Major depression, aka clinical depression, is a serious mental illness. The first and most critical decision the therapist or doctor must make is whether to hospitalize a patient for treatment of major depression. Clear indications for inpatient major depressive disorder treatment are:
- Risk of suicide or homicide
- Grossly reduced ability to care for self in areas of food, shelter, and clothing
- The need for medical diagnostic procedures
A patient with mild to moderate depression can receive depression treatment in the therapist's or doctor's office. The patient's support system (family members, relatives, close friends) should be strengthened and involved in depression treatment whenever possible.
Antidepressants for Treatment of Major Depression
Studies have shown antidepressant treatment for major depression can dramatically reduce suicide and hospitalization rates. Unfortunately, very few suicide victims receive antidepressants in adequate doses, and - even worse - most receive no clinical depression treatment whatsoever.
One of the biggest problems with antidepressant treatment is most patients don't stay on their antidepressant medication long enough for it to be effective. A recent study found only 25% of patients started on antidepressants by their family physician stayed on it longer than one month. Antidepressant treatment of major depressive disorder usually takes 2-4 weeks before any significant improvement appears (and 2-6 months before maximum improvement appears).
First Line Antidepressants in the Treatment of Clinical Depression
The selective serotonin reuptake inhibitors (SSRIs) are typically tried first in major depression treatment and include:
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
- Sertraline (Zoloft)
These medications are considered excellent choices as the patient's first antidepressant because of their low incidence of side-effects (especially weight gain) and their low risk of causing death if taken in an overdose.
If this is the first major depressive episode, once a person positively responds to an antidepressant, this depression treatment should be continued for 4-9 months, according to the most recent (2008) American College of Physicians guidelines.² For those who have experienced two or more depressive episodes, longer treatment may be required.
Withdrawal from antidepressant treatment for depression should be gradual. Never discontinue taking medication without telling your doctor first. Suddenly stopping antidepressant medication could produce severe antidepressant withdrawal symptoms and unwanted psychological effects, including a return of major depression (read about antidepressant discontinuation syndrome).
Keep in mind, prescribing the right antidepressant in clinical depression treatment is challenging. It may take some experimentation on the part of the doctor to find the right antidepressant and dosage for you. Do not give up if everything doesn't come together right away. For cases where multiple medications haven't worked or the depression is severe, a psychiatrist should be consulted as they are experts in prescribing psychiatric medication.
Psychotherapy for Treatment of Major Depression
In general, psychiatrists agree severely depressed patients do best with a combination of antidepressant medications and psychotherapy. Medications treat the symptoms of depression relatively quickly, while psychotherapy can help the patient deal with the illness and ease some of the potential stresses that can trigger or exacerbate the illness.
Psychotherapy treatment of depression is based on the premise human behavior is determined by one's past experience (particularly in childhood), genetic endowment and current life events. It recognizes the significant effects of emotions, unconscious conflicts and drives on human behavior.
The National Institute of Mental Health (NIMH) studied interpersonal therapy as one of the most promising types of psychotherapy in major depression treatment. Interpersonal therapy is a short-term psychotherapy, normally consisting of 12-16 weekly sessions. It was developed specifically for the treatment of major depression and focuses on correcting current social dysfunction. Unlike psychoanalytic psychotherapy, it does not address unconscious phenomena, such as defense mechanisms or internal conflicts. Instead, interpersonal therapy focuses primarily on the "here-and-now" factors that directly interfere with social relationships.
There is some evidence in controlled studies that interpersonal therapy as a single agent is effective in reducing symptoms in acutely depressed patients of mild to moderate severity.
Behavior therapy involves activity scheduling, self-control therapy, social skills training and problem solving. Behavior therapy has been reported to be effective in the acute treatment of patients with mild to moderate depression, especially when combined with antidepressant medication.
Cognitive Behavior Therapy (CBT)
The cognitive approach to psychotherapy maintains irrational beliefs and distorted attitudes toward one's self, their environment and the future perpetuates symptoms of depression. CBT depression treatment attempts to reverse these beliefs and attitudes. There is some evidence cognitive therapy reduces depressive symptoms during the acute phase of less severe forms of depression.
