Atta Abbas, et al / Int. J. of Res.

in Pharmacology & Pharmacotherapeutics Vol-3(1) 2014 [1-6]

International Journal of Research in

Pharmacology & Pharmacotherapeutics

ISSN Print: 2278 - 2648 IJRPP | Vol. 3 | Issue 1 | Jan-April-2014

ISSN Online: 2278 - 2656 Journal Home page: www.ijrpp.com

Review article Open Access

An overview of Depression and its Pharmacotherapy

Marium Khan1, Nasar Aqeel1, *Atta Abbas1, 2
1
Faculty of Pharmacy, Ziauddin University, Karachi, Sindh, Pakistan.
2
Department of Pharmacy, Health and Well Being, University of Sunderland, England,
United Kingdom.
* Corresponding author: Atta Abbas.
E-mail id: [email protected].

Abstract
Depression is a very common mental health disorder, increasing with the socioeconomic and medical condition.
Patients experience different feelings, depending upon the severity, frequency, and duration of symptoms. If left
untreated and/or undiagnosed; can lead to complications such as suicidal thoughts etc. Patients can have an
unhealthy life; caregiver or health care provider should focus on depressed individual to improve the quality of life.
It can affect the normal daily routine, which can interfere in their daily work. Antidepressants often used for the
treatment of depression from mild to moderate depression until and unless there would be the need of
electroconvulsive therapy. Psychotherapy along with antidepressants agents can increase the success rate of
treatment and is also reported to be more effective than treating with medication alone. A pharmacist can play a
pivotal role in this regard.
Keywords: Depression; Pharmacotherapy; Psychotherapy.

Introduction on disease, it affect all the communities around the

world. About 350 million people are affected by
Depression is very common mental health disorder
depression. World mental health survey concluded
but a serious illness.1 It is a major public health
that every 1 in 20 person is affected by depression,
problem and has a greater impact on the condition of
which is an alarming situation across the globe and
the patient or health when co morbid with a chronic
leading cause of other diseases.3
medical condition such as cancer.2 The Global
Patients suffering from depression experience
Burden of Disease 20003 found out that it was the
different feelings depending upon the severity,
fourth leading cause of death in the world and affect
frequency, and duration of symptoms. Some of the
the patient as well as society worldwide. 4 Depression
symptoms associated with depression include
is the most significant contributor of global burden
persistent sadness, anxious feelings of hopelessness

