Treatment of depressive disorder

Cognitive-behavioural treatment is based on the following therapeutic facts and aims:

Cognitive-behavioural treatment is the therapeutic procedure aimed at identifying and modifying the cognitive processes that facilitate the appearance of dysfunctional behaviours, with the final purpose of obtaining less distorted emotions and behaviours. Obviously, the cognitive-behavioural treatment does not have to treat the temporary behaviours, cognitions and/or emotions associated with the different day to day vicissitudes as its aim. Cognitive and behavioural modification makes clinical sense when the thoughts, behaviour, or the emotions are dysfunctional, reflecting the presence of a mental disorder, or when these make it difficult for the individuals to adapt to the requirements of their affected, relational, or intellectual daily life.

Firstly, two aspects associated with this question must be clarified:

• It is not known if there is more risk of a relapse of a depressive disorder by the fact of suddenly withdrawing antidepressant drug treatment than by doing it gradually. That is to say, the so widely spread idea that it is essential to withdraw antidepressant treatment gradually is not demonstrated to be true.
• The antidepressant dose that must be prescribed to prevent a relapse of a depressive disorder is the same that helped to cure the depressive disorder. Thus, the so widely spread idea that once the acute symptoms of a depressive disorder have abated the antidepressant dose can be partially reduced has not been shown to be correct.

The main reason that it is advised to reduce the dose gradually, is not the possible risk of a relapse, but the attempt to avoid, where possible, the appearance of disagreeable side-effects, which are not severe, associated with the abrupt withdrawal of an antidepressant drug. The group of side-effects due to the sudden withdrawal of an antidepressant drug is called withdrawal syndrome.

Once it has been decided to withdraw the drug, the dose reduction is usually made in stages of, at least, 4 weeks. The theoretical justification for this dose reduction by stages is that the clinical effect of a determined dose is likely to be maintained for up to 3 or 4 weeks after the dose change. In this way, the reduction in stages means that between one dose reduction and the next one, there is a period of time needed to be able to evaluate whether or not there is a clinical deterioration.

Some antidepressant drugs can be withdrawn in only two stages (the dose is first is reduced to 50% and, later, the remaining 50% is withdrawn). However, what is usually done is to withdraw a determined number of milligrams in each dose reduction and, for this reason, the number of stages from the initial dose until the total withdrawal of the drug normally depends on the initially prescribed dose.

Withdrawal syndrome can be observed after the withdrawal of practically any antidepressant.

Normally, it does not require any specific treatment. The symptoms are usually mild, and disappear spontaneously in a few days. However, when a patient develops a very intense withdrawal syndrome, it may be advisable to prescribe the treatment again and, one or two weeks later, start its withdrawal again, but much more gradually.

One very important idea is that the withdrawal syndrome has nothing to do with a relapse of the illness. When an antidepressant drug is withdrawn, its antidepressant and anti-anxiety effect continues for at least 3 or 4 weeks. As a result, when an antidepressant drug is withdrawn, if a relapse occurs, the symptoms of this appear from the third or fourth week without treatment. Furthermore, in the cases in which a relapse occurs, the symptoms are not those of the withdrawal syndrome but those of the baseline illness itself.

Electroconvulsive treatment or electric shock is a very effective treatment for only a very small subgroup of patients affected by the depressive disorder subtype, called major depression. There is abundant clinical experience available and a bibliography of high quality that supports both its effectiveness and its safety in these patients.

It consists of the administration of an electric stimulus of short duration (2-3 seconds) in the frontotemporal area (temple). For the electroconvulsive treatment to be effective it must show that there is intense electrical activity in the brain for approximately 20-30 seconds. The treatment is performed under general anaesthetic (to prevent pain). A muscle relaxant drug is administered along with the anaesthetic, with the aim of preventing the electrical stimulus from causing an intense muscle contraction (that is to say, prevent having a motor convulsion) and thus with the maximum possible reduction in the secondary effects associated with the treatment.

In order to obtain clinical remission, between 6 and 12 electric shocks are usually required. Three electric shocks are usually performed each week on alternate days. For this reason, the treatment with electroconvulsive therapy usually lasts between 2 and 4 weeks. The improvement is usually observed from the third or fourth electric shock session.  

The mechanism that makes this treatment effective is currently unknown.

Perforate St. John’s Wort is a product obtained from the Hypericum perforatum plant. In some countries, such as Germany, it is one of the most prescribed antidepressant substances.

The information found in the literature suggests that:

• It is an antidepressant drug with the same efficacy as the classic antidepressant drugs in the acute treatment of mild to moderate depressive syndrome. Although its effectiveness in the long-term has not been demonstrated.
• It is usually very well-tolerated. Side-effects are less common than in the classic antidepressant drugs, and with the same frequency as a placebo. The most common side-effects are gastrointestinal discomforts, photosensitive skin reactions, feeling of fatigue, feeling of unease, headaches, and dry mouth.
• It can also have interactions with various frequently prescribed drugs.
• It must be prescribed with care in patients with a risk of anaemia, as it can reduce the absorption of iron in the intestine.
• In patients with bipolar disorder with a personal history it can predispose to the appearance of acute symptoms of the illness.
• It must not be prescribed to women that are pregnant or breastfeeding.

Other important aspects of the information provided in the literature about St. John’s Wort are:

• The data as regards its effectiveness are practically no-existent; for example, there are no studies available on the efficacy of St. John’s Wort in hospitalised patients in the context of a depressive disorder.
• The data of the efficacy of St. John’s Wort are particularly favourable in studies conducted by doctors in Germany (the reason is unknown).
• The older studies show better results on the efficacy of St. John’s Wort than studies carried out more recently.