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Depression Overview Treatment options range from medications and psychotherapy to deep brain stimulation and electroshock therapy. Which treatments your mental health professional recommends will depend in part on the results of the evaluation. Some people with milder forms may do well with psychotherapy alone. Those with moderate or severe forms of depression most often benefit from medications. Often, the best treatment is a combination of psychotherapy and medication: With medication, the symptoms are alleviated fairly quickly, while psychotherapy helps the patient learn to deal more effectively with life's problems. All forms of depression can also be alleviated with exercise, a healthy diet, and regular sleep. This section includes more on:
Where to turn for help Although psychiatrists are likely to be involved at some point in the treatment for depression--if only to prescribe medication--it is not essential to see one when the symptoms begin. There are a number of different places to turn for help. If you are unsure of where to start, you can even check the yellow pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for an emotional problem and will be able to tell you where and how to get further help. Listed below are the types of people and places that can provide diagnostic and treatment services or refer you to individuals who can.
Lifestyle adjustments Although eating well and exercising are vital parts of any prescription for general good health and well-being, depression usually saps you of the motivation to pursue either. Shopping for nutritious foods and then preparing them, even marching yourself around the block, can be arduous tasks when deep in depression. Both diet and exercise can contribute to an increased sense of control and trigger positive neurochemical changes, however, that support other treatments for depression. By contrast, alcohol can exacerbate depression, so you should drink moderately, if at all. Strategies for limiting stress can also help alleviate depression. Meditation especially has been proven to be effective in helping depressed patients control the obsessive thinking and anxiety that are associated with the illness. Turning to family or friends for support is also key during depressive episodes. Psychotherapy Many forms of psychotherapy can help depressed individuals. "Talking therapies" help patients gain insight into their problems through a conversation with the therapist. Sometimes this is supplemented with "homework" assignments between sessions. "Behavioral" therapists help patients learn how to gain more satisfaction from life by helping them "unlearn" the behavioral patterns that contribute to their depression, among other strategies. Two of the short-term (10 to 20 once-a-week sessions) psychotherapies that research has demonstrated are helpful for some forms of depression are interpersonal and cognitive behavioral therapies. Interpersonal therapy focuses on the patients' disturbed personal relationships that can both cause a depression and make it worse. Cognitive behavioral therapy helps patients change the negative styles of thinking and behaving that are often associated with depression. When patients are able to become aware of the triggers in their thoughts or behavior that may make them feel worse, they then can consciously change their reactions to them. Psychodynamic therapy focuses on resolving the patient's conflicted feelings. It often centers on the way that unhappy childhood experiences may be resonating through adulthood. This type of therapy is often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication along with, or preceding, psychotherapy. Medications Several types of medications are used to treat depressive disorders. The newer medicines are known as the selective serotonin reuptake inhibitors (SSRIs). The older medicines are tricyclics and the monoamine oxidase inhibitors (MAOIs). The SSRIs and other new medications that affect neurotransmitters, like dopamine, norepinephrine, and serotonin, generally have fewer side effects than the tricyclics. But with all these medications, managing the side effects--like the loss of sex drive, nausea, sleeplessness, weight gain, and headaches--can be as challenging as dealing with the depression itself. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for at least three or four weeks (in some cases, as many as eight weeks) before patients feel the full therapeutic benefit. One great danger is stopping the medications too soon. Patients may feel better and think they no longer need medication, or they conclude that because the medication hasn't made them feel immediately better it isn't going to help them. But it is important to continue taking the medication until it has time to work, even if the side effects appear before the depression lifts. Once the individual begins to feel better, the medications should be continued for at least four to nine months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust. No antidepressant medication should ever be stopped without a doctor's supervision and instructions on the safest approach. For individuals with bipolar disorder or chronic major depression, the medication may have to be maintained indefinitely. This section has more on:
