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Even severe depression can be highly responsive to treatment.
Indeed, believing one's condition is "incurable" is often part
of the hopelessness that accompanies serious depression. Such
individuals should be provided with the information about the
effectiveness of modern treatments for depression in a way that
acknowledges their likely skepticism about whether treatment will
work for them. As with many illnesses, the earlier treatment begins,
the more effective and the greater the likelihood of preventing
serious recurrences. Of course, treatment will not eliminate life's
inevitable stresses and ups and downs. But it can greatly enhance
the ability to manage such challenges and lead to greater enjoyment
of life.
The first step in treatment for depression should be a thorough
examination to rule out any physical illnesses that may cause
depressive symptoms. Since certain medications can cause the same
symptoms as depression, the examining physician should be made
aware of any medications being used. If a physical cause for the
depression is not found, a psychological evaluation should be
conducted by the physician or a referral made to a mental health
professional.
Types of Treatment for Depression
The most commonly used treatments for depression are antidepressant
medication, psychotherapy, or a combination of the two. Which
of these is the right treatment for any one individual depends
on the nature and severity of the depression and, to some extent,
on individual preference. In mild or moderate depression, one
or both of these treatments may be useful, while in severe or
incapacitating depression, medication is generally recommended
as a first step in the treatment.3 In combined treatment,
medication can relieve physical symptoms quickly, while psychotherapy
allows the opportunity to learn more effective ways of handling
problems.
Medications
There are several types of antidepressant medications used to
treat depressive disorders. These include newer medications-chiefly
the selective serotonin reuptake inhibitors (SSRIs)-and the tricyclics
and monoamine oxidase inhibitors (MAOIs). The SSRIs-and other
newer medications that affect neurotransmitters such as dopamine
or norepinephrine-generally have fewer side effects than tricyclics.
Each acts on different chemical pathways of the human brain related
to moods. Antidepressant medications are not habit-forming. Although
some individuals notice improvement in the first couple of weeks,
usually antidepressant medications must be taken regularly for
at least 4 weeks and, in some cases, as many as 8 weeks, before
the full therapeutic effect occurs. To be effective and to prevent
a relapse of the depression, medications must be taken for about
6 to 12 months, carefully following the doctor's instructions.
Medications must be monitored to ensure the most effective dosage
and to minimize side effects. For those who have had several bouts
of depression, long-term treatment with medication is the most
effective means of preventing recurring episodes.
The prescribing doctor will provide information about possible
side effects and, in the case of MAOIs, dietary and medication
restrictions. In addition, other prescribed and over-the-counter
medications or dietary supplements being used should be reviewed
because some can interact negatively with antidepressant medication.
There may be restrictions during pregnancy.
For bipolar disorder, the treatment of choice for many years
has been lithium, as it can be effective in smoothing out the
mood swings common to this disorder. Its use must be carefully
monitored, as the range between an effective dose and a toxic
one can be relatively small. However, lithium may not be recommended
if a person has pre-existing thyroid, kidney, or heart disorders
or epilepsy. Fortunately, other medications have been found helpful
in controlling mood swings. Among these are two mood-stabilizing
anticonvulsants, carbamazepine (Tegretol®) and
valproate (Depakote®). Both of these medications
have gained wide acceptance in clinical practice, and valproate
has been approved by the Food and Drug Administration for first-line
treatment of acute mania. Studies conducted in Finland in patients
with epilepsy indicate that valproate may increase testosterone
levels in teenage girls and produce polycystic ovary syndrome
in women who began taking the medication before age 20. 11
Therefore, young female patients should be monitored carefully
by a physician. Other anticonvulsants that are being used now
include lamotrigine (Lamictal®) and gabapentin
(Neurontin®); their role in the treatment hierarchy
of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication.
Along with lithium and/or an anticonvulsant, they often take a
medication for accompanying agitation, anxiety, insomnia, or depression.
Some research indicates that an antidepressant, when taken without
a mood stabilizing medication, can increase the risk of switching
into mania or hypomania, or of developing rapid cycling, in people
with bipolar disorder. Finding the best possible combination of
these medications is of utmost importance to the patient and requires
close monitoring by the physician.
