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The Recognition and Management of Depression
The Recognition and Management of Depression WILFRED DORFMAN, M.D.
With at least 20,000 successful suicides reported each year in the United States, the failure to recognize an acute depression may prove to be as disastrolls as the failure to diagnose an impending coronary occlusion, a penetrating peptic ulcer, or an early diabetic ketosis. It should be noted that many die from more acceptable causes such as traffic accidents, ruptured esophageal varices or the cardiovascular sequelae of overwork, all of which may be related to less overt self-destructive tendencies. There are many types of depression; the differential may make for better management. In some cases, however, target symptoms may be of even greater importance since many patients defy differential diagnosis and refuse to be placed into tight diagnostic categories. Neurotic depression and depressive reactions are now classified in the same category,l indicating that depression is a mood to which the human animal is universally vulnerable. The differences in patients lie in the intensity, adequacy and duration of both the stimulus and the response; in the fact that what is relatively innocuous for one is highly provocative for another. In many, the precipitating cause is a loss-of a mate, a leg, a uterus; it may be a financial loss, or a loss by fire or theft. It may also be a loss which is not concrete and not easily identified, such as a loss in self-esteem. Here the provocative event is indeed difficult to define due to the human need for denial. Manic-depressive illness is a cyclic affair. The premorbid personality is cyclothymic, with its characteristic shifts in affect. As the aging process proceeds, depressions may become more prolonged; there is early awakening, loss of appetite and loss of weight, diumal variations, and a potential for suicide. Milder cases are not necessarily psychotic, and are labeled as cyclothymic personalities. Some therapists feel that psychotherapy with the production of adequate insight and rapport can definitely influence the process. Others are just as equally convinced that manic-depressive illness is metabolic or diencephalic in origin,2 yet can nevertheless be influenced by psychotherapy, provided the goals are reasonable. Involutional Melancholia is a psychosis, in Dr. Dorfman is currently Consultant in Medicine and Psychiatry at Brunswick Hospital Center, Amityville,
LJ., N.Y. 416
which the triad of symptoms include severe depression, agitation and somatic complaints. Since it occurs at the involutional period of life (45-55 in the female; ten years later in the male), the somatic complaints certainly require adequate medical evaluation. Emotional illness provides no immunity to organic disease, and vice-versa; in fact they may be co-existent. Senile depression may be related both to the organic changes concomitant with cerebral arteriosclerosis as well as to psychological considerations. The normal frustrations that accompany the realization that life-long plans and ambitions cannot be accomplished; the devastating results of forced retirement in those who are emotionally unprepared for it make the differential between somatic and psychic etiological factors difficult and at times impossible. Schizoaffective disorders combine the features of schizophrenia with those of depression. Diagnosis here may also be difficult and delayed unless the schizophrenic thought disorder is readily evident. It should be noted that some, in their initial hospitalization may be classified as manic-depressive. Subsequent attacks may clarify the schizophrenic picture. In others, apathy is difficult to differentiate from depression. This often provides difficulties in the interpretation of statistically significant drug studies where one must be constantly aware of the population being studied and the setting in which it is done. Depressive equivalents include somatic symptoms, with or without somatic disease, which frequently mask a depression.a, 4 The clue here may lie in the failure of both specific as well as nonspecific remedies, which usually help others, to alleviate the somatic difficulties. It should alert the physician to the possibility of a masked or hidden depression, despite the fact that the patient may deny it most vehemently. Alcoholism and drug addiction may similarly mask a depression; the same may be true for acting out behavior both in adolescence as well as in older age groups. Depression in Organic Illness Depression may precede roentgenographic or other evidence of carcinoma of the pancreas or lung; it is on occasion found as a symptom of brain tunlor, cerebral arteriosclerosis or General Paresis. In Lupus Erythematosus, depression has been related to organic brain changes produced by collagen deposits surrounding the smaller cereVolume XI
