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Depression: Options for Treatment
by The National Institute of Mental Health
Note: this is an edited excerpt from the article "Depression" published
by The National Institute of Mental Health (NIMH). See the original
here.
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Diagnostic Evaulation and Treatment of Depression
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 can cause the same symptoms as depression, and the physician
should rule out these possibilities through examination, interview, and
lab tests.
If a physical cause for the depression is ruled out, a psychological
evaluation should be done, by the physician or by referral to a
psychiatrist or psychologist.
A good diagnostic evaluation will include a complete history of
symptoms, i.e., when they started, how long they have lasted, how severe
they are, whether the patient had them before and, if so, whether the
symptoms were treated and what treatment was given.
The doctor should ask about alcohol and drug use, and if the patient has
thoughts about death or suicide.
Further, a history should include questions about whether other family
members have had a depressive illness and, if treated, what treatments
they may have received and which were effective.
Last, a diagnostic evaluation should include a mental status examination
to determine if speech or thought patterns or memory have been affected,
as sometimes happens in the case of a depressive or manic-depressive
illness.
Treatment choice will depend on the outcome of the evaluation. There are
a variety of antidepressant medications and psychotherapies that can be
used to treat depressive disorders.
Some people with milder forms may do well with psychotherapy alone.
People with moderate to severe depression most often benefit from
antidepressants.
Most do best with combined treatment: medication to gain relatively
quick symptom relief and psychotherapy to learn more effective ways to
deal with life's problems, including depression.
Depending on the patient's diagnosis and severity of symptoms, the
therapist may prescribe medication and/or one of the several forms of
psychotherapy that have proven effective for depression.
Electroconvulsive therapy (ECT) is useful, particularly 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.
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) seizure within the
brain. The person receiving ECT does not consciously experience the
electrical stimulus.
For full therapeutic benefit, at least several sessions of ECT,
typically given at the rate of three per week, are required.
Medications
There are several types of antidepressant medications used to treat
depressive disorders.
These include newer medications-chiefly
the selective serotonin reuptake inhibitors (SSRIs)-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.
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 3 to 4 weeks (in
some cases, as many as 8 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 the medication 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 individual is feeling better, it is important to continue the
medication for at least 4 to 9 months to prevent a recurrence of the
depression.
Some medications must be stopped gradually to give the body time to
adjust. Never stop taking an antidepressant without consulting the
doctor for instructions on how to safely discontinue the medication.
For individuals with bipolar disorder or chronic major depression,
medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with
any type of medication prescribed for more than a few days,
antidepressants have to be carefully monitored to see if the correct
dosage is being given.
The doctor will check the dosage 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, such as 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 the doctor.
Other health professionals who may prescribe a drug-such as a dentist or
other medical specialist-should be told of the medications the patient
is taking.
Some drugs, although safe when taken alone can, if taken with others,
cause severe and dangerous side effects.
Some drugs, like alcohol or street drugs, may reduce the effectiveness
of antidepressants and should be avoided. This includes wine, beer, and
hard liquor.
Some people who have not had a problem with alcohol use may be permitted
by their doctor to use a modest amount of alcohol while taking one of
the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They are
sometimes prescribed along with antidepressants; however, they are not
effective when taken alone for a depressive disorder.
Stimulants, such as amphetamines, are not effective antidepressants, but
they are used occasionally under close supervision in medically ill
depressed patients.
Questions about any antidepressant prescribed, or problems that may be
related to the medication, should be discussed with the doctor.
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 disorder.
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, carbamazepine (Tegretol®) and valproate (Depakote®).
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.
Other anticonvulsants that are being used now include lamotrigine
(Lamictal®) and gabapentin (Neurontin®): their role in the treatment
hierarchy of bipolar disorder remains under study.
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.
Side Effects
Antidepressants may cause mild and, usually, temporary side effects
(sometimes referred to as adverse effects) in some people.
Typically these are annoying, but not serious. However, any unusual
reactions or side effects or those that interfere with functioning
should be reported to the doctor immediately.
The most common side effects of tricyclic antidepressants, and ways to
deal with them, are:
a.. Dry mouth-it is helpful to drink sips of water; chew sugarless gum;
clean teeth daily.
b.. Constipation-bran cereals, prunes,
fruit, and vegetables should be in the diet.
c.. Bladder problems-emptying the bladder may be troublesome, and the
urine stream may not be as strong as usual; the doctor should be
notified if there is marked difficulty or pain.
d.. Sexual problems-sexual functioning may change; if worrisome, it
should be discussed with the doctor.
e.. Blurred vision-this will pass soon and will not usually necessitate
new glasses.
f.. Dizziness-rising from the bed or chair slowly is helpful.
g.. Drowsiness as a daytime problem-this usually passes soon. A person
feeling drowsy or sedated should not drive or operate heavy equipment.
