Managing Your Condition Which Depression Treatment Is Right for You?

Today, there are more therapies and medications for depression than ever before. But different approaches work for different people. Here’s how to find the right method to get you out of your funk... For Teresa Stevens, a 50-year-old book editor in Lawrenceville, N.J., the search for a depression treatment lasted almost a decade. “I was very unhappy,” she says. She tried talk therapy, but that didn’t provide enough relief. Medications improved her mood, but side effects such as weight gain and lowered sex drive made them hard to live with. Fortunately, the third drug she tried brought her good results and few side effects. Since then she has stayed depression-free, even through the stress of breast cancer treatment and recovery. Stevens’ story isn’t unique. For many women, finding a depression treatment that’s both effective and free of irritating side effects takes patience and persistence. There's some help: In October 2010, the American Psychiatric Association (APA) published updated guidelines for treating major depression that can help your health-care provider make research-based choices about which methods to try. But doctors still don’t have a surefire way of knowing whether a particular depression treatment will be effective for you, says Alan Gelenberg, M.D., chair of the APA work group that wrote the guidelines. So a testing period is often necessary. What the Guidelines Say A quick glance at the 2010 APA recommendations can help you begin your search for the right treatment. If you have mild to moderate depression: The usual treatment is psychotherapy, an antidepressant or both. Personal preference is an important deciding factor. “Some people really want to take a pill or talk in therapy, and others definitely don’t,” Gelenberg says. Exercise also helps. If depression is mild, it might be enough on its own. If you have more severe depression: Medication is generally needed, either alone or combined with psychotherapy. Another option for treating severe, urgent or stubborn symptoms is electroconvulsive therapy (ECT), which involves passing a carefully controlled electrical current through the brain to induce a brief seizure. For those at high risk for suicide, a short stay in the hospital may be advised. If you’re pregnant, planning to have kids, or breastfeeding: For most pregnant women, the guidelines now recommend psychotherapy alone as the first-choice treatment. If you haven’t responded to previous treatments: If you aren’t fully improved after four to eight weeks of psychotherapy or medication, talk to your health-care provider. Options include upping the dose or intensity of your current treatment, switching to a different one or adding another. “There are a lot of treatment options. The more you try, the better the chance you’ll achieve remission,” Gelenberg says. If you’ve recovered from depression: The disease tends to return, so once you’ve gotten well, staying that way is a priority. “If you’ve had two very serious episodes of depression, or if you’ve had three or more total episodes, staying on treatment indefinitely should be considered,” Gelenberg says. For those who prefer psychotherapy, “revisiting a therapist on a regular basis is probably smart.” The Details Here’s an in-depth look at the available depression treatments, along with reasons you might want to consider them. Psychotherapy This kind of therapy, which involves talking through issues with a licensed professional, doesn’t cause side effects the way medicine can. You also learn skills that can be used for a lifetime. On the other hand, going to therapy takes energy, motivation and concentration – which can be in short supply when you’re seriously depressed. “In general, medication may produce faster results, but therapy can produce more durable ones,” says Scott Bea, Psy.D., a psychologist at the Cleveland Clinic in Ohio. Many types of mental-health professionals offer psychotherapy. Here’s how to tell them apart: Psychiatrists are medical doctors who can write prescriptions, and many focus mainly on drug therapy. Others provide psychotherapy too. Clinical psychologists have at least a master’s degree. Many have a doctoral degree and postdoctoral experience. In addition to providing therapy, they can do psychological testing. Clinical social workers have at least a master’s degree as well as clinical experience. Psychiatric nurses are registered nurses with additional training in mental-health care. Advanced-practice registered nurses have at least a master’s degree. Mental-health counselors typically have a master’s degree plus post-degree experience. Licensing requirements vary from state to state. Marriage and family therapists typically have at least a master’s degree plus post-degree experience, although requirements vary. They focus on mental-health problems in the context of close relationships. The following types of talk therapy have been found particularly effective against depression. If one isn’t helpful for you, consider one of the others: Cognitive-behavioral therapy (CBT) helps patients identify and change irrational beliefs and dysfunctional behaviors that contribute to their depressed mood. Behavior therapy helps patients substitute helpful thoughts