Depression Treatment

This article outlines some general treatment information and guidelines which you may want to take into consideration when seeking treatment for clinical depression. There are a wide variety of treatment options available for depression, and it’s highly likely you will find one that works for you.

You should know upfront that research does not predict individual responses to the specific depression treatments. In other words, just because it works for some (or even most) people does not mean it will work for you. It’s important to keep this in mind as you or a loved one undergoes treatment for depression, because the first treatment or set of treatments tried may not be effective.

Most clinicians practicing today believe that depression is caused by an equal combination of biological (including genetics), social, and psychological factors. A treatment approach that focuses exclusively on one of these factors is not likely to be as beneficial as a treatment approach that addresses both psychological and biological aspects (through, for example, psychotherapy and medication). Depression remains a complicated, complex disorder and researchers are only beginning to fully grasp the multitude of factors — personal, genetic, biological, societal, and environmental — that are involved. Any explanation or approach which emphasizes only one factor as the cause of depression is misleading and simplistic. Individuals should avoid accepting a simplistic answer to such a devastating and complex disorder.

Treatment for depression, like for most mental disorders, usually relies on psychotherapy and medication for the quickest, strongest effects (read the article Psychotherapy, Medication or Both? if you’d like to learn more about the research). Treatment is usually begun immediately after the initial clinical interview with a mental health professional.

Depression treatment takes time and patience is needed. The effects of medications will usually be felt within 6 to 8 weeks of taking an antidepressant, but not everyone feels better on the first medication tried. You may have to try 2 or 3 different medications before finding the one that works for you. The same may also be true for psychotherapy — the first therapist may not be the one you end up working with. Most modern psychotherapy treatment for depression takes 6 to 12 months, going once per week for 50 minutes at a time.
Psychotherapy

There are a wide number of different types of effective therapeutic approaches utilized for the treatment of depression today. These range from cognitive behavioral therapy, to behavioral therapy (ala Lewinsohn), to interpersonal therapy, to rational emotive therapy, to family and psychodynamic approaches. Both individual and group modalities are commonly used, depending upon the severity of the depressive episode and the local resources within an individual’s community.

Cognitive-behavioral therapy is the most popular and commonly used therapy for the effective treatment of depression. Hundreds of research studies have been conducted to date which verify its safety and effectiveness in use to help treat people who suffer from this disorder. Aaron T. Beck is the father of this therapeutic technique and he has authored books and studies supporting cognitive-behavioral therapy. Consisting of a number of useful and simple techniques which focus on the internal dialogue which takes place within a person’s mind, cognitive-behavioral therapy is not concerned with causes of the depression so much as what a person can do, right now, to help change the way they are feeling.

Therapy begins by establishing a supportive therapeutic environment which is positive and reinforcing for the individual. Educating the client within the first session or two is usually the next step about how depression for many people is caused by faulty cognitions. The numerous types of faulty thinking that we as humans do are discussed (e.g., “all or nothing thinking,” “misattribution of blame,” “overgeneralization,” etc.) and the client is encouraged to begin noting his or her thoughts as they occur throughout the day. This is imperative to further success in treatment, for the individual must understand how common and often these thoughts are occurring during a single day.

In cognitive-behavioral therapy, emphasis is placed on discussing these thoughts and the behaviors associated with depression. While emotions are certainly a focus of some of the time throughout therapy, it is thought within this theoretical framework that thoughts and behaviors are more likely to change emotions than trying to attempt a post-mortem analysis of why a person is feeling the way they are. Because of this approach, cognitive-behavioral therapy is short-term (usually conducted under two dozen sessions) and works best for people experiencing a fair amount of distress relating to their depression. Individuals who can approach a problem from a unique perspective and those who are more cognitively-oriented are also likely to do better with this approach.

Topics Covered in This Depression Treatment Article:

    Introduction
    Psychotherapy
    Hospitalization
    Medications
    Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS)
    Self-Help
    Psychotherapy, Medication or Both?
    References

Psychotherapy for Depression Continued…

Interpersonal therapy is another short-term therapy utilized in the treatment of depression. Focus of this treatment approach is usually on an individual’s social relationships, and specifically on how to improve them. It is thought that good, stable social support is imperative to a person’s overall well-being and health within this framework. When relationships falter, a person directly suffers from the negativity and unhealthiness of that relationship. Therapy seeks to improve a person’s relationship skills, working on communication more effectively, expressing emotions appropriately, being properly assertive in social and occupational situations, etc. It is usually conducted, like cognitive-behavioral therapy, on an individual basis but can also be used within a group therapy
framework.

Most individual psychotherapy approaches, whether they are cognitive-behavioral, interpersonal, behavioral, rational-emotive, or what-not, will emphasize the importance of the client taking a pro-active approach in therapy. That is, the patient is encouraged to do daily or weekly homework assignments in-between therapy sessions which are imperative to the success of the treatment approach. Therapy is an active collaboration between therapist and client. If the client is not yet able to participate actively in therapy, then a supportive environment should be provided until medication helps energize the individual further.

Psychoanalytic or psychodynamic approaches in the treatment of depression have little research to support their use at this time. While many therapists may make use of psychodynamic theoretical constructs to help conceptualize an individual’s personality or specific case, it is likely that applied approaches in these areas are ineffective and should be avoided.

