Depression is one of the most common mental health disorders in the United States today. In 2015, over 16 million American adults had at least one major depressive episode in the past year. That’s 6.7% of all U.S. adults!
Depression is marked by:
- Persistent sad, anxious or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness or helplessness
- Loss of interest or pleasure in hobbies or activities
- Decreased energy, fatigue or feeling slowed down
- Difficulty concentrating, remembering or making decisions
- Difficulty sleeping, early-morning awakening or oversleeping
- Appetite changes, weight changes
- Thoughts of death or suicide or suicide attempts
- Restlessness, irritability and anger
- Aches or pains, headaches, cramps or digestive problems without a clear physical cause or that do not get better with standard treatments
The good news is that there is help for depression. People do not have to suffer in silence! Depression is usually treated with a combination of counseling/therapy with a professional therapist or social worker, and medication. Lifestyle changes, such as stress-relieving activities, exercise, and social support groups, are also useful to help people feel better, but are not usually enough on their own to relieve the symptoms of depression.
Commonly used medications for depression
Most patients who are diagnosed with depression will try medication to help relieve their symptoms. The most commonly used antidepressants can be placed into four categories:
- Selective serotonin reuptake inhibitors (SSRIs) – These drugs are usually the first-line choice for depression. They tend to have fewer side effects than other types of antidepressants. They work by increasing the levels of the chemical serotonin in the brain. Serotonin is a chemical that helps the brain maintain mood balance. Too little serotonin is associated with depression and anxiety.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs) – Another often-used class of drugs, SNRIs increase the levels of the chemicals serotonin and norepinephrine in the brain. Like serotonin, the chemical norepinephrine seems to help regulate mood. It is also a key chemical for attention and focus. SNRIs are often used for people who have both anxiety and depression.
- Norepinephrine and dopamine reuptake inhibitors (NDRIs) – NDRIs are often used when SSRIs and SNRIs have failed to work, or when the side effects are intolerable. NDRIs increase the levels of the chemicals norepinephrine and dopamine in the brain. Dopamine is a chemical that regulates mood and helps maintain motivation to work towards goals.
Less commonly used drugs for depression:
- Tricyclic antidepressants – These medications were the first antidepressants to be discovered. They increase the levels of the chemicals serotonin and norepinephrine in the brain, but in a different way than the SNRIs do. Tricyclic antidepressants are used less frequently today because they cause more side effects than SSRIs, SNRIs and NDRIs. They are used only if someone has tried other medications without improvement.
- The side effects can be significant, including orthostatic hypotension (drop in blood pressure on standing), constipation, difficulty urinating, dry mouth and blurry vision.
- Some of the drugs in this class are:
- Atypical antidepressants – This is a catch-all category for drugs that are not in other categories. These drugs are usually not used as a first choice, but only if other drugs do not work or cause intolerable side effects.
- Monoamine oxidase inhibitors (MAOIs) – MAOIs are very rarely prescribed because they can have very serious, and occasionally fatal, side effects. People using these drugs must keep a strict diet because of certain dangerous interactions with some foods. Also, people cannot use birth control pills, decongestants or some herbal supplements while taking MAOIs.
In addition to the above types of medications, a small percentage of people may also benefit from taking mood stabilizers, antipsychotics, anti-anxiety medications or stimulant medications for a defined period of time.
When standard treatments are not helping
Unfortunately, some people do not get relief from their depression symptoms with the medications described above, even when used together with professional counseling. For people with severe symptoms of depression that are not improving with standard therapies, there are some other treatment options:
- Electroconvulsive therapy (ECT) – ECT uses electrical currents that are passed through the brain while the person is asleep under general anesthesia. These currents change the chemical balance within the brain to help relieve depression. The procedure is short, and people are usually able to return to their normal routine within an hour or two. ECT is usually used when standard drug therapy does not work or the person cannot tolerate the side effects. It is also sometimes used for people who are at high risk of suicide.
- Most people have four to six treatments before major improvement is seen. Sometimes people need “maintenance ECT” on a less frequent basis, such as once a month or once a year.
- Side effects of ECT may include headaches, muscle pain, nausea, a short time of confusion following treatment (minutes or hours), and memory loss.
- Transcranial magnetic stimulation (TMS) – TMS uses magnetic fields to stimulate nerve cells. A large electromagnetic coil is placed on a person’s forehead and short pulses are directed into an area of the brain believed to control mood. This can help with symptoms of depression. TMS treatments usually take less than an hour, and the person stays awake.
- Several sessions of TMS over a period of weeks are usually needed to see symptoms improve.
- TMS cannot be used for people who have psychosis or bipolar disorder, or people who have a high risk of suicide. It also cannot be used for people with a pacemaker or any metal objects in their head.
- Side effects of TMS include muscle contractions or tingling in the face or the jaw, headache, light-headedness, and seizures (in people with a history of seizures).
- Ketamine injections – Ketamine is a drug that is approved by the Food and Drug Administration for use as an anesthetic, not depression. However, recent studies have suggested that ketamine injections have strong antidepressant effects when given at a dose much smaller than that used for anesthetic. The antidepressant effect is nearly immediate, and lasts for up to several weeks before the injection needs to be repeated. Such injections are legal, but they are an “off label” use of the drug. This means that insurance companies will not pay for this treatment.
- The short-term side effects are fast heart rate, increase in blood pressure, difficulty breathing, mild hallucinations, panic attacks, memory problems, nausea/vomiting, and sleepiness. Doctors do not know what side effects to these injections might be in the long term, because those sort of studies have not been done yet. Studies on ketamine injections for depression and anxiety are now ongoing, but it will be years before the data are ready.
- Ketamine is also used as a street drug (“Vitamin K”, “Special K”) because it can cause the user to hallucinate. The dose used for depression is much lower than that used on the street as an illegal drug.
The key to finding the right treatment for depression is patience, because the process can take time. Most people who have depression find a combination of treatments that helps them return to a full and active lifestyle with an improved outlook.
Mayo Clinic. Depression (Major Depressive Disorder) Treatment.
National Alliance on Mental Illness. ECT, TMS, and Other Brain Stimulation Therapies.
National Institute for Mental Health. Depression Basics.
National Institute for Mental Health. Major Depression Among Adults.