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Depression: Major Depression & Unipolar Varieties

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Basic Information

Introduction and Types of DepressionRelated Disorders / ConditionsHistorical and Current UnderstandingsBiology, Psychology and SociologyTreatment - Medication and PsychotherapyAlternative Medicine and Self-Help ResourcesSpecial IssuesReferences

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Treatment 1 of 2

Mark Dombeck, Ph.D.

Depression
Treatment

Table of Contents

Introduction
Psychotherapy
Hospitalization
Medications
Electroconvulsive Therapy (ECT)
Self-Help
Psychotherapy, Medication or Both?
References

Introduction

This article outlines some general treatment guidelines which you may want to take into consideration when seeking or administering treatment for clinical depression and related mood disorders. The discussion below is not meant as an alternative to seeking treatment for depression from a trained mental health professional.

First, depression as discussed here refers only to Major Depressive Disorder (look at the criteria for a Major Depressive Episode here also). This does not include depression as a result of the loss of a loved one, due to medical causes, or Bipolar Disorder (manic-depression). "Medical causes" does not mean, however, that the depression is caused by some sort of "chemical imbalance." There is no such proven fact, only a theory, just like the half-dozen or so psychological and other medical theories for the cause of depression. Second, the studies discussed below do not yet predict individual responses to the specific treatments mentioned. In other words, just because it works for most people still does not mean it will work for you. It is more likely to work for you, but no scientific study, either in psychology or medicine on this topic, yet are specific to an individual's own situation, environment, genetics, etc. Keep this in mind.

Most clinicians practicing today believe that depression is caused by an equal combination of biological (including genetics), social, and psychological factors. Treatment approaches which focuses exclusively on one of these factors is likely not as beneficial as a treatment method which addresses all three of them. Depression is a very complicated disorder and research is only beginning to fully grasp the complexity of factors -- personal, genetic, biological, societal, and environmental --which are involved. Any explanation or approach which emphasizes only one factor as the cause of depression is misleading and simplistic. Individuals should avoid accepting a simplistic answer to such a devastating and complex disorder.

Psychotherapy

There are a wide number of different types of effective therapeutic approaches utilized for the treatment of depression today. These range from cognitive behavioral therapy, to behavioral therapy (ala Lewinsohn), to interpersonal therapy, to rational emotive therapy, to family and psychodynamic approaches. Both individual and group modalities are commonly used, depending upon the severity of the depressive episode and the local resources within an individual's community.

Cognitive-behavioral therapy is the most popular and commonly used therapy for the effective treatment of depression. Hundreds of research studies have been conducted to date which verify its safety and effectiveness in use to help treat people who suffer from this disorder. Aaron T. Beck is the father of this therapeutic technique and he has authored books and studies supporting cognitive-behavioral therapy. Consisting of a number of useful and simple techniques which focus on the internal dialogue which takes place within a person's mind, cognitive-behavioral therapy is not concerned with causes of the depression so much as what a person can do, right now, to help change the way they are feeling.

Therapy begins by establishing a supportive therapeutic environment which is positive and reinforcing for the individual. Educating the client within the first session or two is usually the next step about how depression for many people is caused by faulty cognitions. The numerous types of faulty thinking that we as humans do are discussed (e.g., "all or nothing thinking," "misattribution of blame," "overgeneralization," etc.) and the client is encouraged to begin noting his or her thoughts as they occur throughout the day. This is imperative to further success in treatment, for the individual must understand how common and often these thoughts are occurring during a single day.

In cognitive-behavioral therapy, emphasis is placed on discussing these thoughts and the behaviors associated with depression. While emotions are certainly a focus of some of the time throughout therapy, it is thought within this theoretical framework that thoughts and behaviors are more likely to change emotions than trying to attempt a post-mortem analysis of why a person is feeling the way they are. Because of this approach, cognitive-behavioral therapy is short-term (usually conducted under two dozen sessions) and works best for people experiencing a fair amount of distress relating to their depression. Individuals who can approach a problem from a unique perspective and those who are more cognitively-oriented are also likely to do better with this approach.

