Treatments for depression

Depressive Illness: An Information Guide

On this page:

• Psychosocial interventions
• Biological treatments
• Different classes of antidepressants
• Frequently asked questions about medications

People with depression are often seen first by their family doctor or general practitioner. In milder cases, family doctors can assess and treat you as an outpatient with medication, counselling or both. They may refer you to other community resources (counselling services, drop-in centres).

If your depressive symptoms are more severe, a family doctor may refer you to a psychiatrist who can treat you as an outpatient or, if necessary, admit you to hospital.

In deciding what is the best plan for treatment, the doctor will consider the severity of your illness, events that may have triggered its onset, and, if applicable, previous treatments you have undergone.

The most commonly used treatments are pharmacotherapy (medications), psychoeducation, psychotherapy and electroconvulsive therapy. These treatments may be used individually or in combination. It is very helpful for a person’s partner or family to learn about the disorder, either through reading materials, attending a family support and education group or talking with a mental health professional.

Psychosocial Interventions

Psychotherapy

Psychotherapy is often used along with medication to treat depression. Psychotherapy is a general term used to describe a form of treatment that is based on “talking work” done with a therapist. The aim is to relieve distress by discussing and expressing feelings, to help change attitudes, behaviour and habits that may be unhelpful, and to promote more constructive or adaptive ways of coping.

Successful psychotherapy depends on a supportive, comfortable relationship with a trusted therapist. Doctors, social workers, psychologists and other mental health professionals are trained in various models of psychotherapy, and work in hospitals, clinics and private practice.

There are many different treatment models of psychotherapy for individuals. Short-term models usually last up to 16 weeks. These therapies include interpersonal therapy and cognitive behavioural therapy. They are structured and focus on current, rather than childhood, issues. In interpersonal therapy, people examine their depression in the context of relationships that may be contributing to their mood difficulties. Cognitive behavioural therapy helps people examine how they interpret events around them, and how negative thoughts contribute to and maintain a depressed mood. In both therapies, the therapist takes an active role in guiding the discussions. Research has found these therapies to be very effective in treating depression.

Long-term therapy is less structured, and can last one year or more. The patient has more flexibility to talk about a variety of concerns related to both past and present day issues. In general, the therapist helps the person to relate how current events trigger issues from childhood, which may now be impairing the person’s performance in relationships, at work or at school. In this model, the therapist is less directive and gives minimal feedback, guiding the patient toward his or her own answers.

Therapy can also be provided in a group context. Meeting with eight to 12 other people who are struggling with  similar issues can help reduce a person’s sense of isolation. The kind of support, understanding and feedback found in group therapy may not be available within a person’s own natural social network. Groups are generally led by one or two mental health professionals who guide the group process and offer structure and direction where needed. Some groups may be process oriented; that is, they focus on the issues the group members raise each week, rather than having a set agenda. Other groups may be quite structured, such as groups that follow cognitive behaviour therapy. In these groups, the members work through a step-by-step process, often guided by a manual that helps them to focus on dealing with attitudes and behaviours that contribute to and help maintain depression. Not all structured groups, however, require the use of a manual. Whether short- or long-term, psychotherapy can be used in combination with medication, and can help you to resolve issues that may be contributing to your depression and affecting your overall life situation.

How do I find a psychotherapist?

It is worth the time and effort required to find a psychotherapist with whom you feel comfortable. Speak with your family doctor about therapists in your area. These may include: psychiatrists (who provide both medication therapy and psychotherapy), general practitioner-psychotherapists, or private social workers, psychologists or other mental health professionals. Contact the general and psychiatric hospitals’ outpatient departments in your area to find out if they offer individual or group psychotherapy. Your local mental health association may offer a referral service. Finally, do not overlook the network of “word-of-mouth” information available through self-help organizations and other people struggling with depression.

Psychoeducation

Psychoeducation is a process where people learn facts and information about depression, and also have an opportunity to talk about the feelings related to living and coping with the disorder. For example, it is common for patients learning about depression to experience strong feelings of fear or denial. Often, talking openly about these feelings helps people to deal with them and better adhere to a treatment plan that makes sense to them. Psychoeducation can occur in groups or in individual counselling with a doctor, social worker or other mental health professional.

