Indications

Tables lists conditions where some antidepressant drugs have been found to be effective. Not all drugs are equally effective in each condition and very few clinical trials of the different compounds in each of the conditions have been conducted. Since the efficacy of antidepressant drugs is in part related to the dose administered and/or blood levels, it is difficult to be certain of the relative efficacy of one compound versus another when only single fixed doses are used. The expense and difficulty of multidose designs in comparing two treatments are extremely large and this is the main factor limiting comparisons of different drugs across the conditions listed in Table.8. In addition, the large number of compounds available would make this a very difficult task indeed. Another issue is that many of the drugs are only officially approved by the American Food and Drug Administration for use in depressed patients. Many of the indications listed in T.able.8 are 'off-label' use of the medication. Since depression is the most prevalent illness, pharmaceutical companies have developed and brought forward drugs with depression as the primary indication. The expense of clinical trials to gain approval for other indications is high. Thus, for many of the conditions listed in Table.8, there is only fragmentary evidence for efficacy of some antidepressants and almost no data or comparable efficacy across drugs.

Table B Clinical indications for antidepressant treatments

There are a number of different diagnostic approaches to depression as listed in Table..8. By and large all of the drugs listed in Tabje.5 have been shown to be effective in the treatment of major depression. Most drugs have been studied in outpatient samples of patients with major depression. Their relative efficacy in the treatment of more severe conditions such as melancholia, psychotic depression, or bipolar depression remain limited. In addition, the relative efficacy of the different compounds as treatments for the depressive subtype, such as atypical depression, dysthymia, or secondary depression, have not been fully studied. There have been some reports that the MAOIs may be more effective in atypical depression(48) but not all studies have validated this. When depression in the elderly is under consideration, the side-effect profile for each drug becomes a much more relevant consideration when choosing a specific drug. (46)

Anxiety disorders have considerable comorbidity with depression. Imipramine was initially found to be effective in the treatment of panic disorder and since then SSRIs have also been effective as well as MAOIs/49 Clomipramine has been found to be effective in obsessive- compulsive disorder and more recently SSRIs have also been found to be effective in the treatment of this condition and they generally have fewer side-effects. Depending on the studies, both SSRIs and MAOIs have been effective treatments in social phobia as well as some tricyclic drugs. In general anxiety disorder and post-traumatic stress disorder, antidepressants have also shown efficacy but not to the same extent as seen in panic disorder.(50)

It is of interest that some antidepressants have been effective in treating eating disorders. They are effective in bulimia nervosa but not in anorexia nervosa. The dose of fluoxetine to treat bulimia nervosa is higher than the treatment of depression. The increase of weight seen following many antidepressants contrasts with some reports of the usefulness of SSRIs in the treatment of obesity.

In clinical practice many clinicians have used trazodone as a night-time sedative. In the treatment of depression, sleep is one of the first symptoms to show improvement following initiation of most antidepressant treatments. Various reports of use of antidepressants in the treatment of narcolepsy and sleep apnoea have also been published.

Antidepressants have been effective in various pain syndromes.(51) Since there is a wide range of the medical conditions producing pain, the results have been quite variable. In general the antidepressants have been able to reduce many of the painful symptoms as well as be effective in treating the secondary depression associated with chronic pain. However, they do not demonstrate the clear analgesic effect of drugs such as opioids.

Antidepressants have been reported to be effective in many other disorders including substance abuse, alcoholism, and smoking cessation. (52) In children with enuresis a dose of imipramine as low as 25 mg has been seen to be safe and effective. In both children and adults, imipramine, desipramine, and nortriptyline have been effective in the treatment of attention-deficient disorder. (53) Antidepressants have found use in the treatment of premenstrual disorders,(54,5.5) and they are also useful in the treatment of several neurological disorders.(5 57 and

In general the indications and uses of a specific antidepressant in part depends on their side-effect profile and on the previously demonstrated efficacy. A major issue in the use of drugs to treat the large number of depressed patients with a comorbid medical condition is the careful choice of drug to minimize possible negative interactions with the medical disease.

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