Treatment

Depression FAQ - Treatment

Your definitive cheat sheet.

Part I discussed the nature of of our illness. Part II examines medical and therapeutic and complementary treatments, talking therapy, ECT, and experimental technologies.

Part III of this FAQ looks at various recovery strategies.

What is depression treatment?

Ideally, a combination of medical treatments, talking therapies, natural treatments, and lifestyle choices. No one treatment, therapy, or lifestyle choice on its own is likely to get the job done. A number of them working as complements to each other ensures your best chance of success. Medical treatments include medications such as antidepressants, ECT or shock therapy, and some experimental techniques. Talking therapies are designed to change erroneous thoughts and behaviors and substitute them with new ones. Complementary treatments include natural substances such as vitamins and minerals and omega-3. Lifestyle choices include good diet, exercise, and sleep, spiritual options, and peer support.

What are antidepressants?

Antidepressants are medications aimed at relieving symptoms of depression. There are three main classes of antidepressants - MAOIs, tricyclics, and SSRIs, plus others that are referred to as having novel actions. Regardless of what class they fall into, all antidepressants work on the principle of enhancing one or more of three neurotransmitters in the brain.

What are neurotransmitters?

Neurotransmitters are molecules that specialize in delivering packets of information from one neuron to another, across a narrow gap called a synapse to receptors on the receiving cell. After a wave of neurotransmitters are released by the presynaptic neuron and absorbed by postsynaptic neuron, the presynaptic neuron vacuums from the synapse any remaining neurotransmitters in preparation for the next wave of neurotransmitters it will release. Two classes of antidepressants work by blocking this "reuptake" action to keep the neurotransmitters in circulation.

What are MAOIs?

MAOIs - monoamine oxidase inhibitors - are old generation antidepressants, Parnate (tranylcypromine) and Nardil (phenelzine) being the best known. They work by blocking the enzyme monoamine oxidase, which allows the neurotransmitters to function as usual. Side effects can be very burdensome, which make these drugs a last option. These include an outside risk of hypertension, which necessitates extreme dietary restrictions. Some psychiatrists, however, believe these drugs work particularly well for atypical depression, and should be regarded as a viable treatment option. Somerset Pharmaceuticals has recently released EMSAM (selegiline), a transdermal patch that is not supposed to have the usual MAOI side effects.

What are tricyclics?

Also called TCAs, tricyclics are old generation drugs that work by blocking the reuptake (or absorption by the neuron) of the neurotransmitters serotonin and norepinephrine, Elavil (imipramine) and Pamelor (nortriptyline) the two best known. Like MAOIs, the side effects can be burdensome, but because the drug operates with equal force on two neurotransmitters, some psychiatrists believe they may be more potent than the more popular single-action SSRIs.

What are SSRIs?

SSRIs - selective serotonin reuptake inhibitors - work by blocking absorption of the neurotransmitter serotonin. The SSRIs include Prozac (fluoxetine), Zoloft sertraline), Paxil paroxetine), Celexa (citalopram), Lexapro (escitalopram), and Luvox (fluvoxamine). Although these drugs have been hyped as breakthroughs for treating depression, they are no more effective than their MAOI and tricyclic predecessors. Their one advantage is their more benign side effects profile. Nevertheless, the side effects can be considerable, including weight gain, dry mouth drowsiness, disturbed REM sleep, and sexual dysfunction.

These Side Effects Scare Me

Most of them are transitory, in the early going. Therefore, unless they are unbearable or pose a risk to your health you should give your body a chance to adjust. Some side effects may be an inconvenience that you may regard as well worth the price of having your life restored. Onerous side effects, however, should not be part of the price you should have to pay for improving your mood.

Does That Mean I Should Just Quit My Antidepressant?

Your first step is to notify your doctor or psychiatrist of the side effects. Your doctor or psychiatrist may then change doses or switch you to a different antidepressant.

Is there anything I can do about sexual dysfunction?

Yes, Viagra can help both men and women. Lowering the dose of your antidepressant may help, or switching to Wellbutrin or Remeron, which both perform better in the bedroom, may be an option.

What about dry mouth?

Lots of water and good dental hygiene.

What are novel action antidepressants?

These include Effexor (venlafaxine), Serzone (nefazadone), Remeron, (mirtazapine), Desyrel (trazadone), Wellbutrin (buproprion), and Cymbalta (duloxetine). Cymbalta, the newest, has an action very similar to the tricyclics, operating robustly on norepinephrine and serotonin while the older Effexor and older still Desyrel have a strong serotonin and weak norepinephrine action. The others work on a combination of neurotransmitters through unique mechanisms. The side effects are similar to those of SSRIs, with Remeron and Wellbutrin causing the least sexual dysfunction.