RECOGNITION OF DEPRESSION
bral blood vessels. It can be equally related to the patient's easily acquired knowledge of this severe illness. In rheumatoid arthritis, obesity, duodenal ulcer, ulcerative colitis, and some dennatologkal diseases, depression may at times alternate with the somatic illness. Rapid cures of the somatic illness or problem may thus disturb psychic homeostatic mechanisms sufficiently to precipitate a psychosis. Pregnancy and various endocrine states are often associated with a depression. Addison's Disease and Cushing's Syndrome, at opposite poles endocrinologically, are both capable of producing a depression. The same is true for hypopituitarism and Acromegaly, as well as hypo and hyperparathyroidism. HypothyrOidism can both mimic and produce a depression. In somatopsychic depression, the diagnosis of a somatic disease can be the trigger that sets off the depressive reaction. Coronary disease and malignancy both carry tangible and realistic threats to one's existence and can readily account for this reaction. Trauma, thrombophlebitis and viral disease, especially if accompanied by long periods of inactivity may be threatening to a patient with a strong need for activity. Depression can follow a surgical procedure if the patient is insufficiently prepared emotionally. Some operative procedures carry a higher risk due to their special significance, in that special organs or areas of the body are involved. A hysterectomy, simple mastectomy, herniotomy or genito-urinary surgery fall into this category. The loss of a uterus in a female past the child bearing age can carry with it the feeling of loss of femininity, despite the fact that her ovaries are left intact and that her uterus is no longer needed for storage purposes. A robust male can tolerate a gastrectomy without any emotional sequelae; however, tapping a hydrocele can produce severe sequelae despite the reassurance that he will not be castrated. Elective plastic surgery, in which expectations far exceed reality can produce difficulties. Cardiac surgery, if it removes the secondary gains of illness too rapidly or makes the patient dependent upon mechanical gadgets may likewise produce repercussions in those who are insufficiently prepared. Depression can follow the use of drugs such as reserpine, ACTH or Cortisone. In the case of reserpine, it has been related both to the biochemical effects of a lowering of the neurohormones, serotonin and norepinephrine as well as to the psychological effects of tranquilization in a personality where this is threatening. ACTH and September-October, 1970
Cortisone can produce difficulties due to a lowering of potassium. There are also psychodynamic effects where once again sudden and dramatic cure can conflict quite radically with the secondary (albeit unconscious) gains of illness. Clinically it accounts for the disturbing emotional upheavals seen after successful steroid treatment of rheumatoid arthritis, where crippling disease had become a way of life. A clinical evaluation of depression should probe its depth, length, differential diagnosis and target symptoms. A family or personal history of depression, and its method of management may be helpful. However, it must also be recognized that a successfully treated neurotic reaction in the past, where psychotherapy alone was utilized, may be inadequate for a more severe depression in the fifties or sixties where an endogenous element is suspected. In some instances it is helpful to know who the previous therapist was, since a strictly unilateral orientation too often dictates the treatment despite the patient's needs. Biochemical and Neurophysiological Factors in Depression New avenues of interpretation and treatment were opened when Hess divided the diencephalon into the ergotropic and trophotropic systems. The ergotropic was concerned with sympathetiC activity, gearing the body for fight or flight and emergency action, while the trophotropic influenced the parasympathetic, and its role in nutrition and repair. The discovery of large quantities of serotonin and norepinephrine in the hypothalamus focused attention on these neurohonnones. In general, the posterior hypothalamus, concerned with sympathetic action, is recognized as the site for the fonnation of norepinephrine. Serotonin is probably better related to the anterior hypothalamus. Both of these neurohonnones are lowered in states of depression and increased as the depression lifts with the aid of amine oxidase inhibitors. The tricyclic drugs, imipramine and amitriptyline, and their derivatives, do not actually increase these honnones; there is evidence, however, that they act on adrenergic synapses and make whatever norepineprhine is available more so. Changes in urinary 17-hydroxycorticosteroids have also been correlated with depreSSive states. 5 The levels were significantly elevated, especially in patients who made serious suicidal attempts or subsequently committed suicide. The elevations were especially marked in the ten day period 417