Interpersonal therapy is another short-term therapy utilized in the treatment of depression. Focus of this treatment approach is usually on an individual's social relationships, and specifically on how to improve them. It is thought that good, stable social support is imperative to a person's overall well-being and health within this framework. When relationships falter, a person directly suffers from the negativity and unhealthiness of that relationship. Therapy seeks to improve a person's relationship skills, working on communication more effectively, expressing emotions appropriately, being properly assertive in social and occupational situations, etc. It is usually conducted, like cognitive-behavioral therapy, on an individual basis but can also be used within a group therapy framework.

Most individual approaches, whether they are cognitive-behavioral, interpersonal, behavioral, rational-emotive, or what-have-you, will emphasize the importance of the client taking a pro-active approach in therapy. That is, the patient is encouraged to do daily or weekly homework assignments in-between therapy sessions which are imperative to the success of the treatment approach. Therapy is an active collaboration between therapist and client. If the client is not yet able to participate actively in therapy, then a supportive environment should be provided until medication helps energize the individual further.

Psychoanalytic or psychodynamic approaches in the treatment of depression have little research to support their use at this time. While many therapists may make use of psychodynamic theoretical constructs to help conceptualize an individual's personality or specific case, it is likely that applied approaches in these areas are ineffective and should be avoided.

Family or couples therapy should be considered when the individual's depression is directly affecting family dynamics or the health of significant relationship. Such therapy focuses on the interpersonal relationships shared amongst family members and seeks to ensure that communications are clear and without double (hidden) meanings. The roles played by various family members in reinforcing the depression within the patient are often examined as well. Education about depression in general can also be an important role of such therapy.

Individuals who suffer from seasonal affective disorder, a form of depression which is related to the change of the seasons within their geographic location, may benefit from bright light phototherapy.

Hospitalization

Hospitalization of an individual is necessary when that person has attempted suicide or has serious suicidal ideation or plan for doing so. Such suicidal intentions must be carefully and fully assessed during an initial meeting with the client. The individual must be imminent danger of harming themselves (or another). Daily, routine daily functioning will likely be negatively affected by the presence of a clear and severe major depression. Most individuals who suffer from major depression, however, are usually only mildly suicidal and most also often lack the energy or will (at least initially) to carry out any suicidal plan.

Care must be taken with regards to any hospitalization procedure. When possible, the patient's consent and full understanding should first be obtained and the client encouraged to check him or herself in. Hospitalization is usually relatively short, until the patient becomes fully stabilized and the therapeutic effects of an appropriate antidepressant medication can be realized (3 to 4 weeks). A partial hospitalization program should also be considered.

Suicidal ideation should be assessed during regular intervals throughout therapy (every week during the therapy session is not uncommon). Often, as the individual who suffers from a depressive disorder is beginning to feel the energizing effects of a medication, they will be at higher risk for acting on their suicidal thoughts. Care should be used at this time and hospitalization may need to be again considered.

Medications

An inadequate or incomplete trial of an antidepressant medication, the preferred medication for use in depressive disorders, is often correlated with increased suicide rates. Patient compliance with medication is a larger concern than often realized, especially when prescribed by a family physician.

Selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed medication for depression today. Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are the most commonly prescribed brand names, but SSRI medications should not be prescribed in conjunction with the older MAOIs (more popular in Europe than in the U.S.). (Allow for at least 5 weeks while switching in between these two classes of antidepressant medications.) There have been few long-term studies conducted on SSRI medication to ensure their safety and effectiveness given for anything longer than a few months at a time. FDA approval was received on these medications after study trials lasting only 8 to 12 weeks. Care should be utilized when taking these medications for more than a year.

The following information should be used with care by physicians. It is presented here as only one physician's opinion based upon his experiences with these medications. Phillip W. Long, M.D. writes,

Failure Of A Drug Trial

If an antidepressant has been used for four weeks at maximal dosages without a therapeutic effect, the clinician should consider either: (1) trying another antidepressant, (2) supplementing the current antidepressant with lithium or liothyronine (T3 or L-triiodothyronine) (Cytomel), (3) supplementing the SSRI antidepressant with a tricyclic antidepressant, (4) supplementing or replacing the current antidepressant with carbamazepine (Tegretol), (5) supplementing the current antidepressant with d-amphetamine (Dexedrine) or methylphenidate (Ritalin), (6) supplementing the antidepressant with phototherapy if the patient has seasonal major depression, (7) supplementing the antidepressant with an antipsychotic medication if the patient has a psychotic major depression, (8) trying electroconvulsive therapy (ECT), or (9) stopping pharmacotherapy and proceeding only with psychotherapy.

