Syndromes of Depression and Their Treatment

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Thyroid disorders, anemia, cancer, Alzheimer's disease, and Epstein-Barr virus infections can lead to depression, so you should consider a physical examination and appropriate laboratory work before starting treatment. Ideally, your depression will resolve when you obtain treatment for your medical problem, although you may require treatment with antidepressants indefinitely if you have Alzheimer's or Parkinson's disease.

Some antihypertensive medications and recreational drugs can also contribute to depression. Coordinate the treatment for your medical problems with your primary care doctor and psychiatrist if you take medication that can cause depression. Try to stop recreational drugs that can worsen your mood.

Psychiatrists have created many classification schemes over the years to aid in sorting out which treatments are most effective for depression. These schemes have described depression in such terms as unipolar, bipolar, endogenous, reactive, atypical, postpartum, involutional, psychotic, seasonal, and others. The specific terms are derived primarily from how depression is understood. The descriptive terms keep changing because advances in our understanding of depression keep undercutting the validity of whatever scheme is in vogue. We will develop accurate terms only when we truly understand the etiology and pathogenesis of depression in the biological, psychological, and social realms.

Whatever diagnostic terms are used, however, there are two main syndromes of depression: acute and chronic. They can both occur by themselves or with other syndromes. For example, people with bipolar disorder experience acute depression, but the symptoms are indistinguishable from people with acute depressions who do not have bipolar disorder. Many people with schizophrenia experience a chronic unhappiness that isn't all that different from people with chronic depression who do not have schizophrenia.

Chronic Depression If you've been depressed for years, psychiatrists in the 1990s would call this dysthymia, a word derived from the Greek, meaning "abnormal mind" but commonly taken to mean depression. Chronic depression may wax and wane in severity but is present to some degree almost all the time, perhaps even starting in childhood. This form of depression may have become such a part of your outlook on life that you are perhaps unaware you could feel differently.

Chronic depression has a pernicious effect on your life that can be surprisingly subtle. It may be hard for you to see that you are, in fact, depressed because your negative outlook has been such a big part of you for so long. You may not even realize that it is depression which makes you find your relationships with others unful-filling, your work as a burden to be borne, and the obstacles of life insurmountable.

Acute Depression This form of depression generally occurs more abruptly, often following the death of a loved one, a physical injury or illness, or an unwanted change in your family or work. You are vulnerable to developing acute depression if you suffer from chronic depression or bipolar disorder. The symptoms of acute depression are generally more severe than in the milder chronic depression (which is why psychiatrists often call this major depression).

Acute depression calls for immediate intensive treatment to prevent a slide into such a state that hospitalization is necessary to maintain your nutrition and self care and to prevent suicide.

How to Start Several antidepressants are "first-line" treatments, that is, they are the most likely to help you with the fewest side effects. I usually recommend a trial of an SSRI because these medications are the most frequently effective and the most easily tolerated. Unfortunately, they frequently inhibit sexual desire and impair sexual responsiveness, effects that intensify at higher doses. You may not care about this when you first start medication if you are focused mostly on the relief you hope to derive, but as you improve, this may become more important to you. After a couple of weeks paroxetine tends to make people tired after a dose, so this may be a useful one to try first if you experience insomnia. Some people try venlafaxine first, but blood pressure can rise and needs to be closely monitored. Bupropion is a reasonable drug to start with, although it can cause anxiety and insomnia. Additionally, the dose needs to be carefully monitored in order to prevent seizures.

TCAs were the mainstays of treatment until the SSRIs came out in the late 1980s. They are very effective, especially in cases of severe depression, but commonly cause weight gain, constipation, light-headedness from low blood pressure, and dry mouth, side effects that are unpleasant enough to make most people choose an alternative. TCAs are sometimes used first in severe depression in spite of their side effects because of some evidence that they are the most effective. Nortriptyline tends to make people drowsy after they take a dose, so may be the best choice if you experience insomnia.

You may respond best to MAOIs or SSRIs if you have "atypical" symptoms, such as excessive sleep and increased weight gain.

Some antidepressants are generally used only if trials of other antidepressants have failed. These "second-line" drugs include the MAOIs and stimulants. You may find stimulants helpful if you are elderly and suffer from a lack of energy as part of your depression. Trazodone, nefazodone, and mirtazapine tend to cause significant sedation. Although this can be helpful for insomnia, the sedation tends to last into the next day. Maprotiline has a greater tendency to cause seizures than other antidepressants.

