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Treatments for Depression
Last Updated: Dec. 1, 2003
The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, a psychological evaluation for depression should be done by the physician or by referral to a mental health professional.
Medications
There are several types of medications used to treat depression. These include newer antidepressant medications – chiefly the selective serotonin reuptake inhibitors (SSRIs) – and older ones – the tricyclics and the monoamine oxidase inhibitors (MAOIs).
The SSRIs, and other newer medications that affect neurotransmitters such as dopamine or norepinephrine, generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does.
Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, medication should never be discontinued without talking to your doctor about it. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.
Research has shown that people with bipolar disorder are at risk of switching into mania, or of developing rapid cycling episodes, during treatment with antidepressant medication. Therefore, “mood-stabilizing” medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, the potential mood-stabilizing effects of newer medications continue to be evaluated through research.
Medications for depressive disorders are not habit-forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, these treatments have to be carefully monitored to see if the most effective dosage is being given. The doctor will check the dosage of each medicine and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.
Medications of any kind – prescribed, over-the-counter, or borrowed – should never be mixed without consulting a doctor. Other health professionals, such as a dentist or other medical specialist, who may prescribe a drug should be told of the medications the patient is taking. Some medications, although safe when taken alone can, if taken with others, cause severe and dangerous side effects.
Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally under close supervision in medically ill depressed patients.
Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this illness. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, valproate and carbamazepine. Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania.
Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.
Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.
Psychotherapies
Several forms of psychotherapy, including some short-term (10-20 weeks) therapies, can help people with depressive disorders. Two of the short-term psychotherapies that research has shown to be effective for depression are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT).
Cognitive-behavioral therapists help patients change the negative thinking and behavior patterns that contribute to or result from depression. Through verbal exchange with the therapist, as well as “homework” assignments between therapy sessions, CBT helps patients gain insight into and resolve problems related to their depression. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression.
For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment.
Electroconvulsive therapy
Electroconvulsive therapy (ECT) is another treatment option that may be particularly useful for individuals whose depression is severe or life threatening, or who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. The exact mechanisms by which ECT exerts its therapeutic effect are not yet known.
In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) generalized seizure within the brain, which is necessary for therapeutic efficacy. The person receiving ECT does not consciously experience the electrical stimulus.
A typical course of ECT entails 6 to 12 treatments, administered at a rate of three times per week, on either an inpatient or outpatient basis. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, must be instituted. Some individuals may require maintenance ECT, which is delivered on an outpatient basis.
Herbal therapy
In the past several years, there has been an increase in public interest in the use of herbs for the treatment of both depression and anxiety. The extract from St. John’s wort (Hypericum perforatum), a wild-growing plant with yellow flowers, has been used extensively in Europe as a treatment for mild to moderate depression, and it now ranks among the top-selling botanical products in the United States.
Because of the increase in Americans’ use of St. John’s wort and the need to answer important remaining questions about the herb's efficacy and long-term use for depression, the National Institutes of Health (NIH) conducted a four-year clinical trial to determine whether a well-standardized extract of St. John’s wort is effective in the treatment of adults suffering from major depression of moderate severity. The trial found that St. John’s wort was no more effective for treating major depression of moderate severity than placebo. More research is needed to confirm the role of the herb in managing less severe forms of depression.
The Food and Drug Administration issued a Public Health Advisory on February 10, 2000 about the use of St. John’s wort. It stated that the herb appears to affect an important metabolic pathway that is used by many drugs prescribed to treat conditions such as heart disease, depression, seizures, certain cancers, and rejection of organ transplants. Also, St. John’s wort reduces blood levels of some HIV medications. If taken together, the combination could allow the AIDS virus to rebound, perhaps in a drug-resistant form. (See the alert on the NIMH Web site: http://www.nimh.nih. gov/events/stjohnwort.cfm).
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