Diagnostic Evaluation and Treatment
Your tendency is just to wait it out, you know, let it get better. You don't want to go to the doctor. You don't want to admit to how bad you're really feeling. -Paul Gottlieb, Publisher
The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional.
A good diagnostic evaluation will include a complete history of symptoms: i.e., when they started, how long they have lasted, their severity, and whether the patient had them before and, if so, if 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 if they were effective. Last, a diagnostic evaluation should include a mental status examination to determine if speech, thought patterns, or memory has been affected, as sometimes happens with depressive disorders.
Treatment choice will depend on the patient's diagnosis, severity of symptoms, and preference. There are a variety of treatments, including medications and short term psychotherapies (i.e., "talk" therapies), that have proven effective for depressive disorders. In general, severe depressive illnesses, particularly those that are recurrent, will require a combination of treatments for the best outcome.
There are several types of medications used to treat depression. These include newer antidepressant medications–chiefly the selective serotonin reuptake inhibitors (SSRIs)–and older ones, 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 the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight 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 it isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects, pages 19 20) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, you should never discontinue your medication without first talking to your doctor. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.
Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.
This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.
The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov.
Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.
Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.
For more information, visit the NIMH website at http://www.nimh.nih.gov/healthinformation/antidepressant_child.cfm.
Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, doctors must carefully monitor these treatments to determine if the patient is getting the most effective dosage. The doctor should check regularly the dosage of each medicine and its effectiveness.
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, including 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, and the patient should carry it at all times. Other forms of antidepressants require no food restrictions. Efforts are underway to develop a "skin patch" system for one of the newer MAOIs, selegiline. If successful, this may be a more convenient and safer medication option than the older MAOI tablets.
Medications of any kind prescribed, over the counter, or borrowed should never be mixed without consulting a doctor. Health professionals who may prescribe a medication, such as a dentist or other medical specialist, should be told of all the medications the patient is taking. Some medications, although safe when taken alone, can cause severe and dangerous side effects if taken in combination with others.
Alcohol, including wine, beer, and hard liquor, or street drugs may reduce the effectiveness of antidepressants and should be avoided. However, doctors may permit people who have not had a problem with alcohol abuse or dependence 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, but they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are also not effective antidepressants, but they are used occasionally, under close supervision, in medically ill depressed patients.
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 illness. Doctors must carefully monitor its use as the range between an effective dose and a toxic one is small. If a person has preexisting 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, valproate (Depakote®) and carbamazepine (Tegretol®). Both of these medications have gained wide acceptance in clinical practice, and the Food and Drug Administration has approved valproate for first line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal®), and topiramate (Topamax®); however, their role in the treatment of bipolar disorder is not yet proven and remains under study.
Most people who have bipolar disorder take more than one medication. In addition to lithium and/or an anticonvulsant, doctors often prescribe a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.
Questions about any medication prescribed, or problems that may be related to it, should be discussed with your doctor.
Before starting a new medication, ask the doctor to tell you about any side effects you may experience. 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 the newer antidepressants (SSRIs and others) are:
- Headache will usually go away.
- Nausea also temporary, but even when it occurs, it is short lived after each dose.
- Insomnia and nervousness (trouble falling asleep or waking often during the night) may occur during the first few weeks but are usually resolved over time or with a reduction in dosage.
- Agitation (feeling jittery) notify your doctor if this happens for the first time after the drug is taken and is persistent.
- Sexual problems consult your doctor if the problem is persistent or worrisome. Although depression itself can lower libido and impair sexual performance, SSRIs and some other antidepressants can provoke sexual dysfunction. These side effects can affect more than half of adults taking SSRIs. In men, common problems include reduced sexual drive, erectile dysfunction, and delayed ejaculation. For some men, dosage reductions or acquired tolerance to the medication reduce sexual dysfunction symptoms. Although changing from one SSRI to another has generally not been shown to be beneficial, one study showed that citalopram (Celexa®) did not seem to cause sexual impairment in patients who had experienced such events with another SSRI.37
Some clinicians treating men with antidepressant associated sexual dysfunction report improvement with the addition of bupropion (Wellbutrin®)38 or sildenafil (Viagra®)39 to ongoing treatment. Be sure to discuss the various options with your doctor and inquire about other interventions that can help.
Tricyclic antidepressants have different types of side effects:
- Dry mouth drinking sips of water, chewing sugarless gum, and cleaning teeth daily is helpful.
- Constipation adding bran cereals, prunes, fruit, and vegetables to your diet should help.
- Bladder problems emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; notify your doctor if there is marked difficulty or pain. This side effect may be particularly problematic in older men with enlarged prostate conditions.
