Depressive disorders are among the commonly researched mental health illnesses. There are different types of depressive disorders which vary in terms of symptoms, persistence, at-risk population and treatment. They include; season affective disorders (SAD), major depression, premenstrual dysphoric disorder (PMDD), bipolar disorder, psychotic depression, persistent depressive disorder, atypical depression, peripartum depression, and atypical depression. Most mental illnesses such as post-traumatic stress disorders and schizophrenia are also characterized by mood changes and depressive symptoms. In general, these disorders result in severe sadness and subsequent interference with normal body functions as well as interests in previously enjoyable activities. Depressive disorders are among the adverse mental health issues affecting the well-being of people, especially in mental health-related cases. Consequently, the impact translates to the wellbeing of the relatives which ideally means that the disorder is a burden to both the family and the entire society. In that case, therefore, understanding the issues surrounding the psychopharmacology of the disorder as well as the mode of effective treatment or therapy would offer a salient insight on the overall well-being. The paper is based on the case of Janie, a 38-year-old female presenting with major depressive symptoms. This paper provides insight into the treatment and diagnostic criteria as well as relevant psychotropic agents that can be used to solve a selected case of depression. This includes an analysis of the selected agent in the treatment of the depressive disorder.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
Most of the depressive disorder diagnosis is still based on DSM-IV criteria. The diagnostic criteria for depressive disorders include a sudden loss of pleasure or interests in activities for a period of more than one week. In addition, the condition is characterized by depressed mood which represents an individual’s baseline. According to the set diagnostic criteria, individuals with depressive disorders often demonstrate impaired social, education and occupational functions. A major symptom of the depressive disorder includes depressed mood or irritability almost all the time. Also, depressed individuals have a significant change in weight or appetite. Other common symptoms include; guilt or worthlessness, suicidal tendencies, fatigue, poor concentration and changes in sleep and activity.
The proposed DSM-V diagnostic criteria is not yet fully adopted. It provides a range of anxiety symptoms that may be used as indicators of depressive disorders. They include; fear that something awful may happen, irrational worry, trouble relaxing, pre-occupation with unpleasant worries, and feeling tense. Also, the latest diagnostic criteria also include screening for behavioral conditions co-occurring with the depressive symptoms including bereavement, substance use, and possible medical illnesses. Some of the functional domains used to assess whether a depressive disorder is moderate or severe include the level of anxiety, self-harm, family relationship, suicidal ideation, school and academic performance and peer relations.
Psychotropic Agent for the Disorder
Generally, to suppress depressive disorder, there is a need to consider antidepressant agents that are salient in reducing further impacts of the disorder to the wellbeing. In this case, therefore, Tricyclic Antidepressants (TCAs) can be salient to the case selected. TCSs are agents that limit the impacts of depression by blocking Serotonin transporter (SERT) (Li, et al., 2016). The agent also works by limiting or blocking the norepinephrine transport (NET). According to Li and colleagues (2016), the most common and recommended forms of TCAs include the imipramine, clomipramine, and amitriptyline which are salient in suppressing major depression. However, TCAs have been linked to adverse side effects that may interfere with the wellbeing of the patient. Such effects include dry mouth, cardiac arrhythmia, cognitive impairments, sedation and blurred vision (Wing, 2000). Therefore, this may necessitate the use of a safer agent or its combination with other salient agents.
Antidepressant medication has evolved and advanced to accommodate issues such as safe dosage for the last 20 years (Health Quality Ontario, 2017). The health impacts that have been associated with the TCAs as a conventional antidepressant agent prompts the use of new groups of such as the selective serotonin reuptake inhibitors (SSRIs). These form of antidepressant agents have developed in the course of antidepressant medication advancement (Health Quality Ontario, 2017). SSRIs have been extensively used as antidepressant agents and are also popular since the side effects generated from their usage are mild benign (Velea, Gheorghe, Trutescu, " Purcarea, 2015). These agents have been noted to have an easier administration which gives it safer dosage to the patient.
