Treating Depression

The success rate for treating depressed patients of all ages is about 80 percent—a figure that would be even more encouraging were it not for the fact that fewer than half of those suffering from it are ever diagnosed and treated. [32]

Treatment of depression takes three major forms—medication, psychotherapy and electroconvulsive therapy.  All three have proven effective for large numbers of patients.

Medication for depression is directed at reversing changes in brain chemistry that accompany the condition. Whether these changes are causes or effects of depression is still the subject of some debate, though the majority opinion among researchers is that they are at least a significant part of the cause.  That position is supported by the fact that depression usually lifts once the brain chemistry deficits are corrected. There are several major classes of antidepressant medications:

• SSRIs (Specialized serotonin reuptake inhibitors): the most widely prescribed medications for unipolar depression (depression without a manic phase).  Their effect is to increase the level of serotonin, a message-carrying chemical (neurotransmitter) in the brain. The heightened level of serotonin increases the activity of the brain cells (neurons), improving mood and reversing the lethargy of depression.  They include such widely known brand names as Prozac, (generic name fluoxetine), Paxil (paroxetine hydrochloride) and Zoloft (sertraline). 
• SNRIs (Specialized norepinephrine/serotonin reuptake inhibitors) inhibit the depletion of both serotonin and a second neurotransmitter, norepinephrine, with the same mood-raising effect of SSRIs. Effexor (venlafaxine) is one example.
• TCAs (Tricyclic antidepressants) These older reuptake inhibitors are now most frequently used in the treatment of severe depression, especially if accompanied by anxiety.  They have fallen out of favor as a first-line treatment because their more generalized effect often produced more numerous and intense side effects, including dry mouth and eyes, light sensitivity, weight gain, constipation, urinary hesitancy, and dizziness when standing up suddenly.  They are also dangerously toxic if taken in overdose, making their use inadvisable in potentially suicidal patients.  Currently prescribed TCAs include Tofranil (imipramine hydrochloride), Triavil (amitriptyline hydrochloride), Pamelor (nortriptyline hydrochloride), Sinequan (doxepin hydrochloride) and Norpramin (desipramine hydrochloride).
• MAOIs (Monoamine oxidase inhibiters) These first-generation antidepressants, turn off an enzyme in the brain that breaks down neurotransmitter molecules, thus allowing more of these message-carrying chemicals to accumulate between neurons.  They work more quickly than TCAs, but they also have potentially serious side effects, including severe hypertension (high blood pressure). Other complaints of patients on MAOIs include insomnia, anxiety, tremors, confusion and memory impairment.  Combining TCAs and MAOIs can have fatal side effects.  The MAOIs most frequently used today are Parnate (tranylcypromine sulfate) and Nardil (phenelzine sulfate).
• Lithium (Lithium carbonate and lithium citrate) Used to reduce mood swings in manic depression (bipolar disorder).  Specifically targets the manic stage of the condition.  While highly effective, lithium is known to have a host of potentially serious side effects and drug interactions, and requires careful patient monitoring by the prescribing physician. Several brand names of lithium carbonate exist, including Eskalith and Lithobid.  Lithium carbonate and lithium citrate are also sold as generics
• Anticonvulsants The U.S. Food and Drug Administration (FDA), has approved the anti-seizure medication valproic acid (Depakote) as an alternative to lithium as a mood stabilizer.  While less potentially toxic than lithium, it, too, requires careful monitoring because of potential liver dysfunction problems.  Other anticonvulsants, including Tegretol (carbamazepine), Lamictal (lamotrigine) and Neurontin (gabapentin) have also been prescribed as mood stabilizers. [33]

While medication has steadily grown as a first-line treatment for depression, it is often accompanied by psychotherapy.  Some depressed patients are successfully treated with psychotherapy alone.  There are several forms of psychotherapy used in the treatment of mood disorders:

• Cognitive-Behavioral Therapy emphasizes the interactive nature of thoughts, emotions and behavior.  It is based on the assumption that the patient’s depression stems from a negative way of viewing and addressing the world.  The three-fold goal of the therapist is to 1) identify those negative ideas and responses and reshape them, 2) to develop new and more flexible ways of viewing the world that do not contribute to depression and 3) to teach the patient to habitually use the more depression-resistant approach to the world.  Usually a cognitive-behavioral treatment program involves weekly sessions over a period of three months or less.
• Interpersonal psychotherapy assumes that the patient’s interpersonal relations are significantly involved in his or her depression. The therapist focuses on four interpersonal relations areas often associated with the onset of depression—grief, conflicts, life changes and the patient’s shortcomings in forming and maintaining supportive relationships. Typically carried out over 15-20 therapy sessions.
• Psychodynamic therapy assumes the patient’s depression stems from unresolved and often unconscious conflicts, frequently originating in childhood.  It endeavors to discover these events and the depressive responses to them in order to allow the patient to re-experience the events and develop more constructive responses to them.  This approach requires a far longer course of treatment, often running for months or even years. [34]

If medication and/or psychotherapy prove unsuccessful in breaking the hold of severe, suicidal depression, a third approach, electroconvulsive therapy, may succeed.  Just why causing the patient to experience the neurological effects of a seizure provides relief from severe depression isn’t known.  But it is successful in 70 percent of those to whom it is administered.

The treatment, once called electroshock therapy, has been represented in movies and elsewhere as a rather violent and crude approach to treatment in which the patient is strapped to a table and given a heavy jolt of electricity to create convulsions rivaling a grand mal epileptic seizure.  That representation of it is profoundly inaccurate and out of date.

Today the patient is given a general anesthetic and a paralytic drug to relax muscles. A brief, carefully controlled pulse of electrical current is applied through electrodes placed on the scalp.  The immediate aftereffects reported by patients upon awakening are usually limited to short-term confusion and memory loss relating to the period of the treatment, which clears up in about an hour.

There may also be residual memory loss for events dating back about six months before the period of the treatment, and some impairment in learning new information.  Both effects typically disappear within a few months.  In a small percentage of patients, there may be more persistent memory problems.  That risk can be reduced by placing both electrodes on one side of the head.  But this unilateral approach doesn’t have as great or rapid a therapeutic effect as the bilateral approach, with an electrode on each side of the head. [35]

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