TREATMENTS FOR DEPRESSION

Of the mental disorders, depressive illnesses are among the most responsive to treatment. Advances in treatment have helped to alleviate and prevent the symptoms and complications of depression, enabling most persons to lead normal lives. Many different types of treatments are available, and the mode chosen depends on the diagnosis, severity and pattern of symptoms. The three basic types of treatment -- medications, psychosocial therapy, and electro convulsive therapy -- may be used singly or in combination.

Medication Therapy

There are numerous antidepressant medications available and more are being developed all the time. Three broad categories of medications are often prescribed: tricyclics and related heterocyclics, monoamine oxidase inhibitors (MAOIs), and lithium. In addition, selective serotonin re-uptake inhibitors (SSRIs), a new category of antidepressants, are currently widely used. Finally, bupropion has been recently marketed in the United States.

The tricyclics, SSRIs, and MAOIs alleviate a wide range of symptoms of depression and anxiety. Lithium is prescribed to control manic-depressive illness and the more recurrent forms of depression.

There are many forms of tricyclics and MAOI antidepressants, each with slightly different mechanisms of action or side effects. Since responses to these agents varies with each individual, it may be necessary to test sequences of several different medications or combinations to determine which works the best with the fewest side effects. Most antidepressant side effects, such as dry mouth, drowsiness, and constipation, occur early in treatment and subside as the body adjusts.

For the typical depression, tricyclics or heterocyclic drugs (that have three or more chemical rings to their structure) traditionally were first-choice medications. They alleviate many depressive symptoms, including loss of appetite and weight and sleep difficulty. However, for those depressed patients who experience increased appetite and sleepiness, the MAOIs are particularly likely to be useful. In addition, depressed people who have high levels of anxiety, hypochondria, and phobic characteristics may also respond well to MAOIs. Those with obsessive-compulsive symptoms are likely to respond to clomipramine (a newly marketed tricyclic in the U.S.) or other antidepressants which work on the serotonin system.

Individuals taking MAOIs must not eat certain smoked, aged, fermented, or pickled foods and, in particular, should abstain from certain medications such as over-the-counter sympathomimetic agents which open the nose or sinuses during colds or the flu. A full list of foods to be avoided will be provided by your physician.

New antidepressants such as fluoxetine, sertraline and paroxetine (all three are SSRIs) and bupropion -- are now being used in some instances as the first choice by many psychiatrists and other physicians because of their milder side-effect profile.

The serotonergic antidepressants, which on the average appear better tolerated than the older classes of medications, nonetheless have their own side effects. These include headaches which usually go away and nausea that, even when it occurs, is transient after each dose. If nervousness and insomnia occur during the first few weeks, dosage reductions over time will usually resolve them. Some patients become agitated; if this occurs for the first time after the drug is taken and is more than transient, the physician should be consulted.

The main drawback of the other new antidepressant, bupropion, is the likelihood of precipitating seizures, especially in those with a history of binge-eating; hence individuals with a personal or family history of seizure disorders should generally avoid this antidepressant, especially if bulimic. On the other hand, bupropion appears well tolerated by patients suffering from recurrent depressions with hypomania (mild manic depression) not requiring hospitalization.

Lithium is generally most effective in reducing the frequency and severity of manic-depressive cycles. However, some persons experiencing only depressive episodes, particularly those who have a family history of manic depression, also respond favorably to lithium.

In a recent National Institute of Mental Health (NIMH) study, at least 70 percent of manic-depressive patients maintained on lithium stopped having episodes or had fewer, shorter, or less severe ones. Because of its effectiveness when taken prophylactically, lithium is said to be to manic-depressive illness what insulin is to diabetes.

There are some manic-depressive patients, however, who do not respond to lithium but do respond to the anticycling medications carbamazepine or sodium valproate. This means that many patients who have rapidly changing cycles can generally be helped by the addition of one of these drugs to lithium.

Maintenance on medication is essential for persons with recurrent forms of depression, particularly manic-depressive disorder and recurring episodes of major depression. Such continuous treatment can offer essentially normal functioning to those whose lives might otherwise be painful beyond endurance. For many patients, it is useful that they receive psychotherapy to help them stay on their medication and to better cope with the psychological problems typically associated with their illness.