The Selective Serotonin Re-Uptake Inhibitors (SSRIs)
This form of antidepressant drugs are referred to as the new generation antidepressant agents and have been widely approved for the treatment of the Major Depression Disorder (MDD) (Carvalho, Sharma, Brunoni, Vieta, " Fava, 2016). Although SSRIs have been appraised as the most advanced form of antidepressant agents, Carvalho and colleagues(2016), asserts that clinical evidence has not outlined the differences in efficacy of the TCAs and SSRIs in the treatment of MDD. SSRIs are often used in cases of extensive depression whereby they help to enhance the function of the nerve cells in the brain that plays the role of emotional regulation. Reuptake refers to the process of replacing the neurotransmitters. Thus, SSRIs work by blocking the reuptake process making serotonin available between neurons to correctly send messages.
Limitation of Treatment using the SSRIs
According to Velea and colleagues (2015), the advancement in the pharmacological industry has been essential in coming up with effective antidepressant agents that are relevant to various depressive cases. However, the workability of these agents exists with both faults and benefits to patients, whereby some people may respond significantly to the treatment while others remain noncompliant. This, therefore, indicates that the risk-benefit ratio of the treatment is a significant consideration in medical interventions while using these drugs (Velea, Gheorghe, Trutescu, " Purcarea, 2015). SSRIs have been associated with potential side effects such as nausea, sedation, and sexual side effects but are known to fade over time (Velea, Gheorghe, Trutescu, " Purcarea, 2015).
In toxicity of the body in the treatment of MDD, there has been a significant concern worth noting. For instance, some incidences of liver toxicity ranging from 0.5 to 1 percent have been seen among patients taking SSRIs (Carvalho, Sharma, Brunoni, Vieta, " Fava, 2016). Additionally, the impact or toxicity risks have been seen to elevate with an increased use or the exposure of the body to nefazodone, bupropion, and duloxetine.
Another issue regarding the function or the treatment of MDD using SSRIs is linked to weight gain among the patients. Studies indicate that long-term use of SSRIs especially in period above six months can potentially increase the risks of weight gain among the patients (Carvalho, Sharma, Brunoni, Vieta, " Fava, 2016). Regarding urinary dysfunctions, Carvalho e al. (2016) indicate that the combination of SSRIs and other agents such as Benzodiazepines and antipsychotics results to genitourinary issues. On another account, SSRIs can induce urinary retention through its activity on the central micturition pathways (Carvalho, Sharma, Brunoni, Vieta, " Fava, 2016).
Tricyclics (TCAs)
Tricyclics are among the oldest antidepressants and are rarely used currently following the introduction of newer and safer medication for depressive conditions. However, they are still prescribed because some patients still respond positively to them. They include sinequan, anafranil, tofranil, vivactil, surmontil among others. The chemical structure of the drugs has three rings; thus the name tricyclics. Apart from depression, tricyclics are used to treat anxiety, fibromyalgia, and chronic pain. Despite these therapeutic benefits, the drugs are associated with major side effects including rash, seizures, anxiety insomnia, nausea and vomiting, sexual dysfunction, arrhythmia, weight loss, urinary retention, constipation among others. The side effects vary from one patient to another. Tricyclics are rarely used as the first line of treatment mainly because some people find it difficult to tolerate the side effects. Sometimes the drugs are prescribed in an off-label use.
Antipsychotics
In some cases, depressive disorders are characterized by psychotic issues. In PTSD and schizophrenia, psychopathic behavior is common. Thus, antipsychotics are prescribed in such depressive conditions. Antipsychotics are categorized into typical and atypical antipsychotics. Examples of typical antipsychotics include Stelazine, Thorazine, Navane, Loxitame among others. On the other hand, atypicap antipsychotics include clozaril, abilify, rizperdal among others.
