Two newer treatments are geared toward people who haven’t responded well to other, more traditional approaches. While they are somewhat similar to ECT, in that they rely on delivering impulses (electrical or magnetic) to achieve results, neither has the proven track record of ECT.

Vagus nerve stimulation
In the summer of 2005, the FDA approved a device known as a vagus-nerve stimulator as a treatment for adults with depression who haven’t responded to four or more other therapies. Extending from the brain through the chest cavity, the vagus nerve helps control your breathing and is linked to the amygdala, hypothalamus, and other parts of the brain that modulate mood and anxiety. A vagus-nerve stimulator is a surgically implanted device similar to a pacemaker that delivers a small electrical impulse to this nerve for about 30 seconds every five minutes. Although vagus nerve stimulation (VNS) was initially developed as a method for controlling epilepsy, researchers found that it improved mood in some people.
 
The FDA based its approval on research showing that VNS was safe and effective. One study cited in the FDA approval documents showed that 31% of people getting VNS responded well to the treatment in the first 12 weeks of therapy and 45% did after one year. The most common side effects are cough and neck pain. Many people also find that their voice often becomes hoarse while the stimulator is delivering its impulse. Between impulses, though, the person’s voice returns to normal.
 
Although the VNS device is on the market, VNS is a relatively untested treatment that has not yet been proved effective by randomized, controlled trials. For this reason, the consumer group Public Citizen petitioned the FDA not to approve it. The FDA has mandated that Cyberonics, the company that makes the device, conduct studies to monitor its effectiveness. For the most part, this treatment should be reserved for exceptional cases where many other therapies have been tried without success.

Repetitive transcranial magnetic stimulation (rTMS)
Another treatment for people whose depression has not responded to traditional therapy, called repetitive transcranial magnetic stimulation (rTMS), is also being tested in several centers. During rTMS, a donut-shaped wand passed along the surface of the scalp focuses magnetic pulses on a small part of the brain. This technique isn’t invasive and doesn’t cause seizures or require anesthesia, as ECT does. A person undergoing rTMS can sit comfortably in a chair and remain awake during the whole procedure, which takes 30�?5 minutes. Usually, it is done once a day for 10 days.
 
Although results in trials are still inconsistent, the news from what now amounts to a large number of controlled studies is getting better. For example, in one study, using rTMS at different frequencies on different areas of the brain improved depression in people who had not responded to drugs. Researchers have also found weekly rTMS helpful to adults with bipolar disorder who are taking lithium.

In a perfect world, every treatment would be right on the mark, every doctor or therapist would earn his or her patient’s confidence, and people would find it easy to follow each bit of helpful advice. Clearly, this isn’t the reality. So what are some of the barriers to getting good treatment and sticking with it? And how can you surmount them?

The health care system
Navigating the health care system isn’t always easy. Some health insurance companies confine your choices to a narrow panel of doctors or therapists. Or there may be relatively few mental health professionals in your area. It may also be hard to advocate for yourself, especially when you’re depressed. Perhaps a supportive family member can help you deal with your insurance plan or accompany you to an appointment.
 
Most private insurers, Medicare, and managed-care plans provide some coverage for mental health treatments. However, copayments may be higher than for other types of care. There may also be a limit on how many visits the company will cover. Calling your insurer is the best way to figure out your out-of-pocket cost.
 
If a psychiatrist or doctor is prescribing your medication and another person is conducting psychotherapy, it may be difficult to coordinate the different aspects of your care. Let both people know that it is important to you that they talk with each other.
 
It’s also important that you do all you can to understand your treatment. Bringing a pad and paper to your appointment and taking notes may help you take in information that is sometimes confusing. For example, studies show that although doctors report telling patients about side effects, many patients don’t remember hearing that information. Also, make sure you bring up any important and possibly time-consuming issues at the beginning of your appointment. Appointment time is often limited, so plan to make good use of the time, and make follow-up appointments when necessary.

Finding the best treatment
Choosing the right treatment is difficult. While research provides guidance, it doesn’t always point individuals in a specific direction. Which treatment works best for which person is still an open question. It’s common to adjust dosages and switch or add drugs depending on your response and side effects. This can be a frustrating process, but your doctor isn’t treating you like a guinea pig �?rather, it’s a normal part of good treatment. Until researchers discover a way to predict an individual’s response to treatment, this step-by-step, trial-and-error process is the state of the art. With persistence, you can reach your goal.

Sticking with treatment
Obviously, no treatment plan has a chance to work if it’s not followed. Yet many, if not most, people don’t take medicines exactly as prescribed, especially if they must take more than one drug at different times of the day.
 
An estimated 5% of patients flatly refuse to take antidepressants or mood stabilizers. Side effects make these drugs intolerable for another 10%�?5% and may encourage countless others to occasionally skip pills, tinker with dosages, or stop taking a drug without their doctors�?knowledge. If you’re having trouble with your medication, talk to your doctor or therapist. He or she can help you sort out the problem and make adjustments if necessary.
 
Some people who opt for therapy find that it can be difficult to keep at it. Change isn’t easy. Even when you’re willing to make life changes, the resulting ripples may affect your friends, coworkers, spouse or partner, and children, some of whom may not be as supportive as you’d like. It sometimes helps to encourage those most important to you to join you in a therapy session or to attend support groups.

Still a stigma
Finally, there’s stigma. Many people still erroneously see symptoms of depression and seeking treatment as a sign of weak character, lack of fortitude, or an inability to pull oneself up by the bootstraps. Because depression can be a source of shame, people with this illness may suffer silently. But by not getting treatment, they remain stuck on a destructive course that leads to more pain, a poorer quality of life, and, at worst, suicide. 

