Depression - Therapy

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What is the general approach to treating depression?

In general, the severe depressive illnesses, particularly those that are recurrent, will require antidepressant medications (or ECT in severe cases) along with psychotherapy for the best outcome. If a person suffers one major depressive episode, he or she has up to about a 75% chance of a second episode. If the individual suffers two major depressive episodes, the chance of a third episode is about 80%. If the person suffers three episodes, the likelihood of a fourth episode is 90%-95%. Therefore, after a first depressive episode, it might make sense for the patient to gradually come off medication. However, after a second and certainly after a third episode, most clinicians will have a patient remain on a maintenance dosage of the medication for an extended period of years, if not permanently.

Patience is required because the treatment of depression takes time. Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for the patient. Sometimes, the dosage must be increased to be effective.

In choosing an antidepressant, the doctor will take into account the patient's age, his/her other medical conditions, and medication side effects. Of particular importance is that antidepressant medication for children and adolescents continues to be used with caution because of uncommon instances in which minors become acutely worse instead of better while receiving this treatment.

Doctors often use one of the SSRIs initially because of their lower severity of side effects compared to the other classes of antidepressants. Side effects of SSRI medications can be further minimized by starting them at low doses and gradually increasing the doses to achieve full therapeutic effects. For those patients who do not respond after taking a SSRI at full doses for six to eight weeks, doctors generally switch to a different SSRI or another class of antidepressants. For patients whose depression failed to respond to full doses of one or two SSRIs or whom could not tolerate those medications, doctors will usually then try medications from another class of antidepressants. Some doctors believe that antidepressants with dual action (action on both serotonin and norepinephrine), such as duloxetine (Cymbalta), (Cymbalta), mirtazapine (Remeron), venlafaxine (Effexor), and desvenlafaxine (Pristiq), may be effective in treating patients with severe depression that is treatment resistant. Other options include bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban), which has action on dopamine (another neurotransmitter). Sometimes doctors may use a combination of antidepressants from different classes or add a medication from a completely different chemical class, such as Abilify or Seroquel, that are thought to enhance the effectiveness of antidepressant medication. Also, new types of antidepressants are constantly being developed, and one of these may be the best for a particular patient.

If the depressed person is taking more than one medication for depression or medications for any other medical problem, each of the patient's doctors should be made aware of the other prescriptions. Many of these medications are cleared from the body (metabolized) in the liver. This means that the multiple treatments can interact competitively with the liver's biochemical clearing systems. Therefore, the actual blood levels of the medications may be higher or lower than would be expected from the dosage. This information is especially important if the patient is taking anticoagulants (blood thinners), anticonvulsants (seizure medications), or heart medications, such as digitalis (Crystodigin). Although multiple medications do not necessarily pose a problem, all of the patient's doctors may need to be in close contact to adjust dosages accordingly.

Patients often are tempted to stop their medication too soon, especially when they begin feeling better. It is important to keep taking medication therapy until the doctor says to stop, even if the patient feels better beforehand. Doctors often will continue the antidepressant medications for at least six to 12 months after symptoms are alleviated because the risk of depression quickly returning when treatment is stopped decreases after that period of time in those people experiencing their first depressive episode. Some medications must be stopped gradually to give the body time to adjust (see discontinuation of antidepressants below). For individuals with bipolar disorder or chronic major depression, medication may have to become a part of everyday life for an extended period of years in order to avoid disabling symptoms.

Antidepressant medications are not habit-forming, so there need not be concern about that. However, as is the case with any type of medication prescribed for more than a few days, antidepressants must be carefully monitored to ensure that the patient is getting the correct dosage. The doctor will want to check the dosage and its effectiveness regularly.

If the patient is taking MAOIs, certain aged, fermented, or pickled foods must be avoided, like many wines, processed meats, and cheeses. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. Remember that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.

People should never mix medications of any kind (prescribed, over the counter, or borrowed) without consulting their doctor. The dentist or any other medical specialist who prescribes a drug should be informed that the patient is taking antidepressants. Some drugs that are harmless when taken alone can cause severe and dangerous side effects when taken with other drugs. This may also be the case for individuals taking supplements or herbal remedies. Some drugs, such as alcohol (including wine, beer, and hard liquor), tranquilizers, narcotics or marijuana, reduce the effectiveness of antidepressants and should be avoided. These and other drugs can also be dangerous when the person's body is either intoxicated with or withdrawing from their effects due to increasing the risk of seizure in combination with antidepressants medications.

Antianxiety drugs such as alprazolam (Xanax), and lorazepam (Ativan) are not antidepressants, but they are occasionally prescribed alone or with antidepressants for a brief period of anxiety. However, they should not be taken alone for depressive disorder. Furthermore, the antianxiety drugs should be phased out as soon as the antidepressant and antianxiety effects of the antidepressant medications begin to work, which is usually in four to six weeks.

Finally, the doctor should be consulted concerning any questions about a medication or problem that the patient believes is medication related.

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See what others are saying

Comment from: rustyangel, 45-54 Female (Patient) Published: January 28

I am undergoing treatment at the moment for depression which was diagnosed 27 years ago, but I feel it is much longer than this. I have e many times been attended to by the emergency team from local hospital. I still feel let down by first line of care eg local GP,. I have a physiologist that seems to take my problems seriously. I now work in aged care where a lot of undiagnosed depression exists. A lot of doctors feel that they are old and don't matter, so I feel my through my experiences. I can help them, we are put on this earth for a reason, we just have to find the best way to share and care.

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Comment from: CleeS, 35-44 Female (Patient) Published: March 21

Do not stop your search for healing depression by treating the symptoms of it. At 42 years old, I finally understand why I have suffered from it all my life. It was never learning self-love due to emotionally detached parents, who also never learned self-love, and who knows how many generations back. Think about how you handle pain. Is it normal feeling? How do you handle nurture? Is it odd to you? Living without self-love means a life of searching for something, but not realizing what because you never knew it to start. Begin with yourself, nurture and encourage, love and be loyal, praise and be hopeful. You THEN have to strength to live without the mountain of pain you have accumulated over the years. Keep trying since we all deserve peace and happiness and love.

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