A Path Toward the Successful Treatment of Depression

pathwayAs an old saying goes, there’s more than one way to get downtown. The same is true for treating depression, but there are two factors that need investigation before a treatment course begins. And they are: a) what’s the individual’s relationship with their depression like, and b) how is the depression serving them.

Depression can be a best friend and a safe haven from the perils of the outside world, or it can be perceived as something a person can’t seem to shake, in spite of their best intentions to do so. It can serve as a source of primary or secondary gain, such as paid leave from work or attracting much desired attention and sympathy. Assessing these factors thoroughly will be the stepping stones for determining the individual’s motivation for getting better. Simply put: the more intimate the relationship with the depression and the greater the gains as a result, the harder it will be for the person to give it up.

What follows is a path – a series of action steps – for managing depression effectively. It’s not a decision tree or algorithm but instead a number of options that can be employed anywhere throughout the treatment process. Here goes:

During the assessment phase, don’t be overly concerned about identifying specific depression subtypes as they are poor predictors of treatment response. Assess what you observe and hear from the client; be cognizant of the unreliability of client self-report; consider the value of collateral sources of information to aid in the confirmation of your findings. Management is largely dependent on how immobilized the individual has become. Forget about neuroscience, it’s not an ally in the treatment room. Focus first on what’s possibly influencing the depression.

Influences on Clinical Depression

  • Reactive issues. This is essentially Adjustment Disorder with Depressed Mood and is triggered by maladaptive responses to identifiable external events with no measurable changes in physical functioning, such as sleep, appetite. Psychotherapy is the modality of choice here; antidepressants are not warranted and typically do not outperform placebo for this type of presentation.
  • Biological issues. Biological presentations are consistent with core symptom changes such as appetite, sleep, a sapping of energy, difficulty experiencing pleasure and low libido. Such symptom changes are worthy of antidepressant medication consideration to preclude further de-compensation and vegetation.
  • Medical disorders can influence depression. There are many contenders here but the two most prevalent culprits are diabetes and hypothyroidism. As I’ve routinely stated for years, when assessing depression start with the medical component first. It’s the easiest to rule out, and it’s simply prudent for anyone under your care to know where they stand medically. Routine blood work is a must to provide competent care.
  • Medications can influence depression. There are the obvious offenders such as alcohol, opiates and anti-anxiety agents. However, certain antihypertensives – beta-blocker drugs (Inderal, Tenormin, Toprol) – can  contribute to depressed mood by slowing an individual down even more, adding to a listless, melancholic feeling. Beware of cortisone drugs also (think prednisone) as they are notorious for their negative influences on mood and at higher doses can precipitate the emergence of psychotic features. Consideration may need to be given to dosage modification or to a change in medication in these instances.
  • Hormonal issues. The obvious here in women is menstrual change in progestin and estrogen which can adversely affect mood. Serotonin antidepressants can help reduce the agitation and irritability symptoms which often have a negative impact on mood. Low testosterone levels (Low T) in aging men can influence depressive symptoms. The treatment of choice here is testosterone supplementation, not antidepressants.   Men who begin feeling dysphoric after age 50, with no prior history of depression, should first have testosterone levels checked before proceeding with any other treatment.
  • Substance abuse. It’s simple; substance abuse complicates every single aspect of the treatment of depression and is often the 10-ton gorilla in the treatment room. The client who won’t honestly fess up to how they’re sabotaging their treatment will languish and continue to live a life of lies. It’s their decision to get better or not, period. Before a treatment course for depression can be made operational, substances of abuse need to be tapered and stopped.

Antidepressants

  • When it comes to employing antidepressants, there’s no right way or wrong way, only possibilities. No one antidepressant consistently outperforms another; side effects do differ.
  • Before someone swallows the first pill, they should be informed as to what to expect from the drug to dispel any unreasonable views the user may have.
  • Patient previous experience with an antidepressant should be investigated. If yes, what were the results? If the drug was discontinued, why?
  • The vast majority of antidepressant users are started on a selective serotonin reuptake inhibitor (SSRI). These agents are incredibly safe, have an advantage of once-a-day dosing and are cost effective as all of the drugs in this class are generically available.
  • I’ve found the most effective strategy for initiating an antidepressant is have the client choose the agent based on acceptable side effects. So have a discussion with your client about the major side effects of antidepressants such as weight gain and sexual dysfunction and have them decide what they are willing to tolerate.

Pharmacological Augmentation Strategies

  • Augmentation becomes a viable option when an individual is not responding to monotherapy or could possibly benefit from the additive effects of other medications. Augmentation should not be employed simply because new symptoms emerge. There must be a clear rational for each and every additive drug choice.
  • Drug options for augmentation purposes include the addition of medications from different chemical classes and combining antidepressants.
    • – Add lithium
    • – Add a psychostimulant (Ritalin, Adderall, etc.)
    • – Add an atypical antipsychotic (Seroquel, Abilify, etc.)
    • – Add thyroid (particularly t3), methylfolate, Sam-e, Omega 3s
    • – Consider the Zyprexa/Prozac combination which goes by the brand name Symbyax
    • – Antidepressant combinations include:
    •      – SSRIs + Wellbutrin
    •      – Effexor + Wellbutrin
    •      – Cymbalta + Wellbutrin

Mechanical Strategies

To potentially stimulate neurotransmission; all FDA approved:

  • ECT (electroconvulsive treatment)
  • rTMS ( repetitive transcranial magnetic stimulation)
  • VNS (vagal nerve stimulation)

What Else?

  • Bright light therapy – particularly beneficial for Seasonal Affective Disorder or any locale with considerable winter darkness
  • Diet – Very few people I have ever treated for depression eat healthy. Fats, sugars and high carbohydrate diets sooth mood and should be curtailed. Malnourished depressed individuals should beef up on healthy proteins and fats. Diet is one of the most critical components of mood improvement.
  • Need I extol the virtues of exercise? The motivation to move is typically low with depression, but moving is critical for sustained improvement. At a minimum, we’re talking about a walk around the block that serves as a springboard from which the person can build upon. Diet and exercise are numbers 1 and 1A when it comes to feeling better.

Address the Demons of Depression in Psychotherapy

  • Social Isolation. From a behavioral perspective, social isolation trumps all when it comes to perpetuating depression. Help the individual define the components of a structured day and emphasize the importance of support in the form of living and breathing human beings in their physical presence.
  • Attitude. Depression is synonymous with poor attitude and fosters an immobilizing inertia accompanied by cynicism, pessimism and negativity. Attitude at its most basic is about one’s view of the world. Assist the individual at setting realistic expectations. Suggest taking on something new, stop making comparisons to others and understanding the value of personal uniqueness.
  • Fear. Poor logic lies at the root of practically all fear. And fear is common to depression because people focus on the worst and will scan their world to support their self-limiting beliefs, turning them into self-fulfilling prophecies. Teach depressed people to step back and just simply acknowledge their fear without attempting to analyze it. Then help them determine the difference between fear that is legitimately in the present from fear that is imagined. Ask: What is the fear really about? What if it came true? What is it preventing me from doing?

There are no reliable algorithms or decision trees for treating depression. Every depression is at least a bit different and manifests differently from one person to another. What I’ve outlined here is a treatment path that has served me very well – a path with multiple routes pursuant to success.

So,

  • Get depressed individuals moving and doing things
  • Help them exorcise their demons
  • If the depression is severe, employ medication, then get them moving and doing things
  • Re-evaluate the need for medication going forward.

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.