Treatment of the major affective disorders

Important advances have been made in the treatment of the major affective disorders, and the majority of these patients can now be treated with a high degree of specificity and success. The most important discoveries have been in the development of potent psychotropic medications for both major depression and the bipolar disorders. The central therapeutic tools in the treatment of the major affective disorders are the antidepressants and lithium.

Because major affective disorders have strong tendencies for recurrence, an important aspect of the patient’s treatment is the comprehensive education of patients and their families about the disorder. It should be emphasized to the patient that these are psychobiologic disorders which involve altered biochemical states in the brain, and that episodes can be triggered by adverse events and stresses in the environment but may occur spontaneously as well. Each patient should be urged to become an expert on his or her own disorder, concentrating on how it manifests and what early signs and symptoms may herald an impending manic or depressive episode. The patient and the family must be urged to take on the responsibility for the early recognition of the impending episode, since the earlier a patient presents for treatment, the easier it is to remediate the episode. The absolute necessity of medication compliance must be emphasized, and the patient must understand thoroughly the need to take the medications as prescribed and to be aware of side effects and of the potential medical sequelae from the medications.

The counseling and therapeutic techniques the physician uses in dealing with patients who are suffering acute manic or depressed episodes are simple and relatively straightforward. During the acute phase of these episodes, patients respond better to short (10 to 20 min) visits one to three times per week. During these visits the general focus is on monitoring the medication and side effects, but it is also essential that the physician be very reassuring and supportive to the patient. Because patients are functioning essentially in an altered state secondary to the depressive or manic episode, the treatment must be sustained by the physician’s optimism and knowledge that with time these episodes can be treated if the right medication and dose are prescribed. Virtually all the mood-stabilizing and -ameliorating psychotropic medications have a significant delay between the time the patient begins the medication and the time of achieving full therapeutic benefits. It is during this time that supportive reassurance and encouragement from the physician is particularly important in sustaining the patient in treatment.

There are approximately 25,000 suicides a year in this country, and clinical surveys have indicated that approximately 30 percent of these patients have major affective disorders. Suicidal ideation is one of the important symptoms which accompany major depression, in both bipolar and unipolar disorders; considerations of suicidal lethality are significant components of the management of these patients. Although it is not possible to distinguish precisely between patients who will attempt suicide and those who will not, there are some factors which should be considered. Generally speaking, many experts agree that patients who have given detailed thought to the method of suicide, who have concomitant alcoholism, and who are socially isolated with few (if any) social supports, in addition to elderly males and patients with terminal medical illnesses, have a greater potential risk for suicide. On the other hand, all of the characteristics lack true specificity in the assessment of suicidal risk.

Once the acute depressive or manic episode is under control, the switch from supportive to more insight-oriented psychotherapy is a useful adjunct to the pharmacotherapy. Recent studies have established that the combination of psychotherapy with pharmacotherapy is significantly better than either of these two modalities alone. There is also evidence that specific types of psychotherapy (e.g., cognitive therapy) can be successfully used in the treatment of mild to moderate depressive disorders, but learning to become a competent psychotherapist requires considerable effort and time to achieve results comparable to that of the relatively simple administration of an antidepressant. It is, therefore, recommended that the nonpsychiatric physician rely primarily on the antidepressants or lithium (depending upon the disorder being treated) in combination with educational and supportive psychotherapeutic approaches in the management of patients with major affective disorders.