The more sedating antidepressants are generally taken at bedtime to help
sleep and minimize daytime drowsiness.
The newer antidepressants have different types of side effects:
a.. Headache-this will usually go away.
b.. Nausea-this is also temporary, but even when it occurs, it is
transient after each dose.
c.. Nervousness and insomnia (trouble falling asleep or waking often
during the night)-these may occur during the first few weeks; dosage
reductions or time will usually resolve them.
d.. Agitation (feeling jittery)-if this happens for the first time after
the drug is taken and is more than transient, the doctor should be
notified.
e.. Sexual problems-the doctor should be consulted if the problem is
persistent or worrisome.
Herbal Therapy
In the past few years, much interest has risen in the use of herbs in
the treatment of both depression and anxiety. St. John's wort (Hypericum
perforatum), an herb used extensively in the treatment of mild to
moderate depression in Europe, has recently aroused interest in the
United States.
St. John's wort, an attractive bushy, low-growing plant covered with
yellow flowers in summer, has been used for centuries in many folk and
herbal remedies.
Today in Germany, Hypericum is used in the treatment of depression more
than any other antidepressant. However, the scientific studies that have
been conducted on its use have been short-term and have used several
different doses.
Because of the widespread interest in St. John's wort, the National
Institutes of Health (NIH) conducted a 3-year study designed to include
336 patients with major depression of moderate severity, randomly
assigned to an 8-week trial with one-third of patients receiving a
uniform dose of St. John's wort, another third sertraline, a selective
serotonin reuptake inhibitor (SSRI) commonly prescribed for depression,
and the final third a placebo (a pill that looks exactly like the SSRI
and the St. John's wort, but has no active ingredients).
The study participants who responded positively were followed for an
additional 18 weeks. At the end of the first phase of the study,
participants were measured on two scales, one for depression and one for
overall functioning.
There was no significant difference in rate of response for depression,
but the scale for overall functioning was better for the antidepressant
than for either St. John's wort or placebo.
While this study did not support the use of St. John's wort in the
treatment of major depression, ongoing NIH-supported research is
examining a possible role for St. John's wort in the treatment of milder
forms of depression.
The Food and Drug Administration issued a Public Health Advisory on
February 10, 2000.
It stated that St. John's wort appears to affect an important metabolic
pathway that is used by many drugs prescribed to treat conditions such
as AIDS, heart disease, depression, seizures, certain cancers, and
rejection of transplants.
Therefore, health care providers should alert their patients about these
potential drug interactions.
Some other herbal supplements frequently used that have not been
evaluated in large-scale clinical trials are ephedra, gingko biloba,
echinacea, and ginseng.
Any herbal supplement should be taken only after consultation with the
doctor or other health care provider.
Psychotherapies
Many forms of psychotherapy, including some short-term (10-20 week)
therapies, can help depressed individuals. "Talking" therapies help
patients gain insight into and resolve their problems through verbal
exchange with the therapist, sometimes combined with "homework"
assignments between sessions.
"Behavioral" therapists help patients learn how to obtain more
satisfaction and rewards through their own actions and how to unlearn
the behavioral patterns that contribute to or result from their
depression.
Two of the short-term psychotherapies that research has shown helpful
for some forms of depression are interpersonal and cognitive/behavioral
therapies.
Interpersonal therapists focus on the patient's disturbed personal
relationships that both cause and exacerbate (or increase) the
depression.
Cognitive/behavioral therapists help
patients change the negative styles of thinking and behaving often
associated with depression.
Psychodynamic therapies, which are sometimes used to treat depressed
persons, focus on resolving the patient's conflicted feelings.
These therapies are often reserved until the depressive symptoms are
significantly improved. In general, severe depressive illnesses,
particularly those that are recurrent, will require medication (or ECT
under special conditions) along with, or preceding, psychotherapy for
the best outcome.
How to Help Yourself if You are Depressed
Depressive disorders make one feel exhausted, worthless, helpless, and
hopeless. Such negative thoughts and feelings make some people feel like
giving up.
It is important to realize that these negative views are part of the
depression and typically do not accurately reflect the actual
circumstances. Negative thinking fades as treatment begins to take
effect.