Electroconvulsive Therapy (ECT) in Major Depressive Disorder Treatment
Electroconvulsive therapy (ECT) is primarily used for severely depressed patients who have not responded to antidepressant medicines and for those who have psychotic features, acute suicidality or who refuse to eat. ECT, as a major depression treatment, can also be used for patients who are severely depressed and have other chronic general medical illnesses which make taking psychiatric medications difficult. Changes in the way ECT is delivered have made ECT a better tolerated treatment for major depression.
Importance of Continuation of Major Depression Treatment
There is a period of time following the relief of symptoms during which discontinuation of the major depressive disorder treatment would likely result in relapse. The NIMH Depression Collaboration Research Program found four months of clinical depression treatment with medication or cognitive behavioral and interpersonal psychotherapy is insufficient for most depressed patients to fully recover and enjoy lasting remission. Their 18-month follow-up after a course of depression treatment found relapses of between 33% - 50% of those who initially responded to a short-term treatment.
The current available data on continuation of clinical depression treatment indicates patients treated for a first episode of uncomplicated depression who exhibit a satisfactory response to an antidepressant should continue to receive a full therapeutic dose of that medication for at least 6-12 months after achieving full remission. The first eight weeks after symptom resolution is a period of particularly high vulnerability to relapse. Patients with recurrent depression, dysthymia or other complicating features may require a more extended course of depression treatment.
In a 1998 article, in the Harvard Review of Psychiatry, entitled "Discontinuing Antidepressant Treatment in Major Depression," the authors concluded:
"The benefits of long-term antidepressant treatment in major depression and the risks of discontinuing medication at various times after clinical recovery from acute depression are not as well defined. Computerized searching found 27 studies with data on depression risk over time including a total of 3037 depressive patients treated for 5.78 (0-48) months and then followed for 16.6 (5-66) months with antidepressants continued or discontinued. Compared with patients whose antidepressants were discontinued, those with continued treatment showed much lower relapse rates (1.85 vs. 6.24%/month), longer time to 50% relapse (48.0 vs. 14.2 months), and lower 12-month relapse risk (19.5 vs. 44.8%) (all p < 0.001). However, longer prior treatment did not yield lower post-discontinuation relapse risk, and differences in relapses off versus on antidepressants fell markedly with longer follow-up. Contrary to prediction, gradual discontinuation (dose-tapering or use of long-acting agents) did not yield lower relapse rates. Relapse risk was not associated with diagnostic criteria. More previous illness (particularly three or more prior episodes or a chronic course) was strongly associated with higher relapse risk after discontinuation of antidepressants but had no effect on response to continued treatment; patients with infrequent prior illness showed only minor relapse differences between drug and placebo treatment."
Treating Refractory Depression
Refractory depression, aka treatment-resistant depression, occurs in as many as 10% - 30% of depressive episodes, affecting nearly a million patients. Katherine A. Phillips, M.D. (1992 winner of a NARSAD Young Investigator Award) has found failure to provide adequate doses of medication for sufficient periods of time is perhaps the most common cause of apparent depression treatment resistance. Once the clinician has determined a patient is truly treatment-refractory, many treatment approaches can be tried. Phillips recommends the following refractory depression treatment strategies:
- Augmentation with lithium and perhaps other agents like a thyroid medication. Trazodone (Oleptro) may be worth trying either alone or in combination with fluoxetine (Prozac) or a tricyclic antidepressant if other approaches have failed.
- Combining antidepressants - supplementing the SSRI antidepressant with a tricyclic antidepressant. Several studies have shown a good response when fluoxetine (Prozac) is added to tricyclics and when tricyclics are added to fluoxetine. It is important to monitor tricyclic levels because fluoxetine can raise tricyclic levels by 4-11-fold and thereby cause tricyclic toxicity.
- Switching antidepressants - stop the first SSRI antidepressant gradually and then substitute another SSRI antidepressant or SNRI antidepressant like venlafaxine (Effexor). Fluvoxamine (Luvox), sertraline (Zoloft) or venlafaxine (Effexor) often are effective for fluoxetine (Prozac) or paroxetine (Paxil) nonresponders (and vice versa).
Read more about depression treatment for hard-to-treat depression.