Depression affects about 121 million people worldwide and is the fourth leading contributor to the global burden of disease. (1)(2)Major depressions are the most severe form of depression that affects the mind, body and mood. (41) It is usually associated with depressed mood and other related symptoms that meddle with one's everyday life, including work, social, family, or physical health.(39) The onset of the disease is triggered by environmental and psychological influence additionally to a pre-existing vulnerability-genetics. (3)(5)However, the exact causes of MDD are still unknown. Nowadays, even the most severe cases of depression are highly treatable. Therefore, what are the current available treatments to MDD symptoms?
After some considerable research, i found that antidepressants are the most widely prescribed and popular treatment for depression. These drugs are the most effective to alleviate depressive symptoms. They work to regulate and balance brain chemicals referred to as neurotransmitters in the brain.
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Each drug differs in how it affects the brain chemicals. So, individuals tend to respond differently to each drug. "Trial and error" switching is thus used to find the right antidepressant. NIMH-funded research suggests that chances of patients' remission increases after switching to or adding another medication to their previous one.(6)
Evidence has suggests that monoamine neurotransmitters serotonin (5-HT) and norepinephrine (NE) are involved in mediating depressive symptoms.(7) Antidepressants thus can be divided into two types, based on the neurotransmission affected.
Single-acting antidepressant, Selective Serotonin Reuptake Inhibitors (SSRIs), such as fluoxetine, citalopram and paroxetine supports a role for 5-HT in depression. These drugs have one main mechanism of action---inhibition of serotonin reuptake. These drugs work by increasing the levels of 5-HT which enhanced neurotransmission and elevate mood. Although the selectivity of these drugs improved its side effects profile, the onset of action is relatively slower resulting in lower remission rates and less effective against physical symptoms.
Mechanism of action of SSRI. (4)
Dual-acting antidepressant which affect both 5-HT and NE neurotransmission, includes several TCAs, Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) Venlafaxine and Duloxetine. These agents increase the levels of both 5-HT and NE by inhibiting their reuptake into cells in the brain. Dual-acting agents tend to convey an advantage over single-acting agents, in terms of antidepressant efficiency, treatment of physical symptoms, chronic and neuropathic pain and cost-effectiveness. (7) (8)Besides, they have high affinity (Ki) value thus having a more favourable safety and tolerability profile.
The normal processes of SNRI. (9)
The mechanism of action of SNRIs. (10)
Relative potency for different sites of action of non-SSRI antidepressants (11)
SNRIs having moderate efficiency in treating neuropathic pain and low side effects. (8)
Venlafaxine(SNRI) causes less side effects due to its high affinity(Ki) value. (12)
Comparison of remission rate of SNRI, SSRI and placebo. (14)
From the chart, it can be seen that SNRI is more effective than SSRI and placebo. But it does not mean that SNRI would be the best drug for every patient. In my opinion, the doctor should work closely with the patient to determine the most appropriate type of medication for the patient.(40) As mentioned before, therapeutic effects of antidepressants may vary in people, depending on each person's genetic makeup. Besides, there are other factors to be considered too, for example drug interaction.
"There isn't one medication that's clearly superior to others. Other medications taken can affect the choice of antidepressant chosen in order to avoid potential interactions." (15)
"Although antidepressants may not cure depression, they can help you achieve remission - the disappearance or nearly complete reduction of depression symptoms." (16)
But overall, medications have indeed been proven to be effective in treating symptoms of depression. Most of the times, medications do not work due to patients discontinuing their medicines once they start to feel better.
"Although antidepressants generally aren't as effective for mild depression, that doesn't mean that they never help. Depression affects each person differently, and each person responds to medications differently." (17)
Many people with mild depression claimed that antidepressants have little effect. However, for severe depression, antidepressants are very effective and make a big difference.
www.mayoclinic.com is a non-profit organization that aims to provide information about the diagnosis and treatment of almost every type of complex illness. I think this source is very trustable and in my opinion, the information provided is factual and valid as they are reviewed by more than 3,300 physicians, scientists and researchers from Mayo Clinic. Besides, this site comply with the HONcode standard for dependable health information with valid certificate that can be found on https://www.hon.ch/HONcode/Conduct.html?HONConduct636199
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An article by the British Association of Pharmacology (evidence-based guidelines) which was published by SAGE in the Journal of Psychopharmacology supports the effectiveness of antidepressants too. Dr Ian Anderson, Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK states that antidepressants should be considered and this support my view of using antidepressants as the best solution to treat MDD symptoms. This medical news can be found at http://www.medicalnewstoday.com/articles/107061.php
I think the news and information provided by this site is trustable and reliable as this site is copyrighted by MediLexicon International Ltd which is a leading Internet publisher of health and medical news and information. Besides, Medical News Today is a top ranked website for medical news. This site provides unprejudiced news from thousands of sources around the world. Moreover, the information is up-to-date as the article is dated 12 May 2008.
