Treatment for Depression: Getting Help

Asking for help may seem like the hardest task in the world, especially if you feel exhausted and hopeless. Yet that’s just what you need to do if you have symptoms of depression or mania. Even if your symptoms are more vague or you don’t know exactly what the problem is, you may still benefit from a doctor’s opinion and evaluation. If you feel lost or stuck, or are concerned about a feeling, thought, behavior, or situation, seek help.
 
The first step is often the hardest. Talk with your doctor about your problems, or get a referral to a mental health professional from your doctor, a friend, or one of the organizations listed in this report (see Resources). If you are in a crisis or feel suicidal, immediately call 1-800-SUICIDE for advice or go to your local emergency room.

Together, you and your doctor or therapist can decide on a treatment plan to alleviate your distress. In addition, the following practical suggestions may help you navigate safely through this difficult time: 

• Ask a friend or family member to accompany you to your first appointment to help describe your problem, assist you in getting treatment, or simply offer support.
  
• Take medications as directed. Don’t skip pills or change doses without consulting your doctor. Also, report any side effects right away, and if necessary, talk to your doctor about adjusting your treatment plan.
  
• Set realistic goals for yourself. Try not to take on more than you can handle.
  
• Join in activities, and try not to isolate yourself from others. Depending on your personal preferences, attending religious services, having a meal with an understanding friend, or going to a movie, ball game, or concert may help lift your mood.
  
• Try to exercise regularly or take a daily walk.
  
• Hold off on making big decisions �?about moving, changing jobs, getting married, or seeking a divorce �?until your depression has eased or is under control.
  
• If you decide to try a "natural" remedy, such as St. John’s wort, ask your doctor or pharmacist whether it might interact with any other medication you’re taking.
  
• Friends and family often want to help. Let them.

If we were all carbon copies of one another, identifying the causes of depression and its proper treatment would be simpler. But unique differences in life experience, temperament, and biology make treatment a complex matter. No single treatment works for everyone. However, research suggests that many people benefit from a combination of medication and therapy (see Drugs and Therapy: A Winning Combination?).
 
Often, treatment is divided into three phases. Keep in mind, though, that there are no sharp lines dividing the phases, and very few people take a straight path through them.  

• In the acute phase, the aim is to relieve your symptoms. Generally, this occurs within 6�?2 weeks, but it may take longer depending on your response to the first treatments you try.
  
• In the continuation phase, you work with your doctor to maximize your improvements. Further treatment adjustments, such as modifying dosage of a medication, can help. This period takes another four to five months.
  
• In the maintenance phase, the aim is to prevent relapse. Ongoing treatment is often necessary, especially if you have already experienced several depressive episodes, have chronic low mood, or have risk factors that make a recurrence more likely.

On your road to treatment, your primary care doctor may be your first stop. A good primary care doctor can assess your symptoms with an eye to whether you have any underlying medical problems. If your doctor believes that depression is the main problem, he or she may suggest an antidepressant. Sometimes the initial response to the medication is good. If so, you may not need to go further.
 
However, if you don’t respond well to the first medication, your doctor may refer you to a mental health professional, such as a psychiatrist, psychologist, social worker, or psychiatric nurse. Most primary care doctors aren’t equipped to do a more detailed review of the mood problem or to take treatment further with psychotherapy or different medications.
 
You can also find a mental health professional through a local clinic or hospital or through recommendations from family members or friends. While some insurance plans leave the choice of therapist up to you, others limit you to professionals enrolled in their networks. Therefore, it’s worthwhile to check with your insurer before choosing a doctor.
 
Since states have different requirements about who may hang out a shingle as a therapist, inquire about the therapist’s training, and opt only for one who has been formally trained and certified (see 10 Questions to Ask When Choosing a Therapist). Some people like to meet with a few therapists before making the commitment to work with one. Even the most highly recommended person may not be the right match for you. Beginning therapy can be uncomfortable, but if a therapist’s demeanor or office set-up puts you off, you needn’t waste your time trying to make the situation work.

Drugs and Therapy: A Winning Combination?

No single treatment �?whether a drug or a style of therapy �?can beat depression in every case. But would you be better off with a combination of drugs and therapy? Research suggests the answer is yes.
 
A review of several studies considered data collected on nearly 600 people treated for major depression. The investigators found recovery was quicker and more likely to occur with interpersonal therapy plus an antidepressant compared with interpersonal or cognitive behavioral therapy alone. A study of more than 400 teens with major depression found similar results: Treatment with the antidepressant fluoxetine along with cognitive behavioral therapy worked better than either treatment alone.
 
Combination therapy may also help ward off recurrences. A three-year study reported in the Journal of the American Medical Association tracked recurrences of major depression in about 200 people ages 60 or older. Of those who received monthly interpersonal therapy and the medication nortriptyline, 80% avoided a recurrence. In contrast, only 57% of those who received the drug alone, 36% of those given just therapy, and a mere 10% in the placebo group did as well.
 