Are there other neurotransmitters being considered?

Yes, but so far they have been disappointments, including Substance P.

Are any companies thinking outside the neurotransmitter?

Yes, to be more precise, they are thinking inside the neuron. The neurotransmitter operates outside the neuron, which is why medications directed at these targets are limited in effectiveness, with burdensome side effects. Inside the neuron are a host of chemical processes that suggest more inviting and precise targets. At the moment, these drugs are far over the horizon. Closer to fruition is the possibility of a drug that operates on the hormone CRF, which results in the stress hormone cortisol being secreted (which is thought to be complicit in depression). Several companies have a CRF drug in development. And way in the distant future is the possibility of drugs using gene technology.

I have been prescribed an antidepressant. What should I expect?

First, don't expect your antidepressant to work at once. It typically takes at least two weeks for the first benefit to be felt and four to six weeks and even longer for the full clinical effect. On the other hand, you will feel the side effects almost at once. Many of these such as heightened anxiety tend to go away after a week or two. Those first few weeks will test your patience. Your depression is raging at its worst, and your antidepressant appears to be making you worse rather than better. Unless the side effects are unbearably severe, you need to give your antidepressant at least six to eight weeks.

What do you mean unbearably severe?

The warning labels of most new antidepressants advise of the possibility of akathisia, a type of mental agitation that may make one feel is if he or she is crawling out of their skin. This is a rare side effect. Another possibility concerns bipolar patients who have been mistakenly diagnosed with simple depression. What often happens is the antidepressant they are prescribed induces a manic episode. Some bipolar patients can be treated with antidepressants, but usually require the addition of moodstabilizing medication. Should you feel hyper or not your usual self, it is advisable to stop taking your medication at once and notify your doctor or psychiatrist.

I gave my antidepressant eight weeks and nothing happened. Now what?

It is not uncommon for your first antidepressant to prove to be a dud. We are all unique, and no two depressions are alike, so a medication that worked for others may not work for you. Studies indicate that there is but a fifty-fifty chance of patients showing a response to their initial antidepressant. But studies also show the odds improve when you try a second antidepressant. Various treatment guidelines, including those put out by the American Psychiatric Association, anticipate initial failures, and advise to keep trying. If initial attempts using one class of antidepressants fail, these guidelines advise switching to a different class.

My doctor doubled my dose. Is this normal?

It is common practice to prescribe antidepressants on a low dose for the first week or two, so the body can adjust, and then raise the dose. There is a body of opinion that suggests we should be starting with high doses, but the jury is still out.

My antidepressant improved my symptoms by 50 percent, but this is still no life. Is this all I can expect?

Absolutely not. Unfortunately, clinical trials regard as a success a 50 percent or better improvement, known as a response, which is not the same as the virtual elimination of symptoms, or remission. The APA and other guidelines state that remission is the goal of medications treatment, so you should not have to settle for half-way. Remission is especially important, as those who merely respond are far more likely to relapse into depression. Switching to another antidepressant is an option, as are combination and augmentation strategies.

What are combination and augmentation strategies?

Both are based on the principle of synergy, of two plus two hopefully equaling five. Combination strategy involves combining two antidepressants for maximum effect, especially ones that work on different neurotransmitters. Augmentation involves using a completely different drug, such as lithium or a thyroid drug, to boost the performance of an antidepressant. Unfortunately, not too many studies have been done regarding combinations and augmentation, so our knowledge is limited.

How long should I stay on my antidepressant?

Antidepressant treatment is long term. The APA depression guidelines recommend at least four to five months of antidepressant treatment after remission is achieved. Those who have suffered previous episodes should expect to stay on antidepressants for several years and probably for life. Studies have found that those who remain on their antidepressants are far less likely to relapse. For many people, depression is a chronic condition, for whom going off their antidepressant is as unthinkable as a diabetic going off his insulin. If you do go off your antidepressant, you should be weaned off gradually under a doctor's supervision, as sudden cessation can cause withdrawal symptoms - this is especially true if you are on Paxil or Effexor.

What about pregnancy and breast feeding?

Studies indicate that antidepressants are safe to take during pregnancy with no harm to the fetus, though long-term effects remain unknown. Minute amounts of antidepressants are secreted into breast milk, but not enough, apparently, to harm the baby. Woman are advised to consult their physician.

Can I drink alcohol?

The short answer is antidepressants and alcohol are not a good mix.

I've tried two antidepressants, plus various combinations, and they all failed on me. What now?

