“We can not change the cards we are dealt, just how we play the hand”
– Randy Pausch
Ok, so I understand that depressive disorders are common and that there are many factors that contribute to its development. But, what can I do about it and does it even need to be treated?
Why is it Important to Treat Depression?
Seeking treatment for depression can be life saving. Suffering from depression goes beyond mood changes. 2/3 people with depression have suicidal thoughts and 10-15% actually commit suicide. Furthermore, being depressed can cause many physical ailments. These conditions include diabetes, cerebrovascular disease, heart disease, chronic obstructive pulmonary disease, cancer and sexual disorders. People with depressive disorders are also more likely to be diagnosed with other mental illnesses such as anxiety, obsessive compulsive, substance use and eating disorders.
What Treatment Option is Best?
When a person is first diagnosed with depression, they should have a full workup to rule out medical causes such as abnormal thyroid function. Once medical causes have been excluded, there are several treatment options. The best treatment outcomes occur with a combination of medications and psychotherapy. Those with milder symptoms may benefit from either one by itself.
What Medications Are Available?
There are many medications to choose from. Only 1/3 of people have full remission with the first medication that they try. However, after up to 4 medication trials 70% experience recovery. The initial medication is chosen based on specific symptoms, co occurring illnesses, prior successful trials and avoidance of side effects. First line therapy is usually an SSRI (Selective Serotonin Reuptake Inhibitor). These medications take 6 weeks at therapeutic dose for full effect. Some common ones include Zoloft, Prozac, and Paxil. SNRI’s (Selective Serotonin Norepinephrine Reuptake Inhibitors) are another commonly used class and include Effexor and Cymbalta. Less frequently used options include TCAs, MOAIs, mood stabilizers and antipsychotics. Treatment should be continued for at least 6 months or the length of the previous depressive episode, whichever is longer. Those with recurrent episodes should consider continuing medication indefinitely.
What Psychotherapies are Efficacious?
Interpersonal and cognitive-behavioral therapy have shown the greatest benefit in depressive disorders. Interpersonal therapy addresses and works to improve relationships between the patient and other people. Cognitive-behavioral therapy examines cognitive distortions such as the cause and validity of perceived negative events in a person’s life. Additionally, this therapy addresses maladaptive behaviors and helps teach the client how to interact with the world in a way that will generate positive feedback. Other therapies that have shown promise include family therapy and psychodynamic therapy. Psychodynamic therapy examines the subconscious and it’s affect on a person’s state of being.
I’ve Heard of Shock Therapy. What is That?
Treatment resistant depression responds well to ECT (electroconvulsive therapy). 70-90% of patients who fail medication and psychotherapy management achieve remission with ECT. The procedure involves inducing a small seizure in a controlled environment, thereby stimulating parts of the brain involved in depression. Results are often seen within hours, but it may take several treatments for a lasting effect. Common side effects include headache and jaw pain which resolve within a day of the procedure. Short term memory loss is another side effect that has been noted in some people and generally improves over time. some people will stay depression free with just one series of ECT treatments, while others require periodic maintenance therapy.
Are There Any Other Treatment Options?
Emerging and less conventional therapies that have shown good results include ketamine infusion, vagal nerve stimulation, transcranial magnetic stimulation, sleep deprivation, and phototherapy. Finally, it is important to note that interventions by family and friends have a huge impact even if not readily apparent. Some studies have shown similar outcomes for people who receive a monthly empathetic postcard and no other treatment to those receiving usual care.
What do you think? Have you had any positive or negative experiences with these treatment modalities? Please share your comments and questions below.