Innovations in the Management of Anxiety and Depression in the Female Patient

Vernon M Neppe MD, PhD, FFPsych(SA), FRCPC

Educational Objectives

To educate in the area of anxiety and depression and to demonstrate areas of similarity and differences.
To discuss the clinical implications with regard to management options and problems.
The development of a broader theory of innovative psychopharmacotherapy and the understanding of concepts such as neuromodulation using the bathtub analogy and partial agonism.
To discuss the clinical and theoretical frameworks for enhancing the effects of antidepressants in cases of clinical refractoriness and side-effects.
To focus these theories on the female patient with consideration of premenstrual, pregnancy, post-partum situations and the pot-menopausal frameworks.

The incidence of depression lifetime in women is 1 in 4. About 80% of depression are associated with a yet more common condition, anxiety. Women may be more predisposed to these conditions at special times namely premenstrually, during pregnancy, post-partum situations and the post-menopausally. Each of these have unique elements. Anxiety and depression in women is unique as well as generalizable to male experience.

The current classifications of anxiety and depression has historical and epidemiologic limitations. Depression and anxiety manifestations are separate and differentiated but they strongly overlap.

We review special perspectives viewed along the normal - abnormal continuum, as well as the frameworks of somatic and psychic anxiety, and cognitive and vegetative features of depression. Similarly, special subdivisions lead to a more fruitful approach as to the patientās pharmacologic needs.

Legitimate approaches such as antidepressant, azapirone (buspirone) and beta-adrenergic blockers are examined. Specialized groups such as addicts, medically ill and geriatric patients, have their own particular problems.

Three clinical scenarios relate to patients who fail treatment after receiving selective serotonin re-uptake inhibitor drugs. Acutely, they may experience the "I'm climbing out of my skin" feeling; more chronically over several weeks the "It's not working anymore" complaint; and over many months an "It worked so well before" amazement. This paper examines theoretical and practical options using combination serotonin antidepressant therapy. Buspirone is the only marketed azapirone (approved for use only in anxiety and mixed anxiety depressive states). However, clinical experience in several other areas is interesting but still at various early research stages, such as serotonin re-uptake inhibitors like fluoxetine induce a serotonergic akathisia which can be blocked by buspirone; or when SSRI compounds stop working with re-exacerbation of depression, adjunctive use of azapirones may theoretically extend their action.

Psychopharmacology is rapidly approaching the age of specialized receptorology and serotonin subtypes play a major role in management of both anxiety and depression. The advent of the azapirones and the new antidepressants such as nefazodone and venlafaxine has been a significant advance and may exemplify the neuromodulating roles played by varying doses of drug impinging on a specific receptors like serotonin 1A and the balance of blockade and re-uptake inhibition at serotonin and norepinephrine levels. Nefazodone and venlafaxine are examined as fruitful alternatives to the SSRIs.

A broader theory of management of such patients can be developed with the understanding of concepts such as neuromodulation, partial agonism and the serotonin bathtub analogy. Moreover, serotonin modulates many basic functions at a large number of levels allowing explanations of such conundrums as the delayed effects of antidepressants. Finally receptor specificity is critical to appreciating why drugs work and fail.