Antidepressant and Antimanic Medications: Contraindications to Use of Antidepressant and Antimanic Medications
There are few contraindications to antidepressant or antimanic medication treatment. Those that do exist are mostly related to specific drugs or to combinations of drugs and are discussed individually in the following sections of this chapter dealing with specific drug types and side effects.
General Treatment Guidelines
The treatment of mood disorders is increasingly recognized as a long-term process, because mood disorders appear to be chronic in nature and patients with mood disorders experience high rates of relapse on discontinuation of drug therapy. Available medications restore function, but the disease process is not halted. In this context, Kupfer (1991) proposed three phases of treatment: an acute-treatment phase, a continuation phase, and a maintenance phase. These concepts are also appropriate to the treatment of mania. The phases are defined in relation to the status of symptoms and involve the concepts of treatment response, relapse, remission, recurrence, and recovery. The phases of treatment for depression are depicted in
Response refers to some effect following an action—in this case a decrease in clinically significant symptoms after initiation of treatment. Relapse involves the return of some symptoms during or on cessation of treatment. Remission refers to a clinically meaningful decrease in symptoms. Recurrence describes the return of symptoms after a remission. Recovery describes a more sustained remission from the most recent episode.
Acute treatment includes making a diagnosis, deciding whether to treat with medications, choosing an agent, initiating treatment, and monitoring the degree of symptom reduction, compliance, and side effects. This stage generally lasts 4-12 weeks.
If a response is obtained, then the continuation phase, which consists of monitoring for completeness of response and side effects, ensues. Discontinuation of medication during or before this phase is associated with a relatively higher rate of relapse, and the rate at which the medication is discontinued may affect the likelihood of relapse. Continuation lasts 4-9 months and can be thought of as a consolidation phase. A recent World Health Organization consensus meeting suggested that the minimum period of time for continuation treatment is 6 months if the target symptoms are in remission (World Health Organization Mental Health Collaborating Centers 1989).
Maintenance is thought of as prophylactic, but it is becoming increasingly clear that for many patients this phase is essential not only for preventing new episodes but also for maintaining the response, because the illness persists. Newer data suggest that medication dosing during maintenance should continue at the level that was used during the acute phase.
Antidepressant and Antimanic Medications
Combined Medication and Psychotherapy
Treatment-Resistant Mood Disorders
Treatment of Mood Disorders in the Medically Ill Patient
Strategies and Tactics in the Treatment of Depression
Revision date: June 18, 2011
Last revised: by Andrew G. Epstein, M.D.