Monoamine Oxidase Inhibitors (MAOIs)
MAOIs are another group of antidepressants commonly prescribed for depressive symptoms. Examples include Selegiline, tranylcypromine, and phenelzine. In most cases, they are used as the first line of therapy before introducing the patient to both SSRIs and SNRIs. Unlike the other antidepressants, Monoamine Oxidase Inhibitors work by inhibiting the action of the monoamine oxidase, which is a brain enzyme. The role of the enzyme is to breakdown neurotransmitters including serotonin. Thus, MAOIs ensure that adequate serotonin is available for neurotransmission. Theoretically, the availability of large quantities of circulating serotonin reduces anxiety and depression by stabilizing the mood. MAOIs can also be prescribed in cases whereby the other depressants including SSRIs are not effective. The reason why these antidepressants are used as follow-up therapy is because of their ability to interact with foods and other medications. Nevertheless, MAOIs are also characterized by major side effects for some patients including anxiety, blurred vision, weight loss or gain, dizziness, headache, fainting, sexual dysfunction, edema, seizures, hypertension, diarrhea among others.
Noradrenaline and Specific Serotoninergic Antidepressants (NASSAs)
NASSAs are used to treat anxiety disorders including depression and personality disorders. Examples include Mirtazapine and Mianserin. Among the most common side effects of these drugs in treating depressive disorders include blurred vision, constipation, drowsiness, weight gain, and dry mouth. The drugs are also associated with more serious reactions such as fainting, seizures and a reduction in white blood cells.
Psychotropic agent Potential effectiveness to Depressive disorder
The effectiveness of the psychotropic agent used in or prescribed to patients with depressive disorder relies on how the agent would limit the recurring of the disorder. Ideally, the disorder is both chronic and episodic in nature which indicates that the remedy should be centered on the ability to limit the recurrence (Health Quality Ontario, 2017).
Psychotropic Agent Effects on Neurotransmission, Behaviours and Hormone System
Antidepressant agents work by altering the functions of the neurotransmitters in the body’s central nervous system. This may include serotonin, dopamine and the norepinephrine (Velea, Gheorghe, Trutescu, " Purcarea, 2015). SSRIs functions by inhibiting serotonin transporter, blocking the reuptake as well as increasing the concentration of neurotransmitter serotonin inside the synapse (Korczak, 2013). The overall system affected by these psychotropic agents is believed to have a significant impact in the modulation of various psychobiological functions such as mood, anxiety, consumption behaviors and sexual activities (Magellan Rx Management, 2016).
Limitations of Pharmacological Approach in Treating Depressive Disorder
Studies have shown that after prescription, pharmacological agents for treating depressive disorder usually result in side effects within the first two weeks. However, the side effects wear off with time. The effects can be mild and sometimes more adverse. Sometimes, the drugs lead to excessive mood elevation and behavior activation. While antidepressants are not known to cause bipolar disorder, they may result in mania and hypomania as a result of excessive mood elevation. Another limitation of pharmacotherapeutic agents in treating depressive disorders is the presence of suicidal thoughts. Although suicidal thoughts are also associated with depressive symptoms, the use of antidepressants leads to a higher risk of having suicidal thoughts. Consequently, such conditions may require another different treatment approach making pharmacotherapy an ineffective treatment modality on its own. The Food and Drug Administration (FDA) requires all pharmacotherapeutic agents to carry a black box with a warning of this side effect.
Pharmacotherapeutic treatment is also associated with withdrawal symptoms. While the number of other drugs can be raised in order to raise the effect, it is different with antidepressants because they are not addictive. In addition, most of them do not result in withdrawal symptoms when one stops using them. However, approximately a third of the users experience the withdrawal symptoms which last between 2 weeks and 2 months. The symptoms include abdominal pain, anxiety, nightmares, dizziness, and flu-like symptoms.
A Comparison of the Medical and Psychological Models Related to Depressive Disorder
Researchers often advocate for a combined intervention for depressive disorders which include both clinical and psychological intervention. In their study, Malla, Joober, and Garcia (2015) examined the validity of integrating mental illness in the medical illness category and how it impact on therapy. While mental illness was a phrase coined in order to enhance the members of the public to accept the condition, the treatment modality takes a medical perspective because it focuses on the neurobiology as the basis for the condition (Malla, Joober, " Garcia, 2015). Another issue that affects mental health treatment is the relationship between disorders and social values. Despite the scientific evidence determining the treatment modality, the values are critical because they focus on the patients' social environment. The values determine the treatment modality adopted in cases of depressive disorder as well as other mental health illnesses. Malla, Joober, and Garcia (2015) suggest that making the medical approach compulsory in patients with depressive disorders negatively affects both personal and societal values.
