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Management of clinical depression

By Kath Carter

The National Service Framework (NSF) for Mental Health states that patients should be offered effective treatments for depression.1 Despite the fact that such treatments are available, there remains a significant burden of disease.2 Choosing the appropriate drug therapy and enhancing concordance by providing appropriate support can help to improve patient outcomes.

Before reaching a diagnosis of depression and initiating treatment, it is important to eliminate other possible causes such as disease processes (eg, hypothyroidism), drug-induced effects (eg, calcium channel blockers, levodopa and cimetidine) and substance abuse (eg, excess alcohol use, withdrawal from amphetamines).

Depression is a common mental illness and the majority of patients are treated in the primary care setting. Referral to secondary care is necessary if the patient has any of the following characteristics:

  • Presents with psychotic features
  • Is actively contemplating suicide
  • Suffers from a bipolar disorder
  • Has not responded to adequate therapy with at least two classes of antidepressants


Antidepressants are the mainstay of drug treatment. Symptoms of depression are believed to occur because of a lack of monoamines within the brain. Most antidepressants increase the availability of such monoamines (see below and Table 1, p224). Despite the development of newer agents, the importance of each neurotransmitter on outcome for individual patients is not known.

Tricyclic antidepressants

The first tricyclics imipramine and amitriptyline were developed in the 1950s and are well established in therapy. Since then, more agents in this class have been introduced. Tricyclic antidepressants inhibit the reuptake of noradrenaline and serotonin (5-hydroxytryptamine, 5HT) to varying degrees. For example, clomipramine acts predominantly by inhibiting the reuptake of 5HT while the principal action of lofepramine is to inhibit the reuptake of noradrenaline.

The need for dose titration and patients’ inability to tolerate side effects can limit the usefulness of tricyclics. Newer compounds have been developed with the aim of producing drugs with fewer side effects. Sedation, anticholinergic effects and cardiotoxicity are common with older drugs whereas lofepramine, a more recent addition to the class, has fewer of these side effects. Trazodone and maprotiline are related to the tricyclics, as is the tetracyclic compound mianserin.

Download the attached PDF to read the full article.

Citation: Hospital Pharmacist URI: 10976424

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