Herbal Therapy
In the past few years, much interest has risen in the use of
herbs in the treatment of both depression and anxiety. St. John's
wort (Hypericum perforatum), an herb used extensively in the treatment
of mild to moderate depression in Europe, has recently aroused
interest in the United States. St. John's wort, an attractive
bushy, low-growing plant covered with yellow flowers in summer,
has been used for centuries in many folk and herbal remedies.
Today in Germany, Hypericum is used in the treatment of depression
more than any other antidepressant. However, the scientific studies
that have been conducted on its use have been short-term and have
used several different doses.
Because of the widespread interest in St. John's wort, the National
Institutes of Health (NIH) is conducting a 3-year study, sponsored
by three NIH components-the National Institute of Mental Health,
the National Institute for Complementary and Alternative Medicine,
and the Office of Dietary Supplements. The study is designed to
include 336 patients with major depression, randomly assigned
to an 8-week trial with one-third of patients receiving a uniform
dose of St. John's wort, another third an SSRI commonly prescribed
for depression, and the final third a placebo (a pill that looks
exactly like the SSRI and the St. John's wort, but has no active
ingredients). The study participants who respond positively will
be followed for an additional 18 weeks. After the 3-year study
has been completed, results will be analyzed and published.
The Food and Drug Administration issued a Public Health Advisory
on February 10, 2000. It stated that St. John's wort appears to
affect an important metabolic pathway that is used by many drugs
prescribed to treat conditions such as heart disease, depression,
seizures, certain cancers, and rejection of transplants. Therefore,
health care providers should alert their patients about these
potential drug interactions. Any herbal supplement should be taken
only after consultation with the doctor or other health care provider.
Psychotherapy
In mild to moderate cases of depression, psychotherapy is also
a treatment option. Some short-term (10 to 20 week) therapies
have been very effective in several types of depression. "Talking"
therapies help patients gain insight into and resolve their problems
through verbal give-and-take with the therapist. "Behavioral"
therapies help patients learn new behaviors that lead to more
satisfaction in life and "unlearn" counter-productive behaviors.
Research has shown that two short-term psychotherapies, interpersonal
and cognitive-behavioral, are helpful for some forms of depression.
Interpersonal therapy works to change interpersonal relationships
that cause or exacerbate depression. Cognitive-behavioral therapy
helps change negative styles of thinking and behaving that may
contribute to the depression.
Electroconvulsive Therapy
For individuals whose depression is severe or life threatening
or for those who cannot take antidepressant medication, electroconvulsive
therapy (ECT) is useful.3 This is particularly true
for those with extreme suicide risk, severe agitation, psychotic
thinking, severe weight loss or physical debilitation as a result
of physical illness. Over the years, ECT has been much improved.
A muscle relaxant is given before treatment, which is done under
brief anesthesia. Electrodes are placed at precise locations on
the head to deliver electrical impulses. The stimulation causes
a brief (about 30 seconds) seizure within the brain. The person
receiving ECT does not consciously experience the electrical stimulus.
At least several sessions of ECT, usually given at the rate of
three per week, are required for full therapeutic benefit.
Treating Recurrent Depression
Even when treatment is successful, depression may recur. Studies
indicate that certain treatment strategies are very useful in
this instance. Continuation of antidepressant medication at the
same dose that successfully treated the acute episode can often
prevent recurrence. Monthly interpersonal psychotherapy can lengthen
the time between episodes in patients not taking medication.
REFERENCES
3 Frank E, Karp JF, and Rush AJ. Efficacy of treatments
for major depression. Psychopharmacology Bulletin, 1993;29:457-75.
11 Vainionpaa LK, Rattya J, Knip M, Tapanainen JS,
Pakarinen AJ, Lanning P, Tekay, A, Myllyla, VV, Isojarvi JI. Valproate-induced
hyperandrogenism during pubertal maturation in girls with epilepsy.
Annals of Neurology, 1999;45(4):444-50.
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