Posted by SLS on October 1, 2005, at 16:33:20
In reply to Re: well.... » med_empowered, posted by ed_uk on October 1, 2005, at 15:22:36
All good points.
Logically, I think it makes sense to choose some sort of cognitive therapy first for non-psychotic depression. If it has failed after the suggested time period, one should move on to an antidepressant while maintaining the cognitive therapy. I don't know if the next set of decisions are so simple to characterize. Was there any progress made in psychotherapy since it was introduced? Is the depression itself presenting with severe vegetative symptoms? Was there a significant deterioration in condition as the first antidepressant was removed? If severe psychomotor retardation is present, I would argue for the continued use of antidepressants while contemplating a change in the mode of psychotherapy. As a matter of fact, if severe vegetative symptoms are present, I would probably want to begin antidepressants and psychotherapy simultaneously.
ALWAYS: Tell the patient that any antidepressant has the potential to make them feel worse. If they do, they are instructed to tell their parents and call the doctor. Visits to the doctor should be weekly. Establishing effective communication between the doctor and patient is critical and should be cultivated. It is the best tool we have for illnesses for which there is still no convenient assay for mood state through a biological test.
I don't think that the strict adherence to any one treatment algorithm as simple as the one proposed is in the best interest of those suffering from depression. The risk of suicide is too high in this population.
I guess if I were a doctor, I would not be so afraid to prescribe antidepressants as a first line treatment for those pediatric and adolescent cases that I deem are critical and present with a symptom profile reflecting a biological diathesis. There is nothing that would prevent me from co-prescribing psychotherapy. If a persistent remission of the biological depression is achieved, the antidepressants could then be removed very gradually while psychotherapy is maintained.
I just think that the whole suicide thing can be minimized with education of the patient and close monitoring. Presentations that include severe anxiety, suicidality, or aggression might be well served to prescibe a benzodiazepine temporarily in early treatment. Gosh, there are so many things that have to be taken into consideration. What if the benzodiazepine produces disinhibition? It might lead to an impulsive act of suicide. Ok then, what about the temporary use of low dosages of a drug like Zyprexa? Probably a better choice clinically, but can using a neuroleptic be justified when psychosis is not present? I think so. Are there any irreversible effects that the short term use of such a drug has on the developing brain? Theoretically and microscopically, maybe. Realistically, I doubt it. Of course, I could be wrong.
Psychiatry is best left to psychiatrists I guess. Lots and lots of stuff to consider. I guess that's why I've been doing nothing more than rambling.
And what of the effects that any psychotropic drug has on a still developing brain that has not completed the maturation and pruning processes? For that matter, what about non-psychotropic medications that manage to pass the blood-brain barrier?
And what of bipolar disorder? Treat immediately with lithium or anticovulsants? Why not? What are the consequences of delaying pharmacological intervention in clearly bipolar or cyclothymic individuals? A decaying prognosis? Should depression resulting from a bipolar diathesis be treated differently than depression without one? How do you tell the difference? Is Prozac truly any less apt to exacerbate depression or promote a suicidal state than the other SSRIs? Ok then, what about tricyclics or MAOIs?
NOT ENOUGH DATA
NOT ENOUGH REPEATABLE STUDIES
Psychiatry is often looked down upon as being a "soft" science. If this is true, why is it so hard to practice effectively? It is no longer for lack of intelligent investigators or brilliant contributions. It remains difficult, however, for the as of yet unmanageable complexity of the human brain and all of the biological processes elsewhere in the body that it controls or interacts with. Even the rodent brain remains unmanageable.
Imagine that.
- Scott
poster:SLS
thread:560944
URL: http://www.dr-bob.org/babble/20050927/msgs/561670.html