Psychoeducation also helps family members or partners understand what the affected person is going through. They learn about the symptoms of depression, its treatment, what they can do to be helpful, and the limitations to the help that they can offer. The family can meet with the treating physician or therapist, or attend a family support and education group.

Finally, psychoeducation helps patients and families deal with their concerns about the stigma of mental illness. Although public education in recent years has raised awareness, there are still many people who do not understand depression as a disorder, and feel uncomfortable when it is discussed. It is important that patients and families have a safe place to discuss this issue and decide what information they wish to share outside of the family.

Family Interventions

Depression can have a profound impact, both on the people with the disorder and on their families. During an acute episode, partners and family members may have to assume the roles and responsibilities of the ill person. As a person recovers, partners and families may struggle to re-establish old routines. Sometimes, their feelings about what has happened, and fears about the future, make it difficult for things to “get back to normal.” This may lead to marital or family conflict. Also, preexisting family or marital stressors may have contributed to the onset of the depressive episode. In these situations, couple or family counselling can be very helpful.

Self-help Organizations

An important part of treatment and recovery both for people with depression and their families is the chance to meet informally with other people who understand their issues and challenges. Self-help organizations, run by clients of the mental health system and their families, are usually located in major cities with chapters in smaller centres; they often have newsletters that can reach people who live in isolated communities.Attending these groups can reduce a person’s sense of isolation, and provides opportunities to learn from other group members’ experiences. For many people, volunteering in these organizations and sharing the wisdom they have gained by living with depression can also be an empowering experience. Selfhelp organizations can be found through your local mental health association, your community mental health services, or your family doctor.

Biological Treatments

Medications

Antidepressant medications can relieve and resolve the symptoms of depression. Because depression is a complex disorder, many psychiatrists now specialize in the biology of depression and medication treatments. It is important to have a prescribing physician with whom you feel comfortable asking questions about medications, their effectiveness and their side-effects.

In the 1950s physicians discovered that Iproniazid, a drug used to treat tuberculosis, also elevated patients’ moods. Iproniazid is a member of the MAOI family of antidepressants, which act by boosting neurotransmitters. Neurotransmitters are the chemicals in the brain that allow cells to communicate with one another, and in some cases regulate our moods. Further research has revealed that depressed patients do not have enough of the neurotransmitter serotonin, and that helping the brain to produce more serotonin seems to help lessen depression. However, the brain is a very complex organ, and serotonin is only one of over 500 neurotransmitters. More basic research is needed to discover how brain chemistry contributes to depression.

Even though many questions remain to be answered, medications are used successfully to treat depression, either on their own or in combination with psychotherapy. With early intervention, medication can prevent people from developing a severe depressive episode, and preserve their current coping skills. Medication also allows people to make better use of talking therapies than would be possible when they are acutely withdrawn and depressed. With more severe depressions, medication offers symptom relief and restores patients’ moods to a more normal level, enabling them to return to regular routines and activities.

Common worries about antidepressants include the fear that one will become addicted to or dependent on medication. Antidepressants are not addictive and serve an important role in the treatment of depression. Many people hesitate to take medication, because they view reliance on them as a sign of weakness. This suggests that they view depression as a weakness in character, rather than a legitimate medical disorder. Depression is an illness that, without treatment, can worsen significantly and even become life-threatening.

Even those patients who accept that medication is useful may find that unpleasant side-effects make following through with taking prescriptions difficult. Common side-effects from older antidepressants include dry mouth, constipation, difficulty urinating, and blurry vision. These side-effects are called anticholinergic. Although older antidepressants work as well as newer ones, patients often stop using them because of these side-effects.

For this reason, a group of newer agents have been developed. These drugs have fewer, and more tolerable, side-effects. These include headaches, insomnia, increased anxiety, sedation and sexual problems. An important part of the assessment and treatment process is for the physician to determine the medication that is best suited to the patient. Very few people will follow through with treatment if they experience intolerable side-effects. If you are struggling with side-effects it is important to consult with your doctor, rather than abruptly stopping the medication. Though antidepressants are not addictive, sudden stoppage can lead to unpleasant reactions and possibly a poorer response to subsequent medications.