PSYCHOSOMATICS
prior to the suicidal attempt. The future significance of this elevation remains to be determined. Hopefully, the correlation of sOciological, biochemical and psychodynamic data may increase the physician's ability to predict suicide potential. Psychodynamic Factors in Depression The underlying factor in depression is a loss. It may be a concrete loss or a symbolic one. A loss in self esteem is most significant; it is this that differentiates depression from mourning. In some instances, it is not loss which triggers the depressive reaction, but success. Here the fear of massive envy and the potential loss of the love and approval of others may be the precipitating factor. As a result, persons with this tendency frequently modestly '\mdersell" themselves. Success may revive conflicts relating to early sibling rivalry and it can also symbolize final victory and defeat of the father. The latter may be revered, yet despised and hated (unconsciously). The resultant feelings of guilt lead to the need for atonement and expiation to regain the lost love object. Anniversary reactions to a parent's death may thus mobilize guilt, depression and selfdestructive feelings. Introjection and identification imply that the needed love object is incorporated. This is clinically evident as dependent needs. Ambivalence to these needs and its rejection create denial. Since hostility cannot be expressed overtly for fear of loss of love or approval, it is repressed and turned against onself. This is depression. Narcissistic needs may be so great that relatively minor disappointments can produce major readions. Self esteem is thus easily disturbed since it is almost entirely dependent upon outside sources. Despite the fact that these psychological factors help the physician to understand what is going on, it is still impossible to forecast who will become depressed, when it might occur, and how long it will last. One of the basic problems is the patient's feeling of having failed. This is often quite illogical and completely contrary to the actual trust and is best related to high, unattainable standards. Trp-atment of Depression Psychotherapy has different meanings for different observers. This is related to basic differences in orientation, training, philosophy of treatment and goals. In the management of acute states, supportive and reparative techniques are preferable to attempts to reconstruct the personality. Reparative psychotherapy should strive for 418
the alleviation of acute distress through ventilation, reassurance, encouragement and emotional support. Reconstructive techniques should be left to the trained psychiatrist or psychoanalyst and are of definitive value in the less acute and chronic depressive neuroses. Electroconvulsive therapy is the treatment of choice in severe depressions, especially when there is a risk of suicide. Drug therapy has many pitfalls as well as tangible potentialities. The pitfalls lie in the desire of both patient and doctor to seek for a magical solution to problems and conflicts which must be realistically faced (if solution is impossible, this too must be accepted); in the choice of drug; in the fact that the attitude of both the patient as well as the doctor to drug therapy definitively influence the results, despite the proven biochemical implications of drug therapy. The potentialities lie in the increased accessibility of many patients to combined drug and psychotherapeutic intervention; in the fact that problems which seem hopelessly insoluble may seem less so when one's mood is a bit brighter; in that drugs may either avert the need for ECT or at least curtail the number of treatments; in the increasing evidence that the efficacy of anti-depressant'> indicate the presence of a biochemical or metabolic root to depressive illness. As for the currently available drugs, it is interesting to note that some depressions respond to pharmaceuticals that are baSically anxiolytic agents. Diazepam (Valium) and tybamate (Solacen, Tybatran) are in this category. The response is best in depressive neuroses and depressive reactions where there is an admixture of anxiety and depression. These drugs may also be of value in deeper depreSSions where their addition to the basic antidepressant, imipramine (Tofranil) or amitriptyline (Elavil), or their derivatives, often enhance their action. Neuroleptics are usually contraindicated in depression. Nevertheless, thioridazine (Mellaril) can be at least the equal of imipramine in patients with both anxiety and depression. 