There are primarily four categories of therapies that are currently offered to patients of depression. Firstly, ‘Psychotherapy’, works towards motivating a patient to increase pleasant activities and teaches them ways to cope up with various kinds of personal problems that may arise in an individual’s life. Such training also provides them with opportunities to explore events and feelings that are painful and overcome them. Secondly, the ‘Cognitive-Behavioral Therapy’ (CBT), although overlaps to a certain extent with the techniques involved in psychotherapy but it essentially works by recognizing negative thinking patterns in depression and correcting them. Next, the ‘Interpersonal Therapy’ (IPT), focuses on how to develop healthier interpersonal relationships at home and at school and how to resolve issues through series of interventions. Lastly, ‘Pharmacotherapy’, employs symptomatic drug therapy to relieve from depression. (Jacobson, Neil S : 74-77)
An interesting fact regarding all these therapies is that all of them have almost the same level of effectiveness which is roughly a 2 : 3 ratio of success. However, the drop-out rates are much lower for the first three psychological treatments as compared to pharmacotherapy. Moreover, there is strong statistical comparison showing that psychological treatments reduce the risk of relapse more than pharmacotherapy. (Antonuccio, David O., Danton, William G., & DeNelsky, Garland Y. : 574 - 581) Apparently, these facts seem compelling enough to abandon pharmacotherapy, however, what has given drugs and medication the status of physicians’ and psychologists’ primary arsenal is the relatively fast rate of results. The time for action for various medications ranges from a few hours up to several years. (Dipiro, Joseph T : 40) This makes pharmacotherapy a very dynamic option that becomes almost a blind choice in emergency cases. Moreover, psychological treatments more often than not fail in cases of severe depression since patients normally are not mentally ready to accept or learn anything new at all. Thus pharmacotherapy clearly seems indispensable. We shall now look into this practice in detail with the view of carrying out a risk-benefit analysis of pharmacotherapy on adolescents.
Medication in pharmacotherapy uses neurological basis of depression. Serotonin and Noradrenalin are traced as the two crucial neurotransmitters that are mainly related to depression. Serotonin is responsible for regulating mood, eating, sleep, arousal, and pain while Noradrenalin takes care of a person’s vigilance. Once their levels drop below a certain level, a person starts showing symptoms of depression. To counter this effect, there are six characteristically different kinds of drugs currently available. Namely Tricyclic, Atypical,
Monoamine Oxidase (MAO) inhibitor, Selective Serotonin Reuptake inhibitor (SSRI),
Noradrenalin-Specific Reuptake inhibitor (SNRI) and Dual-action antidepressants. However, the biochemical activity is generic across these six categories and that is to act on Serotonin or Noradrenalin or both. (Dipiro, Joseph T.)
According to available epidemiological data on the United States, the occurrence of major depressive disorder (MDD) is approximately found in 5 to 8 percent of adolescents and the incidence seems to be increasing in successive generations, with onset at earlier ages. The normally occurring gender ratio (female-to-male) is 2:1, which itself is quite an anomaly. (National Institute of Mental Health) Such a trend can be directly correlated with socio-cultural factors like a family history of depression, family conflict, uncertainty regarding sexual orientation, poor academic performance, and strife for autonomy or identity crisis. This age specially becomes vulnerable when people interact more within peer groups and when social relationships come to them as a completely novel experience. What complicates this situation even further is the typical conflict between a juvenile’s steadily maturing minds sensibility & rationality and his/her tendency to indulge into youthfully attractive activities. This traps young people into the infamous dilemma of ‘right or wrong’ which is one of the most active factors for counter-productively excessive self-reproach. Such attitudes, in the long-run, can potentially turn into cases of chronic depression. Research has also shown that teenagers who smoke are four times more likely to be depressed than non-smokers. This research claimed that nicotine in tobacco degenerates brain’s those regions that are responsible for many symptoms-related behaviors. (Dr. Barry Bittman) Another study conducted at Chiba University in Japan suggested that increased usage of the computer i.e. more than five hours a day may be yet another cause of depression. Such people isolate themselves from society and hence interaction with even family members becomes a difficult task.