Family or couples therapy should be considered when the individual’s depression is directly affecting family dynamics or the health of significant relationship. Such therapy focuses on the interpersonal relationships shared amongst family members and seeks to ensure that communications are clear and without double (hidden) meanings. The roles played by various family members in reinforcing the depression within the patient are often examined as well. Education about depression in general can also be an important role of such therapy. [15]

Individuals who suffer from seasonal affective disorder, a form of depression which is related to the change of the seasons within their geographic location, may benefit from bright light phototherapy. [40]
Hospitalization

Hospitalization of an individual is necessary when that person has attempted suicide or has serious suicidal ideation or plan for doing so. Such suicidal intentions must be carefully and fully assessed during an initial meeting with the client. The individual must be imminent danger of harming themselves (or another). Daily, routine daily functioning will likely be negatively affected by the presence of a clear and severe major depression. Most individuals who suffer from major depression, however, are usually only mildly suicidal and most also often lack the energy or will (at least initially) to carry out any suicidal plan.

Care must be taken with regards to any hospitalization procedure. When possible, the patient’s consent and full understanding should first be obtained and the client encouraged to check him or herself in. Hospitalization is usually relatively short, until the patient becomes fully stabilized and the therapeutic effects of an appropriate antidepressant medication can be realized (3 to 4 weeks). A partial hospitalization program should also be considered.

Suicidal ideation should be assessed during regular intervals throughout therapy (every week during the therapy session is not uncommon). Often, as the individual who suffers from a depressive disorder is beginning to feel the energizing effects of a medication, they will be at higher risk for acting on their suicidal thoughts. Care should be used at this time and hospitalization may need to be again considered.

Topics Covered in This Depression Treatment Article:

    Introduction
    Psychotherapy
    Hospitalization
    Medications
    Electroconvulsive Therapy (ECT) and Repetitive Transcranial Magnetic Stimulation (rTMS)
    Self-Help
    Psychotherapy, Medication or Both?
    References

Medications for Depression

The most commonly prescribed medications for depression are referred to as antidepressants. Most antidepressants prescribed today are both safe and effective when taken as directed by your physician or psychiatrist. Although most antidepressants in the U.S. are prescribed by family doctors or general practitioners, you should nearly always seek out a psychiatrist for the best treatment of depression with medications.

A class of antidepressants called selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed medication for depression today. Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are the most commonly prescribed brand names. SSRI medications should not be prescribed in conjunction with the older MAOIs (more popular in Europe than in the U.S.). SSRIs work on increasing the amount of serotonin in the brain. Researchers are not sure why an increase in serotonin helps relieve depression (there’s little evidence of support for the serotonin theory of depression), but decades’ worth of studies suggest such medications nonetheless help improve mood.

SSRI antidepressant medications were once thought to have lesser side effects than other antidepressants, but research in the past decade suggests differently. While SSRI antidepressants appear to be safe, most people will experience side effects while taking them, such as nausea, diarrhea, agitation, insomnia, or headache. For most people, these initial side effects will go away within 3 to 4 weeks.

Many people taking an SSRI complain of sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some people also experience tremors with SSRIs. Serotonin syndrome is a rare but serious neurological condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances.

Long-term side effects of taking SSRI medications for more than a year include sleep disturbance, sexual dysfunction, and weight gain.

Depression treatment takes time and patience is needed. The large-scale, multi-clinic government research study called STAR*D found that people with depression and who take a medication often need to try different brands and be patient before they find one that works for them. The effects of medications will usually be felt within 6 to 8 weeks of taking an antidepressant, but not everyone feels better on the first medication tried. You may have to try 2 or 3 different medications before finding the one that works for you.

Results from the STAR*D study indicate that if a first treatment with one SSRI fails, about one in four people who choose to switch to another medication will get better, regardless of whether the second medication is another SSRI or a medication of a different class. And if people choose to add a new medication to the existing SSRI, about one in three people will get better. It appears to make some — but not much — difference if the second medication is an antidepressant from a different class (e.g. bupropion) or if it is a medication that is meant to enhance the SSRI (e.g. buspirone). Because the switch group and the add-on group cannot be directly compared to each other, it is not known whether patients are more likely to get better by switching medications or by adding another medication.

Results from one of the findings of the study apply to those who do not get better after two medication treatment steps. At this stage, by switching to a different antidepressant medication, about one in seven people will get better and by adding a new medication to the existing one, about one in five people will get better. Finally, for patients with the most treatment-resistant depression, additional results suggest that tranylcypromine is limited in its tolerability and that up to 10 percent may benefit from the combination of venlafaxine-XR/mirtazapine.

An overall analysis of the STAR*D results indicates that patients with difficult-to-treat depression can get well after trying several treatment strategies, but the odds of beating the depression diminish with every additional treatment strategy needed. In addition, those who become symptom-free have a better chance of remaining well than those who experience only symptom improvement. And those who need to undergo several treatment steps before they become symptom-free are more likely to relapse during the follow-up period. Those who required more treatment levels tended to have more severe depressive symptoms and more co-existing psychiatric and general medical problems at the beginning of the study than those who became well after just one treatment level.

Other medications may also be of help. Atypical antidepressants are often prescribed when a person hasn’t improved with a common SSRI. Such medications include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin). Abilify (aripiprazole) is also an aytpical antipsychotic that is approved for the use in the treatment of depression. It is the first medication approved by the U.S. Food and Drug Administration for “add-on treatment.” That is, your doctor can prescribe it to you even if you’re already taking an antidepressant. In clinical studies, when Abilify was added to an antidepressant treatment, many people experienced significant improvement of their depressive symptoms.