Medical Interventions in the Treatment of Depression

Most experts agree that depression is caused by a combination of biological, genetic, social, and psychological factors. The degree that each one of these factors contributes to the development of depression in any one person is very individual. A combination of psychotherapy and medication is most often the treatment of choice when depression is first diagnosed. Treatment plans should be developed after carefully evaluating each person, to ensure that the plan meets his or her individual needs. Treatment may include one or several of the following medical interventions:

Psychotherapy

There are a number of different approaches to psychotherapy available to people with depression. These include: cognitive-behavioral therapy, interpersonal therapy, family therapy, and psychodynamic therapy. These approaches can be used individually or in group sessions.

Cognitive-behavioral therapy is the most commonly prescribed therapy for the treatment of depression. This technique focuses on the internal dialogue that takes place inside a depressed person’s mind. The focus of the therapy centers on strategies to help change the way they are feeling and thinking, as opposed to determining the cause of the depression. This is usually of short duration, usually less than 24 sessions.

Interpersonal therapy focuses on the person’s interpersonal relationships and explores strategies for improving them. Therapy focuses on building relationship skills, effective communication, expressing emotions, and assertiveness. Like cognitive-behavioral therapy, interpersonal therapy is usually of limited duration. Both cognitive-behavioral and interpersonal therapies require the depressed person to take an active role in therapy.

Psychodynamic therapy is falling out of favor in the mental health community. Research does not appear to support its effectiveness in treating depression. It focuses on analyzing a person’s past to determine the causes of the current illness. Although concepts of this approach are used in other types of therapy, this approach as sole therapy should probably be avoided.

Family therapy focuses on the interpersonal relationships in a family and seeks to improve family dynamics. Roles of different family members in promoting the depression often are examined.

Antidepressant Medications

Antidepressant medications have been found to be extremely successful in treating depression. In fact, about 70 percent of patients who take them experience relief of their depressive symptoms.

No one class of antidepressants has been found to work more effectively than others, if taken at the proper dosage for the right amount of time. However, many people taking antidepressants are not taking the proper amount. This could be because physicians are not familiar with proper dosing or because people do not take them as prescribed.

How long you need to take antidepressant medication depends upon your particular condition. Some people need medication for only a limited amount of time. Others may have to take the medications intermittently during their lives, or even indefinitely.

Some people taking antidepressants complain of side effects, some do not. In fact, each of these medications act differently on different people. This could affect the amount of the drug you need, whether it is effective for you, and generally how it affects your body. Effects of these medications depend on your age, weight, sex, body chemistry, diet, smoking status, other medications you take, and other physical illnesses you may have.

If you have talked to your doctor about your depression, he or she may have recommended treatment with antidepressant medication or a combination of antidepressant medication and counseling. Before you begin treatment, be sure to ask your doctor the following questions:

• When is the best time of day to take this medication?
• What are the side effects?
• Are there any side effects I should worry about?
• Will I need any type of monitoring (blood tests, blood pressure checks, EKGs, etc.) while I am taking this drug?
• When I can expect to start feeling better?

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs reduce depressive symptoms by acting on a neurotransmitter in the brain called serotonin. These medications are usually preferred by doctors for several reasons. They act more quickly in the body, have fewer side effects, and are safer in the event of overdose.

However, these drugs do have a number of negative aspects. They are more expensive than some of the other classes of drugs, can cause sleep disturbances, and may cause anxiety in some people. For women and men who take the SSRIs, the drug can cause a decrease in sexual excitement and the ability to achieve orgasm. Also, this class of drugs may interact negatively with other medications. Discuss any potential drug reactions with your doctor.

Side effects may be treated effectively by changing drugs within the SSRI class, adding other medications to reduce side effects, or briefly stopping the medication (i.e. over a weekend), if carefully monitored by a physician.

Tricyclic Antidepressants (TCAs)

TCAs also affect depression by acting on the serotonin and norepinephrine in the brain. In general, they have several disadvantages over the SSRIs. More than half of all people who have been prescribed TCA medications are unable to tolerate the adverse side effects. These side effects can include sedation, dry mouth, dizziness, arrhythmia, and drug interactions. Also, overdoses of TCAs can be fatal.

Monoamine Oxidase Inhibitors (MAO)

MAO inhibitors should be used only for those with difficult-to-treat depression. People taking MAO inhibitors must follow special diet restrictions and abstain from a list of other medications to avoid serious side effects. Side effects include a potentially fatal reaction called a hypertensive crisis. Symptoms include headaches, stiff neck, sweating, nausea, vomiting, or much worse. Anyone over age 40 should have an electrocardiogram (EKG) before beginning treatment with this category of drugs.

Bupropion (Wellbutrin or Zyban)

One of the newer antidepressants, Bupropion is unrelated to the other classes of antidepressants. It affects the neurotransmitters, dopamine, and norepinephrine, with less of an effect on serotonin. It has fewer side effects than the other antidepressants, but is not indicated for those with seizure disorder, alcoholism, bulimia, or anorexia nervosa.

While taking antidepressant medication, keep these facts in mind:

• Nine out of 10 people are helped with antidepressant medication, but the best choice varies from person to person. If one hasn’t helped, try another. Some people need to try several different medications until they find one that is right for them.
• Antidepressants work slowly to bring the balance of the brain chemicals or neurotransmitters - serotonin, norepinephrine, and dopamine - back in balance. While some people claim to feel better after only two weeks of treatment, it usually takes about four weeks before you notice a difference in your mood. Sometimes your family will notice a change in you before you do. Initially, the change may be so subtle that you may not realize you’re sleeping better or feel like going for a walk.
• Once you find a medication that helps, your doctor will ask you to keep taking it for at least six months. If your depression is severe, you may have to continue for a year or more. People who have a dysthymic disorder may have to take the medication the rest of their lives.
• It’s important to take your medication at each scheduled dose and not just when you are having a “bad day.” These drugs work by restoring the chemicals in your brain to a higher level. That happens over a period of time. They won’t help you if you take them the same way you take a pain reliever when you have a headache.
• You shouldn’t abruptly stop taking the medication when your depression has resolved. Your doctor will instruct you the best way to taper your doses.

Electroconvulsive Shock Treatment

Electroconvulsive shock treatment, or ECT, involves the induction of an electric shock to a person in order to produce a seizure. Studies of ECT show that it is as effective, or more effective than, antidepressant medications in treating severe depression in the short term. It can reduce symptoms in those who have not responded to medication and acts more quickly than antidepressant medication. However, studies suggest that the relapse rate is extremely high unless antidepressant medications are prescribed and continued after therapy.

ECT is the most controversial treatment for mental illness. It has been found to produce memory problems, which continue after the treatment is completed, among other adverse effects. This treatment is indicated for depression only if it is extremely severe and other interventions have been unsuccessful. The decision to undertake ECT is a serious one, requiring the depressed person to carefully weigh the benefits and costs with a doctor.

Hospitalization

Hospitalization is necessary for persons who are depressed after they have attempted suicide, or have developed a plan to commit suicide, and are in imminent danger of carrying out the plan. Hospitalization is usually of short duration (3 to 4 weeks) until the patient is stabilized with antidepressant medications.

ANTIDEPRESSANTS

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