7 The psychomotor stimulants, inclusive of amphetamine derivatives and methyl phenidate (Ritalin) are often of value in depreSSive neuroses. Their usage should be carefully monitored and they should be prescribed for only short periods of time due to the quite definite dangers of addiction. The amine oxidase inhibitors, isocarboxazid (Marplan), phenelzine (Nardil) and tranylcyproVolume XI
RECOGNITION OF DEPRESSION
mine (parnate) have as their target the patient with an "atypical" depression, one where there is no early awakening, weight loss or diurnal variations, with worsening in the morning and alleviation at night. However, the necessary dietary restrictions and the possibility of paradoxical hypertensive reactions restrict their use. In addition, definite dangers do exist in changing from an MAO drug to a tricyclic without a 7-10 day interval. As for the tricyclics, imipramine (Tofranil) seems to work best in endogenous retarded depressions. Since anxiety frequently emerges as the depression lifts, it is advisable to use an anxiolytic drug such as diazepam (Valium) or oxazepam (Serax) concomitantly. The desmethy derivative (Pertofrane, Norpramin) in some instances may work a bit more quickly. Amitriptyline (Elavil) is best for depressions in which there is a moderate degree of anxiety, since it has a built in tranquilizer. It is almost a specific for Involutional Melancholia. In many instances it may avoid ECT or at least limit its amount. This is especially so with the use of the drug parenterally, ", II where is it is used around the c10ek in the five day period often required in the hospital preliminary workup for ECT. Protriptyline (Vivactil) is of value in retarded depressions, whether neurotic or otherwise. Here it is usually wise to utilize small doses and to prescribe an anxiolytic agent concurrently to prevent the emergence of anxiety by this potent, rapidly acting antidepressant. Doxepin (Sinequan), a new tricyclic, similarly combines a tranquilizing action with anti-depressant properties in a single molecule. It is indicated in those depressions where anxiety is also evident. Some reports seem to indicate it may have a target in the hard to treat neurotic depressions.
September·October, 1970
As for the combination of drugs, the use of benactyzine and meprobamate (Deprol) is often of value in depressive neuroses of varying severity. The combination of perphenazine (Trilafon) with amitriptyline (Elavil) in varying dosage as Triavil or Etrafon, often produces a greater reduction of agitation than amitriptyline alone. It is probable that future research will create newer and more efficacious antidepressants and evenhmlly make it possible for the physician to pick and predict which drug is best for each particular patient. If advances in our knowledge of neurophysiology and biochemistry can be correlated with psychodynamic understanding of the individual patient, this goal is indeed reasonable. BIBLIOGRAPHY 1. Diagnostic and Statistical Manual of Mental Dis· orders, Second Edition (OSM·n), published by the American Psychiatric Association, Washington, D.C.,
1968. 2. Kraines, S.: Mental Depressions and Their Treat· ment, New York: The Macmillan Company, 1957. 3. Dorfman, W.: Masked Depression, Bibl. Psychiat. Neurol. (Basel), 118:50, 1963. 4. Dorfman, W.; Current Concepts of Depression. Psy. chosomatics, Vol. 4 No.5 and 6, 1963; Vol. 5 No. I, 1964. 5. Bunney, W. E., Jr., Fawcett, J. A., Davis, J. M., and Gifford, S.: Further Evaluation of Urinary 17·Hydro· xycorticosteroids in Suicidal Patients, Arch. Gen. Psychiat. 21 :138·150, 1969. 6. Dorfman, W.: Recognition and Management of De· pression, I. Med. Soc. of N. I., 66:107·119, 1969. 7. Overall, J. E., Hollister, L. E., Meyer, F., Kimbell, I., Jr., and Shelton, 1.: Imipramine and thioridazine in depressed and schizophrenic patients. I.A.M.A. 189:605, 1964.. 8. Dorfman, W.: A New Parenteral Antidepressant (Elavil). Dis. Neru. Syst. 22:145, 1961. 9. Dorfman, W.: Preliminary Report: Can Parenteral OM) Amitriptyline (Elavil) Avoid ECT? Psychoso· matics, 8:131·132, 1967.