To get the best effect from a medication, a physician will gradually increase the dosage of the medication to the highest level at which it will have a therapeutic effect. This is called optimization. Unlike other medications that relieve symptoms very quickly, antidepressants generally take two weeks or more to take effect. Usually, patients will experience side-effects first and symptom relief later, which may cause them to feel discouraged or disheartened. Side-effects can be offset by other medications, changes in the dosage of the drug, or if necessary, a change in medication. Though they may be annoying, side-effects are a sign that the drug is being absorbed by the body and is starting to work.

In addition to maximizing the dosage, a doctor may augment a medication, or boost its effect, by adding another medication. For example, the drug lithium may be chosen to augment the primary antidepressant.

Research suggests that patients will respond equally well to all classes of antidepressants, but may tolerate certain drugs better than others. It is common for individual patients to try two or more different medications before finding one that has a good effect and is well-tolerated. For some patients who are very dose sensitive (meaning that they react to even small fluctuations in the amount of medication in their system) it is important to take the medication at the same time every day. Once medication has relieved the symptoms of depression, it is often recommended that patients continue to take medication for up to one year or more, in order to avoid relapse.

Different Classes of Antidepressants

This section is a general overview of medications, listing examples of the generic names of drugs, as well as the Canadian trade name. Trade names will vary among countries. Further information can be found in David Healy’s book, Psychiatric Drugs Explained (London: Mosby, 1993) or Jack Gorman’s The Essential Guide to Psychiatric Drugs (New York: St.Martin’s Griffin, 1997).

The Older Drugs

MAOI's — Monoamine oxidase inhibitors

Monoamine oxidase inhibitors, or MAOIs, such as Nardil (phenelzine) and Parnate (tranylcypromine) were the first class of antidepressants.MAOIs block the action of monoamine oxidase, an enzyme that breaks down some neurotransmitters in the brain. By blocking this enzyme breakdown, MAO inhibitors increase the number and the availability of neurotransmitters, which are helpful in the treatment of depression. MAOIs are still prescribed — often for the treatment of atypical depression.

It is important to know that MAOIs also affect a person’s ability to digest and process foods that contain tyramine, foods such as aged and fermented cheeses, smoked meats and some beer. In large quantities, tyramine can be toxic and may lead to dangerous increases in blood pressure. The MAO enzyme protects us from tyramine. Because MAOI drugs inhibit the action of MAO, patients taking these drugs must avoid these foods. This restriction means that patients usually take MAOIs only when other medications have not been effective.

Cyclics

The second group of drugs developed for the treatment of depression were cyclic or tricyclic antidepressants, a group that includes Elavil (amitriptyline), Ludiomil (maprotiline) and Tofranil (imipramine). Because this group also tends to have more side-effects than newer, more refined drugs, they are not often a first choice for treatment. However, some patients find that these drugs are well-tolerated and very effective. Tricyclic medications tend to be more sedating and are associated with anticholinergic side-effects. Weight gain and dizziness may also be experienced with these medications.

The Newer Agents

SSRI's — Specific Serotonin Reuptake Inhibitors

This newer group of drugs, including Prozac (fluoxetine), Paxil (paroxetine), Luvox (fluvoxemine) and Zoloft (sertraline), is usually the first choice for treatment of depression. These drugs generally do not cause the anticholinergic side-effects of the tricyclics.While these drugs are very effective, patients may experience initial side-effects, including nausea, stomach upset and headaches. Other patients may develop long-standing sleep difficulties, such as problems falling asleep or awakening throughout the night.

Other Classes of Newer Drugs

A number of newer medications have proven effective in treating depression. These drugs do not fit into any one category as they affect several different systems in the brain. They include Effexor (venlafaxine), Wellbutrin (buproprion), Manerix (moclobemide) and Serzone (nefazodone), and may have fewer sideeffects than the MAOIs and tricyclics.

Frequently asked questions about medications

Can antidepressants interact with other medications?

It is always important to ask your doctor about potential drug interactions with medications you are taking. If you are taking MAOIs, you should not take nasal decongestants, painkillers or other antidepressants. If you are taking blood pressure medication or are scheduled for surgery where you will receive an anesthetic, tell your doctor that you are on an MAOI.

Are medications safe in pregnancy and while breast-feeding?

