Depression can be treated effectively with antidepressant medications and psychological therapies. Research suggests that antidepressant medications and psychotherapy are equally effective for treating mild to moderate cases of depression. For more severe cases, medications are clearly superior. Electroconvulsive therapy (ECT) is the most effective treatment for depression with psychotic symptoms or when depression is life threatening.

Antidepressant Medications
There are different classes of antidepressant medications and each type has different side effects. Fortunately, all classes of antidepressants are effective. The patient and doctor just have to find the one that works best for the individual. In fact, 60 to 70% of depressed patients who are given an antidepressant recover from their depression in three to six weeks, provided that the dose is sufficient and that the patients take their medication each day as prescribed.

The goal of treatment is complete relief of depressive symptoms, not just partial relief. Patients should be open with their doctors about how they feel after they begin taking an antidepressant. If they feel better after three to six weeks, but their symptoms are still present, the doctor will likely increase the dose of the antidepressant that they are taking. If they cannot tolerate a higher dose, the doctor will likely switch to another medication. If one?s symptoms are no better or worse after three or four weeks, the doctor should suggest that the patient try a different antidepressant.

SSRIs (e.g. Zoloft, Prozac, Paxil, Luvox)
Psychiatrists and primary care physicians prescribe these drugs more than any other class of antidepressants. The side effects are tolerable and the drugs are convenient to use.

Common side effects: Side effects of this class of medication include sleep changes (insomnia or sedation), stomach upset, mild headache, anxiety or restlessness, and changes in sexual performance (decreased libido and/or decreased physical sensations). Restlessness and changes in sexual performance can be counteracted with small doses of an additional medication and the other side effects usually last for only a few days.

Usage: These drugs only need to be taken once a day, which makes them convenient. (Usually, Luvox is taken twice a day.) They do not require any special monitoring other than a doctor's evaluation to determine whether they are effective in relieving one's depressive symptoms. They are also safe in overdose.

SNRIs (Effexor, Serzone)
This class of drugs is also well-tolerated and easy to use.

Common side effects: Overall, the side effects are similar to the SSRIs, although the SNRIs generally cause fewer sexual side effects than the SSRIs. The SNRIs can also produce dry mouth, mild constipation, and urinary retention (excessive build-up of urine in the bladder). At higher doses, venlafaxine (a type of SNRI) may cause high blood pressure; therefore, patients should have their blood pressure checked while taking this medication. The SNRIs are safe in overdose.

Usage: These drugs are usually taken twice a day.

Bupropion (Wellbutrin)
Common side effects: Anxiety, restlessness, and insomnia. At high doses it may cause seizures, so it is not a good choice for individuals with epilepsy or brain injuries.
Usage: One must take Bupropion two or three times a day to limit its side effects, although an extended release form is available that can be used once or twice a day. This drug may cause seizures when taken in large amounts.

Mirtazapine (Remeron)
This is a relatively new antidepressant.
Common side effects: Sedation and weight gain.

Usage: Because mirtazapine is sedating, it is taken once a day at night. This drug is safe in overdose.

TCAs (e.g. Elavil, Pamelor, Norpramin)
This is one the oldest classes of antidepressants. These drugs tend to have more side effects and require closer monitoring to ensure their safety. They may also be fatal in overdose. Nevertheless, they remain effective antidepressants. Many patients find them to be helpful when the newer medications have failed.
Common side effects: Sedating, dry mouth, blurred vision, constipation, urinary hesitancy, orthostatic hypotension (lightheadedness upon standing that may lead to falls), tremor, excitement, heart palpitations, and weight gain.

Usage: Patients with closed-angle glaucoma may not use this class of drug. Sometimes it is necessary to monitor TCA blood levels to ensure that patients receive the optimum dose. Recent data have raised questions about the safety of these medications in patients with heart disease; therefore, patients with heart disease should avoid them. Patients over 40 years old should have a cardiogram prior to starting a TCA.

MAOIs (Parnate, Nardil)
This class of drug is also an older type of antidepressant with a number of side effects. However, it is often selected to treat ?atypical depression? which is characterized by excessive sleep, overeating, somatic complaints (many complaints about body parts hurting), and a hypersensitivity to perceived slights from others. When other classes of drugs have failed, these types of drugs are prescribed.
Common side effects: Mild to moderate dry mouth, blurred vision, constipation, urinary hesitancy, insomnia or overstimulation, and orthostatic hypotension (lightheadedness upon standing that may lead to falls).

Usage: While one is taking MAOIs, he/she must follow a special diet. Specifically, he/she must avoid foods that are high in the amino acid tyramine (naturally aged meats and cheeses, microbrewed or home brewed beers, some red wines, and flat beans such as fava beans). Also, if one is taking this type of drug, he/she must avoid over-the-counter cold remedies that contain the decongestant, pseudoephedrine. Ingesting these foods or this decongestant may cause a potentially fatal hypertensive crisis. Patients over 40 should have a cardiogram before starting a MAOI.

Issues to Discuss With Your Doctor

Patients should spend time talking with their doctors about which type of drug will work best for their particular depressive symptoms.

Patients should ask about the side effects that they might experience while they are taking the drug.

They should find out what type of monitoring will be necessary to ensure that they are using the drugs safely.

They should find out how long they are expected to take the drug.
Psychotherapy
There are a number of effective psychotherapies that have been developed specifically to treat depression, including cognitive-behavioral therapy, interpersonal psychotherapy, and short-term or focused psychodynamic psychotherapy. Clinical trials show that these approaches are equally effective as antidepressant medications for patients with mild to moderate depressive symptoms. Basically, these therapies target one or more aspects of a patient?s thoughts, feelings, or personal interactions that bring on and sustain an episode of depression. Patients should avoid therapies that seem open-ended or that have poorly defined goals. More information about specific types of pscyhotherapies can be found in the Psychotherapy section of the Mental Health Center.

ECT (Electroconvulsive Therapy)
ECT involves the deliberate induction of a brain seizure by passing a small electrical current through the brain. This treatment is recommended for patients with severe, chronic depression, medication resistant depression, catatonia, or serious medical problems. ECT has a success rate of over 80% and can produce a rapid remission of symptoms within one to three weeks. However, ECT cannot prevent a relapse. Patients who have completed a course of ECT are prescribed antidepressant medication, or they receive ECT once a month to prevent recurrence. ECT is performed on an inpatient or outpatient basis and requires general anesthesia. Overall, modern ECT is considered general safe, but there is a varying degree of risk of memory loss and confusion. The memory loss varies from person to person. Some individuals lose only memories surrounding each ECT treatment, while others lose entire chunks of memories of significant past life events. This side effect should be thoroughly discussed with your doctor before proceeding with ECT treatment.

Treatment Resistant Depression
If two adequate antidepressant regimens fail to help an individual, he/she is considered to have treatment resistant depression and should see a psychiatrist immediately.

Treating Relapses
Once depression is under control, patients should continue taking their antidepressant medications at the same dose for nine to twelve months to prevent a relapse. After a second depressive episode, the doctor may prescribe an antidepressant for as long as two years. Patients who have had three or more episodes of depression have a very high risk of recurrence. These patients may need to take an antidepressant for an indefinite period (possibly for life) to decrease the chance of future depressive episodes.

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