Sleep interventions for the treatment of depression

Sleep disturbances are common in depressed patients. Insomnia may predate the onset of major depression, increases the likelihood of a depressive relapse, and is associated with an impaired response to treatment. Benzodiazepine drugs may have inherent antidepressant effects; thus, these and other sedative-hypnotic drugs can be beneficial for treating insomnia in depressed patients and may enhance the overall effectiveness of antidepressant drugs. Sedating antidepressant drugs are used for treating primary insomnia, but their sleep-promoting effects have been demonstrated primarily in depressed patients. Several second-generation antipsychotic drugs are used in low doses to promote sleep, but they also have inherent antidepressant effects. Cognitive-behavioral therapy targeting insomnia can effectively enhance the response to antidepressant medication. Sleep deprivation, which is also associated with a transient antidepressant effect, is difficult to use in routine clinical practice but might be an appropriate strategy for treatment-resistant forms of depression.     

Agomelatine: a novel atypical antidepressant

This article reviews the novel atypical antidepressant drug agomelatine (Valdoxan), which is currently being actively investigated in the United States for the treatment of depression but is not yet approved by the U.S. Food and Drug Administration. Agomelatine is a synthetic analog of the hormone melatonin and has unique pharmacological properties that distinguish it from other currently available antidepressant drugs. Agomelatine is efficacious, safe, and well tolerated but does not appear to have major efficacy advantages compared with other antidepressant drugs. Because of its unique pharmacology and relatively benign tolerability profile, however, it may be a more effective alternative for patients who do not respond to or cannot tolerate currently available antidepressant drugs.     

Vilazodone: another novel atypical antidepressant drug

This article reviews the novel atypical antidepressant drug vilazodone (Viibryd(?)), which was approved by the U.S. Food and Drug Administration in January 2011 for the treatment of major depression. Vilazodone is a dual-acting antidepressant drug, with a primary mechanism of action of blocking the serotonin reuptake transporter together with acting as a 5-HT1A receptor partial agonist. The antidepressant efficacy of vilazodone was established in two 8-week placebo-controlled studies. One long-term (52-week) open-label study has been conducted. The most common side effects are diarrhea, nausea, and headache. The drug has not been studied in pediatric patients or well studied in patients older than 65. Vilazodone is efficacious, safe, and well tolerated, but does not appear to have major efficacy advantages compared with other antidepressant drugs. However, because of its unique pharmacology and relatively benign tolerability profile, it may be a more effective alternative for patients who do not respond to or cannot tolerate currently available antidepressant drugs.     

The use of antidepressants with elderly patients.

If we are to prevent treatment failures, we should eliminate the schism between psychosocial and biological treatments. Most depressed patients require both psychosocial and biological treatments. The patient who responds to biological treatment but does not make appropriate corrections regarding current environmental factors is at an increased risk for relapse. A strong support system can have an important preventive effect without the risks involved in long-term medication maintenance therapy. After a correct diagnosis of a major depressive disorder is made in elderly patients, the dosage of antidepressants should only be about half of the standard adult dose. Preference should be given to those antidepressants with a therapeutic profile appropriate to each particular patient. The antidepressant should have few side effects. Although antidepressant drugs are effective in treating depression, their demonstrable efficacy is surprisingly limited. Because of suicide risk and physical illnesses, older patients are more likely to require electroconvulsive therapy than younger patients. The presence of somatic delusion is a good predictor of positive response. Newer antidepressants have not been proven more effective than the older agents, such as imipramine or amitriptyline, in treating mild or severe depressions. However, they have fewer or varied side effects and therefore they are better tolerated by elderly patients (Figure 6). The consideration of side effects is a major determinant in choosing an antidepressant for a specific elderly patient. Research into the effectiveness of antidepressants has been limited by the existence of heterogeneous groups of depression and by the different therapeutic responses.(ABSTRACT TRUNCATED AT 250 WORDS)     

