Treating Depression

The good news about depression is its treatability. A large and rapidly growing number of antidepressant medications are effective against depression. When drugs don’t work their antidepressant potency can often be augmented by adding a second drug. In addition, several psychotherapies have been shown to be effective. Last, for severe or treatment refractory depression, electroconvulsive therapy is often curative.

 
• Serotonin     The first line of antidepressant treatment is usually one of the class of drugs that act on the chemical messenger serotonin. Prozac (fluoxetine) is the prototype of this family of antidepressants. Other medicines in this class have different side effect profiles so that patients who cannot tolerate one antidepressant can usually take another.  
• Serotonin / Norepinephrine     Another family of medicines act on both serotonin and norepinephrine. In this sense they resemble the older class of tricyclic antidepressants that were the mainstay depression treatment for 20 years, but the newer drugs are much better tolerated because they have fewer side effects. Effexor (venlafaxine) is an example of this class of antidepressants.  
• Atypical Antidepressants     Wellbutrin (bupropion) and a number of other antidepressants do not fit clearly into either of the above classes and it is not clear through which chemical messenger(s) they exert their antidepressant effects. For this reason they are often referred to as “atypical” antidepressants.  
• Tricyclics and Monoamine Oxidase Inhibitors     The older families of antidepressants now are usually reserved for depressions that fail to respond to the newer drugs. The tricyclics, such as Elavil (amitriptylene), have been referred to already. Another family of drugs are the monoamine oxidase inhibitors such as Nardil (phenelzine). These medicines are usually reserved for second line treatment because they can cause unpleasant side effects, interact with other drugs, and complicate medical illnesses.

One of the major advances in treating depression has been the discovery that antidepressants can be made more effective by the simple addition of lithium. Lithium has been used traditionally to control the mood swings of manic-depressive illness, but its ability to augment the effect of antidepressant drugs works in unipolar depressions as well. This augmentation strategy has been so useful that psychiatrists are using a number of other drugs to augment antidepressants but lithium is still supported by the largest body of medical evidence.

Other Methods of Treatment

 
• Psychotherapy     The Practice Guideline for Major Depressive Disorder in Adults published by the American Psychiatric Association lists eight types of psychotherapy for depression. Two commonly used ones are interpersonal therapy and cognitive behavioral therapy. Interpersonal therapy identifies and modifies stresses in the patient’s interpersonal life that precipitate and/or aggravate depression. On the other hand, cognitive behavioral therapy concentrates on irrational beliefs and attitudes that perpetuate depression. Psychotherapy and drugs are not an either/or choice because the two approaches are often applied together.  
• Electroconvulsive or Electroshock Therapy     Electroconvulsive or electroshock therapy is reserved for patients with severe depression that has not responded to medication and patients who are suicidal and need to be treated emergently. Electroconvulsive therapy consists of inducing a medically controlled seizure by passing an electric current through electrodes placed on both temples while the patient is under ansethesia. It usually requires a series of 8 to 12 treatments given on alternate days. This treatment is often effective when other treatments have failed, and it acts more rapidly than either medicine or psychotherapy. After a course of electroconvulsive therapy patients need to take an antidepressant medication to prevent the depression from relapsing.

Dr. Raymond Crowe, M.D.
Peer Review Status: Internally Peer Reviewed by the Department of Psychiatry