A study published in the Archives of General Psychiatry in 2004 found that one reason therapy and medication may complement each other is that they have effects on different parts of the brain.
 
However, if your depression is mild, research suggests that a combination of drugs and therapy is no better than cognitive behavioral therapy or interpersonal therapy alone.
 
Of course, it always makes sense to mull over all of your options. If one type of treatment alone isn’t helping you, consider trying combination treatment.

Often, medications are the first choice in treatment, especially if you’re experiencing a severe depression or suicidal urges. Controlled studies have found that about 65%�?5% of people get some relief from antidepressants, compared with 25%�?0% of people taking a placebo (a pill with no biologically active ingredient). But the very same drug that works wonders for a friend may fail to ease your symptoms. You may need to try a few different medications to find the one that works best for you with as few side effects as possible. In some cases, a doctor may prescribe a combination of antidepressants or an antidepressant along with a drug to treat anxiety or distorted thinking. A drug combination may be more effective than either drug alone.
 
Doctors usually first prescribe medications from a class of drugs known as selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). Although the side effects of each drug vary slightly from person to person, you have an equal chance of success on any of these drugs. If you don’t have a good response to the first drug you try, you and your doctor may decide to switch to another.

Improvement may take time
Although in a few cases people report a change for the better as quickly as one or two weeks after beginning medication, more often it takes from two to six weeks for antidepressants to ease depression. The lag may reflect the time it takes the medications to affect processes inside the nerve cells and in brain circuits. It’s frustrating but true that side effects may appear before the benefits of a drug become obvious. Once you start to feel better, though, it’s important to take the medication for as long as it’s prescribed to get a full response and avoid a relapse.
 
While you are using medications, the doctor prescribing them should regularly monitor the dosage and your response. All medical treatments have advantages and disadvantages, and a doctor cannot predict an individual’s response to a given medication. While there’s a good chance that an antidepressant will relieve your symptoms, there’s also a possibility that you’ll encounter side effects. So when you’re about to embark on treatment, it’s important to weigh the potential benefits against the risks. Thankfully, most side effects can be managed or reversed.
 
Poor response to an antidepressant is often due to an inadequate dose. If the medication doesn’t seem to be working during the first phase of your treatment, don’t be surprised if your doctor suggests increasing the prescribed amount.
 
Not everyone who takes a drug will be bothered by side effects. If you do experience some, the first step is to report them to your doctor. Your doctor may be able to suggest simple, helpful adjustments (see Managing Side Effects). Many side effects disappear once your body becomes accustomed to the medication. Or, if necessary, you can try a different dosage or drug.
 
Antidepressants are not habit-forming or addictive. However, if you are about to stop taking these medications, your body needs to readjust slowly, so your doctor may instruct you to reduce the dosage gradually. Even if you do this, you may experience uncomfortable or disturbing symptoms. Sometimes these symptoms are mistaken for a recurrence of the illness (see Preventing a Relapse).
 
While many antidepressants can be safely combined, some cannot. If you switch medications, you may need a washout period (a stretch of several weeks of taking no drugs) in order to prevent dangerous interactions between a new drug and the lingering effects of the previous one.

One day it may be possible to use biological markers and other indicators to predict exactly which antidepressant will work best for each person. Right now, though, psychiatrists and doctors who prescribe antidepressants choose a particular drug and dosage based on many factors.
 
Diagnosis. Certain drugs work better for specific symptoms and types of depression. For example, some antidepressants may be better when insomnia is an issue. The severity of your illness or the presence of anxiety, obsessions, or compulsions may also dictate the choice of one drug over another.
 
Age. As you age, your body tends to break down drugs more slowly. Thus, older patients may need a lower dosage. For children, only a few medications have been studied carefully.
 
Health. If you have certain health problems, it’s best to avoid certain drugs. For this reason, it’s important to discuss medical problems with a primary care doctor or psychiatrist before starting an antidepressant.
 
Medications, supplements, and diet. When combined with certain drugs or substances, antidepressants may not work as well, or they may have worrisome or dangerous side effects. For example, taking SSRIs with another type of antidepressant known as monoamine oxidase inhibitors (MAOIs) can be fatal. Combining the herbal remedy St. John’s wort with an SSRI or an MAOI could lead to serious side effects, because this herb boosts serotonin. Likewise, mixing St. John’s wort with other drugs �?including certain drugs to control HIV infection, cancer medications, and birth control pills �?might lower their effectiveness. Eating certain foods, such as cheeses and pickles, while taking an MAOI can raise your blood pressure to dangerously high levels.
 