Research has shown that adding lithium or liothyronine (T3 or L-triiodothyronine) (Cytomel) to an antidepressant often is successful in overcoming nonresponse. The addition of 25-50 mcg/day of liothyronine (T3 or L-triiodothyronine) (Cytomel) to an antidepressant regimen for 7 to 14 days may convert antidepressant nonresponders into responders. The adverse effects of T3 are minor but may include a headache and feeling warm. If T3 augmentation is successful, the T3 should be continued for two months and then tapered at the rate of 12.5 mcg a day every three to seven days.

Anticonvulsants carbamazepine (Tegretol) and valproate (Epival, Depakote, Depakene) have been found effective in preventing the return of major depression. Two psychostimulants, d-amphetamine (Dexedrine) and methylphenidate (Ritalin), have also been found to be effective in the treatment of major depression when used to augment antidepressant medication. Patients with psychotic depression usually require an antipsychotic medication in addition to their antidepressant regimen. The antipsychotic medication can be tapered and stopped when the psychosis has subsided.

Electroconvulsive Therapy (ECT)

Phillip W. Long, M.D. goes on to discuss ECT therapy, which should only be used as a treatment of last resort. ECT is never the initial treatment for depression and there are serious questions regarding memory loss which have yet to be adequately answered by the research literature.

When rapid lifting of the depression is deemed necessary to prevent suicide, electroconvulsive therapy may be a treatment of choice. Research, however, has yet to show that ECT is superior to antidepressant medication.

Ordinary ECT treatment should be unilateral, on the nondominant side, and should be given for several sessions beyond remission of the depressive symptoms. Stopping the treatments as soon as remission occurs is associated with a higher incidence of relapse. The total number of treatments is usually between eight and 12, given at a rate of about three per week. ECT may be given in combination with antidepressant or antipsychotic drugs. ECT may cause severe confusion (delirium) when used in combination with lithium.

Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Depression-oriented support groups are especially effective, since they allow the individual an opportunity to socialize and be with others who suffer from similar feelings. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

There are many useful self-help books (such as "The Feeling Good Handbook") which are available on the market today to help an individual overcome depression on their own. Some of these may be effective for some people and no other type of treatment may be needed, especially for people who suffer from a mild case of this disorder. Some books emphasize a cognitive-behavioral approach, which is similar to those used within individual therapy and therefore may be of use to an individual before they even begin therapy.

Patients can be encouraged to try out new coping skills and explore their emotions with people they meet within support groups. They can be an important part of expanding the individual's skill set and develop new, healthier social relationships.

Psychotherapy, Medication or Both?

From the American Psychological Association Monitor:

The preponderance of the available scientific evidence shows that psychological interventions, particularly cognitive-behavioral therapies (CBTs), are generally as effective or more effective than medications in the treatment of depression, even if severe, for both vegetative and social adjustment symptoms, especially when patient-rate measures and long-term follow-up are considered (Antonuccio, 1995).

Yale psychiatrists (Wexler & Cicchetti, 1992) conducted a meta-analysis (a large, comprehensive review of the research literature). When dropout rate is considered with treatment success rates, pharmacotherapy alone is substantially worse than psychotherapy alone or the combined treatment. The review concluded that in a hypothetical cohort of 100 patients with major depression, 29 would recover if given pharmacotherapy alone, 47 would recover if given psychotherapy alone, and 47 would recover if given combined treatment. On the other hand, negative outcome (i.e., dropout or poor response) can be expected in 52 pharmacotherapy patients, 30 psychotherapy patients, and 34 combined patients. This meta-analysis suggests that psychotherapy alone should usually be the initial treatment for depression rather than exposing patients to unnecessary costs and side effects of combined treatment (Antonuccio, 1995).

Moreover, a consistent finding across studies is a higher dropout rate among those receiving medication, either because of side effects or because the medication has not helped. These patients are treatment failures but are not included as treatment failures in the data for their studies (Karon & Teixeira, 1995).