It can be clearly seen from the graph that antidepressants are indeed effective although the effectiveness decline with time. By switching to or adding another class of antidepressant, the effect of antidepressant and chances of patients remission will increase.
There are two types, direct and indirect costs of depression. Direct costs are costs associated with treating, taking care, preventing and diagnosing depressed patients, such as the cost of drugs, hospitalization and consultant fees. The drugs are not much a financial burden to depressed patients when compared to treatment or hospitalization. However, depressive patients need to take the drugs continuously for a long period of time that involved years. This continuous cost will then cause a huge financial burden and economic impact to the patients especially the poor families.
Direct costs from 7 studies. (19)
"In the United Kingdom, the direct costs of depression (estimated on the basis of 1991 costing) were calculated as £417 million, the indirect costs seven times greater (£2.97 billion)" (20)
The indirect costs are the outcomes where depressed individuals cannot maintain their usual economic role, including lost productivity of work. Usually, the indirect costs exceed that of direct costs.
I think that the awareness of depression among people in the society is low. Many with depression never seek treatment because they simply do not recognize the signs or symptoms of depression. (5)(21)(23)Their take-it-easy attitude and reluctance caused them to avoid medications. A finding found that only 31% out of 5400 major depressive patients are treated with a drug prescribed by a doctor. (19)
"Nearly half of all Americans diagnosed with major depression don't receive the treatment they need according to an NIMH-supported survey." (25)
Due to this reason, the illness may deteriorate thus making it harder to treat and for patient to achieve remission. When the illness gets too serious, sometimes medication may not work and patients need to resort to other treatment.
Depression is a debilitating illness that can seriously affect a person's quality of life. Therefore, I think that it is very important that authorities and social services put in the efforts to reduce the number of cases of depression by increasing awareness and encouraging people to take preventative measures, such as exercise and developing stress coping skills. Moreover, investment in this field should be increased.
"Currently, only £4m of the £4.5bn of NHS adult mental health investment is spent on promoting good mental health - less than 0.1 per cent. Greater investment in promotion would be advantageous for both the economy and society."
Andrew McCulloch, chief executive of the Mental Health Foundation (38)
Benefits and Risks
Antidepressants medications are effective in alleviating depressive symptoms. When the symptoms are removed, people can carry out their day-to-day function normally again. They will be able to socialise, work and enjoy their normal leisure activities. (35)So, medications can enhance the quality of life and increase overall happiness.
However, they would also induce side effects. The side effects caused by medication ranged from mild effects like dizziness to serious ones such as suicidal thoughts. Therefore, patients taking antidepressants should be closely monitored. Moreover, once a patient has start on antidepressant, it is hard to stop as many will suffer from withdrawal symptoms. Yet, withdrawal symptoms can be avoided when antidepressants are taper off slowly and under the supervision of a physician. (28)
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In my viewpoint, patients should be well informed about the risks of taking antidepressants and it is very important that they follow the doctor's advice and not stop or switch antidepressants on their own. Based on some findings, expert has concluded that the benefits of medications far outweigh that of the risks associated. (29)
Electroconvulsive Therapy (ECT)
Generally, this method involves passing weak electric current through a patient's brain, inducing central nervous system seizure. The patient has to be given anaesthesia and muscle relaxants, so that damage to the body muscle is not resulted. The mechanism is still unknown, but the seizure somehow alters the neurotransmitter level, alleviating depression. (30)(40)
Electroconvulsive therapy is performed 2 or 3 times a week for at least 6 months, as the chances of relapse are high without the continuation. However, distressing side effects, like confusion, memory impairment and cardiovascular complications might follow. The severity varies with every patient, but it is considered safe generally.
"ECT has been shown to have an extra effect in severe depression - it seems, in the short term, to be more helpful than medication." (34)
Up to 80% of success rate of treating all kinds of depression comes with this method. (31) It is especially useful when patients fail other treatments. In fact, electroconvulsive therapy is considered a better option for patients who are completely suicidal as other treatments might need some time to be effective.(32)(33)
Repetitive Transcranial Magnetic Stimulation (rTMS)
This therapy is relatively new and recently received Food and Drug Administration (FDA) approval for the treatment of depression. (26) (27) Some researchers has proven that rTMS is effective for some types of MDD under certain conditions. It is effective for treatment-resistant patients.
This therapy is done by placing an electromagnetic coil on the scalp near the forehead of patient. The coil is then switched on and off repeatedly to produce stimulating pulses. The electric currents then stimulate the nerve cells that control mood. (24)
By doing this, depressive symptoms can be alleviated but the exact mechanism is still currently unclear. It may take a few weeks for symptoms relief to take place.
This therapy is safe and causes no pain when the electric current is passed through the scalp. It requires no anaesthesia or sedation and caused fewer side effects which result in low rate of discontinuation. However, the risk of seizure is comparatively high in rTMS compared to other therapy. (22)