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In Transition

On The Treatment of Mood Disorders - Part 2

by

Dr. Peter Melgaard Thompson

In the last column I talked about treatment of Major Depression. As a general rule of thumb, all antidepressants have the same level of effectiveness. What distinguishes them are their side effects and price. The older antidepressants such as amitriptyline, imipramine, desipramine, nortriptyline and tranylcypromine work just as well as newer ones but cost pennies a tablet. Newer antidepressants such as fluoxetine, paroxetine, sertraline, venlafaxine and nefazodone also work well but cost dollars a tablet. Because these newer medications cause significantly fewer and milder side effects, my feeling is that they are well worth the price. In the analysis of taking medication all of these factors must be weighed.

Initially, most insurance and HMO's did not cover the newer medications because of their high price. This situation is slowly changing. More and more health care providers are recognizing that the bottom line is not the cost of the medication but the total cost of an illness. So when they evaluate their cost effectiveness they are now taking into account whether the medication reduced doctors visits, hospital days and death. In the bigger picture additional issues are quality of life, work productivity and the down stream effects on a family. These issues have yet to be addressed on the individual company level. A better forum for this discussion should be on the national level. In that case society can make the decision to treat health care as a right or a privilege.

I have drifted some from the topic of mood disorders, though not as far as it may seem.

Another type of depression is Dysthymia. This syndrome can be considered a smoldering, chronic form of Major Depression. Typically in Dysthymia there are less symptoms than Major Depression but they last longer - usually years. So a person can feel blue a and have low self esteem, or they may feel blue and have low energy and have this syndrome. Historically, clinicians have attributed this syndrome to a maladaptive approach in dealing with life, usually seen in person with a personality disorder. I will leave the etiology of Dysthymia to another time when I have the energy to ferret though the science versus pseudoscience, religious and idiosyncratic arguments about the etiology of mental illness. For our purposes lets just call it idiopathic (unknown). All this is a long winded way of saying that Dysthymia responds very well to antidepressant treatment. There is some evidence that the newer classes of medications - especially the SSRI's (selective serotonin reuptake inhibitors) - are more effective than the older tricyclics. This observations is different than what is found in Major Depression.

Bipolar Illness is one of the oldest recognized mental Illnesses. It is characterized by periods of depressed mood, manic mood at other times (to be discusses in a later column) and then periods of normal mood. Here there is very good evidence that the newer medications are much safer than the tricyclic medications. What is different in the treatment of Bipolar Disorder compared to Major Depression is the doses and length of treatment. Because of the risk of switching a Bipolar Depressed patient into a mania, the treatment guideline is to use the lowest dose for the shortest time. Whereas you might be left on antidepressant medication for 1 to 5 years for Major Depression, in bipolar Disorder after the depression has lifted the medication should be tapered off.