The use of dopaminergic and stimulant drugs for the treatment of depression

The brain reward system consists of extensive neural pathways that mediate reward behavior such as pleasure and motivation. These pathways may be involved in the development of symptoms such as apathy, anhedonia, and cognitive dysfunction seen in patients with major depression. These pathways are served primarily, although not exclusively, by the chemical neurotransmitter dopamine, which has suggested a therapeutic role for drugs that influence dopamine activity. A small number of clinical trials using various dopaminergic and stimulant drugs for the treatment of major depression and bipolar depression have demonstrated some benefit when combined with standard antidepressant drugs. Based on this work, several ongoing trials are investigating the use of the stimulant drug lisdexamfetamine (Vyvanse?) as an adjunctive treatment for depression.     

Suicide and documentation: don't let the pen kill your career

1. Nurses' notes must reflect the assessment performed regarding their patients' risk factors, red flags, and protective supports, especially for suicidal patients. 2. Nursing interventions range from the least-restrictive methods to full restraints, if necessary to prevent patients from harming themselves. 3. Medications, such as antidepressant, antipsychotic, and antimanic agents, as well as benzodiazepines, have been shown to help psychiatric patients cope with depression, psychosis, and mood stability.     

Severe premenstrual syndrome and bipolar disorder: a tragic confusion

Bipolar disorder and severe premenstrual syndrome (PMS) have many symptoms in common, but it is important to establish the correct diagnosis between a severe psychiatric disorder and an endocrine disorder appropriately treatable with hormones. The measurement of hormone levels is not helpful in making this distinction, as they are all premenopausal women with normal follicle-stimulating hormone and estradiol levels. The diagnosis of PMS should come from the history relating the occurrence of cyclical mood and behaviour changes with menstruation, the improvement during pregnancy, postnatal depression and the presence of runs of many good days a month and the somatic symptoms of mastalgia, bloating and headaches. Young women with severe PMS do not respond to the antidepressants and mood-stabilizing drugs typically used for bipolar disorder.     

Lithium: underappreciated and underused?

Lithium is a remarkable drug with a fascinating history. Although less popular than other anticonvulsant and atypical antipsychotic mood-stabilizing drugs, lithium is beneficial in bipolar disorder and may be superior to other drugs for treatment-resistant depression and for reducing suicidal behaviors. Various studies have demonstrated that lithium has neuroprotective and neurotrophic cellular effects in the brain, suggesting it may be "brain healthy" for patients with mood disorders and useful for patients with other neurodegenerative disorders. In this article, I describe the history of lithium and review important aspects of its clinical use.     

Potential effects of antidepressant agents on the growth and development of children and adolescents

The regulatory bodies of both the United States and United Kingdom have issued cautionary statements about prescribing antidepressant medications to treat major depressive disorder (MDD) in children younger than age 18. Despite these cautions, antidepressant agents, particularly SSRIs and serotonin activators, are regularly used to treat MDD in this age group, and increasingly so in very young children. This article considers the possible effects of antidepressant agents on the growth and development of children younger than age 18 and provides recommendations for the use and careful monitoring of these medications, including screening for physiological effects, selfinjurious behavior, and suicidal ideation. Guidelines for use of antidepressant agents with these populations include incorporating medications into comprehensive, holistic treatment, assessing for onset of severe akathesia as a marker of increased risk for self-harm, and advocating for more clinical trials of these medications in different childhood age groupings.     

Transpeople,Hormones, and Health Risks in Southeast Asia: A Lao Study

ABSTRACT

Cross-sex hormones, while often effective in producing some of the bodily changes desired by transpeople, may also involve harmful side-effect risks, especially when used against contraindications and precautions, and in the wrong dosages. Same-sex hormones blockers (interrupting the person's own sex hormone production) may also have potential side effects. Yet there is evidence from Southeast Asia that transpeople commonly use hormones of both types without any medical supervision, often unaware of the risks at which they put themselves. This report, employing a sample of Lao transwomen, examines the degree to which participants using hormones seek out medical advice regarding their use, as well as examining participants’ knowledge and experience of hormone effects and side effects. The results suggest that as few as one in eight of those using hormones consulted medical professionals about doing so, instead most often relying on friends for advice. Though all who took hormones were aware of the positive effects they were having on their bodies, only half knew of any possible side effects, with only one in ten able to list any of the more serious (potentially life-threatening) effects. Around a half who took hormones had stopped doing so within six years of first taking them, nine out of ten citing unwanted or unhealthy side effects. The implications for transgender health care are discussed.     