419
With at least 20,000 successful suicides reported each year in the United States, the failure to recognize an acute depression may prove to be as disastrolls as the failure to diagnose an impending coronary occlusion, a penetrating peptic ulcer, or an early diabetic ketosis. It should be noted that many die from more acceptable causes such as traffic accidents, ruptured esophageal varices or the cardiovascular sequelae of overwork, all of which may be related to less overt self-destructive tendencies. There are many types of depression; the differential may make for better management. In some cases, however, target symptoms may be of even greater importance since many patients defy differential diagnosis and refuse to be placed into tight diagnostic categories. Neurotic depression and depressive reactions are now classified in the same category,l indicating that depression is a mood to which the human animal is universally vulnerable. The differences in patients lie in the intensity, adequacy and duration of both the stimulus and the response; in the fact that what is relatively innocuous for one is highly provocative for another. In many, the precipitating cause is a loss-of a mate, a leg, a uterus; it may be a financial loss, or a loss by fire or theft. It may also be a loss which is not concrete and not easily identified, such as a loss in self-esteem. Here the provocative event is indeed difficult to define due to the human need for denial. Manic-depressive illness is a cyclic affair. The premorbid personality is cyclothymic, with its characteristic shifts in affect. As the aging process proceeds, depressions may become more prolonged; there is early awakening, loss of appetite and loss of weight, diumal variations, and a potential for suicide. Milder cases are not necessarily psychotic, and are labeled as cyclothymic personalities. Some therapists feel that psychotherapy with the production of adequate insight and rapport can definitely influence the process. Others are just as equally convinced that manic-depressive illness is metabolic or diencephalic in origin,2 yet can nevertheless be influenced by psychotherapy, provided the goals are reasonable. Involutional Melancholia is a psychosis, in Dr. Dorfman is currently Consultant in Medicine and Psychiatry at Brunswick Hospital Center, Amityville,
LJ., N.Y. 416
which the triad of symptoms include severe depression, agitation and somatic complaints. Since it occurs at the involutional period of life (45-55 in the female; ten years later in the male), the somatic complaints certainly require adequate medical evaluation. Emotional illness provides no immunity to organic disease, and vice-versa; in fact they may be co-existent. Senile depression may be related both to the organic changes concomitant with cerebral arteriosclerosis as well as to psychological considerations. The normal frustrations that accompany the realization that life-long plans and ambitions cannot be accomplished; the devastating results of forced retirement in those who are emotionally unprepared for it make the differential between somatic and psychic etiological factors difficult and at times impossible. Schizoaffective disorders combine the features of schizophrenia with those of depression. Diagnosis here may also be difficult and delayed unless the schizophrenic thought disorder is readily evident. It should be noted that some, in their initial hospitalization may be classified as manic-depressive. Subsequent attacks may clarify the schizophrenic picture. In others, apathy is difficult to differentiate from depression. This often provides difficulties in the interpretation of statistically significant drug studies where one must be constantly aware of the population being studied and the setting in which it is done. Depressive equivalents include somatic symptoms, with or without somatic disease, which frequently mask a depression.a, 4 The clue here may lie in the failure of both specific as well as nonspecific remedies, which usually help others, to alleviate the somatic difficulties. It should alert the physician to the possibility of a masked or hidden depression, despite the fact that the patient may deny it most vehemently. Alcoholism and drug addiction may similarly mask a depression; the same may be true for acting out behavior both in adolescence as well as in older age groups. Depression in Organic Illness Depression may precede roentgenographic or other evidence of carcinoma of the pancreas or lung; it is on occasion found as a symptom of brain tunlor, cerebral arteriosclerosis or General Paresis. In Lupus Erythematosus, depression has been related to organic brain changes produced by collagen deposits surrounding the smaller cereVolume XI
