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Current evidence strongly points to the fact that depression continues to be one of the greatest disease burdens in the world and a major contributor to mortality and morbidity across all segments of the population in the developed world as well as in third world countries. While this is the case, there have been considerable parental and health-related concerns about exposing depression patients to psychopharmacological medications, particularly due to the generally perceived negative effects associated with some medications.
The summarized study, titled “Revised Psychopharmacological Algorithms for the Treatment of Mood Disorders in Japan”, was therefore informed by the need to develop new algorithms for the psychopharmacological treatment of depression and related disorders, particularly with respect to developing new treatment methodologies for depression made possible by the emergence of new medications that were non-existent during the development of the previous psychopharmacological algorithms for the treatment of depression.
The researchers mainly wanted to include some new medications in the revised algorithms which were non-existent during the initial formulation of the algorithms in 1999, such as fluvoxamine, paroxetine and milnacipran (Motahashi et al., 2008).
The article that will be summarized in this paper was found in the EBSCOhost Databases. The search words “depression” and “psychopharmacological treatment” were used and the search results limited by period (from 2005 onwards) and content (scholarly/academic papers only) to search for a relevant article. It is imperative to note that the summarized article was found under the Academic Search Premier Database within the EBSCOhost Databases.
The article “Revised Psychopharmacological Algorithms for the Treatment of Mood Disorders in Japan”, by Motahashi and colleagues, aimed at developing new algorithms for the treatment of depression and related mood disorders in Japan.
The rationale for undertaking this particular study stemmed from the need to develop newer treatment algorithms that could have the capacity to incorporate newer medications for the treatment of depression and other mood disorders.
From the study, it is clear that the existing psychopharmacological algorithms for the treatment of depression were already constrained by a number of factors, key among them the fact that they were based on a limited number of drugs that were available during the time of formulation, and also the fact that modern science had brought new evidence-based medications that needed to be incorporated into the treatment protocols and stratagems for depression to attain optimal results (Motahashi et al., 2008).
Although the study lacks a clear hypothesis, it sets out to develop a number of modern psychopharmacological algorithms for the treatment of depression in Japan. Indeed, the researchers came up with six algorithms for the treatment of “mild or moderate depression, severe non-psychotic depression, psychotic depression, mania, bipolar depression, and rapid cycling bipolar disorder” (Motahashi et al., 2008, p. 11).
In methods, it is of essence to note that the researchers heavily relied on both evidence-based medicine (EBM) and everyday clinical practice to develop the algorithms for the treatment of the above-named conditions.
The study design was mostly quantitative in nature, and a questionnaire survey was employed to collect primary data from about 200 psychiatrists residing in 19 health facilities (13 university health institutions, five national institutes, and one private psychiatric health facility) throughout Japan.
According to Motahashi et al. (2008), “…the questionnaire asked about the selection of drugs, dose, duration of treatment, use of concomitant drugs, alternative drug therapy for failures to the initial therapy, and so on” (p. 11).
This particular study came up with significant findings for the psychopharmacological treatment and management of depression and related mood disorders.
For instance, an estimated 57% of the respondents said they used selective serotonin reuptake inhibitors (SSRIs) as the first line of treatment for major, mild or moderate depressive disorders, while an estimated 18% said they used serotonin-noradrenaline reuptake inhibitor (SNRI) as the first line of treatment for the same (Motahashi et al., 2008).
It is important to note that SSRIs such as fluvoxamine and paroxetine had not been approved by health agencies when the psychopharmacological algorithms for the treatment of depression were initiated in Japan in 1999, thus the need to conduct this particular study.
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Going on with the significant findings for the study, it was found that an estimated 84% of the psychiatrists surveyed switched to another antidepressant medication when the first line of treatment failed.
It is also important to note that TCAs, SSRIs, SSRI and electroconvulsive therapy (ECT) were used by 57, 19, 9, and 8% of the respondents, respectively, in the treatment and management of major depressive disorder, which can be described as severe but with no psychotic aspects (Motahashi et al, 2008).
The researchers used these findings to develop the psychopharmacological algorithms for the treatment of depression. Based on predetermined evidence levels purposed to display either good research-based evidence, fair research-based evidence, or a group consensus with minimal research-based evidence, the researchers came up with the following algorithms:
Algorithm for the treatment & management of major depressive disorder, mild or moderate: Selective serotonin reuptake inhibitors (fluvoxamine and paroxetine) and a serotonin-noradrenaline reuptake inhibitor (milnacipran) selected as first-line treatments, in large part because of their efficacy, less toxic and tolerable nature. It was also reviewed that these medications should be started in low doses and then increased gradually.
