Treating Depression: Medications and Therapies
Sadness and low mood are a normal part of our lives. Everybody encounters good reason for an occasional bout of depression. But if your feelings of sadness last for more than two weeks and are so intense that they interfere with your normal daily routine, you are probably suffering from depression and need medical help. Although many bouts of depression clear up on their own, lots of people develop a serious depression that can last from six months to a year. For some individuals the condition becomes so chronic that they start to believe it is normal. But it is not. Fortunately, there are treatments that can help. Usually, a combination of medication and psychotherapy delivers the best results while other treatments, such as electromagnetic stimulation, can be used for stubborn cases of depression.
Antidepressant medications alleviate the emotional suffering of depression and are prescribed to treat moderate to severe cases of depression. They can be effective on their own or in combination with other forms of therapy, though they cannot alter your circumstances. By providing relief from debilitating symptoms of depression, medications give people a chance to benefit from psychotherapy aimed at addressing the underlying psychological or social issues that may be the cause or a contributing factor to the depression. Several types of antidepressant medications are now available, including selective serotonin re-uptake inhibitors, serotonin and norepinephrine re-uptake inhibitors, norepinephrine and dopamine re-uptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors and the medication for bipolar disorder, lithium. If one type is not effective, another often will work.
Tricyclic antidepressants. These older medications cause a variety of side effects and are prescribed only if other antidepressants such as selective serotonin re-uptake inhibitors fail to improve the symptoms. They act by increasing the availability of serotonin and/or norepinephrine in the brain. Possible side effects include blurred vision, constipation, a dry mouth, a feeling of light-headedness or confusion, retention of urine or weight gain, sweating, low blood pressure, a racing heartbeat and allergic skin reactions. Serious side effects, which are extremely rare, include elevated intraocular pressure and seizures. Tricyclic antidepressants include the following drugs:
- Anafranil (clomipramine)
- Adapin, Sinequan (doxepin)
- Aventil, Pamelor (nortriptyline)
- Elavil, Endep (amitriptyline)
- Norpramin (desipramine)
- Surmontil (trimipramine)
- Tofranil (imipramine)
- Vivactil (protriptyline)
Selective serotonin re-uptake inhibitors (SSRIs) work by increasing the levels of available neurotransmitter serotonin in the brain by inhibiting its reuptake into the presynaptic cell. SSRIs generally have fewer and less troublesome side effects than tricyclic or other antidepressants. Because of having lesser effect on the cardiovascular system, they can be prescribed to patients who have suffered a stroke or have heart disease. Although side effects occur in some people during the first few days of treatment, they tend to disappear after a few weeks but some patients do report a sustained decrease in sexual function. Reported side effects include sleep disturbances, anxiety, stomach cramps, nausea and skin rash. In extremely rare cases, a patient may experience a seizure. In general, the selective serotonin re-uptake inhibitors may be continued as long as necessary to prevent recurrence of the depression. The currently available SSRIs include:
- Celexa (citalopram)
- Lexapro (escitalopram)
- Luvox (fluvoxamine)
- Paxil (paroxetine)
- Pexeva (paroxetine mesylate)
- Prozac, Sarafem (fluoxetine)
- Zoloft (sertraline)
Serotonin and norepinephrine re-uptake inhibitors (SNRIs) are second generation antidepressant drugs alongside SSRIs and NDRIs (norepinephrine and dopamine re-uptake inhibitors). They increase the concentration of mood-enhancing neurotransmitters serotonin and norepinephrine in the brain. Studies suggest that SNRIs are more successful in the treatment of depression than single acting agents such as SSRIs and NRIs (norepinephrine re-uptake inhibitors used in the treatment of ADHD and narcolepsy). Examples of possible side effects include blurred vision, headache, drowsiness, strange dreams, light-headedness, fever/chills, constipation, increased or decreased appetite, dry mouth, tremor and nausea. SNRIs include the following drugs:
- Cymbalta (duloxetine)
- Effexor (venlafaxine)
- Pristiq (desvenlafaxine)
Norepinephrine and dopamine re-uptake inhibitors (NDRIs) are second generation antidepressants prescribed for the treatment of depression, ADHD and narcolepsy. NDRIs act by increasing extracellular concentrations of neurotransmitters norepinephrine and dopamine in the brain. Bupropion with its several trade names, such as Alpenzin, Budeprion, Buproban and Wellbutrin, falls into this category. Although their side effects are similar to those of SSRIs and SNRIs, they are less frequently associated with decreasing sexual function.
