Treating depression

If practical difficulties are the cause of depression, dealing with these or obtaining advice on how to resolve them may be of help. For more severe depression, help is available from trained counsellors, psychologists, and psychiatrists and can be accessed through an HIV clinic or voluntary HIV/AIDS services.

Doctors or psychiatrists may suggest the use of antidepressants, drugs that relieve the symptoms of depression by acting on various neurotransmitters. Antidepressant drugs may be of help, especially if depression is accompanied by physical symptoms such as weight loss or sleep problems. They usually take a few weeks to work and have side-effects which should be discussed with a doctor before treatment begins. Often, drug treatment and psychotherapy are combined and some research suggests this is a more effective approach.

There are several classes of antidepressants:

Tricyclic antidepressants (TCAs) were first developed in the 1950s and include the drugs amitriptyline (Elavil), nortriptyline (Allegron, Pamelor), desipramine(Norpramin), clomipramine (Anafranil), doxepin (Sinequan), imipramine (Tofranil), protriptyline (Vivactil), trimipramine (Surmontil), and tranylcypromine (Parnate). Side-effects include cardiac arrhythmia risk, confusion, constipation, dry mouth, sedation, weight gain, and sexual dysfunction. Even though these drugs are effective and inexpensive, they need to be titrated to an appropriate therapeutic level, and for this reason, are not as commonly used now.

Monoamine oxidase inhibitors (MAOIs) include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). MAOIs are very effective in treating anxiety and affective disorders. Their main disadvantage is the risk of hypertension; patients taking these drugs should be counselled on following a low tyramine diet. Other side-effects include anxiety, insomnia, weight gain, and sexual dysfunction.

Selective serotonin re-uptake inhibitors (SSRIs) are the most recent type of antidepressant to be developed. This group includes fluoxetine (Prozac), citalopram (Cipramil), escitalopram (Cipralex), fluvoxamine (Faverin), paroxetine (Seroxat), sertraline (Lustral), and escitalopram (Lexapro). Serotonin-norepinephrine inhibitors include the drugs venlafaxine (Effexor), duloxetine (Cymbalta), mirtazapine (Remeron), and desvenlafaxine (Pristiq). Due to a better side-effect profile, these drugs are more frequently prescribed than those in the other classes. Nevertheless, a significant proportion of people experience early side-effects such as diarrhoea, insomnia, and nausea. These side-effects often resolve in a few weeks.

Fluoxetine tends to be prescribed more frequently than other SSRIs because of a larger body of experience on its use. SSRIs also have fewer interactions with other drugs. Impotence or delayed ejaculation are potential side effects with some SSRIs. Mirtazapine has been shown to be superior to other SSRI drugs in major depression that is accompanied by severe insomnia and anxiety. Several studies suggest that dual-action drugs such as duloxetine, mirtazapine, and venlafaxine have a faster onset of activity and better efficacy in managing pain and other somatic symptoms.¹ In general, SSRIs are not recommended for use in persons under the age of 18, except in the case of fluoxetine.

Other drugs used include trazodone (Desyrel) and nefazodone (Serzone), that affect serotonin, but are chemically unrelated to SSRIs; bupropion (Wellbutrin), which works by inhibiting dopamine reuptake; and central nervous system stimulants, such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin).

The herbal remedy St John's wort (Hypericum perforatum), which contains 0.3% hypericum and 6% hyperforin, is an unlicensed treatment that has shown effect against mild depression, but not against moderately serious depression. St John's wort should not be taken at the same time as some protease inhibitors or non-nucleoside reverse transcriptase inhibitors (NNRTIs), since it can reduce blood levels of these drugs. The chemical action of St John's wort is similar to that of SSRI drugs.

Non-pharmacologic treatments include psychotherapy; counselling; stress reduction activities, such as meditation and yoga; a balanced diet, and physical activity. Electroconvulsive therapy (ECT); light therapy, transcranial magnetic stimulation, and vagus nerve stimulation have also been used in the treatment of depression.

It is unclear how long antidepressants should be taken for in order to 'cure' depression. There are many conflicting theories amongst psychiatrists and psychotherapists about the treatment of depression. Some argue that antidepressants only need to be taken for a short period of time (three to six months), but others suggest that they may need to be taken longer. Clinical depression tends to reoccur in 50 to 80% of persons who experience depression once. Other people may stay on antidepressants as a preventive measure. It is generally more useful to think of treatment goals as response and remission versus cure.