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The following is derived from a lecture I gave in March 2004 intended for the teaching of general practitioners. This information is intended for education purposes by health professionals and should not be used as a substitute for any health professionals' individual advice and treatment. Every patient needs to be treated as an individual and individual requirements may differ from general guidelines or principles like those suggested below. Disclosure: Honorarium received from Pfizer (distributor of Edronax) for lecture. ContentsWhat is an “adrenalin rush”?
What is an “adrenalin rush”? |
 | Lungs: SOB, choking, parasthesia (increased resp. rate, increased blood O2) |
| Heart: Palps, chest pain, flushes (increased HR) |
| Muscles: Trembling, tension, sweating |
| GIT: Dry mouth, butterflies, nausea, belching (increased blood flow to gut) |
| Brain: Dizziness, faintness, lightheadedness (increased blood flow to brain), catastrophic cognitions & fear (direct effect) |
Compare the following organisms:
"Everyone who believes, as I do, that all the corporeal and mental organs … of all beings have been developed through natural selection, or the survival of the fittest, together with use or habit, will admit that these organs have been formed so that their possessors may compete successfully with other beings, and thus increase in number ..."
Charles Darwin, 1876
"Now an animal may be led to pursue that course of action which is most beneficial to the species by suffering, such as pain, hunger, thirst, and fear; or by pleasure, as in eating and drinking, and in the propagation of the species, etc.; or by both means combined, as in the search for food.
Pleasurable sensations … stimulate the whole system to increased action.
Hence it has come to pass that most or all sentient beings have been developed in such a manner, through natural selection, that pleasurable sensations serve as their habitual guides. We see this in the pleasure from exertion, even occasionally from great exertion of the body or mind,--in the pleasure of our daily meals, and especially in the pleasure derived from sociability, and from loving our families. "
Charles Darwin, 1876
"But pain or suffering of any kind, if long continued, causes depression and lessens the power of action, yet is well adapted to make a creature guard itself against any great or sudden evil.
If all the individuals of any species were habitually to suffer to an extreme degree, they would neglect to propagate their kind; "
Darwin Francis (ed), The Life & Letters of Charles Darwin, 1887.
In Chapter 1.VIII "The passages which here follow are extracts, somewhat abbreviated, from a part of the Autobiography, written in 1876..."
In Park |
History of child abuse increases risk of MDD (& panic disorder, social phobia, GAD, PTSD &
personality disorder)
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| Loss of parent at early age | ||
| Lack of perceived parental warmth (neglect/maternal deprivation) |
(Kendler, Nemeroff & others)
| Loss of Attachment
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| Loss of rank
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| Loss of other reproductive resources that would have increased reproductive success
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| [CRF]CSF |
| HPA dysfunction |
| Reduced function in certain neural circuits |
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Hippocampal shrinkage
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| Ventricular enlargement, sulcal prominence | ||||
| MRI hyperintensities (Sackeim, 2001) |
| Engagement | ||||||||||||||||||||
| Psychoeducation | ||||||||||||||||||||
| Supportive psychotherapy | ||||||||||||||||||||
| Cognitive psychotherapy | ||||||||||||||||||||
| Behavioural psychotherapy | ||||||||||||||||||||
| Pharmacotherapy
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Finding
the right type of oil for the gearstick to move & keep it out of Park
Core symptoms of depression
Other serotonergic symptoms:
Obsessions
Compulsions
Panic
PTS
PMS
Social ph cognitions
| No. of days in bed |
| No. of days of lost work |
| Reduction in work productivity |
| Reduction in social functioning |
| Energy level correlates better with ultimate patient outcome than does depressed mood! |
| Must restore back to normal, not merely to avoid making worse (Stahl, 2002) |
Linked to deficiencies in neurotransmission of all 3 monoamines:
| Dopamine (DA) |
| Serotonin (5HT) |
| Noradrenalin (NA) |
However, fatigue strongly correlates with deficiencies in DA & NA
(Stahl, 2002)
| Long-term, any antidepressant can restore energy if it results in remission of all symptoms |
| Short-term, sedating agents may make you worse before they make you better |
| Short-term, enhancing 5HT neurotransmission may make you worse before it makes you better (5HT regulates both NA & DA by inhibiting their release) |
Energising |
Fluoxetine |
Sertraline |
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Neutral |
Citalopram |
Paroxetine |
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Sedating |
Fluvoxamine |
| Theoretically, the faster, more robust & long-lasting the enhancement of DA & NA transmission, the better for restoring energy | ||||||||||||
| Accomplished by agents that block the reuptake pumps for NA or DA or both:
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Overall: REBOX = FLUOX = IMI = DES | ||||||
| Depression subtype: ECT, TCA, VFX, MIRT & REBOX in Melancholic | ||||||
| Age:
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| Gender:
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| Presence of fatigue, amotivation, lethargy |
| Failure of SSRI(s) |
| Incomplete remission on SSRI |
| Treatment resistance e.g. incomplete remission on VFX, MIRT, MAOI, TCA |
| Sig. pt sensitivity wrt risk of weight gain |
| Mono vs combination depends on history, profile & symptomatic response from other Rx |
| Single-pathway antidepressant: inhibits NA reuptake |
| No effect on DA |
| Weak 5HT reuptake effect |
| Low affinity for adrenergic & histamine receptors |
| Some anticholinergic activity |
Not for publication
