As we’ve already seen in previous questions, the first step for someone seeking help for symptoms of depression typically involves seeing a family doctor first and having a complete checkup. Since a family doctor already has a complete medical history, he or she can quickly rule out other possible explanations for the symptoms. A family doctor can also prescribe medication that might help as well. It is still important to get all the necessary information first, including possible side effects or drug interaction effects, before agreeing to take that medication however.
Even for those people who decide against medication, there are a wide range of alternative treatments, and their doctor is likely the best referral source for mental health services in their area. This can include individual psychotherapists, mental health clinics, or the local hospital depending on how severe the symptoms are and what treatment options happen to be available nearby.
Unfortunately, many of these services tend to be concentrated in the larger cities, and people living in rural areas may have trouble finding the help they need. Many people dealing with depression, especially adolescents and teenagers, might also be reluctant to talk to a counselor face-to-face.
One alternative that is becoming increasingly popular for many people with depression is accessing mental health care online or using one of the toll-free hotlines maintained by many national organizations (some examples are provided in the appendix). Most of these hotlines are serviced at all times by trained counselors or volunteers who can offer support as well as provide information about local resources that might be available. For many people with depression, much of the appeal for these services stems from the ability to access them anonymously. For adolescents and teens feeling suicidal or dealing with issues that they may be reluctant to share with their parents, online sites or hotlines can literally be a lifesaver in many cases.
Along with sites for national organizations, there are also chat room sites where people can discuss specific issues and interact with others who might be going through the same issues themselves. Some of these chat sites are part of a large community with users from across the country who have a variety of interests and personal issues that they might want to talk about. Make sure that the chat site you are using is being moderated to avoid dealing with “trolls” who may sabotage the conversation with malicious posts.
No matter the advice that you may receive, whether online or in person, it is always up to you to make the final decision about the kind of treatment you want. It’s also important to recognize that there is no miracle cure or “quick fix” when dealing with depression. This is why it is important never to give up hope and, if the first attempt at seeking help doesn’t work out, to not be afraid to try again.
36. What are some of the most common forms of treatment for children and adults dealing with depression?
There are a wide range of different treatment options available for helping children, adolescents, and adults dealing with depression. Still, there is no one-size-fits-all approach, and the treatment that people with depression may receive will often depend on what symptoms they happen to be showing, their life history, the treatment they have received in the past, and the progress they are making over time.
For most people seeking help for depression, whether they are adolescents or adults, treatment usually begins with an evaluation to determine how to proceed and also to start developing a treatment plan (see Question 37). This is basically a road map that will help guide people through the treatment process. Also, depending on how severe the symptoms are and whether there are additional problems such as substance abuse, suicidal thoughts, or anxiety, some people may require round-the-clock care in an inpatient facility.
In most cases, however, depression can usually be treated with a combination of antidepressant medication and psychotherapy. Though the medication may be prescribed by either a family physician or a psychiatrist, psychotherapy usually begins with one-to-one sessions with a trained psychologist or counselor. The main purpose of individual treatment is to make clients comfortable enough to be willing to open up about their depression and other related issues. It is also through individual sessions that clients can start talking about other issues that may be triggering their mood problems. This can include having a history of childhood physical or sexual abuse, posttraumatic symptoms, family concerns, social anxiety, and so on. Many clients may prefer to deal exclusively with individual counseling while others may prefer to move into group treatment as soon as possible.
One of the advantages of individual counseling is the added privacy that it provides. This means that clients can open up in a way they might not feel comfortable doing in a group setting. Individual counseling can either be open ended or with a fixed number of sessions. Open-ended treatment means that sessions will continue until such time that the client is seen as ready to try group treatment. In addition to individual counseling, people in therapy may also be seen in family counseling sessions with participating family members to learn how to work together to overcome the depression.
For many patients who have successfully completed individual counseling and who feel ready to talk about their emotional problems more openly, the next step is to join a therapy group. The type of therapy offered often depends on what the person in treatment hopes to achieve. Groups can include:
Psychoeducation training programs. Much as the name suggests, these programs focus on educating depressed patients about their emotional issues and the barriers they may face in learning to move on with their lives. Training modules can include anger management, relaxation training, good nutrition and exercise, and meditation.
Skill development programs. Using an interactive training approach allowing group members to share their own insights and ideas, these group sessions focus on training members to handle anger effectively, forming stronger social networks, coping strategies, relaxation training, and recognizing the triggers that can lead to negative thinking.
