Treatment, Services and Support
Only one-half of Americans experiencing an episode of major depression receive treatment.
Treating Major Depression
Although depression can be a devastating illness, it often responds to treatment. The key is to get a specific evaluation and a treatment plan. Today, there are a variety of treatment options available for depression. There are three well-established types of treatment: medications, psychotherapy and electroconvulsive therapy (ECT). A new treatment called transcranial magnetic stimulation (rTMS), has recently been cleared by the FDA for individuals who have not done well on one trial of an antidepressant. For some people who have a seasonal component to their depression, light therapy may be useful. In addition, many people like to manage their illness through alternative therapies or holistic approaches, such as acupuncture, meditation, and nutrition. These treatments may be used alone or in combination. However, depression does not always respond to medication. Treatment resistant depression (TRD) may require a more extensive treatment regimen involving a combination of therapies.
Medications often effectively control the serious symptoms of depression, but people living with depression must also learn to recognize their individual patterns of illness and develop ways to cope with them. Taking medication prescribed by a doctor is just one way to manage major depression. Psychotherapy is another way to help manage depression and research demonstrates that a combination of medication and psychotherapy is often the most effective treatment. Education, peer support by people who have “been there,” supportive relationships, aerobic exercise and attention to co-occurring conditions are also useful in supporting recovery.
It often takes two to four weeks for antidepressants to start having an effect, and six to 12 weeks for antidepressants to have their full effect. In some cases, people may have to try various doses and different antidepressants before finding the one or the combination that is most effective. Friends and relatives will sometimes notice an improvement on medication before the depressed person will notice any changes. Antidepressants are not habit forming; however they should not be stopped abruptly as withdrawal symptoms (muscle aches, stomach upset, headaches) may occur. Below is a list of medications often used to treat depression.
Selective serotonin reuptake inhibitors (SSRIs) act specifically on the neurotransmitter serotonin. They are the most common agents prescribed for depression worldwide. These agents block the reuptake of serotonin from the synapse to the nerve, which increases the level of serotonin. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro). Common side effects include sexual dysfunction and gastrointestinal problems.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) are the second most popular antidepressants worldwide. These agents block the reuptake of both serotonin and norepinephrine from the synapse into the nerve, which increases the amounts of these chemicals. SNRIs include venlafazine (Effexor), desvenlafazine (Pristiq) and duloxetine (Cymbalta).
Bupropion (Wellbutrin) is a popular antidepressant medication classified as a norepinephrine-dopamine reuptake inhibitor (NDRI). It acts by blocking the reuptake of dopamine and norepinephrine and increases these neurotransmitters in the brain. It also helps with smoking cessation strategies. Buproprion generally causes fewer side effects than most other antidepressants (particularly nausea, sexual side effects, weight gain, and fatigue or sleepiness). Its side effects include restlessness, insomnia, headache or a worsening of pre-existing migraine tendencies, tremor, dry mouth, agitation, rapid heartbeat, dizziness, nausea, constipation, menstrual complaints and rash. For some people, buproprion causes significant anxiety symptoms and for others it is a very effective treatment for anxiety. However, buproprion has been shown to increase the likelihood of having a seizure and those prone to seizures, or at doses above 450mg a day should never be taken at doses above the recommended maximum dose. Buproprion is not recommended in people with a history of an eating disorder, head injury or seizure disorder.
Mirtazapine (Remeron) works differently from the compounds discussed above. Mirtazapine targets specific serotonin and norepinephrine receptors in the brain, thus indirectly increasing the activity or several brain circuits. Mirtazapine is used less often than other, newer antidepressants (SSRIs, SNRIs, buroprion) because it is associated with more weight gain, sedation and sleepiness. However, it appears to be less likely to result in insomnia, sexual side effects and nausea than the SSRIs and SNRIs. Other side effects include headaches, dry mouth and constipation. Remeron is not recommended for those with hepatic or renal dysfunction, a history of mania or seizure disorder.
Atypical antipsychotics. Aripirazole (Abilify) and quetiapine (Seroquel) are atypical antipsychotics that were approved by the FDA in 2007, and used to augment the depression when used along with antidepressants. The specific combination of olanzapine and fluoxetine (Symbax) is also approved.
Tricyclic antidepressants (TCAs) are older agents seldom used today as first-line treatment. They work similarly to the SNRIs, but have other properties that often result in higher rates of side effects, as compared to almost all other antidepressants. They are sometimes used in cases where other antidepressants have not worked. TCAs include amitriptyline (Elavil), desipramine (Norpramin), doxepin (sinequan), imipramine (Tofranil), nortriptyline (Pamelor, Aventyl) and protriptyline (Vivactil). TCAs (and duloxetine) may be helpful with chronic pain as well. TCAs generally have more side effects than all other antidepressants, including headaches, sleepiness and drowsiness, significant weight gain, nervousness, dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness and skin rash.