Three additional tips: 1) You will generally improve only with the addition of an antipsychotic if you experience hallucinations or delusional thinking. 2) Benzodiazepines can relieve the intense agitation that may accompany your depression. 3) Extra caution needs to be taken in the treatment of depression if you have bipolar disorder in order to prevent the occurrence of a manic episode. The use of antidepressants in bipolar disorder is discussed in chapter 8.

Monitoring the Effectiveness of Your Antidepressant Although you may notice some effects right away, an antidepressant generally takes some weeks to become fully effective. You should observe any physical or psychological changes as you evaluate its effectiveness and be on the lookout for side effects.

If the Medication Is Effective If you're fortunate, and many people are, the drug you choose will be helpful without side effects that are significantly troubling to you. However, you may experience unpleasant side effects with any antidepressant. It is important to sort out whether a particular side effect is transitory or will continue as long as you take the medication.

If the side effect is one that will continue, there are three options. First, you can lower the dose. Unfortunately, the dose at which the side effect disappears may not alleviate depression. Second, you can consider adjunctive treatment. For example, yohimbine can improve the diminished sexual desire caused by SSRIs. (Adjunctive treatments to minimize side effects are described in chapter 19.) Third, you can change to a different antidepressant. If the side effect is one that is common to all drugs in that class, such as dry mouth and weight gain from TCAs, it may make sense to change to a different class.

You may want to go off the medication after you've been feeling better for a while. Most people do best if they stay on the medication until the situation that led to the depression has resolved. If you have had more than one bout of depression, however, research has shown that you are likely to suffer additional depressive episodes in the future. Recurrent bouts of depression are probably best treated by staying on the medication indefinitely.

If the Medication Is Not Effective If you stopped the trial prematurely because of a side effect, it is reasonable to change to a different antidepressant. Depending on the problem you experienced, you may want to choose a new medication in the same class or a different one.

You may remain depressed even after an adequate trial of a high enough dose for a long enough time. This generally means the highest dose recommended by the manufacturer for a minimum of two to three weeks. You should probably obtain a blood level if you take a TCAto ensure that you have an adequate amount in your system. (Therapeutic blood levels have not been determined for other anti-depressants.) It is reasonable to change to a different antidepressant if you remain depressed after an adequate trial, because you may respond positively to a different one.

If you have tried several antidepressants without benefit, consider augmentation. Augmentation with lithium or thyroid supplementation has helped some people. Augmentation strategies include using two antidepressants of different classes at the same time. A combination of a TCA and an SSRI has helped many people. Some combinations of antidepressants should not be taken because they can cause severe side effects. For example MAO inhibitors should not be combined with TCAs or SSRIs because of the potential for life-threatening reactions. Two SSRIs should not be taken at the same time because of the possibility that a person may experience the "serotonin syndrome," symptoms of which include fever, muscular rigidity, instability in blood pressure and pulse, and changes in mental functioning that can be so severe as to progress to delirium and coma.

IfYou Experience Suicidal Thoughts or Behavior Suicidal thoughts frequently occur in people with depression. Very infrequently (less than 1%), people who take antidepressants find that they begin to experience suicidal thoughts when they've never had them before. Sometimes people who've had some suicidal thoughts find that they become more frequent or more intense. How or why this occurs is not entirely clear. It may be a specific reaction to the drugs in some people. It may be that the drugs give people more energy and motivation to do things, fueling hopelessness rather than hope, resulting in more intense suicidal thoughts.

Whatever the cause, you need to contact your provider if you experience suicidal thoughts, especially if they are getting more intense or more frequent. You need to make sure you can keep yourself safe until you regain your perspective that life is worth living and can be good for you. You may need to change medications or change other aspects of your treatment to feel better. These decisions are best made in consultation with your provider—don't decide that the antidepressant isn't working and stop it on your own.

If You Don't Feel Better There are three things to keep in mind if you continue to feel depressed in spite of using antidepressants. First, is your complete diagnosis of depression correct? For example, are there medical problems that are contributing to your depression and need treatment? Is your distress better understood as unhappiness over your life situation rather than depression? Discuss this issue with your doctor.

Second, are there other treatments that might help you? For example, do you need to go to Alcoholics Anonymous and get some help stopping your alcohol use? Should you engage in therapy to address issues that are troubling you, such as couples therapy with your spouse to work on communication problems?

Finally, and most important, don't give up! Depression is an insidious condition that changes your perspective and makes you think you can't lead an enjoyable life. This isn't true—but it will take effort on your part to use the tools we have to make your life better.

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