Psychosocial Therapies

Psychosocial therapies come in many variations and are offered for groups, families, couples and individuals. There are "talking" therapies during which problems are discussed and resolved through the emotional support, insights and understanding gained from the verbal give-and-take. Other therapies concentrate on behaviors: patients are taught to be more effective in obtaining rewards and satisfaction through their own actions. Some therapies examine the past seeking resolution of present problems by shedding light on earlier experiences. Others focus strictly on current conflicts and interpersonal problems.

Currently, among the most widely used forms of psychosocial therapy are those referred to as psychodynamic. These therapies are based on the assumption that internal psychological conflicts (e.g., wanting both to be independent and cared for, or feeling angry while believing that one should always be kind and loving) are at the heart of the patient's disorder. Resolution of such conflicts is thought to be essential to successful treatment. Unresolved conflicts maybe rooted in early childhood, with many conflicts evolving from child-parent relationships; a key aspect of such treatment involves bringing the conflict into the therapeutic situation where it can be dealt with and resolved in a more adaptive fashion. Psychodynamic therapy is typically open-ended in terms of time, but new short-term versions also are used to treat clinical depression.

Given the long-term nature of psychodynamic therapies, recent research has focused on developing more practical, focused and time-limited therapies for depression.

Short-term therapies, 10-20 sessions over several months, focus on specific areas of concern that are thought to be maintaining the depression. In some cases, these may be interpersonal problems -- disturbed social relationships that cause depressive symptoms which, in turn, exacerbate these disturbed relationships. Thus, a dysfunctional cycle is set up and perpetuated. Other short-term therapies focus on the negative styles of thinking and behaving commonly observed among depressed persons. These therapies try to help patients attain a more realistic view of themselves and their worlds and to encourage behaviors that will engender positive responses from others. Current evidence suggests that these interpersonal and cognitive-behavioral therapies represent practical alternatives to long-term therapy for many sufferers of the milder depressions.

For other patients, the most effective treatment is a combination of psychotherapy and antidepressant medication. Moreover, patients whose depression persists in spite of psychotherapy should be evaluated for treatment with medication. Finally, depression with established chronicity rarely responds to psychotherapy alone.

Electro convulsive Therapy

With the availability of antidepressant agents, use of electro convulsive therapy (ECT) has declined. Although ECT has received unfavorable publicity, it continues to be the most effective treatment for endogenous or psychotic (delusional) depression. Its use should be seriously considered in the following circumstances: the individual is severely depressed (especially if delusional), is at high risk for suicide, is severely malnourished, does not respond to medications, or, as commonly occurs among the elderly, cannot take antidepressants because of a medical problems such as a heart condition. In these situations, ECT not only curtails suffering, but is often life saving.

With current ECT practice, the patient is briefly put to sleep with an intravenous anesthetic, ensuring that the procedure is neither experienced nor remembered. A muscle relaxant is administered to minimize muscular response during the treatment.

Electrodes are placed either on both sides of the scalp (bilaterally) or on one side of the scalp (unilaterally) on the "nondominant" side of the brain (usually the right side). There is substantial evidence that unilateral electrode placement over the nondominant hemisphere produces less disruption of memory and less confusion following treatment. However, there is also some evidence that unilateral nondominant placement may be less effective or require more treatments than bilateral placement, which often requires 7 to 12 treatments.

With bilateral treatments in particular, patients experience transient memory loss of events immediately surrounding the treatment. After ECT is ended, despite publicity to the contrary, memory of past events and the ability to learn new information remains basically unaffected in most patients.

Treatment Choice Depends On The Severity & Type Of Illness

There are different forms of depressive illnesses and different types of treatment. Choice of treatment typically depends on the pattern, severity, and persistence of symptoms, and the history of the illness.

The following briefly describes the types of therapeutic approaches that would most likely be taken under the conditions outlined below. However, treatments will be modified and adjusted to suit the individual need of each patient. Close monitoring is essential to track a patient's progress and response to medications that may be prescribed.

Mild Episodes

A large number of individuals experience brief depressive episodes with relatively mild symptoms lasting over days. These episodes may cause personal distress and discomfort, but do not seriously interfere with the ability to function at work or at home. Such episodes often improve without intensive treatment, but will be helped by counseling, psychotherapy and sometimes, ant anxiety medication.

