HEALTH AND WELLNESS -Depression - Part 2 - Treatment options

As I promised, I wanted to devote four of my postings to depression. Today's topic is dedicated to treatment options.

I suspect that the growing percentage of suicide attempts in baby boomers may be influenced by the increasing amount of stressors facing our generation and the reluctance to seek treatment for depressive symptoms. Of course medication cannot magically remove the threat of foreclosure or stop a partner from their emotional or physical abuse. But there is hope for those suffering from the symptoms of depression and we will discuss a number of possible treatments in today's article.

Have you ever heard of the term BIOPSYCHOSOCIAL? It is a combination of the words biological, psychological and sociological. And it is these important aspects of our lives that should be taken into consideration when treating depression.

Biological concerns address not only family history of mental illness, medical illnesses that could contribute to depression, but also to substance abuse problems. This information can contribute to treatment recommendations that might include follow up for current medical symptoms and referrals to substance abuse programs.

Psychological considerations are paramount in considering treatment options. How do you cope with sadness, with stressors, with unexpected changes in your workplace or daily routine? Are you one to "cry over spilled milk" or do you pride yourself in making "lemonade from lemons"? Our defense mechanisms come to play when things go wrong emotionally. I have clients who claim that "this too shall pass" and never need any significant interventions. Others may collapse on my desk with the same mild symptoms, demanding that I find immediate relief. No two individuals experience similar episodes in exactly the same way. Some turn to substances to self-medicate or stop taking medication the minute they experience a side effect that might be transitory or if relief of symptoms does not come within a short period of time. They can perceive their situation quite differently which effects the way they feel and, ultimately, the way they behave.

Social concerns have more recently been at the core of my clients depression. Job losses and financial concerns, foreclosures, broken marriages that occur after years of celebrating anniversaries are just a few of my client's stressors. In addition, a strong support system is an essential element of the care plan. Are family members invested in the welfare of this person? Does the client live alone? Are there caring neighbors? Do they have a spiritual base and is a church family present?

All of the above considerations need to be a part of the initial assessment. Will the client need medication only? If a family member has a history of depression as well, did they respond to a certain medication? Are other medical problems under control or contributing to the situation? Are the client's defense mechanisms inadequate to deal with their current situation? Would a referral to a counselor such as a social worker or psychologist be necessary at this time? Is a case manager needed to address the financial situation, living arrangements or unexplored entitlements that the clients may desperately require?

Without team management, my task is made more difficult because medication alone may not solve the problem. However, I am a psychiatrist and it is my function to treat the symptoms with medication and to refer to the wonderful social workers, psychologists and case managers if needed. God Bless them all. I feel that these important individuals are so overworked and underpaid. They are truly devoted caretakers. And I am proud to claim that my daughter, Molly, is one of those dedicated LISW's.

Now about medication. For client's presenting with mild symptoms, medication may not be necessary. If the symptoms are more moderate or severe, and I am referring to the number of symptoms that they are experiencing, then medication is advised. If the patient has physiological complications, with poor sleep, loss of weight, dramatic change in functioning, or suicidal thoughts, plan or intent, then hospitalization is usually recommended at that time.

The selection of medication depends on the symptoms that are described by the client. And certain neurotransmitters in our brain are utilized to help target and relieve symptoms. I am referring to serotonin, norepinephrine, and dopamine.

If anxiety, obsessive compulsive traits, or ruminations are present(those thoughts that show up at bedtime or tend to act like a broken record), then my first choice is a serotonin agent. They are classified as SSRI's or Selected Serotonin Reuptake Inhibitors (lexapro, zoloft, celexa, paxil, prozac, luvox) and can be very efficacious in targeting symptoms that include anxiety, ruminations, guilty conscious, and obsessive compulsive traits that predominate one's depression. Concerns that often leads to non-compliance are side effects - transient stomach or abdominal discomfort, headache, or more importantly, sexual dysfunction, specifically the inability to experience an orgasm. This needs to be discussed with patients prior to treatment.

Medications that include both serotonin and norepinephine also supply benefit for concentration and anxiety. If focus is a problem, often times a combined drug can offer benefits. SNRI's (Serotonin Norepinephrine Reuptake Inhibitors) include effexor, pristiq, cymbalta, and remeron. Remeron is benefical if the client is unable to sleep as it has sedative properties and causes no sexual side effects. Cymbalta is used in clients that have some of the physiological symptoms of depression. Effexor and pristiq provide not only serotonin and norepinephrine, but some affinity for dopamine which is addressed below.

Dopamine, to me, is the "feel better" neurotransmitter, providing energy, motivation and concentration. If the symptoms are more consistent with a "couch potato", or a withdrawn nature, than a dopamine agent like wellbutrin may be indicated. Although it also has no sexual side effects, it is limited in client's who have no history of seizure disorder or eating disorders.

Education is an important aspect of the initial assessment. Medication needs to be taken consistently and the client needs to be aware that responses to medication may require at least 2 to 3 weeks. Any concerns regarding side effects or thoughts of discontinuation of the medication need to be discussed with the doctor. Follow-up appointments are critical in determining the response to the medication, whether dosage needs to be adjusted or whether other agents need to be considered for adjunctive benefits.

There it is - my philosophy of medication management in a nutshell (actually "blogshell").

In summary, discuss your full spectrum of symptoms with your doctor so that the right medication can be prescribed. Do not leave the office without a full understanding of the side effects and benefits of the medication. Do not change your dosage or stop treatment unless discussing this with your physician first Should suicidal thoughts develop during the inital part of the treatment (often seen in children, adolescents, and young adults), notify your doctor immediately or present to the Emergency Room for a risk assessment.

Next week we will discuss the topic of suicide.

Until then, I wish you Peace and Good Mental Health. Dr.Elaine