Cognitive behavioral psychotherapy (CBT). In a CBT group, members are trained in how to recognize and change maladaptive beliefs and behaviors that can reinforce negative thoughts and beliefs. One of the central principles of CBT is to learn how to anticipate problems and develop self-control using effective coping strategies. Cognitive behavioral strategies can include cognitive restructuring, problem solving, stress inoculation training, relaxation training, mindfulness, and relapse prevention techniques (see Question 42 for more information).
While most patients can receive treatment on a weekly basis, people with long-standing depression and a history of relapses may require much more intensive treatment than what is usually offered. They may also need more intensive monitoring of the medications they are receiving including whether they are experiencing side effects that are complicating their recovery.
Even after treatment is completed, therapists and their patients need to decide on what will happen next. Many users who have completed treatment may choose to attend maintenance treatment sessions with their counselor on a monthly or bimonthly basis. This allows the counselor to monitor the progress being made as well as give patients the chance to review material covered during the treatment sessions and share details of new concerns as they arise. It is also important for patients who have completed treatment to remember that the risk of relapsing into depression may always be present and avoid the kind of triggers that could lead to a setback. Many of the different treatment options available to people with depression will be covered in more detail in the next few sections.
37. What is a treatment plan?
As we have already seen, there is no such thing as a one-size-fits-all treatment for depression. The kind of treatment needed will vary widely depending on the age of the person requesting help, whether there are related mental health problems that also need to be treated, whether the patient is suffering from medical problems that can complicate recovery, and whether the treatment professional needs to deal with other issues such as childhood a
buse or trauma.
For anyone seeking treatment, the first step begins with meeting with a counselor and formulating a treatment plan that outlines the goals that need to be met and the type of treatment that might be needed to achieve those goals. Once the goals are laid out, the therapist and the client then establish priorities (i.e., which goals need to be met first and which can be addressed later). While the primary goal of treatment will be to learn how to cope with depression, there are also going to be secondary goals that can include improving family relationships, learning to be more social, repairing problems at work or school that may have originated because of emotional issues, and so on. As part of the treatment plan, the therapist and the client also need to work out which goals can be achieved in the short term (i.e., within the next six months) and which are more long term. Achieving the short-term goals can often provide treatment clients with the confidence they need to stay in treatment.
The important thing to remember is that no two treatment plans are the same. Even if two people with similar problems enter treatment at the same time, the goals they will set are often very different. The treatment each will need is going to be shaped by their different life experiences and the different problems they will be trying to overcome as well as their individual strengths and weaknesses.
With many treatment plans, the first step involves developing a problem list. As you might expect, this means itemizing those problems that the patient happens to be experiencing at that point in time. Over the course of treatment, the problem list is going to change, as old problems become more manageable and new problems crop up. In developing the problem list, the patient needs to be able to describe the problem clearly and also come up with concrete ways of measuring the progress they will make in dealing with that problem.
For example, the problem could be stated as “I can’t be around other people.” The concrete evidence for this problem could include complaints from friends or family members over ducking social responsibilities. Additional evidence for this problem could include hiding in your room, skipping school or work, and so on. Other problems that can go on the problem list include emotional issues such as social anxiety or substance abuse.
The next step is to outline the short-term and long-term goals that patients would like to accomplish. While overcoming depression can be considered a long-term goal, patients and their therapists also need to identify more short-term goals that could act as signposts that indicate the progress being made. Achieving these goals can help patients gain the confidence they need to continue in treatment and learn how to get their lives back on track.
Once the goals are established, the next step is to outline the type of treatment to be used to help patients achieve the goals. Over the course of the treatment period, the treatment plan is periodically reviewed to determine how successful the patient has been at meeting the original goals.
As these goals are met, the treatment plan often changes as well depending on what is happening in the patient’s life and the progress that ends up being made. Since relapses are often going to happen, patients are encouraged to treat these episodes as learning opportunities and form new goals that can help them regain their confidence and avoid relapses in the future.
Even after the treatment ends and the patient manages to meet all the planned goals, the treatment plan can continue to act as a road map for future progress by outlining the different ways that patients can maintain the progress they have made. This can include maintenance sessions once every six months so patients can review what they have learned and establishing additional long-term goals that patients can continue to try achieving over time.
38. How do antidepressant medications work?
In a real sense, the use of chemical compounds to treat the symptoms of depression is as old as medicine itself. Traditional healers have long depended on such herbal compounds as St. John’s Wort, xiao yao, “holy basil,” poppy extract, cannabis, and so on for treating depression or melancholia (as it was commonly known).