Moderate Depressions

If symptoms continue for weeks and include anxiety, sleep difficulty, loss of interest and pleasure in usual activities, difficulty concentrating, headache, backache or other bodily complaints, and when there often is at least some interference with work and family activities (the individual, however, can carry out usual responsibilities, but with difficulty), a comprehensive diagnostic assessment, including medical examination, is essential. Medical evaluation is necessary, especially after age 40, because a variety of physical illnesses can produce or precipitate depression. Once this is ruled out, the patient and clinician have a choice of antidepressants and/or forms of brief focused psychotherapy. Often, however, combinations of medication and psychotherapy are most effective.

Severe Depressions

More intensive treatment is called for when depression involves thoughts of death, suicide attempts, impaired judgment, and marked mood swings or bipolar tendencies. For these types of depression, antidepressants or ECT (electro convulsive therapy) are usually mandatory.

Hospitalization

Most depressed people can be treated as outpatients; however, severe episodes particularly involving serious weight loss, marked agitation, or suicidal intent may require brief periods of hospitalization. During hospitalization, careful evaluations can be done, the patient can be protected, and biological and psychosocial treatments initiated.

Chronic Depressions

A significant number of depressives, 20-30 percent, experience depressive symptoms which persist for long periods of time, even years. Often these symptoms misleadingly appear to be part of the individual's "personality." Recent research at both the National Institute of Mental Health and the University of Tennessee, Memphis, has shown that depression is not secondary to a character flaw. Rather than suffering in silence or accepting these symptoms as basic characteristics of the self, individuals should consider intensive treatment, including medications. MAOIs (monoamine oxidase inhibitors) and serotonergic antidepressants appear particularly useful for such patients.

Helping The Depressed Person

Perhaps the most important thing family and friends can do is to encourage the depressed person to get appropriate treatment. The very nature of depression -- the feelings of helplessness, hopelessness, and worthlessness -- can keep the depressed person from seeking help. When symptoms linger beyond a reasonable time, or if there seems no apparent reason for the individual's persistent feelings of unhappiness and gloom, the observant and caring friend or relative should help the depressed person get professional assistance.

Family and friends can also provide much needed support, love, and encouragement. Depression destroys self-esteem and confidence, and family and friends can help the depressed person feel worthwhile by applying the following "Dos" and "Don'ts":

DO

Maintain as normal a relationship as possible.

Point out distorted negative thinking without being critical or disapproving.

Acknowledge that the person is suffering and in pain.

Offer kind words and pay compliments.

Express affection.

Show that you care, respect, and value the depressed person.

DON'T

Blame the depressed person for his or her condition.

Criticize, pick on, "put down" or voice disapproval until the depressed person is feeling better.

Say or do anything to exacerbate his or her poor self-image.

In addition, friends and family can help by keeping the depressed person busy and active. Depression tends to feed on itself, and a moderately depressed person becomes apathetic and inactive leading to more depression, more withdrawal, and more inactivity, resulting in a vicious cycle. Gentle assertiveness may be required to stand by the depressed person, particularly if the individual is withdrawn and rejecting.

Depression typically involves strong feelings of guilt, and it is important that family and friends do not compound such feeling by blaming the individual for his or her symptoms. Depressed people often arouse anger in others, and it is tempting to become impatient, to tell the depressed person to snap out of it, or to indicate that depression is a sign of weakness. The depressed person is in pain and needs understanding and help.

Also, the possibility of suicide must always be considered in cases of depression. Though a depression may appear relatively mild, it does not exclude the possibility of suicide. Sometimes seemingly mild depression has much deeper roots. Nor is it true, as many people believe, that a person who talks about suicide will not attempt it. Those who attempt suicide often appeal first for help by threatening to do so.

Even when there appears little or no danger of suicide, a mental health professional should be consulted when a serious depressive disorder is suspected. The earlier the depressed person receives help, the sooner the symptoms are alleviated and the speedier the recovery.

Depression is the most treatable of all the mental illnesses. Individuals no longer have to suffer its debilitating symptoms. With modern treatment methods, they can return to full and productive lives.