Find the Right Depression Treatment for You

You’ve been diagnosed with depression – now what? Your doctor may prescribe antidepressants, therapy, or even magnetic stimulation. Which is right for you? Top psychiatrists tell how to get the best help and results... One in four women will experience clinical depression at some point in their lives, according to the National Institutes of Health. But treatment plans are tailored to each person. Your doctor’s first step should be a physical workup to rule out underlying health conditions, like a thyroid problem. Then, they’ll analyze your personal history for more clues. “You have to look at a patient’s character, history of depression, family background and past responses to medication,” says Alan Manevitz, M.D., associate professor of clinical psychiatry at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York City. With an illness like depression, these factors can vary dramatically. Manevitz looks at “the spectrum of symptoms – some people may be low on energy and sleeping a lot. Others may not be able to sleep at all.” This background information helps doctors design your individual treatment plan, usually consisting of talk therapy, medication or a combination of the two. Which is right for you? Overall, patients experience the best results with both treatments, says Nada L. Stotland, M.D., professor of psychiatry at Rush University Medical Center in Chicago. But if you prefer one treatment over another, speak up. “One person may feel that trouble at work or in a relationship kicked off her depression and wants to get to the bottom of the issue by talking about it. Another may say, ‘Just give me a pill,’ ” Stotland says. You should question your doctor’s recommendations. “It’s your right to ask, ‘Why do you think I should take medicine? Why aren’t you recommending psychotherapy?’ and vice versa.” Assessing Your Antidepressants If your doctor determines you need antidepressants, they’ll generally start you on a low dose and slowly raise it to a “therapeutic dose” level where you benefit from the drug without side effects. But don’t expect to feel better overnight, says psychologist Shawn McClintock, Ph.D., assistant professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. It can take 4-6 weeks for a drug to start easing depression symptoms. “People suffer quite a lot during that period, though most respond fully or partially by week four,” Manevitz says. You might not respond at all to the first medication your doctor tries. Only 33% of people experience remission (meaning their symptoms ease) in the first 12 weeks of antidepressant treatment. Of those, about 20% suffer a relapse – meaning symptoms return. These statistics come from the government’s landmark STAR*D trial, which followed more than 4,000 patients for seven years and established that medicines don’t work the same for everyone. So, if you aren't feeling better after starting antidepressant treatment, don’t lose hope. Your doctor may switch to another medication in the same or a different class, or try a combination of drugs. Common Antidepressant Types Here are the medications doctors and therapists usually prescribe to treat depression symptoms: Selective serotonin reuptake inhibitors (SSRIs) How they work: Their brand names – Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Celexa (citalopram) and Lexapro (escitalopram) – may be familiar. SSRIs help the mood-boosting brain chemical serotonin work more efficiently. If you’re new to antidepressants, you’ll probably be prescribed an SSRI. Possible side effects: Dry mouth, sexual problems, nausea, nervousness and insomnia. Serotonin and norepinephrine reuptake inhibitors (SNRIs) How they work: SNRIs, which include Effexor (venlafaxine) and Cymbalta (duloxetine), increase levels of serotonin and norepinephrine, another brain chemical linked with mood. Possible side effects: Dry mouth, weight loss, sexual problems, increased heart rate, an increase in cholesterol levels and constipation. Norepinephrine and dopamine reuptake inhibitors (NDRIs) How they work: These boost levels of norepinephrine and dopamine, which is associated with feelings of happiness and pleasure. Only one NDRI has been FDA-approved: buproprion, available under the brand name Wellbutrin Possible side effects: Nausea, headache, agitation, loss of appetite and insomnia. NDRIs are off-limits for people with bulimia or a seizure disorder. Monoamine oxidase inhibitors (MAOIs) How they work: The oldest among the antidepressants, MAOIs keep an enzyme called monoamine oxidase from breaking down serotonin, dopamine and norepinephrine. As result, their levels remain high, helping mood. Common MAOIs are Nardil (phenelzine), Parnate (tranylcypromine), Marplan (isocarboxazid) and Emsam (selegiline transdermal). Possible side effects: Side effects include weakness, dizziness, headaches and trembling. Tricyclics How they work: These also keep levels of serotonin and norepinephrine and, to some degree, dopamine, high. Brand name tricyclics include Elavil (amitriptyline), Asendin (amoxapine), Anafranil (clomipramine), Norpramin (desipramine), Sinequan (Doxepin), Tofranil (Imipramine) and Pamelor (Nortriptyline). Possible side effects: Side effects are more serious than those associated with other antidepressants and include dry mouth, blurry vision, trouble urinating, constipation and fatigue. Tricyclics can also affect blood pressure and heart rate and aren’t advised for anyone who has glaucoma. Finding the Right Therapist Regardless of the type of therapist you see – licensed clinical social worker, psychologist or psychiatrist – talking about what’s bothering you can ease your mind. But you’ll get better results if you like the person treating you. “You have to feel comfortable with the therapist and have a sense of trust,” Stotland says. When meeting or consulting for the first time, Stotland recommends asking the following questions: What’s your approach to treatment? How often do you see patients? How long does treatment usually last? Are you comfortable treating people of my gender (or race or religion)? Don't make a snap judgment about the therapist until you've had a few sessions, says Steven Hollon, Ph.D., professor of psychology at Vanderbilt University in Nashville. To evaluate the sessions, Stotland recommends asking yourself the following questions: Does the therapist listen to me? Does the therapist care about my problems? Does the therapist’s suggestions make sense to me? Does the therapist understand me? Does the therapist ask questions that get at what I think is important? Has the therapist explained why she thinks medication might help me (or not)? But before you decide to switch therapists, keep in mind that therapy can force you to face painful subjects that ultimately help ease your suffering. “Sometimes, you’re going to come into conflict with a therapist because he’s trying to do the right thing and look at something you’d rather not explore,” Stotland says. How long will it take to find relief? That can depend on your relationship with the therapist, the type of treatment, severity of symptoms and even your health insurance plan. The Mental Health Parity and Addiction Equity Act – which applies to group health plans with more than 50 employees – requires that coverage of mental health conditions such as depression should be equal to that given for preventive or surgical care. But some insurers limit the number of sessions if they’re not considered medically necessary. If money isn’t a concern, you can continue treatment as long as you need it. Talk Therapy Types The type of therapy you choose depends on your symptoms, doctor’s recommendation or the therapist's specialty. The most common types include: 1. Cognitive Behavioral Therapy (CBT) Considered the fastest therapy for getting results, CBT examines how thoughts influence feelings and behaviors – and provides tools to change them. Generally, CBT has a set number of sessions, usually about 8-12. “You can start seeing good relief in two to three weeks,” says Hollon, a CBT expert. 2. Psychodynamic Therapy More open-ended than CBT, this technique examines the role that the unconscious and the past play in a person’s current life issues. 3. Interpersonal therapy (IPT) This short-term therapy, usually lasting for 12-16 sessions, focuses on building relationships to lessen psychological problems. 4. Dialectical Behavior Therapy (DBT) DBT differs from other treatments in how it tackles issues: It organizes treatments into stages and addresses problems in a strict order. “It’s a nice way of setting a course to get you somewhere but not so fast that it overwhelms you,” Hollon says. 5. Acceptance and Commitment Therapy (ACT) ACT teaches you how to overcome painful thoughts and feelings through acceptance and mindfulness techniques and encourages self-compassion and flexibility. What If They Don’t Work? In some cases, people don’t respond to medication or therapy. If you’re one of them, your doctor may consider another option, Transcranial magnetic stimulation (TMS), approved by the FDA in 2008 for treating depression. TMS is done in a psychiatrist’s office using what’s known as the NeuroStar TMS Therapy system. How it works: The doctor applies a treatment coil to your head above your left prefrontal cortex — the area of the brain that regulates mood. You don’t need anesthesia or sedation. Targeted magnetic fields then produce small electrical currents, which activate cells within the brain that may release neurotransmitters. A patient typically has five treatments per week over 4-6 weeks, each lasting about 40 minutes. Studies have shown TMS can help when other options fail. In one study, published in the Biological Psychiatry journal in 2007, researchers followed 301 patients, who had not responded to other treatments, for four to six weeks. Just over half received TMS, and the remainder underwent sham TMS. By week four, patients treated with TMS saw symptoms of depression improve. At week six, remission rates were twice as high as those who received sham TMS. Could You Be Depressed?