General Treatment Principles

With the growth in knowledge and the availability of newer drugs has come an increase in the number of factors that should be taken into account in appropriately selecting antidepressant medications. This section will provide an overview of the decision-making process involved in using available medications for depression, including known benefits, potential side effects, and proper usage.

It is important to note the limitations in our current concepts of antidepressant, mood stabilizer, and antimanic. Antidepressant implies selectivity and specificity for depression. This is inaccurate. Antidepressant drugs are effective in the acute treatment of milder mood disorders such as dysthymia as well as other mental disorders such as generalized anxiety, panic disorder, social phobia, obsessive-compulsive disorder (OCD), bulimia and anorexia nervosa, and posttraumatic stress disorder (PTSD). Similarly, antimanic and mood stabilizer drugs can be used to enhance antidepressant effects as well as being useful in agitation.

Antidepressant, antimanic and mood stabilizer drugs affect the core brain systems involved in modulating stress. Not surprisingly, the conditions in which antidepres-sant drugs are indicated are exacerbated by stress, suggesting that antidepressants may simply restore function by reversing the adverse effects of stress or buffering the brain from stressful life events. Antidepressants do not "cure" depression or any other condition (Hyman & Nestler, 1996; Duman et al., 1997, 1999; Stahl, 1998). This is most evident through the high rates of recurrence on discontinuation of successful treatment, even after long periods of medication-induced remission (Keller, 2001).

The limitations of concepts such as 'antidepressant', 'antimanic', and 'mood stabilizer' argue for us to think about these drugs in a different way than we have in the past. Previously, we conceptualized the treatment of mental disorders as being analogous to insulin treatment of diabetes. However, this implies that antidepressants are providing some missing natural substance that leads to a cure. We know that this is not the case. It may be more accurate to use a different model. For example, the model of corticosteroids and inflammatory illnesses may be closer to what is actually happening. Corticosteroids do not restore a missing substance when they help someone with arthritis or someone else with a rash. Corticosteroids can reduce inflammation, no matter what the cause is. Corticosteroids work whether inflammation is caused by cancer, a genetic disease, or simply overuse. Corticosteroids also do not cure any disease or condition; they just slow down or reduce one of the consequences of disease (inflammation). Therefore, antidepressant drugs may be much more than antidepres-sant, they may be antistress and seem to have beneficial effects in many different mental conditions associated with stress (Duman et al., 1999; Delgado et al., 1997).

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