- Sexual problems sexual functioning may change; men may experience some loss of interest in sex, difficulty in maintaining an erection or achieving orgasm. If they are worrisome, discuss these side effects you're your doctor.
- Blurred vision – will pass soon and will not usually necessitate a new glasses prescription.
- Dizziness rising from the bed or chair slowly is helpful.
- Drowsiness as a daytime problem – usually passes soon. If you feel drowsy or sedated you should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.
Several forms of psychotherapy, including some short term (10 20 weeks) therapies, can help people with depressive disorders. Two of the short term psychotherapies that research has shown to be effective for depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive behavioral therapists help patients change the negative thinking and behavior patterns that contribute to, or result from, depression. Through verbal exchange with the therapist, as well as "homework" assignments between therapy sessions, CBT helps patients understand their depression and resolve problems related to it. Interpersonal therapists help patients work through disturbed personal relationships that may be contributing to or worsening their depression. Psychotherapy is offered by a variety of licensed mental health providers, including psychiatrists, psychologists, social workers, and mental health counselors.
For many depressed patients, especially those with moderate to severe depression, a combination of antidepressant medication and psychotherapy is the preferred approach to treatment. Some psychiatrists offer both types of intervention. Alternatively, two mental health professionals may collaborate in the treatment of a person with depression; for example, a psychiatrist or other physician, such as a family doctor, may prescribe medication while a nonmedical therapist provides ongoing psychotherapy.
"You start to have these little thoughts, 'Wait, maybe I can get through this. Maybe these things that are happening to me aren't so bad.' And you start thinking to yourself, 'Maybe I can deal with things for now.' And it's just little tiny thoughts until you realize that it's gone and then you go, 'Oh my God, thank you, I don't feel sad anymore.' And then when it was finally gone, when I felt happy, I was back to the usual things that I was doing in my life. You get so happy because you think to yourself, 'I never thought it would leave.'" --Shawn Colten, National Diving Champion
Electroconvulsive therapy (ECT) is another treatment option that may be particularly useful 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. The exact mechanisms by which ECT exerts its therapeutic effect are not yet known.40
In recent years, ECT has much improved. Before treatment, which is done under brief anesthesia, patients are given a muscle relaxant. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) generalized seizure within the brain, which is necessary for therapeutic efficacy. The person receiving ECT does not consciously experience the electrical stimulus.
A typical course of ECT entails six to 12 treatments, administered at a rate of three times per week, on either an inpatient or outpatient basis. To sustain the response to ECT, continuation treatment, often in the form of antidepressant and/or mood stabilizer medication, must be instituted. Some individuals may require maintenance ECT (M ECT), which is delivered on an outpatient basis at a rate usually of one treatment weekly, tapered off to bi weekly to monthly for up to one year.
The most common side effects of ECT are confusion and memory loss for events surrounding the period of ECT treatment. The confusion and disorientation experienced upon awakening after ECT typically clear within an hour. More persistent memory problems are variable and can be minimized with the use of modern treatment techniques, such as application of both stimulus electrodes to the right side of the head (unilateral ECT).40,41 A recent study showed no adverse cognitive effects of M ECT after one year.42
In the past several years, there has been an increase in public interest in the use of herbs for the treatment of both depression and anxiety. The extract from St. John's wort (Hypericum perforatum), a wild growing plant with yellow flowers, has been used extensively in Europe as a treatment for mild to moderate depression, and it now ranks among the top selling botanical products in the United States. Because of the increase in Americans' use of St. John's wort and the need to answer important remaining questions about the herb's efficacy for long term treatment of depression, the National Institutes of Health (NIH) conducted a clinical trial to determine whether a well standardized extract of St. John's wort is effective in the treatment of adults suffering from major depression of moderate severity. The trial found that St. John's wort was no more effective for treating major depression of moderate severity than an inert pill (placebo).43 Another study is underway looking at St. John's wort for the treatment of minor depression.
Research from NIH has shown that St. John's wort interacts with some drugs including certain drugs used to control HIV infection. The Food and Drug Administration issued a Public Health Advisory on February 10, 2000, which stated that the herb appears to affect an important metabolic pathway that many prescription drugs use to treat conditions such as heart disease, depression, seizures, certain cancers, and rejection of organ transplants. The same pathway is also responsible for the effectiveness of oral contraceptives to prevent pregnancy. Using the herb may limit the effectiveness of these medications. People taking HIV medications should be especially careful since St. John's wort may reduce the HIV medication levels in the bloodstream and could allow the AIDS virus to rebound, perhaps in a drug resistant form. Health care providers should alert their patients about these potential drug interactions, and patients should always consult their health care provider before taking any herbal supplement.