Your definitive deppression treatment cheat sheet.

by John McManamy


What is depression treatment?

In a wide sense, we are talking about everything likely to make you better. In a narrow sense, we are tend to focus on medical treatment and talking therapies. On this website, I distinguish between treatment and recovery. The distinction is artificial, but it is useful in helping readers find what they are looking for and to figure out their own strategies for managing their illness and related issues.

So how do you distinguish between treatment and recovery?

In treatment, we are guided by a professional, be it a family doctor, a psychiatrist, a psychologist, an MSW, or other clinician. The focus tends to be on treating the disease. In recovery, the focus is more on what you need to do to get well and stay well (such as practicing mindfulness), and what you want out of life. Again, the two are related. Recovery tends to be a non-starter without treatment. Treatment without recovery is going to keep you stuck in a miserable half-life.

So, what are the areas you cover in treatment?

Medications, obviously, plus nutritional supplements, which come in the same kind of bottles. Then there are medical treatments such as ECT. In addition, there is talking therapy.

What are antidepressants?

Antidepressants are medications aimed at relieving symptoms of depression. The best known class are SSRIs that target the brain's serotonin system.

Do antidepressants work?

A good deal of the time they don't, which our doctors neglect to tell us. The clinical benefit on average is modest, the failure rate is high, and relapses are the rule rather than the exception. Moreover, there are side effects that may make your depression worse.

Then why bother with an antidepressant?

Because your situation is so desperate that you are ready to try anything. Moreover, there is a decent chance that an antidepressant may be the perfect med for you.

So what should I expect from an antidepressant that works?

You will probably get better results if you keep your expectations low. Even a small improvement may be all you need to achieve the critical mass to allow you to implement your own wellness routines, such as exercise.

I just started an antidepressant. Nothing is happening.

It usually takes three or four weeks for the clinical benefit to start kicking in and six weeks or more to achieve its full effect. In the meantime, you are likely to feel the side effects right off. So you may be feeling worse before you feel better.

What about the side effects?

Most side effects are transitory and will go away. But if they become physically intolerable or you are feeling mental distress (such as severe agitation) then you need to inform your doctor, who will probably advise discontinuing the med and trying another med.

What about long-term side effects?

Onerous side effects should not be the price you pay for improving your mood. A good many side effects, in fact, will make your depression worse in the long term. These include messed-up sleep, sexual dysfunction, and weight gain. These may be acceptable short-term trade-offs, but not over the long haul.



Is there anything major I should watch out for?

Yes, and listen very carefully. A good many patients diagnosed with clinical depression actually have bipolar, or they are bipolar cases waiting to happen. An antidepressant may not only make the bipolar worse, it may actually cause a first episode.


Antidepressants can induce mania and mixed states in bipolar patients and speed up their cycles. But there is also good evidence this may happen in certain types of unipolar patients, as well, namely those with highly recurrent depressions which come and go in a manner similar to bipolar patients. Thus, before you even consider taking an antidepressant, make sure your doctor has expressly ruled out a bipolar diagnosis or anything that could conceivably fit into the wider bipolar spectrum.

Keep talking

You need to watch for two things: 1) You antidepressant working too fast, say after a day or two, which may indicate you are on the fast train to mania, or 2) Signs of mental agitation, as if you're crawling out of your skin, which may be evidence of a mixed depression-mania state. In either case, you need to get off your antidepressant fast.

Anything else?

Yes, the bipolar effect may be more subtle. The antidepressant may appear to be working, but it may only be speeding up an underlying mood cycle. Then you will crash. You may start feeling irritable and agitated. Your doctor will interpret the initial improvement as a favorable response to the antidepressant, and urge you to stay the course or try you on another antidepressant, then another. In all likelihood, you will end up feeling much worse. Inevitably - most likely years later - you will be diagnosed with bipolar. But whether you had bipolar in the first place or the antidepressant caused the bipolar is hard to say.

Are doctors really that stupid?

Let's put it this way. I would love to give advice to trust your doctor or psychiatrist, but I question their misplaced faith in the power of medications and in their concern for your well-being. These days, psychiatrists see more than a thousand patients in the course of ten-minute meds checks. This is no way to practice medicine.

I've been on my antidepressant for six weeks. No sign of improvement.

The best evidence we have suggests weaning off the antidepressant and trying another. Your second one may work like a charm. Two failed antidepressants, however, is a strong predictor of your third failing to work. A good many people simply do not respond to an antidepressant.

My antidepressant obviously works, but I am not well. This is no way to live.

It's best to chalk up the improvement as a resounding success. The antidepressant did its job. Now you need to work at having talking therapy, support, lifestyle, and so on do their jobs.

How long should I stay on my antidepressant?