Note: Although antidepressants generally reduce suicidal thoughts along with your other symptoms of depression; children, adolescents and young adults starting an antidepressant medication should be monitored frequently for the emergence or worsening of suicidal thoughts due to the possibility of increased suicidality in some young people who are taking antidepressant medication. The FDA public health advisory on this issue is available at www.fda.gov
Monoamine oxidase inhibitors (MAOIs) are less commonly used today. MAOIs work by inactivating enzymes in the brain, which catabolize (breakdown) serotonin, norephinephrine and dopamine from the synapse, thus increasing the levels of these chemicals in the brain. They can never be used in combination with SSRI antidepressants. MAOIs can sometimes be effective for people who do not respond to other medications or have atypical (abnormal) depression with marked anxiety, excessive sleeping, irritability, hypochondria or phobic characteristics. They have important food and medication interactions, which requires strict adherence to a particular diet. MAOIs include phenelzine (Nardil), isocarboxazid (Marplan), tranylcypromine sulfate (Parnate) and selegiline patch (Emsam). Selegiline (Emsam) is a patch approved by the FDA in 2006. This delivery system reduces the risk of the dietary concerns noted above.
The FDA periodically approves medication. For a current list, visit www.fda.gov
There are several types of psychotherapy that have been shown to be effective for depression, including cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). In general, these two types of therapies are short-term; treatments usually last only 10-20 weeks. Research has shown that mild to moderate depression can often be treated successfully with either medication or psychotherapy alone. However, severe depression appears more likely to respond to a combination of these two treatments.
Cognitive behavioral therapy (CBT) helps to change the negative thinking and behavior associated with depression while teaching how to unlearn the behavioral patterns that contribute to their illness. The goal of this therapy is to recognize negative thoughts or mindsets (e.g., "I can't do anything right") and replace them with positive thoughts (e.g., "I can do this correctly"), leading to more effective, beneficial behavior. It is also noted that simply changing one's behavior can lead to an improvement in thoughts and mood. This might be as simple as leaving the house and taking a 15-minute walk every day.
Interpersonal therapy (IPT) focuses on improving personal relationships that may contribute to a person's depression. The therapist teaches people to evaluate their interactions with others and to become aware of self-isolation and difficulties getting along with, relating to or understanding others.
Psychodynamic therapy is often more available than CBT and IPT in many communities, but researchers in depression recommend it less often due to a relative lack of data indicating that it works for this condition. In fact, one study found that psychodynamic psychotherapy was no more effective than a placebo for depression.
Psychoeducation involves teaching a person about his or her illness, how to treat it and how to recognize signs of relapse so they can get necessary treatment before the illness worsens or occurs again. NAMI Peer-to-Peer is a recovery-focused educational program for adults living with mental illness who wish to establish and maintain wellness.
Family psychoeducation helps to reduce distress, confusion and anxieties within the family and can help the person recover. NAMI Family-to-Family is an educational course for family, caregivers and friends of individuals living with mental illness.
Self-help and support groups for people and families dealing with mental illnesses are becoming more widely available. In this venue, people rely on their lived experience to share frustrations and successes, referrals to qualified specialists and community resources and information about what works best when trying to recover. They also share friendships and hope for themselves, their loved ones and others in the group. NAMI sponsors two support groups. NAMI Connection Recovery Support Group is a weekly recovery support group for people living with mental illness, and NAMI Family Support Groups for family, friends and caregivers.
Electroconvulsive Therapy (ECT)
ECT is a highly effective treatment for severe depression episodes and for severe depression with psychosis. When medication and psychotherapy are not effective in treating severe symptoms-such as acute psychosis or thoughts of suicide-or if a person cannot take antidepressants, ECT may be considered. ECT can be combined with antidepressants for some individuals. Memory problems can follow ECT treatments, so a careful risk-benefit assessment needs to be made for this important and effective intervention.
Repetitive Transcranial Magnetic Stimulation (TMS)
In October 2008, the FDA cleared the use of rTMS for major depression. Early returns indicate it to be a low-risk intervention that may help a person who has not responded to one antidepressant trial. At this time, rTMS does not appear to be effective for major depression with psychotic features. More will be learned about this new treatment as research continues.