Each woman’s situation is individual and should be discussed with her treating physician. Research has found the newer antidepressants, such as Prozac, to be generally safe during pregnancy. The older drugs have not been well-studied, so any risk to the unborn child is not well understood. A further problem with the older drugs is their potential to lower blood pressure, which also happens naturally during pregnancy. The combined effect may be a health risk for the mother. While breast-feeding, antidepressants are not necessarily contra-indicated, because the body filters many impurities out of breast milk and only about 30 per cent of the medications can be detected. Given that an infant’s organ systems are still immature, however, it may be wiser to bottle-feed the baby, or at least to supplement breast milk with bottle-feeding.

For any pregnant woman with a history of depression, the question of antidepressants during pregnancy usually comes down to a risk-benefit analysis. If not taking an antidepressant during pregnancy means a high risk of relapse and a serious depressive episode, which may affect prenatal care and a mother’s ability to parent her newborn child, then the benefits of the antidepressant may outweigh the risks. This is particularly true with respect to sleep, which can be seriously disrupted in depression and become a major problem for pregnant and new mothers. Women who feel uncomfortable remaining on medication may choose to try a period of being medication-free while they carefully monitor their mood. This is an individual choice for each woman to make in consultation with her doctor.

What about medications and the treatment of depression during menopause?

Depression in menopause can be the result of both hormonal and psychological factors. Antidepressants can help to ease the symptoms of depression. Hormone replacement therapy may also be effective. Supportive talking therapies and education-support groups can also help women to better understand this phase of their lives, cope with symptoms and adjust to other life changes that may affect their moods.

What about medications and driving?

Ask your doctor whether your medication may cause drowsiness. Depression itself can lead to fatigue and concentration problems, affecting your ability to drive. It is important to self-monitor, that is to keep track of these symptoms so you can make wise decisions about your ability to drive and stay alert to road conditions.

Do medications interact with caffeine?

Some MAOIs and SSRIs may have a mild interaction with coffee. Even if you are on a different class of medication, it is better to drink decaffeinated coffee and beverages. Caffeine itself can cause problems if you struggle with depression or anxiety. Depression disrupts sleep and caffeine, a stimulant, can make the problem worse.

What about complementary or alternative therapies?

Many people are becoming increasingly interested in using herbal or alternative remedies to treat depression. Some clinical trials in Europe have found St. John’s Wort to be an effective treatment of mild depression. However, research has been limited and it is not easy to get information about the effectiveness of this and other herbal treatments. For North Americans there is the additional problem that the herbal industry is unregulated. This means that over-the-counter herbal remedies vary widely in consistency from manufacturer to manufacturer. If you are interested in herbal remedies, it is important to talk to your doctor. It is helpful to have a doctor who is knowledgeable about alternative therapies, because these herbs can interact with other medications you may be taking.

Many people also benefit from learning relaxation techniques and stress management strategies. Others find massage and acupuncture helpful in dealing with some of the symptoms, such as anxiety, associated with depression.

Light Therapy and Seasonal Affective Disorder (SAD)

Light therapy, spending one half-hour every day under specially designed light boxes, can provide relief for 65 per cent of those diagnosed with seasonal affective disorder.

Electroconvulsive Therapy (ECT)

Electroconvulsive therapy, also referred to as “shock therapy,” is a long-standing, effective and misunderstood treatment for acute depression. It has been both condemned and promoted in the mental health field and the media. In its early days, ECT was a more crude procedure that resulted in short- and longer-term memory loss. For most of these patients, however, memory problems resolved after six months.

Today, ECT remains the most effective treatment for major depression. However, it is usually seen as a last resort because of people’s fears and misconceptions. Physicians usually treat patients with less intrusive methods, such as medication, before moving on to ECT.

ECT does not resemble the shock therapy portrayed in films such as One Flew Over the Cuckoo’s Nest. Now patients are given muscle relaxants and a general anesthetic before a mild electrical shock is administered to one or both sides of the brain. There is no visible movement in the person who is undergoing treatment.

It is not clear why ECT works, but after about five courses, usually given every other day, most patients’ moods begin to improve. Up to 12 courses or more may be offered, depending on the patient’s response. Many severely depressed patients,who have been disappointed by the failure of medications to relieve their symptoms, find ECT “kickstarts” them out of an acute depressive state. The improvements can then be maintained with medications, occasional ECT treatments and psychotherapy or rehabilitative therapy.

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