and actions for destructive behaviors. For example, people with depression may focus on scheduling pleasant activities, even if they don’t feel like it. Once they get moving, a better mood often follows. Interpersonal therapy helps patients address relationship factors that trigger depression symptoms. For example, they might focus on building a social support system, coming to terms with a change in their social role, or mourning the loss of a loved one. Medication Dozens of different antidepressants are now available. But each carries a risk of troublesome side effects, which may include weight gain, loss of sex drive, nausea, headaches, restlessness and trouble sleeping. Finding one that works well for you may take trial and error, Gelenberg says. The following antidepressants are usually tried first because of their milder side effects: Selective serotonin reuptake inhibitors (SSRIs), such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil) or sertraline (Zoloft). These increase brain levels of serotonin, producing a sense of well-being. Selective norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor), desvenlafaxine (Pristiq), or duloxetine (Cymbalta). These increase brain levels of norepinephrine, which tends to produce a sense of mental stimulation; some increase serotonin as well. Mirtazapine (Remeron) uses a different process but also seems to increase norepinephrine and serotonin. Bupropion (Wellbutrin) increases brain levels of norepinephrine and dopamine, which plays a role in the brain’s pleasure and reward systems. Other medical treatments Electroconvulsive therapy, although controversial, has the highest success rate of any depression treatment, with 70%-90% of those treated showing improvement. Modern methods are considerably safer and gentler than the “shock therapy” of decades past. But there are still potential side effects, including temporary confusion and lasting memory loss. Newer options are also available. Transcranial magnetic stimulation uses rapid pulses of magnetic fields to stimulate certain brain cells. Vagus nerve stimulation uses a small implanted device, similar to a pacemaker, to deliver mild electrical impulses to a nerve that extends from the brain to the abdomen. It then transmits the pulses to brain areas that affect mood and other symptoms of depression. Alternative therapies If you have mild depression and prefer alternative treatments, consider the herbal remedy St. John’s wort or the nutritional supplement SAM-e. Both have been studied as mood boosters, although APA guidelines say evidence for their effectiveness is “modest at best.” St. John’s wort can also interact with a number of medications – for example, it can reduce the effectiveness of birth control pills. Talk to your doctor before self-treating with supplements. Acupuncture is another possibility. Although research has yielded mixed findings, a study in the March 2010 issue of Obstetrics and Gynecology showed promising results. According to Stanford University researchers, pregnant women with depression showed a greater decrease in symptoms if they received depression-specific acupuncture than if they were treated with a different kind of acupuncture or massage. Getting high-quality care A 2010 study published in the Archives of General Psychiatry showed that only about half of those with depression received some kind of treatment. “But only about one in five got depression care that conformed to established guidelines,” says lead researcher Hector Gonzalez, Ph.D., an assistant professor of family medicine and public health sciences at Wayne State University in Detroit. To make sure you get the right treatment, start with a referral to a mental-health professional or clinic, or ask your primary-care physician for help. Your doctor can prescribe antidepressant medication, but you may have better results with a psychiatrist – especially if your symptoms don’t go away within a couple of months. “It’s also important to get a psychiatrist involved if you have a coexisting issue such as substance abuse, suicidality, bipolar disorder or disabling anxiety,” says Ken Duckworth, M.D., medical director of the National Alliance on Mental Illness. If you have one treatment provider for medication and another for psychotherapy, it’s important they work closely together. Find professionals who have a collaborative relationship already in place. Your doctor might be able to refer you to a therapist, or vice versa. Keep trying, and you won’t have to settle for staying depressed or feeling just a little better. With the right treatment, becoming symptom-free is a realistic goal. Linda Wasmer Andrews is a freelance writer who specializes in health and psychology. She’s author or coauthor of four books about depression, including Encyclopedia of Depression (Greenwood) and Monochrome Days (Oxford University Press). For more information, visit our Depression Health Center. How Much Do You Know About Depression? Despite all the progress in diagnosing and treating this disease, many people still are in the dark when it comes to understanding depression. How much do you really know? Take this depression quiz, which includes information from Dr. Lawson Wulsin's book, Treating The Aching Heart, and see how well you know fact from fiction.