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Help for Depression

    • Depression is a complex disease that can leave its sufferers feeling isolated and hopeless. The stigma of depression weighs heavily on those with the illness and can leave some reluctant to seek help.

      Comedian and mental health activist Kevin Breel recently captured this dilemma well in a TED talk: "If you break your arm, everyone runs over to sign your cast, but if you tell people you're depressed, everyone runs the other way. That's the stigma." But that stigma is slowly shifting, in part due to the death this year of beloved actor and comedian Robin Williams, which opened up a public discussion on depression.

      The good news is that effective treatment options are available for people with depression. But the first and sometimes hardest step is overcoming the stigma associated with having a mental health diagnosis.

      MyLifeStages spoke with two Sutter Health experts on the topic to find out what treatments are right at each stage of the illness, and what may be on the horizon.

    • Diagnosing Depression

    • An accurate diagnosis of depression is vitally important, says San Francisco Psychiatrist Winston Chung, M.D., also an expert in Child and Adolescent Psychiatry with Sutter Pacific Medical Foundation . “It’s important to not only look at subjective symptoms but the person’s medical history, social and family history, and current medications. Together, these help paint the picture of what is happening with the individual and can guide what type of treatment is most appropriate."

      Many primary care physicians now conduct a screening for depression during regular health checkups. This can be a good way to open up the conversation and identify people who may need a more comprehensive evaluation.

      According to Sacramento psychiatrist Raheel Khan, D.O., of Sutter Center for PsychiatryOpens new window, a good evaluation can tell if the depression is mild, moderate or severe – as well as first time, or recurrent. These are important considerations in deciding on a treatment method.

    • Treating Depression without Medications – Changing Habits and “Talk Therapy”

    • For some, treating depression without medications is the right approach. This could be due to side effects of anti-depressants, possible interactions with other drugs being taken for medical conditions, or patient preference. Mild cases may be relieved by lifestyle changes, such as dietary changes and exercise. In particular, increasing the amount of Omega 3 fatty acids in the diet are believed to help symptoms of depression. (For a full list of non-medication ideas for coping with depression, see Dr. Molly Roberts blog post on Holistic Help for Depression.)

      In addition, traditional “talk therapy” can be very effective, says Dr. Khan. “Psychotherapy really, really works well for some patients, and provides them with coping skills that can be used lifelong.”

      Dr. Chung notes that two particular styles of therapy have been shown in evidence-based trials to be particularly effective for depression: Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT). These are planned to be short-term interventions and involve specific, practical tasks for the patient.

      Psychotherapy can also be used in conjunction with anti-depressant medications – and this combination often works better than medications alone, says Dr. Chung.

    • Anti-Depressant Medications – SSRIs and NSRIs

    • The most widely used treatment for depression is antidepressant medication. Available since the 1980s, these oral medications are effective at least 50 percent of the time when treating depression on the first go round, says Dr. Khan. For the approximately 50 percent of patients whose depression does not improve, another 25% are helped by switching to a different brand of same medication. In general, these medicines take four to six weeks to be effective.

      There are two basic types of anti-depressants – SSRIs and SNRIs. SSRIs are Selective Serotonin Reuptake Inhibitors, which impact the amount of the brain chemical Serotonin is circulating in the brain. Most common brand names of SSRIs are Prozac, Celexa, Luvox, Zoloft, Lexapro and Paxil.

      The medications do have side-effects that include changes in sex drive and possible weight gain.

      SNRIs are a second-line treatment for some patients. SNRIs work on two chemicals in the brain – norepinephrine and serotonin. Common brand names are Effexor XR, Cymbalta, Pristiq, and Fetzima.

      SNRIs also have side-effects and their use must be balanced against the benefits of relieving depression.

      Treatment of depression with medications can be very effective, but should also be carefully monitored by the patient and his/her medical provider. Dr. Khan recommends that first-time users stay on their medications for at least a year – weathering all seasons and life event anniversaries. If the decision is made to cut back or eliminate the medications, it should be done under medical supervision and gradually.

      For patients who have had two or more bouts of serious depression in their lives, Dr. Khan recommends staying on medication, always measuring any side-effects against the benefits of reducing the impact of depression.

    • Anti-Depressants in Children, Adolescents and Seniors

    • Anti-depressants should rarely be used in young children, explains Dr. Chung. For adolescents and young adults (under 25), they also carry strong warnings of potential increase in suicidal thoughts, particularly during the first few weeks of use. (Read one viewpoint that the risk of suicide with antidepressant use is overestimated.) If antidepressants are found to be helpful for adolescents or young adults, their use should be very closely monitored.

      In seniors, Drs. Chung and Khan recommend caution when prescribing antidepressants to seniors, whose bodies may not process medications as efficiently with age, and who are more likely to be taking multiple other medications that may interact with antidepressants.

    • Resetting the Brain – Electroconvulsive Therapy

    • Although movie portrayals may have given electroconvulsive therapy (ECT) a bad name, Dr. Chung and Dr. Khan list it as a very effective treatment for depression in the right individuals. It is mostly used for recurrent episodes of depression that have not been managed by anti-depressant medications, although there is discussion now among professionals about why ECT is not offered earlier, given its proven effectiveness. ECT sends electric current through the brain, which seems to shift the mood-regulating areas of the brain.

      Dr. Chung notes that a relatively new procedure called Transcranial Magnetic Stimulation is also available and shows potential promise, while being less intense that traditional Electroconvulsive Therapy. TMS was approved by the FDA in 2008, but is currently not covered by most health plans. It uses magnetic pulses to also “reset” functioning of the mood-regulating areas of the brain.

    • Something New on the Horizon?

    • There are several new drug therapies for depression being explored via research – although they are not yet available to physicians to use for treatment.

      One is Ketamine, a drug used initially for anesthesia. Initial research has shown it to be rapidly effective in reducing depressive symptoms and suicidal thoughts. Further research on ketamine is underway, and recently received an FDA “breakthrough therapy designation”, according to the National Institute for Mental Health.Opens new window

      Another drug combination, currently going by the name ALKS 5461, recently received fast track designation by the FDA to speed up the necessary clinical trials needed before final FDA approval. This new drug combination doesn’t work on serotonin, but instead targets opioid receptors in the brain, elevating mood without causing a “high.”

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