Side effects to antidepressants Most adverse reactions to antidepressants are annoying or temporary and not serious. However, any side effect or reaction that seems especially uncomfortable or intrusive should be reported to the doctor immediately. SSRIs The past decade has seen the introduction of new antidepressants that work as well as the older ones but with fewer side effects. A group of these medications primarily affect one neurotransmitter--serotonin--and are called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), and citalopram (Celexa). The great benefit of these medicines is that their dosage does not have to be carefully monitored with frequent blood tests, like some of the older antidepressants, because the SSRIs are not fatal in an overdose. As a result, increasingly general practitioners, internists, even pediatricians feel comfortable prescribing the SSRIs, and psychiatrists often use them as the first line of treatment before resorting to other options. This section also includes information on side effects. Side effects of the SSRIs SSRIs are generally very well tolerated, but some side effects are typically associated with them. They include: Headache: This usually goes away quite quickly. Nausea: This also usually is temporary. But even when nausea persists, it typically is transient after each dose. Diarrhea: Generally, this is temporary and can often be eased by adjusting the dosage. Nervousness and insomnia (trouble falling asleep or waking often during the night): These may occur during the first few weeks; dosage reductions or time usually will resolve them. Agitation (feeling jittery): If this happens for the first time after the drug is taken and is more than transient, then the doctor should be notified. Sexual problems: This is one of the most frequently reported side effects and often the reason that patients discontinue use. The basic problem is markedly decreased sexual desire or libido and a difficulty in achieving orgasm. The doctor should be consulted if the problem persists and is worrisome. Monoamine oxidase inhibitors For reasons that are not entirely understood, some depressed patients respond to MAO inhibitors and to no other drugs. So although these drugs have more side effects than some of the more recently introduced antidepressants and some of the people who take them have to avoid some common foods like pickles and wine, physicians continue to prescribe them. This section has more information on side effects. Side effects of the MAO inhibitors A small number of people who take the MAO inhibitors have to avoid foods and medicines that contain high levels of the amino acid tyramine. Many cheeses, wines, and pickles, as well as medications like decongestants, must be avoided because they interact with the antidepressant and can cause a sharp increase in blood pressure. This is known as a hypertensive crisis and can cause a stroke. These medications can cause other side effects that are less serious. Below are the most common side effects of MAOIs and suggestions for how to deal with them: Headache: This is usually temporary and passes soon. But if it persists, the doctor should be consulted. Weight gain: Careful attention to both diet and exercise is important when on these medicines because weight gain often occurs. Sexual problems: Sexual functioning may change; if worrisome, it should be discussed with the doctor. Dizziness: This is the most common side effect of the drug. Reducing the dose may help, but doing so may provoke other problems. Increasing intake of water to about eight glasses a day has helped some people, as has increasing salt intake. Sometimes the use of support stockings can also alleviate the problem. Drowsiness in the daytime: This usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are usually taken at bedtime to help the person sleep and to minimize daytime problems. Insomnia: This also usually passes soon, but if it persists, an additional prescription for a sleeping aid may be required. Tricyclics and tetracyclics These drugs have been used since the 1950s for the treatment of depression. Like many of the antidepressant drugs, they work on the neurotransmitter norepinephrine. But they are especially powerful and affect other neurotransmitters as well, so those who take them must be monitored very carefully by blood tests. Unlike the SSRIs, it is possible to overdose on these medicines and die. Indeed, one of the reasons that they are not prescribed as frequently today as they were earlier is that in some patients these drugs can cause a rapid heartbeat and cardiac conduction abnormalities. Still, for people for whom neither the SSRIs nor the MAOIs are effective, the tricyclics and tetracyclics are the treatment of choice. This section includes more information on side effects. Side effects of the tricyclics and tetracyclics Below are the most common side effects of tricyclic and tetracyclic antidepressants, along with suggestions for dealing with them: Dry mouth: It is helpful to drink sips of water, chew sugarless gum, and brush teeth several times a day. Constipation: Bran cereals, prunes and other fruits, and vegetables should be in the diet. Bladder problems: Emptying the bladder may be troublesome, and the urine stream may not be as strong as it has been before. The doctor should be notified if there is marked difficulty or pain with urination. Weight gain: Careful attention to both diet and exercise is important because weight gain often occurs. Sexual problems: Sexual functioning may change. If worrisome, it should be discussed with the doctor. Blurred vision: This should pass quite quickly. Dizziness: Rising from the bed or chair more slowly is helpful. Drowsiness during the daytime: This usually passes quite quickly. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are usually taken at bedtime to help sleep and minimize daytime problems. Tachycardia: In rare cases, these medicines can cause unpredictable, rapid beating of the heart, which is known as tachycardia. While not fatal, this requires attention by the doctor and can usually be alleviated by adjusting the dose of the medication. Children and antidepressant medications Over the past few years, parents have been overwhelmed with information about the effectiveness and safety of having children take antidepressant drugs. Some reports say that the drugs--especially the SSRIs, which are the only antidepressant medications approved for children--are the best medicine for debilitating melancholy. Others say that paradoxically, the drug may increase the risk of suicide in young people. This debate has been further complicated by an ongoing controversy about whether