It was also noted that the concomitant utilization of the medication benzodiazepine is inherently useful for up to the first month of treatment, not mentioning the fact that the goal of therapy in the acute phase should be to curtail or eradicate the depressive symptoms with a view to regaining psychological and social functioning (Motahashi et al., 2008).
Algorithm for the treatment and management of severe non-psychotic depression: Hospitalization for severe cases should be encouraged as a general practice due the severity of the social/occupational function of the patient. Here, patients should be treated with TCAs and an SNRI (particularly venlafaxine) rather than being subjected to SNRIs.
Also, it was demonstrated that majority of inpatients exhibiting severe depression to a point of suicide ideation responded well to paroxetine and ECT. Thus these two medications can be selected as the first-line of treatment for such patients (Motahashi et al., 2008).
Algorithm for the treatment and management of psychotic depression: Here, it was revealed that treatment approaches should be considered according to the real or perceived risk of suicide ideation, severity of agitation, and the capability to take the medicines using oral means.
Low-risk patients can be effectively managed using antidepressants such as amoxapine or fluvoxamine as first-line treatments, while high-risk patients (those exhibiting increased risk for suicide ideation and/or agitation) can be effectively managed using an antidepressant-antipsychotic combination, such as a combination therapy with SSRIs and atypical antipsychotic medication. ECT can be administered as the second-line of treatment if the mix fails to work.
Algorithm for the treatment and management of bipolar disorder, manic episode: Mood stabilizers such as lithium, carbamazepine, and valproate need to be administered as first-line treatments, followed by antipsychotics such as sultopride and zotepine to treat cases of mania.
It is imperative to note that sultopride and zotepine can administered either in isolation or in combination with the mood stabilizers to treat mania. Recent advances in medicine have brought some atypical antipsychotics, such as olanzapine, quetiapine and risperidone, which are thought to be effective in the treatment of bipolar disorder due to the extremely low incidences of extrapyramidal side effects (Motahashi et al., 2008). ECT can be considered in subsequent treatments.
Algorithm for the treatment and management of bipolar disorder, depressive episode: This disorder can be treated by administering a high dose of lithium in combination with carbamazepine or valproate or introducing other antidepressants such as SSRI or SNRI (Motahashi et al., 2008). Here, it is essential to note that ECT can be effectively used in the treatment of refractory bipolar disorder.
Algorithm for the treatment and management of rapid cycling mood disorder: This type of depressive disorder should be treated using valproate or carbamazepine as the preferred first-line treatments, but precautionary measures should be taken to curtail the severe side-effects that may be induced by the administration of carbamazepine.
Additionally, the combination of lithium and valproate may be effective in instances of partial or no efficacy of the first-line treatment medications. In extreme cases where instances of no efficacy are noted while using the above medications, clonazepam and known antipsychotic medications such as olanzapine may be administered. Still, ECT can be used in severe cases.
It is indeed true that this particular study addressed a pertinent issue affecting society as a whole since depression has been accused as the leading cause of morbidity and mortality globally (Motahashi et al., 2008). Any research interested in developing standard treatment strategies and protocols for the various forms of depression should, therefore, be viewed as welcome to the extent that the knowledge gathered goes a long way to ameliorate that suffering brought forth by the harmful effects of depression.
The results of this study, in my view, are objective and valid due to the fact that evidence-based techniques were used to develop the algorithms that have been summarized in this paper. The researchers are clear on how they used scientific techniques to collect primary data; thus it can only be safe to assume that the results can be generalizable not only in Japan but also internationally.
One of the most domineering limitations of the study, it seems, is the use of technical terms without taking the initiative to explain in a separate sheet what these terms imply. Due to these limitations, it may get confusing for a non-practitioner to get to know what the researchers really means when they go about explaining the medications used in the treatment of the various forms of depression.
Also, the researchers neither identify the specific variables under study, nor take time to explain to the reader how sampling was done and the criteria used for exclusion. It would have been much more plausible if a large sample size was included in this study.
Lastly, it can be argued that the article provides an in-depth analysis of the current medications used in the treatment and management of the various forms of depression, not mentioning the fact that it provides current practitioners with some form of a ‘baseline map’ on how to go about treating depression depending on scope and severity. As such, this particular article is relevant to what is learnt in class as well as to professional practice.
Motahashi, N., Shioe, K., Nakamura, J., Ohshima, A., Yamada, K., Ozawa, H…Higuchi, T. (2008). Revised psychopharmacological algorithms for the treatment of mood disorders in Japan. International Journal of Psychiatry in Clinical Practice, 12(1), 11-18. Retrieved from Academic Search Premier Database