articles for Research Chemicals Company.

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