RECOGNITION OF DEPRESSION
bral blood vessels. It can be equally related to the patient's easily acquired knowledge of this severe illness. In rheumatoid arthritis, obesity, duodenal ulcer, ulcerative colitis, and some dennatologkal diseases, depression may at times alternate with the somatic illness. Rapid cures of the somatic illness or problem may thus disturb psychic homeostatic mechanisms sufficiently to precipitate a psychosis. Pregnancy and various endocrine states are often associated with a depression. Addison's Disease and Cushing's Syndrome, at opposite poles endocrinologically, are both capable of producing a depression. The same is true for hypopituitarism and Acromegaly, as well as hypo and hyperparathyroidism. HypothyrOidism can both mimic and produce a depression. In somatopsychic depression, the diagnosis of a somatic disease can be the trigger that sets off the depressive reaction. Coronary disease and malignancy both carry tangible and realistic threats to one's existence and can readily account for this reaction. Trauma, thrombophlebitis and viral disease, especially if accompanied by long periods of inactivity may be threatening to a patient with a strong need for activity. Depression can follow a surgical procedure if the patient is insufficiently prepared emotionally. Some operative procedures carry a higher risk due to their special significance, in that special organs or areas of the body are involved. A hysterectomy, simple mastectomy, herniotomy or genito-urinary surgery fall into this category. The loss of a uterus in a female past the child bearing age can carry with it the feeling of loss of femininity, despite the fact that her ovaries are left intact and that her uterus is no longer needed for storage purposes. A robust male can tolerate a gastrectomy without any emotional sequelae; however, tapping a hydrocele can produce severe sequelae despite the reassurance that he will not be castrated. Elective plastic surgery, in which expectations far exceed reality can produce difficulties. Cardiac surgery, if it removes the secondary gains of illness too rapidly or makes the patient dependent upon mechanical gadgets may likewise produce repercussions in those who are insufficiently prepared. Depression can follow the use of drugs such as reserpine, ACTH or Cortisone. In the case of reserpine, it has been related both to the biochemical effects of a lowering of the neurohormones, serotonin and norepinephrine as well as to the psychological effects of tranquilization in a personality where this is threatening. ACTH and September-October, 1970
Cortisone can produce difficulties due to a lowering of potassium. There are also psychodynamic effects where once again sudden and dramatic cure can conflict quite radically with the secondary (albeit unconscious) gains of illness. Clinically it accounts for the disturbing emotional upheavals seen after successful steroid treatment of rheumatoid arthritis, where crippling disease had become a way of life. A clinical evaluation of depression should probe its depth, length, differential diagnosis and target symptoms. A family or personal history of depression, and its method of management may be helpful. However, it must also be recognized that a successfully treated neurotic reaction in the past, where psychotherapy alone was utilized, may be inadequate for a more severe depression in the fifties or sixties where an endogenous element is suspected. In some instances it is helpful to know who the previous therapist was, since a strictly unilateral orientation too often dictates the treatment despite the patient's needs. Biochemical and Neurophysiological Factors in Depression New avenues of interpretation and treatment were opened when Hess divided the diencephalon into the ergotropic and trophotropic systems. The ergotropic was concerned with sympathetiC activity, gearing the body for fight or flight and emergency action, while the trophotropic influenced the parasympathetic, and its role in nutrition and repair. The discovery of large quantities of serotonin and norepinephrine in the hypothalamus focused attention on these neurohonnones. In general, the posterior hypothalamus, concerned with sympathetic action, is recognized as the site for the fonnation of norepinephrine. Serotonin is probably better related to the anterior hypothalamus. Both of these neurohonnones are lowered in states of depression and increased as the depression lifts with the aid of amine oxidase inhibitors. The tricyclic drugs, imipramine and amitriptyline, and their derivatives, do not actually increase these honnones; there is evidence, however, that they act on adrenergic synapses and make whatever norepineprhine is available more so. Changes in urinary 17-hydroxycorticosteroids have also been correlated with depreSSive states. 5 The levels were significantly elevated, especially in patients who made serious suicidal attempts or subsequently committed suicide. The elevations were especially marked in the ten day period 417