Often times you will find doctors and researchers discussing "double-blind placebo controlled" studies as being the "gold standard" within this area of study. This simply is either ignorance or naivete. Seymour Fisher and Roger Greenberg (1993) among others, have shown the double-blind placebo controlled study is not blind. Side effects are so obvious that more than 80% of the patients know whether they are on active medication or placebo, patients are equally accurate about other patients on the ward, and nurses and other personnel are privy as well. In some studies the only people who claim to be blind are the prescribing physicians, and in other studies the prescribing physicians admit being as aware of the patients' condition as everyone else (Karon & Teixeira, 1995).

Greenberg, Bornstein, Greenberg, and Fisher (1992) conducted another meta-analysis, covering 22 controlled studies (N=2,230). This study calls into serious question the perceived efficacy of tricyclic antidepressant medications, which are shown only to be more effective than inert placebo and only on clinician-rated measures, not patient-rated measures. If patients cannot tell that they are better off in a controlled study, one must question the conventional wisdom about the efficacy of antidepressant drugs. The newer selective serotonin reuptake inhibitors (SSRIs, such as Prozac, Paxil, and Zoloft) do not appear to fare much better (Antonuccio, 1995).

With active placebos, so that the patients and psychiatrists are not easily informed, the empirical data show that medication effect sizes are hard to distinguish from the placebo. Also not mentioned is that most antidepressant medications habituate, and the patients' symptoms return. Most patients believe they would feel even worse if they were not taking their medication (Karon & Teixeira, 1995).

While everyone knows that it often takes years to provide evidence of safety and effectiveness and be approved by the Food and Drug Administration (FDA). But what is not known is that although these studies often have large number of participants, patients may have been given the medication for only short periods of time -- much shorter periods of time than in clinical practice. Prozac, for example, has been advertised as having been administered to either 11,000 or 6,000 patients in preapproval clinical trials. But in all the controlled preapproval trials there were only a total of 286 patients on Prozac, and the controlled trials lasted only six weeks (Breggin & Breggin, 1994). In all the preapproval data submitted, 86% of the patients received Prozac for less than three months. Only 63 patients out of thousands had taken the drug for two years or more -- the way it is used in clinical practice (Karon & Teixeira, 1995).

Points which should be taken from the above article include:

Combined treatment of psychotherapy and medication is the usual and preferred treatment of choice for depression. This is likely the most commonly-used treatment for depression today and there is absolutely nothing wrong with it, since it, too, has been proven very effective. Never go against professional advice given with regards to your treatment, unless you have first discussed it with your treatment providers. Especially with depression, it is better to play it safe, than be sorry.

Psychotherapy is likely the second treatment of choice for depression, regardless of the depression's severity or symptoms. Multiple meta-analyses have come to this conclusion, so it is not a conclusion based on just one lone case study or the like. (No one study, even the NIMH study on depression, should ever be used to draw far-reaching, generalized conclusions about a treatment's effectiveness. Meta-analyses are always preferred by research scientists.)

Medication alone should be your last choice and only used as a last resort. Although you will likely gain some short-term relief of the most outward symptoms of your depression, the above-cited meta-analyses and multiple studies have shown that medications don't work very well in the long-term.

Always consult your physician or psychiatrist before beginning or stopping any medications. This article is not meant as advice to your specific situation, but as overall education.

People who are taking psychotropic medications should better inform themselves as to the negative and adverse side effects of those medications. Ask your physician about these, or consult the insert for the medication (which you can also request from your doctor if you do not already have one). Also, drug handbooks found in many larger bookstores in the medical section might come in handy, as will the PDR. You might also benefit from a more thorough understanding of how political and un-scientific the drug approval process is in the United States by reading Breggin & Breggin's book, Talking back to Prozac (1994).

As Consumer Reports noted in their two articles, Pushing Drugs (Feb., 1992) and Miracle Drugs (March, 1992), physicians are actively marketed to by drug companies, given free gifts and vacations. That "professional" you think you're paying to receive the best and most thorough treatment available may be in the pocket of a pharmaceutical company. So don't be too surprised that when a new antidepressant medication is marketed (such as Serzone) that you suddenly see a whole host of psychiatrists prescribing it, not based upon the medical research, but because it's new.

References:

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