This description is stark, but there’s hope. Therapy and medications can help tremendously, and given the advances in our understanding of this condition, it seems likely that people with depression will soon have even greater treatment options. Public awareness about depression is growing, partly as a result of national public service campaigns, and perhaps funding for the development of new treatments will follow suit. As more and more people seek treatment, it may also be easier for families and friends of those suffering from depression to be more active in encouraging them to get help.

What If My Depression Doesn’t Go Away?

Until doctors have a way to test people ahead of time to see which treatment will work for each individual, finding the right approach is a matter of trial and error. For some people, that process may be quick and simple: The first treatment used is successful, or only some minor tweaking of medications or dosages is needed. But for others, it takes a good deal of patience and willingness to try several different approaches before an effective treatment is found.
 
What might be a typical course of treatment if your depression doesn’t respond well to the initial choice? If the first medication you try doesn’t work after 6�?2 weeks of treatment, your doctor may increase your dosage. If that doesn’t work, he or she may suggest that you switch to another drug in the same class or a drug in a different class. Your doctor may also recommend adding psychotherapy if that hasn’t been part of your treatment plan.
 
If you still don’t respond to these therapies, your doctor may prescribe an additional medication, such as lithium, to be taken with the antidepressant. The next step may be trying ECT or light therapy. Newer therapies, such as vagus nerve stimulation or magnetic stimulation, are other options for you and your doctor to discuss.
 
Having to go through all of these steps may sound discouraging, but finding the treatment that works for you will be worth the effort. Also, keep in mind that there are some things you can do to improve your chances for success, including making sure you take medication as directed and keeping up with therapy appointments (see Overcoming Barriers to Treatment).

How to Cope When a Loved One is Depressed, Suicidal, or Manic

Like a pebble thrown into a pond, depression, dysthymia, and bipolar disorder create ripples that spread far from their immediate point of impact. Those closest to people who have these illnesses often suffer alongside them. It’s upsetting to see a loved one so distressed, and it’s exhausting and often frustrating to deal with the inevitable fallout. But you can do a lot to help a loved one and yourself handle this difficult period.
 
Encourage him or her to get treatment and stick with it. Remind the person about taking medication or keeping therapy appointments. Don’t ignore comments about suicide. If you believe your loved one is suicidal, call his or her doctor or therapist. If neither is available, call a local crisis center or emergency room.
 
Care for yourself. Being a caretaker is a difficult job. You may want to seek individual or group therapy. Numerous mental health organizations sponsor such groups (see Resources) and can also provide you with information on the illness and the latest treatments.
 
Offer emotional support. Your patience and love can make a huge difference. Ask questions and listen carefully to the answers. Try not to brush off or judge the other person’s feelings, but do offer hope. Suggest activities that you can do together, and keep in mind that it takes time to get better. Remind yourself that a disease is causing your loved one to act differently or perhaps be difficult. Do not blame him or her, just like you wouldn’t if it were chronic physical pain that caused the person to change in certain ways.
 
Try to prevent reckless acts during manic episodes. It’s all too common for a person to make poor decisions when manic, so it’s a good idea to try to prevent this problem by limiting access to cars, credit cards, and bank accounts. Watch for signs that a manic episode is emerging (see Manic Episode Checklist). Disruption of sleep patterns can trigger an episode, so support your loved one in keeping a regular sleep schedule. Consistent patterns for other activities such as eating, exercising, and socializing may also help.

Treatments on the Horizon

Our understanding of depression and bipolar disorder has changed radically since the mid-1990s, and we’re likely to learn even more in the coming years. Right now, the following avenues of inquiry look promising.

Genes and treatments
Researchers are now pinpointing the genes involved in depression and elucidating their functions. For example, we now know that a variation at the gene known as G1463A causes low levels of serotonin, making you less responsive to drugs like SSRIs. If this work fulfills its promise, eventually doctors will be able to use genetic testing to predict which medication or therapy will help a particular person’s depression. That new era is still years from making it into your doctor’s office, but the science is evolving rapidly.

Diet and supplements
Could fish truly be a brain food essential to your mental health? The jury is out until larger, more rigorous studies take place, but some preliminary research suggests a link between inadequate intake of omega-3 fatty acids �?which are found in such foods as tuna, salmon, and sardines �?and depression and bipolar disorder.

In addition, the B vitamin folate may have an effect on mood because of its role in metabolizing certain brain chemicals. A study in 2000 found that 500 micrograms (mcg) of folic acid daily increased the effectiveness of Prozac in women (but not in men). However, larger trials are needed to confirm this finding.

New medications
Researchers and drug manufacturers are exploring a variety of new treatments for depression and bipolar disorder. One approach attempts to calm an overly active stress-response system, either by blocking the overproduction of corticotropin-releasing hormone (CRH) from the hypothalamus or by sopping up cortisol. Drug manufacturers are looking for agents that could accomplish these tasks.

Deep brain stimulation
Deep brain stimulation involves surgically implanting electrodes in the brain that are connected to a pacemaker-like device in the chest. This device sends tiny, weak electrical impulses to stimulate an area of the brain believed to play a role in depression. According to one small study, these techniques may be helpful when other therapies have failed. This therapy has been used successfully to treat Parkinson’s disease. However, it is still experimental for people with depression.
 
Because surgery is necessary, if deep brain stimulation is eventually approved to treat depression, it will most likely be used only for people with serious depression who haven’t been helped by a variety of other proven treatments.