"I'm Depressed. Is there hope?" ABSOLTUTELY!

One of the most difficult questions a Psychiatrist has to answer happens to be the title of this post.  It comes in several forms:

     "Will I ever get better?" 

     "These stupid meds aren't working!"

     "I've lost all hope."

Have you ever felt this way?  I am writing this blog today to address these very important concerns. With education, understanding, patience, and support, depression is very treatable.

Before I delve right in and discuss treatment options, there are three important concerns that need to investigated.   Without knowledge of these influencing factors, adequate treatment for depression is less likely to be achieved.   

Have you ever heard of the term BIOPSYCHOSOCIAL? It is a combination of the words biological, psychological and sociological.  Let me explain.

Biological concerns address not only family history of mental illness and medical illnesses that could contribute to depression, but also substance abuse problems. One question I will always ask the patient is if their use of alcohol or drugs has increased to help them cope.  I don't ask them if they drink or use drugs because the answer is often "No".  I don't ask them how much, either, because I would probably need to double the amount.  Self-medicating is less threatening and they are more likely to answer with an affirmative or just deny ever using.  I will use this information as a teaching point - they cannot expect to respond to medication as effectively if under the influence of alcohol or drugs.

Psychological considerations are paramount in considering treatment options. Answer me this question: How do you cope with sadness, with stressors, with unexpected changes?  For example, some may "cry over spilled milk" while others may make "lemonade from lemons"? Our defense mechanisms come to play when things "go wrong".  No two individuals experience similar episodes in exactly the same way. Some may gather family for support and identify the stressor and take action to minimized their symptoms.  Some may turn to substances to self-medicate or stop taking medication the minute they experience a side effect that might be transitory.  Or they may feel the medication is ineffective if relief of symptoms does not come within a short period of time. These, again, are important teaching points.  Some individuals want immediate relief.  If they are not informed that, unlike tylenol that relieves a headache in 20 minutes, anti-depressants require more time and work differently, they may be less compliant with treatment.  Education is key. 

Social concerns have always influenced our emotional state.  Job losses and financial concerns, foreclosures, broken marriages that occur after years of celebrating anniversaries are just a few of the stressors challenging my patients. In addition, a strong support system is an essential element of the care plan. Do you have access to family members or friends when life throws you punches or do you isolate?

All of the above components are necessary when considering treatment options. Are the symptoms beginning to affect function? If so, an anti-depressant might be prescribed at this time. Are other medical problems or substance abuse issues under control or contributing to the situation? If not, then involving the primary care provider and/or referral to a substance abuse program is also necessary.  How strong are the coping or defense mechanisms?  What was your answer to the above question? Are you making lemonade or crying over the spilled milk?  A referral to a counselor such as a social worker or psychologist may be necessary at this time? Is a case manager needed to address the financial situation, living arrangements or unexplored entitlements?  Support comes in all forms and may be a very critical element in the overall treatment plan.

Now about medication. For client's presenting with mild symptoms, medication may not be necessary. Did you know that research has determined that exercise including yoga can be effective for these individuals?  If the symptoms are more moderate or severe, and I am referring to the number of symptoms present, then medication is advised. Remember the pneumonic SIGECAPSS in my last blog?  The more symptoms present will influence treatment.  And certainly if the patient has a dramatic change in functioning, or is expressing 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.

And I cannot sign off without commenting on the media's influence on the public's attitude towards medication.  (Don't even get me started on the movie industry's depiction of the medicated patient - a "walking zombie"!)  Perhaps the increased suicidal thoughts of adolescents when first placed on anti-depressants was an important discovery.  What do you do with that information?  You work more closely with the patient and educate the patient and family.  You don't scare the public into thinking that anti-depressants are responsible for suicide.  On the contrary, because the scare prevented teens and parents, and even adult patients, from seeking treatment, teen suicides increased.  What a shame!  Depression is treatable.  Don't be afraid to seek treatment.

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

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