Treatment Options

The development of newer antidepressant medications and mood-stabilizing drugs has improved the treatment of depression. Medications can relieve symptoms of depression and have become the first line of treatment for most types of the disorder.

Treatment may also include psychotherapy, which may help you cope with ongoing problems that may trigger or contribute to depression. A combination of medications and a brief course of psychotherapy usually is effective if you have mild to moderate depression. If you're severely depressed, initial treatment usually is with medications or electroconvulsive therapy. Once you improve, psychotherapy can be more effective.

Doctors usually treat depression in two stages. Acute treatment with medications helps relieve symptoms until you feel well. Once your symptoms ease, maintenance treatment typically continues for four to nine months to prevent a relapse. It's important to keep taking your medication even though you feel fine and are back to your usual activities. Episodes of depression recur in the majority of people who have one episode, but continuing treatment greatly reduces your risk of a rapid relapse. If you've had two or more previous episodes of depression, your doctor may suggest long-term treatment with antidepressants.

Medications

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often consider selective serotonin reuptake inhibitors, such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro), as the first-line treatment for depression because they have fewer serious side effects. They seem to work by increasing the availability of the neurotransmitter serotonin in your brain. Drugs similar to SSRIs include serotonin and norepinephrine reuptake inhibitors (SNRIs), such as trazodone (Desyrel) and venlafaxine (Effexor), and dopamine reuptake inhibitors, such as bupropion (Wellbutrin).
• Tricyclic and tetracyclic antidepressants. These medications also affect neurotransmitters, but by a different mechanism than SSRIs. They may be used for any type of depression, be it mild or severe. Among tricyclic antidepressants are amitriptyline, desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), trimipramine (Surmontil) and a combination of perphenazine and amitriptyline. Tetracyclics include maprotiline and mirtazapine (Remeron).
• Monoamine oxidase inhibitors (MAOIs). These drugs, which include phenelzine (Nardil) and tranylcypromine (Parnate), prevent the breakdown of neurotransmitters. The drugs have potentially serious side effects if combined with certain other medications or food products. Doctors rarely use them unless other options have failed. Your doctor may prescribe them if you have chronic depression and eat or sleep excessively.
• Stimulants. Your doctor may initially prescribe a stimulant such as methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine, Dextrostat) or modafinil (Provigil) if you can't take antidepressants because they're contraindicated due to another medical condition. These medications are also sometimes given in conjunction with antidepressants.
• Lithium and mood-stabilizing medications. Doctors prescribe lithium (Eskalith, Lithobid), valproic acid (Depakene), divalproex (Depakote) and carbamazepine (Tegretol, Carbatrol) to treat bipolar depression. Medications called atypical antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) were initially developed for treatment of psychotic disorders. Doctors sometimes also use them to treat bipolar disorder.

According to the American Diabetes Association (ADA), certain antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure. That's why the ADA recommends that doctors screen and monitor anyone taking Risperdal, Seroquel and Zyprexa.

Not everyone responds the same way

Most antidepressants have a similar level of effectiveness. But a medication that works for someone else might not work for you. Doctors choose antidepressants based on your family history and the match between your symptoms and the medication's side effects. For example, if you have insomnia, a sedating antidepressant may help you. But if you're lethargic, then a more energizing antidepressant may be more helpful.

It can take up to eight to 12 weeks before you feel the full effects of an antidepressant, though you may feel some changes earlier. If your response to medication hasn't resulted in satisfactory progress after that time, your doctor may suggest either adding another antidepressant or replacing the first medication with another drug from a different chemical family.

Side effects of medications

As with any medication, side effects are possible. You may notice side effects before you can feel the drug begin to ease your depression. Most of the side effects from antidepressant are temporary and will disappear as your body gets used to the medication. Let your doctor know about any side effects that interfere with daily functioning, or if they're especially bothersome.

• SSRIs. Side effects that may occur with SSRIs and other new antidepressants include headache, nausea, insomnia, agitation or a jittery feeling, and sexual difficulties.
• Tricyclic antidepressants. Older medications, such as tricyclics, may cause dry mouth, constipation, sexual difficulties, blurred vision, dizziness, bladder problems and daytime drowsiness.
• MAOIs. These drugs can cause a significant increase in blood pressure if you eat foods high in tyramine, such as wine, cheese or pickles, or if you take certain drugs, such as decongestants, while taking an MAOI. Ask your doctor or pharmacist for a list of foods and drugs to avoid.

Alcohol can interfere with the way your body absorbs antidepressants. Talk with your doctor before drinking alcohol while you're taking an antidepressant.

Concerns with children and teens

In children and teenagers, there's some concern that the use of antidepressants to treat major depression may lead to an increased risk of suicide - from about 2 percent for children not taking these medications to 4 percent for children taking an antidepressant for major depression. Physicians, parents and children need to weigh the benefits of these medications against the potential risks. Because of the increased risk, the Food and Drug Administration (FDA) directed manufacturers of antidepressants to include a warning on the medication that explains the risk and recommends that children be closely observed by their families, caregivers and physicians while on these medications.

Other treatments

In addition to medications, depression treatment may include:

• Psychotherapy. There are several types of psychotherapy. Each type involves a short-term, goal-oriented approach aimed at helping you deal with a specific issue. Prolonged psychotherapy is seldom necessary to treat depression. If an underlying factor contributing to your depression is an inability to get along with others or difficulty finding your place in life, then prolonged psychotherapy could help you.

  The success of therapy depends on finding a doctor, psychiatrist or psychologist you're comfortable with. Both medications and psychotherapy can take weeks to have an effect. Specialized and supervised group therapy, such as bereavement groups, stress management classes, marital counseling and family therapy, also may help.

• Electroconvulsive therapy. Despite the images that many people conjure up, electroconvulsive therapy is generally safe and effective. Experts aren't sure how this therapy relieves the signs and symptoms of depression. The procedure may affect levels of neurotransmitters in your brain. The most common side effect is confusion that lasts a few minutes to several hours. Some people experience some transient memory loss. This therapy is usually used for people who don't respond to medications and for those at high risk of suicide. It may be the only treatment available for severely depressed older adults who can't take medications because of heart disease.
• Light therapy. This therapy may help if you have seasonal affective disorder. This disorder involves periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Scientists believe fewer hours of sunlight may increase levels of melatonin, a brain hormone thought to induce sleep and depress mood. Treatment in the morning with a specialized type of bright light, which suppresses production of melatonin, may help if you have this disorder.

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