While the actual benefit of these various herbal remedies remains controversial, one of the first modern antidepressants, reserpine, was first developed in the 1950s from another traditional remedy, a tea made from the Rauwolfia plant found in many parts of Asia and Africa. Long used as a treatment for insanity, fever, and snakebite, Western scientists took a closer look at Rauwolfia and learned to synthesize it under laboratory conditions. Despite early success in treating depressed patients using reserpine, problems with side effects spurred researchers to search for better alternatives.
Over the past six decades, medical researchers have developed a wide range of different medications for the treatment of conditions such as depression. While a full description of these different drugs would run into thousands of pages, they usually fall into three specific categories:
Tricyclic antidepressants. Among the earliest antidepressant medications to be developed, tricyclic antidepressants (TCAs for short) have largely been replaced by more modern medications due to their frequent side effects, though they can still be used to treat depression symptoms in acute cases. Including such drugs as imipramine, amitriptyline, desipramine, and nortriptyline, TCAs work by directly acting on neurotransmitters such as serotonin and norepinephrine to increase their levels in the brain. Unfortunately, TCAs are also well known for side effects such as dry mouth; constipation; blurred vision; and, in many cases, sexual problems, excessive sweating, tremors, and weight changes. More rarely, it can also lead to seizures, disorientation (especially in older adults), and changes in heart rate. There is also the risk of drug interactions, which can lead to excessively high serotonin levels in the brain resulting in a “serotonin syndrome” with symptoms such as rapid heart rate, agitation, lack of coordination, and excessive sweating.
MAO inhibitors. First developed in the 1950s, monoamine oxidase inhibitors (MAOIs) act on the brain by inhibiting the monoamine oxidase enzyme, which breaks down serotonin, norepinephrine, and dopamine to make them inactive. By inhibiting this enzyme’s activity, MAOIs allow these neurotransmitters to stay much longer in the brain than they normally would. Because they also affect dopamine levels in the brain, MAOIs can also be used to treat Parkinson’s disease. Popular MAOIs include isocarboxazid, phenelzine, selegiline, and tranylcypromine. These drugs are also known to cause many of the same side effects seen in TCAs along with insomnia and headaches and can also lead to serotonin syndrome depending on drug interactions. People taking MAOIs also need to follow dietary restrictions and avoid foods high in tyramine, which can affect blood pressure, as well as avoid alcohol. Due to these potential complications, MAOIs are not commonly used today, as safer alternatives are now available.
Selective serotonin reuptake inhibitors. More commonly referred to as SSRIs, these are the most commonly prescribed antidepressant medications used today. By selectively acting on serotonin receptor sites while only weakly affecting dopamine and norepinephrine receptors, SSRIs can significantly boost serotonin levels in the brain. As a result, they can relieve the symptoms of severe depression with far fewer side effects than other kinds of medication. Along with depression, SSRIs have been used in treating other conditions such as anxiety and obsessive-compulsive disorders. Some of the most well-known SSRIs are citalopram, fluoxetine, escitalopram, sertraline, and vilazodone, though others have already been approved by government regulators for treating depression and other disorders. Side effects still occur, though they are usually temporary. They include drowsiness; blurred vision; headaches; insomnia; and diarrhea and, more rarely, serotonin syndrome, if used in combination with some other medications.
There are other types of antidepressant medications available including atypical antipsychotics (mostly used with bipolar disorder), norepinephrine-dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors, to name some of the most common alternatives. The kind of medication that someone with depression will receive often depends on the nature of the symptoms,
whether there are other medical issues that might affect how the drug works, and the training that the prescribing doctor has received. As for the actual risks associated with these different medications, we will explore that further in the next section.
39. Are there risks associated with taking antidepressant medication?
Even if a doctor recommends starting on an antidepressant medication, the final decision about whether or not this is a good idea belongs to the person who is going to take them. Still, while medication can help many people with depression control their symptoms, it isn’t necessarily the best solution for everyone. Before starting any medication, it is essential to do some basic research about that medication, including becoming fully aware of the potential side effects and other risks involved. Here are just a few caveats that need to be considered:
First of all, it takes time for most medications to build up in the system before the benefits become noticeable. For many people, this can mean weeks before their symptoms start to subside.
Medications don’t work the same way for everybody who takes them. Though some people start recovering right away, many people with depression may require trying several different medications before finding one that works. For people with more than one diagnosis—depression and social anxiety, for example—a combination of different medications may be needed to get all the different symptoms under control. This can increase the risk of drug interaction effects as well as side effects.
Depression Page 10