Complementary and Alternative Medicine (CAM)
CAM refers to alternative forms of medicine that are not considered part of conventional (Western) medicine. In recent years, CAM had become increasingly popular, but no CAM strategy has won the FDA approval. While there is still limited data showing support for many CAM practices and some inconsistency in results, there are studies which support the usefulness of CAM strategies that are considered to have minimal if any adverse effects. One practice that has shown some promise for the treatment and management of bipolar disorder, as well as other mental illnesses, is omega-3 fatty acids, which are commonly found in fish oil. Some researchers hypothesize that omega-3 may be beneficial in treating mental illness because of its ability to protect or supports the replenishing of neurons and connections in areas of the brain that are affected by these illnesses.
People with mental illness are at greater risk of vitamin deficiencies due to a number of issues. Specifically, scientific studies have shown that people with depression and other mental illnesses may be more likely to have folate deficiency than others. People with folate deficiency may appear confused, irritable or depressed and may experience changes in thinking and personality. L-methylfolate is an active form of folate and for individuals with low folate levels it may be useful as an additional treatment along with their other regularly prescribed psychiatric medications. S-adenosylmethionine (SAM-e) has been shown to be effective in one study in combination with other antidepressants. St. John’s Wort has been shown in several studies to not be better than a placebo.
Studies and literature now support that aerobic exercise can aid in treating mild depression. A 2005 study at the University of Texas Southwest Medical Center was the first study to look at exercise alone in treating mild to moderate depression in adults aged 20-45 showed that depressive symptoms were reduced almost 50 percent in individuals who participated in 30-minute aerobic exercises three to five time a week. Harvard Medical school notes exercise enhances the action of endorphins, and endorphins reduce the perception of pain as well as potentially have the ability to improve mood. In addition, exercise stimulates the neurotransmitter norepinephrine, which may directly improve a person's mood. For mild to moderate depression, aerobic exercise is usually a key component to a treatment plan. For more on exercise and wellness, visit NAMI's Hearts & Minds program.
Friends and Family
There are many actions a caregiver can take to provide help to a loved one living with depression. Offering emotional support, talking and listening carefully to what a loved one is experiencing and learning about the illness so you can understand what your friend or relative is experiencing are all great ways to be supportive.
Caregivers also need support and the opportunity to talk to people who understand and can help. It is common for both the person living with the illness and family members to experience grief because of the drastic changes in their lives and the trauma that previous episodes may have caused.
Individuals living with mental illness, and their families, must work together to discuss past episodes so that they can clearly recognize the early signs of a developing episode. Whatever the indicator of possible relapse is, everyone should agree on what the objective signs of a possible episode are.
How well treatment works depends on the type of depression, its severity, how long it has been going on and the medical and psychological interventions offered. A multicenter trial funded by the National Institute of Mental Health (NIMH) called STAR*D is currently offering new information on treatment outcomes in real-world settings.
The development over the past 25 years of antidepressants and mood-stabilizing drugs has improved the treatment of clinical depression, particularly for those with more serious or recurrent forms of the disorder. A comprehensive array of treatments can be effective overall, and most people with biological depression get significant relief from medications—especially when the depression is moderate or severe, recent or long-term. Left untreated, however, depression can become more serious or go on indefinitely. Treatment is important because it works and continued treatment after getting well can prevent recurrences. More than one-half of people who experience a first episode of depression will have at least one other episode in their lives. After two episodes, the chances of having a third episode are even greater.
The STAR*D study noted above has already shown that it can take up to six to eight weeks to get a good response to treatment and that people should keep trying different strategies. For instance, one-third of people who did not get better with a first treatment saw all symptoms reduced (into remission) with the addition of a second medicine. Another one-quarter improved to remission after switching to another antidepressant. This study helps to support the idea that staying with the battle against depression is essential.
Although most people who live with depression can be treated successfully as outpatients, severe episodes and episodes accompanied by suicidal thinking may require brief hospitalization for careful evaluation, protection and initiation of treatment. In combined treatments, medications are used to treat the symptoms of depression, while psychotherapy is used to help alleviate the problems depression causes in daily living. Psychotherapy is particularly important to undertake for anyone experiencing suicidal thoughts or profound psychosocial impairment.
The use of alcohol, a central nervous system depressant, can be a serious complication for depressed individuals who use it to try to change moods. Alcohol should generally be avoided during treatment for depression for several reasons. First, after its initial anti-anxiety effect, alcohol can cause increased feelings of anxiety or depression, Alcohol can cause a depressed mood that lasts for weeks, even after alcohol use stops. Second, in combination with many antidepressants, alcohol can make drug side effects much worse, even dangerously so, and may make antidepressants less effective. Third, alcohol reduces inhibitions, which increases the risk of suicide.