A. Palma, P. Pancheri - Vol. 6, Dicembre 2000, num.4
Testo Immagini Bibliografia Summary Riassunto Indice
Costrutti Teorici ed Obiettività clinico-sperimentale
dell'intervento terapeutico nelle Depressioni Minori, "Sintomatiche Subcliniche"
o "Subsindromiche"
Theoretical constructs and clinical-experimental objectivity of therapeutic
intervention in Minor,
"Sub-clinical Symptomatic" or "Sub-syndromal" Depressions
Background and objectivesReference criteria to decide whether to treat or not sub-clinical depressions, and the threshold for such treatment are currently unclear. Our paper aims at offering some reflections on the indications and contraindications of various therapeutic interventions proposed for "Subsyndromal Depressions", otherwise called "Sub-clinical Symptomatic Depression" (SSD) or "Minor Depressions". After a brief summary of general indications established according to international guidelines for the psychological or biological (somatic) treatment of depressive disorders, the concept of normal vs. pathological in psychiatry to decide therapeutic threshold is dealt with, with particular reference to the clinical features of Sub-syndromal Depression. Finally, some considerations are made on some experimental data and clinical criteria of antidepressant drug efficacy of molecules most frequently used in the treatment of SSD. For the sake of completeness, reference is made also to the efficacy of some psychotherapies and to the "clinical role" of some currently widely used phytotherapeutic preparations.
Method
To define drug choice criteria in "Minor" e "Sub-syndromal"
depressions, we took into account data in literature relative to the potency/tolerability
ratio of the main antidepressant molecules, which we considered here on the
basis of their neurotransmitter systems orientation, according to a clinical
dimensional approach. The drug choice that empirically showed the best efficacy
proved, in fact, to be one that does consider essentially a diagnostic "category",
but that instead assesses the dominant symptomatology, symptoms associated
with comorbidity and other clinical parameters with a manifest dimensional
connotation.
Results and conclusions
In minor and sub-syndromal depressions, the definition of the biological substrate
and trait is given priority as regards the most adequate pharmacodynamic profile
to the patient’s temperament and clinical history. Data in literature agree
in indicating the most well-tolerated antidepressant molecules. Antidepressant
drug safety and tolerability are factors of the utmost importance for ensuring
therapeutic continuity. According to some authors, these two pharmacodynamic
characteristics allow for a greater control of the risk of recurrences, of
clinical pictures of increased severity, often chronic and with suicidal tendency,
which specially in SSD, is unpredictable. In fact, suicide has been frequently
described in subjects with family history positive for psychiatric disorders
and affected by recurrent minor depression or in cases of mild depression
with associated anxiety and/or severe somatic disorders. Unfortunately, studies
published on this topic are scanty and most controlled studies on the biological
treatment of SSD regards the use of 5-HT agonists. According to these data,
the therapeutic option to prefer is that with a demonstrated high tolerability,
hence regards drugs with a prevalent serotonergic activity, slow-release antidepressant
preparations or substances with a "paraphysiological" mechanism
of action, such as sulpho-adenosine methionine (SAMe). Furthermore, low initial
doses and drugs with rapid onset of activity are indicated. In patients with
sub-syndromal depressive features, the study of "target dimensional areas"
and premorbid temperamental structure is a modality that showed reduced risk
of stimulating individual biological susceptibility and that generally increases
compliance to drug prescription. Regarding psychological intervention, some
meta-analytical studies point at a greater effectiveness of cognitive-behavioural
psychotherapies with respect to insight-oriented (psychodynamic/psychoanalytical)
psychotherapies. Furthermore, it appears that the combination of a psychological
and a biological therapy increases antidepressant drug compliance; in fact,
in some cases, somatic side effect complaints are reduced. Generally, psychotherapy
is indicated in mild depressive forms provided that psychotic aspects, recurrent
course of the disorder or melancholic traits with suicide risk are not present.
It should be underlined that despite the great current demand for phytotherapeutic
compounds, side effects related to their use remain unclear as well as their
minimal effective and optimal doses for multiple conditions of "non-specific
upset".