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or pessimism, guilt, worthlessness, helplessness, urban areas. The mean overall point prevalence was
irritability and or restlessness. The patients are likely 33.62%. In another study the prevalence rate of 30%
to lose interest in their activities and/or hobbies. Over was reported from Karachi. Crude estimates for
the long run it leads to fatigue, difficulty in males were 18.1% and for females 42.2%.7
concentrating, memory retention, and decision These studies have found various risk factors for
making. Associated complications of depression depression in studied population. Rates for depressive
include insomnia, narcolepsy, anorexia, suicidal disorder are reported to be higher in women than
thoughts that sometimes become difficult to treat.1 men. This is consistent with the figures from western
countries. However it was observed that significantly
Classification of Depression higher rates in married than single females. In a cross
sectional epidemiological study carried out by N.
It is classified into following types include, major
Haider 7 in urban middle class population of Karachi,
depressive disorder (MDD), depression with
specifically aimed at the psychosocial risk factors,
melancholic or catatonic features, atypical
found the close knitted family systems to be a
depression, psychotic features, bipolar depression,
particular risk factor for depression. It also reported
single or recurrent episode, dysthymia, and seasonal
low level of education, poverty and economic
affective disorder (SAD). The differential diagnosis
constraints as other risk factors however the former
for depression includes other psychiatric disorders,
being the dominating one. Another important risk
CNS diseases, endocrine disorders, drug-related
factor observed for depression is socio-economic
conditions, infectious and inflammatory diseases, and
status. It is a complex factor it comprise family
sleep-related disorders.5 Major depressive disorder
problems, income, standard of living, occupational
(MDD) was identified by the World Health
status, and education as sub-domains.7
Organization (WHO) in 2001 as the fourth leading
Depression is one of the causes of suicide attempts.
cause of disability and premature death in world. It is
As the suicidal death study shows that 3.5 per cent
estimated that by the year 2020 MDD would be
the maximum intensity consisted only of feelings that
second to ischemic heart disease in regard to disease
life was not worth and this feeling occur in
burden. The WHO media center published a fact
depressive patient mostly. Subjects experiencing
sheet in 2001 on mental and neurological disorders
suicidal feelings in the last year reported more minor
which stated that 25% of individuals develop one or
psychiatric symptoms, particularly of depression,
more mental or behavioural disorders at some stage
were more socially isolated, less religious, and to a
in their lives, in both developed and developing
lesser extent had experienced more stressful events
countries. A cross sectional study was conducted
and more somatic illness. In addition to this, female
which reported depression all over in Karachi,
were more likely to commit suicide.8
Pakistan, and also reported an increases prevalence of
Along with suicide, depression is one of the major
depression in society due to stress, related to socio-
causes for provoked seizures. It was reported in a
economic factors. If it remains un-noticed, un-
study that depression has been shown to increase risk
checked and un-observed it would result in a big
for epilepsy and suicide attempts. Major depression
disaster. It is suggested that healthy lifestyle habits
and attempted suicide independently increase the risk
can help prevent depression, include eating properly,
for unprovoked seizure. The data reported from the
sleeping adequately, exercising regularly, learning to
study suggested that depression and suicide attempt
relax, and not drinking alcohol or using drugs.6
may be due to different underlying neuro-chemical
An epidemiological study was conducted in Pakistan
pathways, each of which is important in the
in 2007 which reported the high prevalence rates in
development of epilepsy (95% CI). A history of
northern Pakistan and big urban center i.e. Karachi.
major depression was 1.7 fold more common among
The study reported every third individual is expected
cases than among controls (95% CI, lower 1.1 upper
to suffer from depression and anxiety. Some
2.7). A history of attempted suicide was 5.1-fold
community based studies conducted in various
more common among cases than among controls
regions of Pakistan reported prevalence as high as
(95% CI, lower 2.2 upper 11.5). Attempted suicide
66% in women from rural areas to 10% in men from

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increased seizure risk even after adjusting for age, to 15 percent of women experience postpartum
sex, cumulative alcohol intake, and major depression depression after giving birth.
or number of symptoms of depression.9
Patients with depression need to take good care of Seasonal affective disorder SAD
them to feel better, due to the symptoms, they suffer Seasonal affective disorder (SAD) the onset of
from insomnia and restlessness. The patients may depression during the winter months, when there is
also suffer from anorexia and lose interest in daily less natural sunlight. The depression generally lifts
activities. Due to the aforementioned factors, it leads during spring and summer. SAD may be effectively
to detrimental health consequences.10 treated with light therapy, but nearly half of those
with SAD do not get better with light therapy alone.
Major Depressive disorder MDD Antidepressant medication and psychotherapy can
Major depressive disorder, or major depression, is a reduce SAD symptoms, either alone or in
combination of symptoms that interfere with a combination with light therapy.
person's working, sleeping and normal daily routine
habits and/or activities. Some patients may Bipolar disorders
experience only a single episode in their lifetime, but Bipolar disorder, also called manic-depressive illness,
more often a person may have multiple episodes. is not as common as major depression or dysthymia.
Dysthymic disorder or dysthymia is long-term (2 It is characterized by mood swings. Some other
years or longer) symptoms that may not be severe associated illnesses may come on before depression,
enough to disable a person but can prevent normal cause it, or be a consequence of depression. But
functioning of the body. People with dysthymia may depression and other illnesses interact differently in
also experience one or more episodes of major different individual.
depression during their lifetime.
Chronic depression
Minor depression Chronic depression is illness which last for 2 years or
Minor depression is characterized by having more and comprises of 4 subtypes of depressive
symptoms for 2 weeks or longer that do not meet full illness i.e. chronic major depressive disorder,
criteria for major depression. Without treatment, dysthymic disorder, dysthymic disorder with major
people with minor depression are at high risk for depressive disorder “double depression” and major
developing major depressive disorder. Some forms of depressive disorder with poor inter-episodic
depression are slightly different, or they may develop recovery.11
under unique circumstances. It is still debatable how Anxiety disorders, such as post-traumatic stress
to characterize and define these forms of depression. disorder (PTSD), obsessive-compulsive disorder,
They include, psychotic depression, occurs when a panic disorder, social phobia, and generalized anxiety
person has severe depression plus some form of disorder, often associated with depression PTSD can
psychosis, such as having disturbing false beliefs or a occur after a person experiences a terrifying event or
break with reality (delusions), or hearing or seeing suffering, such as a violent assault, a natural disaster,
upsetting things that others cannot hear or see an accident, terrorism or military combat. Alcohol
(hallucinations). and other substance abuse or dependence may also
co-exist with depression. Studies have shown that
Postpartum depression mood disorders and substance abuse have been
Postpartum depression, which is much more serious observed to co-exist with latter complementing the
than the "baby blues" that many women experience former. Depression is also reported to be associated
after giving birth, when hormonal and physical as co-morbidity with other major and serious
changes and the new responsibility of caring for a illnesses like heart disease, stroke, cancer,
newborn can be overwhelming. It is estimated that 10 HIV/AIDS, diabetes, and Parkinson's disease and its
adequate treatment can also help improve the
outcome of associated co-morbidities.