There is no firm answer. Doctors tend to advise remaining on an antidepressant for at least a year and probably forever in order to keep you well and prevent episodes. But relapses are common, even on an antidepressant. The evidence base for long-term antidepressant treatment is sorely lacking, but there is support for staying on these meds for about six months.




How do I know when to go off my antidepressant?

You won't, and your doctor or psychiatrist is hardly the best one to turn to for advice. Because doctors are over-reluctant to take patients off meds, or even lower their doses, an informed decision rests with you. But don't quit on your own. Consult your doctor.

Why consult my doctor?

Because antidepressants require a slow wean. There is the strong likelihood of rebound effects (including depressive relapse) for going off these meds too quickly. As a general rule, you go to successive half doses spaced over days and weeks. But some antidepressants such as Paxil require extremely slow weans. Again, the decision to go off the drug may be your own, but you need to do it under a doctor's guidance.

What is cognitive therapy?

Cognitive therapy works to change erroneous thoughts (such as "It's the end of the world") into more positive ones (such as, "Let's find a solution"). Once one is thinking and behaving in a positive way - such as working toward a solution than bewailing the end of the world - one actually begins feeling better. The therapy typically lasts 10 sessions, and involves active participation and homework.



What about behavioral therapy and interpersonal therapy?

Behavioral therapy and interpersonal therapy are also short-term, manual-based therapies that focus on coping skills. By changing destructive behaviors and dealing better with people, one can successfully negotiate the stressful situations that can trigger a mood episode.

Can I use meds and talking therapy together?

The evidence points to each enhancing the other. In one study, those on both an antidepressant and cognitive therapy had much better outcomes than those on either one alone.

What about other types of talking therapy?

Consider this: If your boss is making you unhappy and your family is causing you stress, simply taking an antidepressant is not going to make your life bearable. Long-term talking therapy that can help you resolve these issues may eliminate the true cause of your depression and literally save your life. But this is not a quick fix.

What about ECT?

Electroconvulsive therapy, also known as shock treatment, is considered the most successful treatment for depression, but because of risk of short-term memory loss - and in more rare cases long-term memory loss - is regarded as a treatment of last resort.

Keep in mind that as our view of antidepressants has grown more jaded over the years, improvements in ECT have made steady gains. The debate is heated, but you need to coolly consider your options.

Are there alternatives to ECT?

A recently approved technique is rTMS, repetitive transcranial stimulation, which involves passing a magnetic coil over the scalp. An experimental treatment is MST, magnetic seizure therapy, which uses rTMS to induce ECT-like seizures. There is also VNS, which involves electrically stimulating the vagus nerve via an implant in the chest. VNS is FDA-approved for treatment-resistant depression.

What about light therapy?

Special portable light boxes are used to treat seasonal affective disorder, and can also be used for simple depression. An outdoor walk on even a cloudy day can act as natural light therapy.

What about nutritional supplements?

Nutritional suplements include St John's wort, Sam-e, omega-3 fatty acids, amino acids, and vitamin and mineral supplements. I won't go into the specifics of each, but feel free to ask about general principles.

Okay, what about the general principles of supplements?

We are locked into the mindset of taking "this" for "depression" or "that" for "anxiety," and so on. Often, the results are disappointing. Instead of treating for the illness, it may be more productive to treat for: 1) The vitamin or nutrient deficiency (such as B6, if you test deficient in this); 2) A specific symptom (such as lack of energy or lack of concentration, both which are symptoms of depression); 3) Over-all brain maintenance (a healthy brain is likely to be a less depressed brain).

My friend swears by Vitamin X. Should I follow her advice and take it?

Not exactly. Owing to bio-individuality, various specific vitamins and nutrients don't achieve the same results for everyone. Your cells may be metabolizing Vitamin X just fine. Maybe Vitamin Q would help you more.

Is there any way of knowing in advance which vitamin or nutrient is likely to work best for me?

You can ask your doctor for a panel of lab tests. You may also want to consult a nutritionist or someone with good credentials who knows what they are talking about. Otherwise, it's hit-or-miss. There is no financial incentive to conduct clinical trials, which means the evidence is lacking.

But absence of evidence doesn't mean evidence of absence, right?

Exactly. People do get good results on nutrients and supplements, but it is difficult to establish which ones work for which particular condition across large populations. This opens the way for shysters of all stripes making all kinds of wild claims. Be skeptical. Do your homework.

Any closing remarks?

Yes. If antidepressants worked as well the drug industry and our doctors would have us believe, there would be no depression to kick around, anymore. Instead, the widespread use of antidepressants has not made a dint in the numbers. But there is a time and place for these meds, and we need to be smart. Short-term talking therapies are also useful, but these are also just one part of the equation. Keep an open mind about ECT. And be mindful of the fact that in the medicine cabinet, supplements look just like meds. Be smart. Live well ...

See also: Depression FAQRecovery FAQ

Reviewed July 6, 2016


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