PSYCHOSOMATICS
prior to the suicidal attempt. The future significance of this elevation remains to be determined. Hopefully, the correlation of sOciological, biochemical and psychodynamic data may increase the physician's ability to predict suicide potential. Psychodynamic Factors in Depression The underlying factor in depression is a loss. It may be a concrete loss or a symbolic one. A loss in self esteem is most significant; it is this that differentiates depression from mourning. In some instances, it is not loss which triggers the depressive reaction, but success. Here the fear of massive envy and the potential loss of the love and approval of others may be the precipitating factor. As a result, persons with this tendency frequently modestly '\mdersell" themselves. Success may revive conflicts relating to early sibling rivalry and it can also symbolize final victory and defeat of the father. The latter may be revered, yet despised and hated (unconsciously). The resultant feelings of guilt lead to the need for atonement and expiation to regain the lost love object. Anniversary reactions to a parent's death may thus mobilize guilt, depression and selfdestructive feelings. Introjection and identification imply that the needed love object is incorporated. This is clinically evident as dependent needs. Ambivalence to these needs and its rejection create denial. Since hostility cannot be expressed overtly for fear of loss of love or approval, it is repressed and turned against onself. This is depression. Narcissistic needs may be so great that relatively minor disappointments can produce major readions. Self esteem is thus easily disturbed since it is almost entirely dependent upon outside sources. Despite the fact that these psychological factors help the physician to understand what is going on, it is still impossible to forecast who will become depressed, when it might occur, and how long it will last. One of the basic problems is the patient's feeling of having failed. This is often quite illogical and completely contrary to the actual trust and is best related to high, unattainable standards. Trp-atment of Depression Psychotherapy has different meanings for different observers. This is related to basic differences in orientation, training, philosophy of treatment and goals. In the management of acute states, supportive and reparative techniques are preferable to attempts to reconstruct the personality. Reparative psychotherapy should strive for 418
the alleviation of acute distress through ventilation, reassurance, encouragement and emotional support. Reconstructive techniques should be left to the trained psychiatrist or psychoanalyst and are of definitive value in the less acute and chronic depressive neuroses. Electroconvulsive therapy is the treatment of choice in severe depressions, especially when there is a risk of suicide. Drug therapy has many pitfalls as well as tangible potentialities. The pitfalls lie in the desire of both patient and doctor to seek for a magical solution to problems and conflicts which must be realistically faced (if solution is impossible, this too must be accepted); in the choice of drug; in the fact that the attitude of both the patient as well as the doctor to drug therapy definitively influence the results, despite the proven biochemical implications of drug therapy. The potentialities lie in the increased accessibility of many patients to combined drug and psychotherapeutic intervention; in the fact that problems which seem hopelessly insoluble may seem less so when one's mood is a bit brighter; in that drugs may either avert the need for ECT or at least curtail the number of treatments; in the increasing evidence that the efficacy of anti-depressant'> indicate the presence of a biochemical or metabolic root to depressive illness. As for the currently available drugs, it is interesting to note that some depressions respond to pharmaceuticals that are baSically anxiolytic agents. Diazepam (Valium) and tybamate (Solacen, Tybatran) are in this category. The response is best in depressive neuroses and depressive reactions where there is an admixture of anxiety and depression. These drugs may also be of value in deeper depreSSions where their addition to the basic antidepressant, imipramine (Tofranil) or amitriptyline (Elavil), or their derivatives, often enhance their action. Neuroleptics are usually contraindicated in depression. Nevertheless, thioridazine (Mellaril) can be at least the equal of imipramine in patients with both anxiety and depression. 