Antidepressants & suicide: putting the risk in perspective

Suicidal thoughts are a symptom of depression, and completed suicide is a tragic complication of depressive illness. Although pharmacotherapy is effective for the treatment of depression, the U.S. Food and Drug Administration has ordered that all antidepressant medications carry a warning indicating that they are associated with an increased risk of suicidal thinking, feeling, and behavior in children, adolescents, and young adults. These warnings have received much attention in the general media and have caused much controversy and debate about the relative safety of these commonly used drugs and the appropriateness of their use, especially in younger patients. In this article, I will discuss this issue with the goal of putting the risk in perspective.     

Alternative and complementary therapies for the menopause

Despite a re-evaluation of risks in recent years, hormone replacement therapy is still surrounded by controversy. Almost 30% of women in a recent survey sought a natural approach to combat climacteric symptoms. Nevertheless, a large proportion of patients felt that they wanted a good safety profile and strong evidence base for treatment. This article seeks to review the evidence supporting non-hormonal approaches to treatment. There is only conflicting evidence at best to support alpha-2 agonists, e.g. clonidine and limited evidence for dihydroepiandrosterone and natural progesterones. There is limited randomized controlled trial data for gabapentin, selective norepinephrine re-uptake inhibitors (SNRIs) and selective serotonin re-uptake inhibitors (SSRIs), many of these studies being related to breast cancer patients. Of the herbal medicinal products, the largest evidence base rests with phytoestrogens. A Cochrane Database review looking at all types of phytoestrogens, e.g. red clover extracts, dietary soya and soya extracts concluded that there was no evidence to support improvement in climacteric symptoms and the meta-analysis of a 178 studies on soy products was inconsistent. Nevertheless, other studies disagree. Mammographic density is not affected by soy or phytoestrogen products and recent in vitro work shows only a weakly proliferative effect of soy isoflavone on breast cancer cells and evidence that soy isoflavone blocks the proliferative effect of estradiol on these cells. There are no studies looking at clinical outcome measures for cardiovascular disease but a number of studies looking at biochemical markers including arterial wall stiffness and apolipo protein B. Recent studies have also looked at the effects of red clover isoflavone on mood and depression, using specific depression rating scales. Finally, it is important to note that herbal medicinal products should not be used without caution. Some may produce quite marked side-effects in high doses and others can interact with pre-existing medication. A strategy for which patients are suitable for herbal medicinal products is reviewed.     

Aging, physical activity, and hormones in women--a review

Women experience significant changes in endocrine function during aging. Decreasing levels of anabolic hormones may be associated with musculoskeletal atrophy and decrease in function that is observed in older women and, as a result, there has been an increase in the use of pharmacological hormone therapies. It is difficult to distinguish, however, between physiological changes that are truly age related and those that are associated with lifestyle factors such as physical activity participation. Some research has shown that circulating levels of anabolic hormones such as DHEA(S) and IGF-I in older women are related to physical activity, muscle function, and aerobic power. Exercise-intervention studies have generally shown that increasing age blunts the acute hormonal response to exercise, although this might be explained by a lower exercise intensity in older women. There have been relatively few studies that examine hormonal adaptations to exercise training. Physical activity might have an effect on hormone action as a result of changes in protein carriers and receptors, and future research needs to clarify the effect of age and exercise on these other components of the endocrine system. The value and safety of hormone supplements must be examined, especially when used in combination with an exercise program.     