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concentrating and suicidal thoughts must be present

Risk factors of depression daily or for at least last 2 weeks.15
Most likely, depression is caused by a combination of Health awareness would be helpful in developing the
genetic, biological, environmental, and psychological understanding of the mental disease which will in
factors. Studies reported imbalance of important turn help in understanding the condition of the patient
neurotransmitters NT in depression. But it is difficult and eventually lead towards management of the
to prove if depression is the solitary reason for such. treatment.16 Antidepressants are often used for the
It is also evident from some studies that depression treatment of depression from mild to moderate
tends to run in families i.e. the genetic predisposition. depression until and unless there would be a need for
But at the same time depression can occur in people electroconvulsive therapy.14 Primary care physician
without having family histories. Some researches are consulted before obtaining the services of mental
indicate that risk for depression results from the health care provider, when patients suffers from
influence of several genes acting together with depression. Depressed patients often deny, oversight
environmental or other factors. In addition, trauma, their particulars somatic and cognitive/behavioural
loss of a loved one, a difficult relationship, or any symptoms, undervalue symptoms severities. Elderly
stressful situation may trigger a depressive episode. patients suffering from depression have an
Research indicates that depressive illnesses are approximate prevalence between 5%-50%, increase
disorders of the brain.1,12 in age result in more suicidal thoughts and attempts.
In the case of cancer patient it was observed in a Depressive disorder occurs at any stage of life,
study these patients experience less common percentage of major depression has been elevated as
depression and anxiety, but mood swings in 30-40% already discussed in the beginning. Pharmacological
hospitalized patients without a significant difference treatment and non-pharmacological treatment such as
in palliative and non-palliative care settings and cognitive and psychotherapy have observed to
concluded that the clinicians should be vigilant for increase benefits in depressive patients.
mood disturbance along with episodes of
depression.13 Pharmacotherapy for depression
Pharmacotherapy of depression is a process which
Diagnosis of depression includes thoughtful insight to medication side effects,
The widely used criteria for diagnosing depressive adverse effect and patient specific factors.17
conditions in depressive individuals are found in the The outcome is not immediately seen as weeks are
American Psychiatric Association’s Diagnostic and needed to get the desired response. Medicines
Statistical Manual of Mental Disorders DSM-IV-TR14 prescribed must comply with the patient appropriate
and the World Health Organization’s International condition. For this targeted response patient
Statistical Classification of Diseases and Related adherence to the medications must be important
Health Problems ICD-10. There is no clinical factor in order to get relief from symptoms. A clinical
laboratory test for major depression and both the pharmacist can come in handy is drug selection,
DSM-IV-TR and ICD-10 identify specific depressive optimization and medication adherence. In addition
symptoms. The ICD-10 banks upon three typical to this, improvement in symptoms and quality of life
depressive symptoms i.e. depressed mood, anhedonia are normally the goals of therapy. A combination of
and fatigue as biomarkers of depression, two of pharmacotherapy and psychotherapy are beneficial
which needed to be present to determine depressive rather giving monotherapy.18
disorder diagnosis. According to the DSM-IV-TR, Psychotherapy along with antidepressants agents can
there are two biomarkers i.e. depressed mood and increase the rate of treating patients correctly. This
anhedonia, one of which must be present to can also be associated with higher improvement rate
determine diagnosis of a major depressive episode, than medications alone. It also increase medication
and five symptoms out of the following such as adherence by patient which in turn would lead to
depressed mood, anorexia, insomnia, psychomotor better outcomes. However, evidence on medication
agitation, fatigue, guilt or worthlessness, difficulty in adherence-enhancing effects of psychological