7 The psychomotor stimulants, inclusive of amphetamine derivatives and methyl phenidate (Ritalin) are often of value in depreSSive neuroses. Their usage should be carefully monitored and they should be prescribed for only short periods of time due to the quite definite dangers of addiction. The amine oxidase inhibitors, isocarboxazid (Marplan), phenelzine (Nardil) and tranylcyproVolume XI
RECOGNITION OF DEPRESSION
mine (parnate) have as their target the patient with an "atypical" depression, one where there is no early awakening, weight loss or diurnal variations, with worsening in the morning and alleviation at night. However, the necessary dietary restrictions and the possibility of paradoxical hypertensive reactions restrict their use. In addition, definite dangers do exist in changing from an MAO drug to a tricyclic without a 7-10 day interval. As for the tricyclics, imipramine (Tofranil) seems to work best in endogenous retarded depressions. Since anxiety frequently emerges as the depression lifts, it is advisable to use an anxiolytic drug such as diazepam (Valium) or oxazepam (Serax) concomitantly. The desmethy derivative (Pertofrane, Norpramin) in some instances may work a bit more quickly. Amitriptyline (Elavil) is best for depressions in which there is a moderate degree of anxiety, since it has a built in tranquilizer. It is almost a specific for Involutional Melancholia. In many instances it may avoid ECT or at least limit its amount. This is especially so with the use of the drug parenterally, ", II where is it is used around the c10ek in the five day period often required in the hospital preliminary workup for ECT. Protriptyline (Vivactil) is of value in retarded depressions, whether neurotic or otherwise. Here it is usually wise to utilize small doses and to prescribe an anxiolytic agent concurrently to prevent the emergence of anxiety by this potent, rapidly acting antidepressant. Doxepin (Sinequan), a new tricyclic, similarly combines a tranquilizing action with anti-depressant properties in a single molecule. It is indicated in those depressions where anxiety is also evident. Some reports seem to indicate it may have a target in the hard to treat neurotic depressions.
September·October, 1970
As for the combination of drugs, the use of benactyzine and meprobamate (Deprol) is often of value in depressive neuroses of varying severity. The combination of perphenazine (Trilafon) with amitriptyline (Elavil) in varying dosage as Triavil or Etrafon, often produces a greater reduction of agitation than amitriptyline alone. It is probable that future research will create newer and more efficacious antidepressants and evenhmlly make it possible for the physician to pick and predict which drug is best for each particular patient. If advances in our knowledge of neurophysiology and biochemistry can be correlated with psychodynamic understanding of the individual patient, this goal is indeed reasonable. BIBLIOGRAPHY 1. Diagnostic and Statistical Manual of Mental Dis· orders, Second Edition (OSM·n), published by the American Psychiatric Association, Washington, D.C.,
1968. 2. Kraines, S.: Mental Depressions and Their Treat· ment, New York: The Macmillan Company, 1957. 3. Dorfman, W.: Masked Depression, Bibl. Psychiat. Neurol. (Basel), 118:50, 1963. 4. Dorfman, W.; Current Concepts of Depression. Psy. chosomatics, Vol. 4 No.5 and 6, 1963; Vol. 5 No. I, 1964. 5. Bunney, W. E., Jr., Fawcett, J. A., Davis, J. M., and Gifford, S.: Further Evaluation of Urinary 17·Hydro· xycorticosteroids in Suicidal Patients, Arch. Gen. Psychiat. 21 :138·150, 1969. 6. Dorfman, W.: Recognition and Management of De· pression, I. Med. Soc. of N. I., 66:107·119, 1969. 7. Overall, J. E., Hollister, L. E., Meyer, F., Kimbell, I., Jr., and Shelton, 1.: Imipramine and thioridazine in depressed and schizophrenic patients. I.A.M.A. 189:605, 1964.. 8. Dorfman, W.: A New Parenteral Antidepressant (Elavil). Dis. Neru. Syst. 22:145, 1961. 9. Dorfman, W.: Preliminary Report: Can Parenteral OM) Amitriptyline (Elavil) Avoid ECT? Psychoso· matics, 8:131·132, 1967.
419