Therapy of a depressive episode is carried out in phases.
After the first, more acute phase has been successfully managed, the patient moves on to maintenance treatment. Such a regimen prevents frequent and early relapses of depression, i.e. the return of the acute phase of the illness.
The therapeutic strategy does not differ according to whether the depression is mild, moderate or severe.
Rather, the symptoms of depression, the patient's personality, age, comorbidities and the occurrence of side effects are taken into account.
The phases of the depression treatment plan are listed. However, often the boundaries between the phases are blurred:
- Acute phase of treatment - This is a period of 6 to 12 weeks until remission is achieved.
- Continuing treatment phase - This lasts for at least 1 year.
- Maintenance phase - This is also called thymoprophylaxis. It may be stopped after 5 years.
- Complete remission of the disease
By adhering to the above lengths of each treatment phase, the risk of relapse can be reduced by up to 70-80%.
Most antidepressants are indicated, prescribed and monitored for effectiveness by a specialist psychiatrist.
An adult GP may prescribe tricyclic (TCA) and tetracyclic (TeCA) antidepressants and selective serotonin reuptake inhibitors (SSRIs).
Monoamine reuptake inhibitors (thymoleptics)
This broad group of drugs includes tricyclic (TCA) and tetracyclic (TeCA) antidepressants. Their main action is the non-selective inhibition of neurotransmitter reuptake, specifically serotonin, noradrenaline and dopamine. They are among the first antidepressants.
In the 1930s, they topped the list of treatments for depression. In modern medicine, they are more of a second choice after SSRIs.
1st generation thymoleptics
These include activating tricyclic antidepressants. The main representatives are nortriptyline and dosulepin. They act as noradrenaline and dopamine reuptake inhibitors but are not suitable in the treatment of the acute phase of depression.
Their therapeutic effect is to improve mood and clarify thinking. They carry an increased risk of suicidal ideation. They are suitable for patients who are depressed and have not been diagnosed with suicidal ideation.
2nd generation thymoleptics
This group of antidepressants has the advantage of a weaker anticholinergic effect compared to the previous group. Therefore, they are also more suitable for polymorbid and elderly patients. Representatives of this group of drugs are dibenzepine, maprotiline, mianserin, viloxazine and trazodone.
Adverse effects often occur before the expected therapeutic effect. These include xerostomia (dry mouth), visual acuity disturbances, urinary disturbances, constipation and rapid heart rate (tachycardia). Less commonly, dizziness, disorientation, confusion, drowsiness and hypotension may occur.
Generation 3 thymoleptics
This group includes the most commonly used antidepressants. The mechanism of action is inhibition of reuptake of only one of the three monoamines.
They inhibit the reuptake of either serotonin (SARI, SSRI), noradrenaline (NARI) or dopamine only (DARI).
Selective serotonin reuptake inhibitors (SSRIs)
These are the antidepressants of first choice. They include drugs such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline.
One of the advantages is that they can be used in pregnancy. They have a low teratogenic effect, i.e. risk of fetal harm.
The disadvantage is that patients with untreated hypothyroidism are resistant to SSRI treatment.
Serotonin antagonists and reuptake inhibitors (SARIs)
These are antidepressants with dual serotonin action. They block serotonin receptors and also inhibit its reuptake. A representative of this group is trazodone, which has a sedative effect and also counteracts anxiety.
Selective noradrenaline reuptake inhibitors (NARIs)
In this group of antidepressants, the main representative drug is reboxetine. It has a stimulant effect. It improves symptoms such as disinterest, demotivation and depression. The advantage is that it does not act as a sedative and therefore does not depress.
It is a very safe drug in terms of drug interactions. It is not dangerous in case of possible overdose.
4th generation thymoleptics
These include antidepressants which have a dual action. Their mechanism of action is to inhibit the reuptake of both serotonin and noradrenaline (SNRIs). The second group are dopamine and noradrenaline reuptake inhibitors (DNRIs).
The SNRI group includes venlafaxine and milnacipran. These are relatively modern antidepressants. The great advantage of venlafaxine is the rapid onset of its therapeutic effect, within 1 week.
The rapid action of the antidepressant improves the patient's cooperation and thus increases the chance of achieving complete remission of the disease.
Antidepressants directly affecting receptors
In addition to its antidepressant effect, mianserin has anxiolytic (anti-anxiety), sedative (anti-insomnia) and analgesic (pain-relieving) effects.
Sexual dysfunction may occur in patients taking SSRIs. Mianserin may improve this disorder.
Mitranzapine also has a dual effect but does not counteract pain like mianserin.
These include antidepressants such as tranylcypromine or moclobemide. They are indicated when depression is mild and atypical. They have fewer side effects than tricyclic antidepressants.
Tranylcypromine is not recommended in patients with alcohol dependence, in patients with Parkinson's disease, and in persons over 65 years of age.
Moclobemide, on the other hand, is very effective for depression in the elderly. It improves cognitive function and clarity of thought.
Psychotherapy and supportive psychotherapy
Psychotherapy is an integral part of the treatment of depression.
Neither patients nor therapists should underestimate the positive effect of confidential conversation. The patient can talk to an unbiased person and thus release difficult thoughts.
Psychotherapy should last at least 6-8 weeks in regular sessions, ideally up to 4 months, until the symptoms of depression improve.
Recent studies clearly confirm that the best treatment effect is when psychotherapy and antidepressants are combined.
Supporting psychotherapy is the support of the patient with depression by his/her loved ones and environment.
The patient with depression needs kindness, understanding, listening, encouragement to achieve realistic goals and appreciation of every success in his progress.