In the meantime:
a.. Set realistic goals in light of the depression and assume a
reasonable amount of responsibility.
b.. Break large tasks into small ones, set some priorities, and do what
you can as you can.
c.. Try to be with other people and to confide in someone; it is usually
better than being alone and secretive.
d.. Participate in activities that may make you feel better.
e.. Mild exercise, going to a movie, a ballgame, or participating in
religious, social, or other activities may help.
f.. Expect your mood to improve gradually, not immediately. Feeling
better takes time.
g.. It is advisable to postpone important decisions until the depression
has lifted. Before deciding to make a significant transition-change
jobs, get married or divorced-discuss it with others who know you well
and have a more objective view of your situation.
h.. People rarely "snap out of" a depression. But they can feel a little
better day-by-day.
i.. Remember, positive thinking will replace the negative thinking that
is part of the depression and will disappear as your depression responds
to treatment.
j.. Let your family and friends help you.
How Family and Friends Can Help the Depressed Person
The most important thing anyone can do for the depressed person is to
help him or her get an appropriate diagnosis and treatment.
This may involve encouraging the individual to stay with treatment until
symptoms begin to abate (several weeks), or to seek different treatment
if no improvement occurs.
On occasion, it may require making an appointment and accompanying the
depressed person to the doctor. It may also mean monitoring whether the
depressed person is taking medication.
The depressed person should be encouraged to obey the doctor's orders
about the use of alcoholic products while on medication.
The second most important thing is to offer emotional support. This
involves understanding, patience, affection, and encouragement. Engage
the depressed person in conversation and listen carefully.
Do not disparage feelings expressed, but point out realities and offer
hope.
Do not ignore remarks about suicide. Report them to the depressed
person's therapist. Invite the depressed person for walks, outings, to
the movies, and other activities. Be gently insistent if your invitation
is refused.
Encourage participation in some activities that once gave pleasure, such
as hobbies, sports, religious or cultural activities, but do not push
the depressed person to undertake too much too soon.
The depressed person needs diversion and company, but too many demands
can increase feelings of failure.
Do not accuse the depressed person of faking illness or of laziness, or
expect him or her "to snap out of it." Eventually, with treatment, most
people do get better.
Keep that in mind, and keep reassuring the depressed person that, with
time and help, he or she will feel better.
Where to Get Help
If unsure where to go for help, 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 will make a
referral to, or provide, diagnostic and treatment services.
a.. Family doctors
b.. Mental health specialists, such as psychiatrists, psychologists,
social workers, or mental health counselors
c.. Health maintenance organizations
d.. Community mental health centers
e.. Hospital psychiatry departments and outpatient clinics
f.. University- or medical school-affiliated programs
g.. State hospital outpatient clinics
h.. Family service, social agencies, or clergy
i.. Private clinics and facilities
j.. Employee assistance programs
k.. Local medical and/or psychiatric societies
Resources for Depression
a.. Depression
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
Rm 12-105 Parklawn Building
Rockville, MD 20857
Phone: 301-443-8956
Fax: 301-443-9050
http://www.samhsa.gov/
b.. National Institute of Mental Health
Office of Communications
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513
Fax: 301-443-4279
TollFree: 1-866-615-NIMH (6464)
TTY: 301-443-8431
http://www.nimh.nih.gov
c.. American Psychiatric Association (APA)
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901
Phone: 703-907-7300
http://www.psych.org/index.cfm
d.. American Psychological Association
750 1st Street, NE
Washington, DC 20002-4242
Phone: 202-336-5510
TollFree: 1-800-374-2721
http://www.apa.org
e.. Depression After Delivery, Inc. (DAD)
91 East Somerset Street
Raritan, NJ 08869
TollFree: (800) 944-4773
http://www.depressionafterdelivery.com
f.. Depression and Related Affective Disorders Association (DRADA)
2330 West Joppa Road, Suite 100
Lutherville, MD 21093
Phone: 410-583-2919
Email:
mailto:drada%40jhmi.edu
http://www.drada.org/
g.. National Alliance for Research on Schizophrenia and Depression
(NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021
Phone: 516-829-0091
TollFree: 800-829-8289
Email:
info@narsad.org
http://www.narsad.org
Reviewed October 4, 2005 by V. J. Smith, RN, BSN, MA.
http://www.hepatitisneighborhood.com/content/treatment_options/lifestyles_and_emotions_1972.aspx
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