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Management
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In common with the management of all psychiatric disorders management is divided into managing the acute and chronic phases, and also consists of using management strategies which may include physical, psychological and social.
This section will first consider treatment strategies for manic and depressive episodes, then will look at specific issues in the use of antidepressants and electroconvulsive therapy (E.C.T.). Pharmacotherapy and psychotherapies are covered more generally in their specific sections.
Manic episode.
Short term |
Long term |
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Physical |
neuroleptic medication |
consider lithium, carbamazepine or sodium valproate as prophylaxis |
Psychological |
support for patient and family |
support may need to continue |
Social |
admission to hospital should be considered to minimise risk to patient and others |
a minority need rehabilitation and supervised care |
Depressive episode
Short term |
Long term |
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Physical |
antidepressant medication |
if treatment resistance consider; second or an alternative antidepressant, lithium, anti-epileptic medication |
Psychological |
support |
more emphasis on specific psychotherapies such as C.B.T., dynamic, family therapy etc. |
Social |
support for carers |
specific social interventions e.g. housing, finance |
Antidepressants.
Tricyclic antidepressants (TCAs) are the longest established pharmacological treatment for depressive disorders, but are associated with a higher rate of adverse effects (including toxicity in overdose) compared with the newer serotonin selective reuptake inhibitors (SSRIs).
Patients may not persevere with treatment if they are not warned to expect unwanted effects and a delay before improvement. Anticholinergic side effects can be minimised by starting at a low dose e.g. amitriptyline 25 mg, increasing to a "treatment" dose of 150 mg.
75 mg of TCAs are often used in general practice. This is sometimes reported as being effective, perhaps because a milder form of depression is often seen in the community. However, most studies have strongly suggested that generally, and particularly in hospital practice, a dose of 75 mg is sub-therapeutic and 150 mg or greater is usually required.
There is dispute about whether TCAs or SSRIs should be the first line treatment for depression. SSRIs should probably be first choice in the elderly, those with cardiac problems or epilepsy, those with high suicidal intent, and those who have been over sedated or put on weight when on TCA’s.
Monoamine oxidase inhibitors (MAOIs) are very much second line treatments, though the new reversible MAOI, moclobamide, does not need the same dietary restrictions, and therefore may gain favour. Newer antidepressants such as venlafaxine, a serotonin and noradrenaline reuptake inhibitor (SNRI), and reboxetine, a noradrenaline reuptake inhibitor (NARI), are now being used in clinical practice.
Electroconvulsive therapy (E.C.T.).
Despite its adverse image modern E.C.T. is a relatively safe procedure, particularly when compared to TCA use. The main side effects are headache, myalgia (probably related to the muscle relaxant used in the anaesthetic) and mild memory problems (retrograde and anterograde) that settle over the 6 weeks after treatment finishes.
E.C.T. is particularly useful in severe depression i.e. where there are marked melancholic or psychotic features. It is also strongly indicated where a delay in the treatment is unacceptable such as in cases where there is a serious risk of suicide or the patient is not eating or drinking.
E.C.T. use may also be indicated in resistant mania and in the elderly (due to its comparative safety and rapid onset of action).
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