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Table 25 9 Antidepressant drug interactions with other drugs
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Drug Antacids Anticoagulants Cimetidine Clonidine Digitalis Disulfiram Guanethidine Haloperidol Insulin Lithium Methyldopa Other anticholinergic drugs Phenytoin Procainamide Procarbazine Propranolol Quinidine Rauwolfia derivatives Sedatives Sympathomimetic drugs Terfenadine, astemizole, cisapride MAOIs Antihistamines Belladonna-like drugs Dextromethorphan Guanethidine Insulin Levodopa Meperidine Methyldopa Pseudoephedrine Reserpine Succinylcholine Sulfonylureas Sympathomimetic drugs
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Effects Decreased absorption of antidepressants Increased hypoprothrombinemic effect Increased antidepressant blood levels and psychosis Decreased antihypertensive effect Increased incidence of heart block Increased antidepressant blood levels Decreased antihypertensive effect Increased clomipramine levels Decreased blood sugar Increased lithium levels with fluoxetine Decreased antihypertensive effect Marked anticholinergic responses Increased blood levels Decreased ventricular conduction Hypertensive crisis Increased hypotension Decreased ventricular conduction Increased stimulation Increased sedation Increased pressor effect Torsades de pointes
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Tricyclic and other non-MAOI antidepressants
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Increased sedation Increased blood pressure Same as meperidine Decreased blood pressure Decreased blood sugar Increased blood pressure Increased agitation, seizures, coma, death Decreased blood pressure Hypertensive crisis (increased blood pressure) Increased blood pressure and temperature Increased neuromuscular blockade Decreased blood sugar Increased blood pressure
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Terfenadine and astemizole are not commercially available in the United States MAOIs, monoamine oxidase inhibitors
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employer, or friends is often necessary to mobilize the patient who experiences no joy in daily activities and tends to remain uninvolved and to deteriorate Insistence on sharing activities will help involve the patient in simple but important daily functions In some severe cases, the use of day treatment centers or support groups of a specific type (eg, mastectomy groups) is indicated It is not unusual for a patient to have multiple legal, financial, and vocational problems requiring legal and vocational assistance
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8 Phototherapy Phototherapy is used in major depression with seasonal onset It consists of exposure (at a 3-foot distance) to a light source of 2500 lux for 2 hours daily Light visors are an adaptation that provides greater mobility and an adjustable light intensity The price of these full-spectrum light sources ranges between $300 and $400 The dosage varies, with some patients requiring morning and night exposure One effect is alteration of biorhythm through melatonin mechanisms 9 Experimental treatments In preliminary studies, transcranial magnetic stimulation appears to be effective in nonpsychotic depression Vagal nerve stimulation has shown promise in extremely refractory cases and has recently been approved by the FDA
D Behavioral
When depression is a function of self-defeating coping techniques such as passivity, the role-playing approach can be useful Behavioral techniques, including desensitization, may be used in problems such as phobias where depression is a byproduct When depression is a regularly used interpersonal style, behavioral counseling to family members or others can help in extinguishing the behavior in the patient
B Psychological
It is seldom possible to engage an individual in penetrating psychotherapeutic endeavors during the acute stage of a severe depression While medications may be taking effect, a supportive approach to strengthen existing coping mechanisms and appropriate consideration of the patient s continuing need to function at work, to engage in recreational activities, etc, are necessary as the severity of the depression lessens If the patient is not seriously depressed, it is often quite appropriate to initiate intensive psychotherapeutic efforts, since flux periods are a good time to effect change A catharsis of repressed anger and guilt may be beneficial Therapy during or just after the acute stage may focus on coping techniques, with some practice of alternative choices Depression-specific psychotherapies help improve selfesteem, increase assertiveness, and lessen dependency Interpersonal psychotherapy for depression has shown efficacy in the treatment of acute depression, helping patients master interpersonal stresses and develop new coping strategies Cognitive behavioral therapy for depression addresses patients patterns of negative thoughts, called cognitive distortions, that lead to feelings of depression and anxiety Treatment usually includes homework assignments such as keeping a journal of cognitive distortions and of positive responses to them As previously noted, numerous studies have shown that the combination of drug therapy plus interpersonal psychotherapy or cognitive behavioral therapy is more effective than either modality alone It is usually helpful to involve the spouse or other significant family members early in treatment Mindfulness-based cognitive therapy is a new form of therapy showing promise in reducing depression recurrence This therapy incorporates meditation and teaches patients to distance themselves from depressive thinking
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