Vassilis N. Panagopoulos, MD
Major depressive disorder (oftentimes referred to as “depression” by the general public) is the most common major psychiatric disorder. Approximately 15% of the general population is affected by this illness at some point during their lifetime. Depression is almost twice as common in women as it is in men.
Major depressive disorder is characterized by the occurrence of episodes of clinical depression which are called “major depressive episodes”. A major depressive episode lasts for at least 2 weeks and is characterized by the following symptoms:
The above symptoms represent a significant change in social, occupational or other domain of functioning and cause significant distress.
Major depressive disorder is usually an episodic illness, i.e. it comes and goes in discrete episodes with the symptoms described above. In-between episodes the symptoms may resolve completely or partially.
Major depressive disorder is a very treatable illness. The goal of treatment is two-fold: complete resolution of the current episode of depression, as well as prevention of recurrence of future episodes. In other words, the treatment targets the currently present symptoms as well as avoiding a recurrence of symptoms in the future.
There are two aspects of treatment: 1) biologic treatments and 2) psychotherapy.
Biologic treatments include antidepressant medications. There are multiple different categories of antidepressant medications with a different mechanism of action and a different side effect profile.
The other important treatment method for depression is psychotherapy (talk therapy). It involved meeting regularly with a trained mental health professional (counselor, psychologist, psychiatrist) and discussing about how one thinks, feels and acts. There are several different schools of psychotherapy that are utilized for the treatment of depression.
Treatment for depression can be beneficial for all patients with major depressive disorder. In milder forms, many people may prefer to try psychotherapy instead of medications; and that may indeed be a reasonable decision. However, in moderate to severe major depressive disorder treatment with medications is recommended. In fact, combination treatment with psychotherapy and antidepressants at the same time has been proven to be more effective than either treatment alone. This makes sense because they work in very different and complementary ways. Therefore, combining psychotherapy with antidepressants is typically recommended for patients with moderate to severe major depressive disorder. Increasing access to care for depression in particular is very important because treatment can be life-saving. Unfortunately, many people who suffer from depression do not receive proper treatment for various reasons (stigma related to suffering from a mental illness, poor insight, not having access to psychiatric care).
Unfortunately, approximately 15% of patients with depression die of suicide. In addition, patients with untreated depression have worse medical outcomes regarding other, unrelated medical problems such as diabetes. This maybe because the body's reserves are exhausted due to the depression or because a person with serious depression is less likely to take care of oneself (adhere to one's medication regimen daily, attend physician appointment's regularly etc.). So, major depressive disorder is not a strictly psychological issue that does not affect physical health. Quite the contrary...depression is accompanied by significant mortality and morbidity rates. This is why receiving treatment is so important, and family members and friends of people with depression should encourage their loves ones to receive treatment.
The most commonly prescribed antidepressant medications belong to a category called SSRIs (Selective Serotonin Reuptake Inhibitors). These medications presumably work by increasing the levels of a neurotransmitter (i.e. a molecule used by the brain cells to communicate with each other) in the brain. This neurotransmitter is called Serotonin, and is thought to be involved in the regulation of mood. Medications, such as the SSRIs, that increase serotonin tend to be effective antidepressants.
SSRIs is an acronym for Selective Serotonin Reuptake Inhibitors. They include the following medications:
These antidepressant medications are effective for depression and have a favorable side effect profile which is why they are regarded as first choice for the treatment of major depressive disorder for the majority of the patients. Of course, treatment has to be individualized by a professional to the particular circumstances and other medical problems of each patient.
The side effects are usually mild. At the beginning of treatment (first few days) they may include mild nausea, diarrhea, anxiety, sleep disturbance, dizziness but usually these symptoms resolve in a few days as the body adjusts to these medications. Another side effect of SSRIs includes sexual dysfunction. SImilarly with any type of medications, there is a low possibility of more serious side effects but this a rare occurrence. A carefully orchestrated psychiatric treatment plan involves weighing carefully the risks and benefits of treatment. Most of the time, the benefits of treatment with antidepressants outweighs the risks by far when treatment is administered under the supervision of an experienced clinician in regular intervals. If a side effect occurs, an experienced clinician can readily adapt their recommendations for instance by prescribing a lower dose of the medication or switching to a completely different medication. Patients are strongly encouraged to discuss openly about any potential side effects of their prescribed medications.
Contrary to popular belief, SSRIs are not addictive or habit-forming. SSRIs do not cause people to get high or feel euphoria (in contrast to alcohol or drugs). They work gradually within a few weeks to lift the depression without causing an immediate euphoric rush.
In addition, these medications typically do not influence the appetite level and do not cause weight gain or weight loss. It should be noted, that in severe depression accompanied by severe loss of appetite and weight, patients will likely start gaining back weight after the initiation of effective treatment of depression. However, this is a desired reaction to the treatment of severe depression rather than a direct side effect of these medications.
SSRIs do not typically cause somnolence or sleepiness. It should be noted, that in depression accompanied by insomnia the insomnia tends to improve with treatment. At the same time, in depression accompanied by excessive sleep (hypersomnia), this symptom also is likely to improve with treatment. Again, these are not really side effects of the medications but rather part of achieving the treatment goal of complete resolution of the symptoms of depression.
Some medications for depression can cause problems to the developing unborn baby (embryo). Some psychiatric medications are more dangerous in that respect, and other psychiatric medications are less risky. At the same time, severe untreated depression can be detrimental for both the mom as well as the unborn baby. This is an important discussion that all women of reproductive age with depression need to have with their own psychiatrist. An experienced psychiatrist will carefully weigh the risks and benefits of treatment with medication taking into account the severity of the illness. Then, the psychiatrist will be able to provide individualized medical advice, so that they can together come up with the best plan for both the mom and her future baby.
Yes, SSRIs are also considered first-choice treatment for most anxiety disorders. This is important because many people who suffer from depression also suffer from anxiety. At the same, time it should be noted that they are effective for anxiety disorders even in the absence of major depressive disorder.
There are several different psychotherapeutic approaches for depression. One of the most frequently used and evidence-based types of psychotherapy is called Cognitive-Behavioral Therapy (CBT). CBT has been studied extensively, and based on the results of these studies is considered as an effective treatment for depression. CBT involves working closely with the therapist to recognize negative patterns in one's feelings, thoughts and behavior. The person learns how to observe oneself in these domains. With the aid of logic the negative patterns of thinking and behavior gradually become more realistic and more positive. This is a fairly practical type of psychotherapy, which often involves homework assignments. This school of psychotherapy is focused much more in the way the patient responds to day-to-day situations rather than the events of the distant past such as one's childhood. This is a very action-oriented approach: the person is encouraged to change one's current patterns of behavior where needed, engaging in more adaptive behaviors that serve one's quest to well-being more effectively. It typically lasts for several weeks or a few months but this varies significantly depending on the therapeutic effect and the needs of the person.
Dr. Panagopoulos will obtain a comprehensive psychiatric history during the first session. Based on the latest uptodate clinical practices, Dr. Panagopoulos will discuss the diagnosis and will design an individualized treatment plan for each patient. For depression, this would typically include psychotherapy (talk therapy) and / or the prescription of antidepressant medications if that is indicated.
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