The medical models of depressive disorders mainly focus on the development and use of pharmacotherapeutic regimen targeting the brain and its functions in order to stabilize the mood. From the analysis, most of the drugs/antidepressants are developed based on the neurobiology and experience of the mental condition. The drugs focus on restoring the supply and flow of neurotransmitter substances such as serotonin to stabilize the patients’ mood. Another important is in neurobiological focus is the role of genes in terms of increasing the risk of mental health illnesses including depressive disorders (Malla, Joober, " Garcia, 2015). For instance, in post-traumatic stress disorder, only a small percentage of individuals exposed to a traumatic event develop the condition. Thus, it is important to examine the genetic factors that predispose them to the disorder.
On the other hand, the psychological models provide a holistic treatment modality that encompasses the clinical, social, and personal needs of the patient. Most of the psychotherapeutic modalities such as eye movement desensitization and reprocessing (EMDR) therapy, cognitive behavioral therapy and exposure therapy focus on the origin of the problem based on the patients’ history. In the psychological model, the psychotherapist explores the social and personal aspects of the disorder including its interaction with the medical modalities. Therefore, in addition to medical prescription, the therapist guides the patient into behavioral changes that are critical to the recovery of symptom reduction. The primary criteria used in the diagnosis is based on the paradigm established in the DSM manual that lists all the mental illnesses, their presenting symptoms, complications and differential diagnosis. However, the psychotherapists operate under the established biomedical models.
Current research suggests that both the medical and psychological models have not been fully effective independently. There are cases whereby patients end up being worse following either a medical or a psychological treatment model. This brings into focus the side effects of both treatment modalities and how they can be minimized to improve the patient outcomes. Integration of the two modalities is more effective because it is holistic in nature. In addition, it is easier to treat comorbid conditions presenting with the depressive symptoms by prescribing drugs as well as providing the patient with psychotherapeutic interventions.
There are cases whereby the psychological problems are a comorbid product of a pending medical problem. Comorbid conditions require an integration of the treatment modality to address both the medical and psychological needs of the patient. According to Breland, Mignogna, Kiefer, and Marsh (2016), there exists a bidirectional relationship between depression and chronic medical conditions. Thus, patients tend to benefit more from a care model that encompasses the treatment of the depressive symptoms in specialty medical settings (Breland, Mignogna, Kiefer, " Marsh, 2016). Nevertheless, there is no adequate research into this relationship including its effectiveness in improving the patients quality of life as well as symptom reduction (Breland, Mignogna, Kiefer, " Marsh, 2016). Thus, future research should examine the types of specialty medical settings that are more effective for the implementation of this model for depression treatment. Also, the research should examine whether the treatment models are effective in reducing depressive symptoms.
There are studies that are focusing on the interaction between the biomedical and psychotherapeutic models in the treatment of depressive disorders. According to Hussung (2015), the biomedical model purports that mental disorders including depressive disorders have a physical cause. In most cases, the genesis of the physical pain is in the brain. Thus, the therapeutic approach is centered on the role of the neurotransmitters, genetics, neuroanatomy, and neurophysiology in the development of the condition.
Both the physical structure and the mode of functioning in the brain play a vital role in the development of mental disorders (Hussung, 2015). This implies that the symptoms associated with depressive disorders including suicidal thoughts are just symptoms of the underlying physical condition. The concept of psychiatric medication also comes in as a result of the integration between the biomedical and psychotherapeutic models (Hussung, 2015). In this case, psychotherapists prescribe medication to patients similar to other medical doctors. The goal is to treat the medical abnormality leading to the development of the depressive symptoms (Hussung, 2015). This is crucial in the treatment of depressive symptoms because of the drugs aid in restoring the imbalances of brain chemistry which contributes to mood changes and other abnormal brain functions (Hussung, 2015). Thus, psychotherapists should behave the knowledge on the interaction between the drugs, the brain chemistry and overall outcome of behavior.
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