adults who take SSRIs have higher rates of suicide. After Food and Drug Administration hearings on the subject in February of 2004, the FDA told manufacturers of antidepressant medications to place black box warnings on the drug packaging saying that antidepressants can cause suicidal actions in children and adolescents. Recently, the FDA modified its warning, saying that the drugs "increased the risk of suicidal thinking and behavior in short-term studies of adolescents and children" with depression. Teenagers and young adults are at the highest risk for suicide. Each year, about 20 percent of adolescents contemplate suicide; by the end of high school, 1 in 10 has attempted it with almost 2,000 succeeding each year. About half of those who die suffer from major clinical depression. So what are the options? Adolescent depression is a common, potentially lethal, and treatable disease. Recent studies of depression in adolescents have shown that the best treatment may be a combination of antidepressant medications and psychotherapy. While there is a risk in the use of antidepressants by adolescents, there is also a risk in doing nothing. Careful monitoring of the child's behavior during treatment is critically important. Getting in touch with the physician if there are any worrisome changes in a child's mood or behavior can do a great deal to prevent any tragic outcomes and ensure that the treatment will be successful. Electroconvulsive therapy Electroconvulsive therapy (ECT), or "shock treatment," has an unsavory reputation, mostly as a result of movies like One Flew Over the Cuckoo's Nest and The Snake Pit. And in fact, in the early days, it was a brutal procedure. But today, new, milder techniques have made wild seizures, bitten tongues, and broken bones largely a thing of the past. Basically, the treatment involves sedating a patient, then placing electrodes at certain points on the head and administering a jolt of electricity. The electric current seems to reconfigure the synaptic responses in the brain, and, while it may result in some short-term memory loss--among other side effects--it can be very effective in treating depression. The use of ECT is on the rise. In 1981, more than 33,000 people received ECT; in 2001, nearly 100,000 underwent the procedure. Repetitive transcranial magnetic stimulation (rTMS) A burgeoning number of researchers are investigating an old idea--that the brain is an electromagnetic organ and disorders like depression may result from disarray in the brain's electromagnetic functioning. The idea has huge appeal to psychiatrists and patients alike since for many people the side effects of psychiatric drugs are almost as difficult to manage as the depressive disorder itself. Further, about 30 percent of those who suffer from depression do not respond to the antidepressants available now. In rTMS, a magnetic coil placed on the scalp creates fields that induce mild electric currents in the brain. Much as a defibrillator shocks a heart into beating regularly, the magnetic pulses may jolt nerve cells into functioning more regularly. In clinical trials, many patients who failed to respond to several other treatments improved within a week of rTMS treatment, and the vast majority were significantly better after two weeks of daily 20-minute sessions. Deep brain stimulation Deep brain stimulation is the most invasive treatment of all. It involves implanting an electrode directly into a particular part of the brain. It was originally used to treat movement disorders like Parkinson's disease, but researchers found--serendipitously--that if the electrode was slightly misplaced it could either cause or alleviate the symptoms of depression, including hopelessness and suicidal thinking. Vagus nerve stimulation With vagus nerve stimulation, a stimulator is slipped into the chest wall, much as a pacemaker would be, and electrodes are attached to the left vagus nerve in the neck. Recently, the FDA approved a vagus nerve stimulation system for people with treatment-resistant depression. St.-John's-wort Hypericum perforatum, or St.-John's-wort, has been promoted as having antidepressant properties. It can be taken in three forms: capsules, teas (where the dried herb is added to boiling water and steeped for a time), and extracts (where specific types of chemicals are removed from the herb, leaving the desired chemicals in a concentrated form). Some people who suffer from mild to moderate depression and do not want to take antidepressants prefer to take this herbal supplement. While some European studies point to St.-John's-wort as being effective for alleviating mild to moderate depression, results from the first large-scale, controlled study of the herb for major depression revealed that the herb was no more effective than a sugar pill, or placebo, for treating major depression of moderate severity. More research is needed to look at the role of St.-John's-wort in managing less severe forms of depression. But it is important to note that there is evidence that the herb can reduce the effectiveness of certain medications, and its use should be discussed with a doctor before it is tried. This section has more on adverse reactions. St.-John's-wort and adverse reactions Many so-called natural substances can have harmful effects--especially if they are taken in too large a quantity or they interact with something else the person is taking. St.-John's-wort interacts with a variety of drugs, including certain drugs used to control HIV infection (such as indinavir) and chemotherapeutic, or anticancer, drugs (such as irinotecan). The herb may also interact with drugs that help prevent the body from rejecting transplanted organs (such as cyclosporine). Using St.-John's-wort limits these drugs' effectiveness. People taking St.-John's-wort can experience adverse reactions. They include a dry mouth, dizziness, diarrhea, nausea, increased sensitivity to sunlight, and fatigue. |
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