Depression: Evaluation and Treatment of Depression

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The first step to getting appropriate treament for depression is a complete physical examination by a family physician or internist. Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done, usually by a psychiatrist or psychologist.

A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.

Last, a diagnostic evaluation should include a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.

Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Some people with milder forms may do well with psychotherapy alone. People with moderate to severe depression often benefit from antidepressants. Most do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life’s problems, including depression. Depending on the patient’s diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have proven effective for depression.

Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes that deliver electrical impulses 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. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.

Medications

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications–chiefly the selective serotonin reuptake inhibitors (SSRIs)–the tricyclics, and the 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. Sometimes your doctor will try a variety of antidepressants before finding the medication or combination of medications most effective for you. Sometimes the dosage must be increased to be effective. Antidepressant medications must be taken regularly for as many as 8 weeks before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn’t helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for 4 to 9 months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust. For individuals with bipolar disorder or chronic major depression, medication may have to be maintained indefinitely.

Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly.

For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.

Medications of any kind--prescribed, over-the counter, or borrowed–should never be mixed without consulting the doctor. Other health professionals who may prescribe a drug–such as a dentist or other medical specialist–should be told that the patient is taking antidepressants. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.

Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants; however, they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are not first-line antidepressants and share the habit-forming risks of antimedication for postpartum depressions and sleeping pills.

Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

Lithium has for many years been the treatment of choice for bipolar disorder, 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 is small. If a person has pre-existing thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit 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. Other anticonvulsants that are being used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®).

Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Side Effects

Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious. However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:

  • Dry mouth–it is helpful to drink lots of water; chew sugarless gum; clean teeth daily.
  • Constipation–bran cereals, prunes, fruit, and vegetables should be in the diet.
  • Bladder problems–emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; the doctor should be notified if there is any pain.
  • sexual problemssexual functioning may change; if worrisome, it should be discussed with the doctor.
  • Blurred vision–this will pass soon and will not necessitate new glasses.
  • Dizziness–rising from the bed or chair slowly is helpful.
  • Drowsiness as a daytime problem–this usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

The newer antidepressants have different types of side effects:

  • Headache–this will usually go away.
  • Nausea–even when it occurs, it is transient after each dose.
  • Nervousness and insomnia (trouble falling asleep or waking often during the night)–these may occur during the first few weeks; dosage reductions or time will usually resolve them.
  • Agitation (feeling jittery)–if this happens for the first time after the drug is taken and is more than transient, the doctor should be notified.
  • sexual problems–the doctor should be consulted if the problem is persistent or worrisome.

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, Hypericumis 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 receiving a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression, and the final third receiving 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.

Psychotherapies

Many forms of psychotherapy, including some short-term (10-20 weeks) therapies, can help depressed individuals. “Talking” therapies help patients gain insight into and resolve their problems through verbal “give-and-take” with the therapist. “Behavioral” therapies help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.

Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioral therapies. Interpersonal therapists focus on the patient’s disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive-behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.

Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient’s internal conflicts. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

How to Help Yourself if You are Depressed

depressive disorders make one feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the situation. Negative thinking fades as treatment begins to take effect. In the meantime:

  • Set realistic goals and assume a reasonable amount of responsibility.
  • Break large tasks into small ones, set some priorities, and do what you can as you can.
  • Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
  • Participate in activities that may make you feel better.
  • Mild exercise, going to a movie, a ballgame, or participating in religious, social, or other activities may help.
  • Expect your mood to improve gradually, not immediately. Feeling better takes time.
  • It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition–change jobs, get married or divorced–discuss it with others who know you well and have a more objective view of your situation.
  • People rarely “snap out of” a depression. But they can feel a little better day by day.
  • Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression responds to treatment.
  • Let your family and friends help you.

How Family and Friends Can Help the Depressed Person

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication. The depressed person should be encouraged to obey the doctor’s orders about the use of alcoholic products while on medication. The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person’s therapist. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness, or expect him or her “to snap out of it.” Eventually, with treatment, most depressed people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

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