Alcohol or drugs. Alcohol and other substances can cause depression and make antidepressants less effective. Doctors often treat alcohol or drug addiction first if they believe either is causing the depression. In many instances, simultaneous treatment for addiction and depression is warranted.
 
Mental health and medication history. Depending on the nature and course of your depression (for example, if your depression is long-lasting or difficult to treat), you may need a higher dosage or a combination of drugs. This may also be true if an antidepressant has stopped working for you, which may occur naturally or after you’ve stopped and restarted treatment with it.

Depression can bring everything in your life �?work, relationships, school, and even the most minor tasks �?to a grinding halt, or, at the very least, gum up the works. The aim of psychotherapy is to relieve you of symptoms and to help you manage your problems better and live the healthiest, most satisfying life you can.
 
Some evidence suggests that by encouraging more constructive ways of thinking and acting, psychotherapy makes future bouts of depression less likely. Three schools of psychotherapy �?cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy �?play a primary role in combating depression.
 
Which type of psychotherapy works best? There’s no simple answer. Just as people respond differently to different drugs, you might do better with one type of therapy than with another. Many people find that a blended approach �?one that draws on elements of different schools of psychotherapy �?suits them best.

Cognitive behavioral therapy
Cognitive behavioral therapy aims to correct ingrained patterns of negative thoughts and behaviors. To accomplish this, you are taught to recognize distorted, self-critical thoughts, such as "I always screw up"; "People don’t like me"; "It’s all my fault." During cognitive behavioral therapy, your therapist may ask you to judge the truth behind these statements, to work to transform such automatic thoughts, and to recognize events that are beyond your control.
 
Along with cutting down on the number of negative thoughts, cognitive behavioral therapy also focuses on breaking jobs into smaller, more manageable pieces that set you up for success. You rehearse new ways of coping with problems and practice social skills that can help wean you from actions that provide a fertile breeding ground for depression, such as isolating yourself. Your therapist may assign you tasks to reinforce your learning. For example, you might keep a log of thoughts that occur as you try out your new skills. As negative patterns become clearer, you can learn to redirect them.

Interpersonal psychotherapy
Interpersonal psychotherapy concentrates on the thornier aspects of your current relationships, both at work and at home. Weekly sessions over three or four months will help you identify and practice ways to cope with recurring conflicts. Typically, therapy centers on one of four specific problems:

• grief over a recent loss
• conflicts about roles and social expectations
• the effect of a major change, such as divorce or a new job
• social isolation.

Psychodynamic therapy
Psychodynamic therapy focuses on how life events, desires, and past and current relationships affect your feelings and the choices you make. In this type of therapy, you and your therapist identify the compromises you’ve made to defend yourself against painful thoughts or emotions, sometimes without even knowing it. For example, someone with an overbearing parent may unconsciously find it difficult to risk developing intimate relationships, out of fear that all close relationships will involve a domineering partner. By becoming aware of links like this, you may find it easier to overcome such obstacles.
 
You and your therapist may talk about disruptions in your early life �?perhaps the death of a parent, your parents�?divorce, or other disappointments �?to determine their effect on you. While the duration of psychodynamic therapy can be open-ended, a variation called brief dynamic therapy is limited to a specific amount of time (generally 12�?0 weeks). It applies a similar lens to a specific emotional problem.

Not just for individuals
Group, family, or couples therapy may also be part of a plan for treating depression or bipolar disorder. Group therapy draws on support generated from people in the group and uses the dynamics among them, along with the leader’s help, to explore shared problems. Family therapy and couples therapy also delve into human interactions. Like group therapy, the aim is to define destructive patterns �?such as scapegoating one family member or enabling a spouse’s alcohol abuse �?and replace them with healthier ones. These therapies can uncover hidden issues and establish lines of communication. Family therapy is especially useful when one person is struggling with emotions that spill over into the family.

There are many different approaches to psychotherapy, but all good therapy shares some common elements. To start with, make sure that your therapist has a state license. While psychotherapy isn’t always comfortable, you should feel reasonably at ease with your therapist. In the best case, the two of you will be, or will become, a good match. Of course, both of you must respect ethical and professional boundaries.

It’s important that therapy provide some relief. Your therapist should not only offer reassurance and support, but also suggest a clear plan for how the therapy will proceed. You and your therapist should agree upon realistic goals for the therapy early on. While well-defined problems might be addressed relatively quickly, you may need to approach more difficult problems from many angles, which will take longer.

Since mood disorders can have a broad influence on relationships, work, school, and leisure activities, therapy should address these areas when �?or if possible before �?they become a problem. Therapy isn’t just for uncovering painful thoughts, although that’s part of the work. Good therapy also addresses how you can adjust, adapt, or function better. And it helps you understand the nature of your distress. You should feel that your therapist approaches the important issues in your life in a way that’s unique to your needs, not from a one-size-fits-all perspective. Pertinent issues springing from your culture, sex, and age, as well as individual differences, should shape the direction therapy takes.