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intervention was reported in a study in which two due to the differences in follow-up or clinical skills.
groups were studied with one being treated with Managed care plans do not appear to reduce the
pharmacotherapy in combination with psychotherapy intensity or severity of depression treatment, case
and the latter with pharmacotherapy alone. Therefore, management do escalate the likelihood for failure of
psychotherapy is considered best along with treatment.20 The primary goal of management of
pharmacological treatment with objectives of depression is to improve the overall mood of the
improving quality of life, enhance patient’s social patient and relieve depression and its symptoms i.e.
functioning, promote adherence to medication and suicidal thoughts. The secondary target is to find out
prevent recurrence.19 the underline cause and eliminate or reduce it. The
The American Psychiatric Association (APA) management and treatment of depression is a two
emphasizes the need to customize a treatment plan way approach as discussed earlier i.e. treatment by
for each patient based on a careful assessment of pharmacotherapy and psychotherapy.21 Monitoring is
symptoms, including rating scale measurements, as required for sudden mood changes, suicidal
well as an analysis of therapeutic benefits and side tendencies. The care plan for depression will be
effects. The treatment would be based on the various directed towards pharmacologic treatment initially
biomarkers such as clinical assessment, co- followed by an assessment of the condition after
mobidities, stressors analysis, patient preferences and some period of time. Finding the underline cause and
results of previous treatment.5 Medications used to its treatment is essential as the condition is normally
treat depression include selective serotonin reuptake the outcome of an underlining cause. Major
inhibitors SSRIs, serotonin-norepinephrine reuptake depression needs pharmacotherapy and psycho
inhibitors SNRIs, monoamine oxidase inhibitors therapeutical approach. It will be helpful to educate
MAOIs, tricyclic antidepressants TCAs, central the patient and care givers about the condition and
alpha2-receptor antagonists, and norepinephrine and how to cope with it along with effective
dopamine reuptake inhibitors. Antidepressants pharmacological therapy for the problem.21
influence the overall balance of the three
neurotransmitters in the brain that regulate emotion, Conclusion
reactions to stress, sleep cycles, appetite, and In a nutshell, further researches on depression can
sexuality. Side effects to monitor for sudden help the health care professionals to deal with it, as
behavioural changes include worsening of well as studies on pharmacotherapy options will help
depression, withdrawal from normal social situations, the health care providers to select the treatment
agitation, irritability, anxiety, panic attacks, insomnia, options such as pharmacological approach and
aggressiveness, impulsivity, and increased thoughts psychotherapy which will prevent the recurrence of
of suicide.15 Psychotherapy and pharmacotherapy depression. A pharmacist can play an important role
does decrease the rate of treatment failure. Choice of not only in spreading health awareness about
psychiatrist decreases the likelihood of treatment depression but also in the selecting the
failure, independent to the number of psychotherapy pharmacotherapy and performing educational
sessions and antidepressant prescriptions. The effect interventions such as patient counseling.
of health care provider on treatment failure could be

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