Monoamine oxidase inhibitors (MAO inhibitors). Though as effective as other classes of antidepressants, these drugs are, because of their potentially serious dietary and drug interactions, prescribed only when the patient has not responded to other treatments. MAO inhibitors work by increasing the amount of serotonin and norepinephrine in the brain. They may be a useful alternative for patients suffering from heart problems or glaucoma that prevent them from taking other types of antidepressants. Patients treated with MAO inhibitors must avoid yogurt, aged cheese, certain beans, pickles, liver and large amounts of caffeine, alcohol and chocolate. Due to the risk of serious drug interactions, patients must check with their doctor before taking any medications or herbal supplements. Common side effects include headache, neck stiffness, chest pain, heart racing, nausea and vomiting. However, newer topically applied MAO inhibitors (transdermal skin patches) may cause fewer side effects than oral forms. Monoamine oxidase inhibitors include the following medications:
- Eldepryl, Zelapar (selegiline)
- Emsam (selegiline – transdermal skin patch)
- Nardil (phenelzine sulfate)
- Marplan (isocarboxazid)
- Parnate (tranylcypromine sulfate)
Lithium is the medication of choice for patients with bipolar disorder. This drug seems especially effective in preventing mania. The manic symptoms typically diminish within two weeks while depressive symptoms are usually also reduced. Reported side effects include tremor, nausea, mild diarrhea, weight gain and skin rashes. Less frequently, patients encounter slurred speech, confusion, dizziness, muscle weakness, difficulty in walking, extreme fatigue or excitement and sleep disturbances. In order to avoid dehydration while on lithium, patients should drink 10 to 12 glasses of water a day.
Other medications. Some antidepressants fail to fit any of the major categories, yet clearly provide relief. One such drug is mirtazapine (Avanza, Mirtazon, Remeron), a noradrenergic and specific serotonergic antidepressant (NaSSA). Mirtazapine was proven especially helpful for treating depression accompanied by sleep disorders and anxiety. It is free of some of the troublesome side effects associated with SSRIs, such as agitation and sexual dysfunction. Another one is tradozone (Depyrel, Desyrel), an antidepressant drug of the serotonin antagonist and reuptake inhibitor (SARI) class. Like mirtazapine, it is sedating and should be therefore taken in the evening. A newer drug named vilazodone (Vilibryd) is a serotonergic antidepressant that is said to have a low risk of sexual side effects.
Saint John’s Wort. The active ingredient in the herb Saint John’s Wort, called hypericin, was in some studies found to be effective in the treatment of depression. However, its true benefits are still being examined. Because Saint John’s Wort can interact with prescription antidepressants, you need to check with your doctor before taking it. Various over-the counter preparations of this herb are available at pharmacies. But bear in mind that dietary supplements like these are not regulated the same way as pharmaceutical drugs.
For some depressed individuals psychotherapy is often the first course of treatment. Many patients with depression can benefit as much from short-term psychotherapy as from antidepressants. Studies show that even though antidepressants tend to relieve the symptoms faster, patients with moderately severe depression who receive psychotherapy instead of medicine gain as much relief from symptoms of depression after four months of treatment. Therefore, psychotherapy is a viable alternative for those depressed patients who suffer unpleasant side effects from medications. However, patients with severe form of depression do best with a combination of medication and psychotherapy. Psychotherapy consists in verbal interaction between a trained health professional and a depressed patient. The therapist helps the patient to gain insights about themselves and change their thoughts, feelings and behavior that are contributing to the condition. Several treatment approaches have been proven useful:
Cognitive-behavioral therapy is based on the view that patient’s perceptions of themselves and various common situations control their emotions. Different forms of talk therapy and behavioral exercises are used to change their views of themselves and the world around them and thus dispel their negative thought patterns and beliefs.
Interpersonal psychotherapy is based on the theory that depression arises from disturbed personal and social relationships with family members, friends, co-workers, etc. Therapists try to help depressed individuals to learn to cope with interpersonal conflicts.
Psychoanalysis is an approach that stems from the assumption that depression is a result of past conflicts which have been pushed back into the patient’s unconscious and these unconscious mental processes now determine their thoughts. The aim of the therapy is to identify and resolve past conflicts connected to present problems.
Psychodynamic psychotherapy views human behavior as the sum of one’s past experience, genetic inheritance and current reality. Like psychoanalysis, this therapy attributes present-day problems to unresolved, generally unconscious conflicts from the past. Treatment is based on psychoanalytic principles but it is shorter and less intense.
For some dangerously depressed patients at high risk for suicide, old-fashioned shock treatments can still be a lifesaver. The same neurotransmitters in the brain that are affected by antidepressant medications are believed to respond to electroconvulsive therapy (ECT), previously known as a shock treatment. However, improved second generation antidepressants have supplanted electroconvulsive therapy for most patients. Nonetheless, ECT is still an effective treatment for those who do not respond to medications or cannot take them because of a heart disease or advanced age.
Transcranial Magnetic Stimulation
This method uses an electromagnetic device to induce small electric currents to stimulate small regions of the brain. In contrast to electroconvulsive therapy, there is no need for general anaesthesia and no controlled seizure. With the exception of a mild headache, side effects associated with this therapy are reported to be minimal. Transcranial magnetic stimulation is an effective treatment option when other therapies have failed or when the patient develops resistance to drug treatment.
Vagus Nerve Stimulation
Vagus nerve stimulation appears to be an effective therapy for treatment-resistant, severe depression. First, a small electrical generator must be implanted in the chest and attached to the vagus nerve. The vagus nerve runs from the neck into the brain. Then, electrical pulses that the device delivers to the vagus nerve are sent via this nerve to areas of the brain that control mood.