There may be other treatment options, but when your second antidepressant fails it is strongly suggested that you and your psychiatrist talk about revisiting your diagnosis. For instance, you may have a history of recurrent depression - short depressions that come and go - which suggests your depressions cycle like bipolar, even if you don't have bipolar. In this case, an antidepressant may actually make you worse. Also, the priority may be on treating your cycle rather than the symptom of the day. So a mood stabilzer used for bipolar treatment may be the answer. Another possibility is you may have a "mixed" depression, with elements of mania or hypomania and for good measure anxiety. Again, a mood stabilizer may be an option, but only after very careful discussion with your psychiatrist.

Are you referring to the mood spectrum?

Yes. The important point about the mood spectrum is that the leading experts consider depression as part of the same phenomenon as bipolar. But here's the catch: even though depression and bipolar may be part of the same phenomenon, the treatments are very different. So if your depression is cycling like bipolar or has some features of bipolar mania or hypomania, you may need to be treated as if you have bipolar, even though technically you just have depression.

My antidepressant is working, but I'm really not well. What's next?

Antidepressants are imperfect, at best, so it's not surprising that people are dissatisfied with these drugs, especially after the hype surrounding their introduction gave the false impression that a breakthrough treatment had hit the market. For some people, antidepressants may not be an option, especially if the side effects prove too burdensome. Fortunately, there are other treatments and options available. And fortunately still for people who only partially respond to antidepressants, the medication can be combined with other treatments, natural remedies, and lifestyle choices to good effect.

What is cognitive therapy?

Cognitive therapy - also called cognitive behavioral 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 to 20 sessions, and involves active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone. That same study also found talking therapy worked much better than antidepressants for women who had been abused as children.

What are 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.

What about other types of talking therapy?

Before you engage in therapy that involves working on painful issues or suppressed memories, it is very important that your depression be stabilized, as otherwise these therapies can cause your condition to deteriorate. Some talking therapists take a dim view of medications, and their opinions on the subject are the last thing you need to be exposed to while you are still recovering and vulnerable. Having said that, 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.

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 rare cases long-term memory loss - is regarded as a treatment of last resort, except if the patient's depression puts him or her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on.

The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than candid over the memory loss element, and neglects to mention that relapses are common, which necessitates additional periodic "booster" treatments.

Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their depression in remission should do their research now and make their decision accordingly, while they have their wits about them. You can state your wishes in the form of a psychiatric advance directive.

Are there alternatives to ECT?

An experimental technique is rTMS, repetitive transcranial stimulation, which involves passing a magnetic coil over the scalp. Because the current passes through the skull as if it were not there (as opposed to ECT, where the skull deflects and scatters the current), the treatment has the potential to be far more precise, with the possibility of targeting specific parts of the brain. Another possibility is MST, magnetic seizure therapy, which uses rTMS to induce ECT-like seizures.

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.

Are there alternative or complementary treatments for depression?

Yes. These include St John's wort, Sam-e, omega-3 fatty acids, vitamin and mineral supplements, and acupuncture.

Tell me about Sam-e and St John's wort.

These are advertised as natural antidepressants, and have demonstrated efficacy for partial improvement. Consult your doctor before using, and buy only from a reputable supplier.

Tell me about omega-3 fatty acids.

Omega-3 is found in deepwater fish such as salmon and in flax. Two studies found that countries with low fish consumption coincided with high depression and bipolar rates. A pilot study using omega-3 found it effective in treating the depressed phase of bipolar, and another using an omega-3 extract found the substance to be effective in treating depression. Until we know more, it is advised that omega-3 be considered as a complement to, rather than as a replacement for, one's normal meds. Buy only preparations that have more EPA than DHA.

Tell me about vitamins and mineral supplements.

Unfortunately, much of the food we eat comes from soil depleted of nutrients. The raw materials for producing neurotransmitters are nutrients. A deficiency of vitamin B6, for instance, may affect how serotonin is synthesized. Various small studies are finding single nutrients or nutrient combos can have affects ranging from subtle to pronounced. One pilot study found a certain supplement combination dramatically improved symptoms in bipolar patients. And it isn't just about mood. Antioxidants, for example, can improve memory and protect against free radicals that can damage neurons. Use under a doctor's supervision. Consulting a nutritionist is also recommended. It is advisable to use supplements as a complement to meds rather than as a replacement.

What about acupuncture?

A pilot study comparing depression treatment (where the needles were placed at specific "depression" points) to sham treatment (the needles were randomly applied) found those in the depression treatment group experienced a 42 percent reduction in symptoms compared to 22 percent for the controls, with virtually no side effects.

Updated Feb 10, 2008