If a doctor other than your therapist prescribes antidepressants for you, the two should communicate. If they don’t do so on their own, you may want to encourage collaboration by asking your therapist and doctor to speak regularly. Your therapist ought to understand the medication portion of your treatment, encourage you to take medications as prescribed, and help monitor your response.
 
Although it’s not uncommon to feel stuck at times, don’t persist for months with that feeling. Some difficult problems take a long time to unravel, but you should sense progress. If you don’t, it’s a sign that the match between you and either the technique or the therapist isn’t right. If four to six months have gone by and you don’t feel better, it’s a good idea to consult another therapist.

10 Questions to Ask When Choosing a Therapist

Whether you get a recommendation for a therapist from your primary care doctor, a friend, or your insurance company, finding out about his or her background and training can help you feel comfortable with your choice. Here are some questions to ask before settling on a therapist:  

1. What’s your training (i.e., what certification or degrees do you hold)?
2. How long have you worked in this field?
3. What kinds of treatment or therapy do you think might help me?
4. What are the advantages and disadvantages of the different approaches, including medication?
5. How does the treatment work?
6. What are the chances that treatment will work?
7. How soon should I start feeling better?
8. How will we assess my progress?
9. What should I do if I don’t feel better?
10.  How much will treatment cost?

It’s hard for a therapist to give precise answers to some of these questions, because no single therapist or type of treatment is best for everyone. But there are some general responses you should be looking for. The therapist should have formal training and certification, or be on the way to getting it. There’s a tendency for mental health professionals to offer the particular type of psychotherapy that they do best. It’s good if the person can describe the merits and drawbacks of different types of treatment, including ones they don’t do.

The therapist should also let you know how he or she will monitor your progress. If you don’t feel there’s been improvement after several months, consider getting a second opinion.

Electroconvulsive Therapy

Reality often fails to jibe with movies and books. While psychotherapy and antidepressants have garnered some positive fictional portrayals, electroconvulsive therapy (ECT) typically evokes only frightening pictures. More than 30 years after One Flew Over the Cuckoo’s Nest won its Academy Awards, the images from the film linger in many people’s minds. Yet ECT remains one of the most effective treatments for severe depression, with response rates of 80%�?0% for people with major depression. ECT may also be used to treat mania when a person fails to respond to other treatments.
 
Despite its effectiveness, doctors usually reserve ECT for situations in which several drugs have failed. That’s partly because of its technical complexity, and partly because of its negative image.

How ECT works
The discomfort of ECT is roughly equivalent to that of a minor surgical procedure. The purpose of ECT is to induce a seizure, which acts as the therapeutic agent. Before receiving treatment, a person is given general anesthesia. Then the doctor places electrodes on the patient’s scalp and administers an electric current in a brief pulse that causes a seizure. Medicine is given to prevent the muscular effects of the seizure, so there are no obvious convulsions. The seizure is evident only because it registers on an electroencephalographic monitor. The procedure takes a few minutes, after which the person is roused from the anesthesia.
 
On average, 6�?2 treatments are given over several weeks. Contrary to what some people might expect, when there is a good response, the improvement occurs gradually over the course of treatment, rather than all at once. Generally, the response occurs faster than with medications, making ECT a good treatment for severely depressed people who may be at very high risk for suicide.
 
In the best-case scenario, a prospective patient is well-educated about ECT. Usually, doctors and nurses explain the treatment in detail, and often patients watch videotapes of the procedure. Sometimes other people who have had ECT explain what the experience is like to further demystify it. Patients decide if they want to try ECT only after they have been fully informed about how the procedure works and what its risks and benefits are. Most states have clear safeguards against involuntary ECT treatment.

ECT and memory
The most commonly discussed side effect of ECT is memory loss. Routinely, patients lose memories of events that occurred just before and soon after treatment. After the treatment concludes, some people will have difficulty remembering things that occurred during the course of treatment. Once all the treatments have ended, relatively few people have persistent memory problems. However, ECT may exaggerate problems in people already having memory trouble.
 
Other side effects are also fleeting. Some people feel a bit sedated or tired on the day of the procedure, or they might have a mild headache or nausea. However, these symptoms might come from the anesthesia rather than ECT itself. To date, no study has shown that ECT causes brain damage.
 
One drawback to ECT is a relapse rate of about 50% in people treated for severe depression. It may be even higher with so-called double depression (the combination of depression and dysthymia). To help avoid a relapse, a person who responds to ECT might also take an antidepressant medication or mood stabilizer. If dual treatment doesn’t work, some people receive maintenance ECT on an outpatient basis about once a month. Some people with severe depression have done very well with this approach.