Depressed Mood and Sexual Functioning

Abstract

Although some studies have reported substantial correlations between clinical depression and hypoactive sexual desire, thus far only a few studies have addressed the association between depressed mood and different facets of sexuality (such as sexual satisfaction, sexual activity and level of sexual problems) in close relationships. This study sought to fill this gap by examining 198 couples recruited through advertisement. The associations between depressed mood measured by the Beck Depression Inventory (BDI) and sexuality within one person (actor effects) and between partners (partner effects) were analyzed using the Actor-Partner Interdependence Model by Kenny and Cook (1999). Our findings show that actor effects of the BDI score on sexual experiences are somewhat higher than partner effects, and that depressed mood is mainly associated with one's own hyposexual desire, sexual aversion and sexual arousal problems. However, there were no substantial partner effects between depressed mood and sexual arousal problems.     

Depression during menopausal transition: a review of treatment strategies and pathophysiological correlates

It has long been recognized that women are at a higher risk than men to develop depression and that such risk is particularly associated with reproductive cycle events. Recent long-term, prospective studies have demonstrated that the transition to menopause is associated with higher risk for new onset and recurrent depression. A number of biological and environmental factors are independent predictors for depression in this population, including the presence of hot flushes, sleep disturbance, history of severe premenstrual syndrome or postpartum blues, ethnicity, history of stressful life events, past history of depression, body mass index, socioeconomic status and the use of hormones and antidepressants. Accumulated evidence suggests that ovarian hormones modulate serotonin and noradrenaline neurotransmission, a process that may be associated with underlying pathophysiological processes involved in the emergence of depressive symptoms during periods of hormonal fluctuation in biologically predisposed subpopulations. Transdermal estradiol and serotonergic and noradrenergic antidepressants are efficacious in the treatment of depression and vasomotor symptoms in symptomatic, midlife women. The identification of individuals whom might be at a higher risk for depression during menopausal transition could guide preventive strategies for this population.     

Understanding the placebo effect. Part 2: underlying psychological & neurobiological processes

Placebo and nocebo effects are interesting and complex phenomena. In this article, I discuss some findings about the psychological and neurobiological processes that may underlie these effects on the basis of studies of pain, Parkinson's disease, and depression. From a psychological perspective, expectancy and conditioning theories have been used to explain placebo and nocebo effects. These psychological processes may be translated into physiological effects through overlapping brain circuits that are important for cognitive information processing, analgesia, and reward expectations. These brain circuits may represent a fundamentally important common underlying pathway that mediates placebo and nocebo effects in many conditions. Understanding these effects is important for designing clinical treatment studies and interpreting their results and is highly relevant for clinical practices.     

Neurosurgical approaches to therapeutic brain stimulation for treatment-resistant depression

During the 1940s and 1950s, psychosurgery was used for the treatment of severe mental disorders but was associated with significant complications. These problems and the advent of psychotropic drugs led to a decline in the use of psychosurgery. Neuroanatomical and brain imaging studies have revealed distinct brain regions and the pathways that connect them, which may underlie depression and other mental disorders. On the basis of this knowledge, modern stereotactic neurosurgical methods have been used to implant electrodes in the brain to provide therapeutic stimulation. Electrical stimulation by these electrodes with pacemaker-like devices can be used to modulate brain function by stimulating or inhibiting the activity of specific brain regions, without causing permanent or destructive lesions that cannot be reversed. Deep brain stimulation and cortical brain stimulation are two such neurosurgical approaches to therapeutic brain stimulation for treatment-resistant depression.     

Exploring the factors influencing relapse and recovery among drug and alcohol addicted women

1. Both women who were in treatment for relapse to and in sustained recovery from drugs and alcohol had multiple co-occurring addictions such as relationship, spending, food, and shopping that complicated the recovery process. 2. Depression is a major trigger for relapse in women with alcohol and drug problems. Recognition and treatment of depression is critical to achieve successful outcomes of treatment for these women, and teaching them to monitor their mood changes and seek help will improve the chances of preventing relapse. 3. Subjects in neither the relapse nor recovery sample recognized the significant influence of current violent partnerships or the ending of a violent relationship on their relapse or recovery.