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Taking Depression Seriously: A treatment overview

In the third post in the Taking Depression Seriously series, Sophia Xiao and physician Randall Stafford address the treatments available for depression.

Depression is a disease arising from multiple causes, including biological, psychological, and social factors. Existing treatments address these factors, but each individual responds best to a different mix of therapies.

We've written previously about a patient named Ms. C, a 55-year-old former salon owner. When her depression was diagnosed, she tried a variety of treatment methods. Because she is very physically active, Ms. C. found exercise and meditation most helpful. While she did find antidepressants mildly effective, she reacted poorly to her initial prescription and delayed working with her doctor to find another.

This blog post gives a quick overview of the different categories of treatment.

Medications

The antidepressants that doctors often prescribe first are called selective serotonin reuptake inhibitors (SSRIs). SSRIs, like fluoxetine (brand name Prozac, FDA-approved in 1987), are safer and generally cause fewer side effects than other antidepressants. The related selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) are rising in popularity.

Studies have shown noticeable improvement in depressed individuals treated with antidepressants compared to those taking a placebo. As with Ms. C, however, patients sometimes must try several antidepressants before they find the one that works best for them. This requires patience. However, if you have family members who have taken antidepressants, their experience can be helpful because response to specific antidepressants is partly genetic. 

People sometimes take dietary supplements, like SAMe and St. John's wort, for depression, although they are not as effective as prescription antidepressants and can interact negatively with commonly prescribed medications.

"The issue with dietary supplements is that encouraging people to monitor their own medications can be quite dangerous," says Susan Edelman, MD, a Palo Alto-based psychiatrist. "I would encourage people to tell their doctors what they're doing, because oftentimes patients are afraid to bring it up with their doctors, and doctors often don't ask their patients if they're taking any."

Since dietary supplements are not FDA-approved, there is more variability and less regulation in the production of these supplements. As a result, if you are considering the use of dietary supplements to manage depression, talk to your doctor first.

Talk therapy

Different types of talk therapy can be very effective for depression. Interpersonal therapy emphasizes relationships, which are often a major part of depression. Cognitive behavioral therapy focuses on helping people change the mindsets and behaviors that reinforce depressed feelings. A less structured approach, client-centered therapy, focuses on the client as much as possible.

Therapy can occur in person or online, one-on-one or in groups, and can be short term or long term. While usually provided in person, experiments with online and even automated talk therapy appear promising. Clinical trials have found that patients treated with talk therapy improve significantly compared to those not receiving it.

Health behavior changes

Regular physical activity, strong social support networks, good nutrition, adequate sleep, and stress reduction can all improve and treat depression. For individuals with milder forms of depression, exercise alone may be a reasonable alternative to antidepressants. Furthermore, in an analysis of 35 different trials, a moderate clinical benefit favored patients who exercised regularly.

Therapeutic intention

Any therapeutic intention to treat depression can have a positive impact. In trials measuring effectiveness of antidepressants against placebo, many patients taking a placebo saw noticeable improvement. This therapeutic intention (often called a "placebo effect") should be taken seriously. The intent to treat can instill hope, raise expectations of improvement, and make patients feel in control again, all changes that can lead to improved mood.

Treatment is often complicated, and every person responds differently. Many patients need to expend effort finding the right antidepressant, a comfortable frequency or type of talk therapy, and feasible lifestyle changes. Physicians also recommend that medication, psychotherapy, and lifestyle changes be utilized together for maximum effectiveness.

This is third in a series of blog posts, Taking Depression Seriously, that aims to help patients and family members better understand depression as a chronic disease and more successfully navigate the health care system. The next blog will highlight the different types of medication available and review their effectiveness.

Sophia Xiao is a masters degree student in Community Health and Prevention Research at Stanford University. She studies barriers to health care and the role of public health education in improving access to care. Stanford professor and primary care physician Randall Stafford, MD, PhD, studies strategies to improve chronic disease treatment, including increasing the role of patients in their health care.

Photo by moshehar

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