When depression takes over adolescents, there are is a particular set of symptoms that they exhibit. This includes loss of appetite, interest and energy, unexplained fatigue, abandoning all playful activities and pursuits, generally becoming very despondent and losing self-esteem. This leads to secondary symptoms of weight- loss, generally bad mood and minor offenses. An interesting pattern to note is the similarity of symptoms among adolescent patients of depression. This, in particular, includes the frequency and severity of most symptoms ranging from sadness and remorse up to suicidal thoughts and attempts. (Shaffer, David, and Bruce D. Waslick)
Pharmacotherapy is used on adolescents with much caution primarily due to lack of research and experimental data. Also, an adolescent system is already in a state of transition with a lot of metabolic activity therefore physicians and psychologists have to watch for scores of potential side-effects. Before evaluating the risks associated with drug therapy, there is one benefit that undoubtedly holds a lot of weight and that is the lack of articulacy of expression in adolescents that makes it very difficult for psychologists to practice psychotherapy and CBT.
The two major drugs in use from the six described above include Tricyclic and SSRI antidepressants. The side effect profiles for both of them are varied with Tricyclic losing to SSRI in safety and reliability. Tricyclics cause mild anticholinergic symptoms and weight gain along with threatening cardio-toxic effects. There have been reports of sudden adolescent deaths since an overdose can cause lethally abnormal heart rate. This condition must be specially monitored on adolescents who generally have a more rapid liver metabolism of medications. This cardiotoxic potential is a serious risk that must not be overlooked. As for SSRIs, side effects include mild gastrointestinal upset and sedation. Sometimes dosage administration misleads physicians into thinking that the dosage is sub-therapeutic when, in fact, patients need a cut-down. Also, combination of SSRI and tricyclics or MOA inhibitors causes serotonin syndrome that is potentially life threatening. Apart from that, Tricyclics and SSRIs both have discontinuation syndromes potentially causing flu, dizziness, nausea and headaches. Therefore, both these drugs must be discontinued gradually. However, among the two, SSRIs dominate the drug therapy of depression because of their relative safety. They are as effective as tricyclics and have almost none of their side effects. (“Dipiro, Joseph T.”, “Kirsch, I., Moore, T.J., Scoboria, A., & Nicholls, S.S : 5”)
After assessing the risks involved, it’s time to weigh the risks and benefits. The motivation to use drugs for therapy in adolescents has come almost entirely from the data available on experimental successes in adults. I believe if pharmacotherapy is initiated with complete pre-treatment tests like electrocardiography, blood serum tests, resting blood pressure & pulse, and weight, the probabilities of risks materializing may be substantially minimized. Moreover, with regular follow-ups and strict dosage administration, symptoms like toxicity and palpitation can be caught in time. Thus, by minimizing risks and qualified drug administration we can possibly create risk-benefit equilibrium. (Karon, Bertram P. & Teixeira, Michael A.)
All the prevalent methods of therapies have their trade-offs. When a therapy is potent and by far more effective in the short-run, it has the shortcoming of a high relapse risk and lethal side-effects. Otherwise, when a therapy is time-consuming, patient-specific and clearly more challenging, it offers a lower relapse risk and minimal or no side-effects. Thus, I choose to agree with the consensus of currently practicing psychologists and physicians that CBT and Psychotherapy should be considered in conjunction with Pharmacotherapy to offer a significantly reliable treatment for depression that has the qualities of long-term outcome, fewer health hazards and quicker convalescence, all together, which drug therapy or psychological treatment could not provide singly.
Works Cited
Antonuccio, David O., Danton, William G., & DeNelsky, Garland Y. Psychotherapy Versus Medication for Depression: Challenging the Conventional Wisdom With Data Professional Psychology: Research and Practice. December 1995 Vol. 26, No. 6, 574-585.
Bittman, Barry. Depression and Brain Damage: 2 more reasons not to smoke: The Pediatrics. October 2000.
Corsini, Raymond J. The Dictionary of Psychology. London: Brunner-Routledge, 2002.
Dipiro, Joseph T., et al. Pharmacotherapy Handbook. New York: McGraw-Hill, 2002. 39-54.
Jacobson, Neil S. Cognitive-Behavior Therapy Versus Pharmacotherapy: Journal of Consulting and Clinical Psychology. February 1996 Vol. 64, No. 1, 74-80.
Karon, Bertram P. & Teixeira, Michael A. Guidelines for the Treatment of Depression in Primary Care and the APA Response: American Psychologist June 1995 Vol. 50, No. 6, 453-455
Kirsch, I., Moore, T.J., Scoboria, A., & Nicholls, S.S. The emperor's new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration: Prevention & Treatment 2002. 5, np.
Shaffer, David, and Bruce D. Waslick. The Many Faces of Depression in Children and Adolescents. Vol. 21. Arlington, VA: American Psychiatric P, 2002.
United States of America. National Institute of Mental Health (NIMH). Depression in Children and Adolescents: A Fact Sheet for Physicians. Bethesda, MD: NIH Publication, 2000.
