Management
Managing depression is challenging due to the variability in biological contributors, heterogeneity of disease, psychosocial history, current stressors exacerbating the condition, medical and psychiatric comorbidities, lifestyle factors, and patient willingness to accept and engage in treatment recommendations.1 According to a survey published in 2018, 30.2% of adults with depression in the United States reported needing treatment but not receiving it.2 Most of those with untreated depression have visited a primary care physician within the last year. Many are unaware that they are experiencing depression or are reluctant to discuss their symptoms with their physician. In the United States, the population most likely to be treated for depression had medical insurance and were either separated, widowed, or divorced. The least likely to get help were uninsured adults, racial and ethnic minorities, and men.3
Management of depression often involves a combination of pharmacological and psychological therapy.4 Most patients respond well to treatment for major depressive disorder (MDD) and achieve some relief from their symptoms.5
Mild Depression
Patients diagnosed with mild depression may be able to take the “wait and see” approach. In some cases, mild depression may improve with time and lifestyle modifications. Exercise is recommended as an important treatment for mild depression.4
Mild to Moderate Depression
Therapy, including cognitive behavioral therapy and counseling, can be very beneficial in patients who have not improved with the “wait and see” approach or in patients with moderate depression.4
Moderate to Severe Depression
Antidepressants, in combination with therapy, can be beneficial in patients with moderate to severe depression. The combination of medication and therapy works better than either treatment alone.4
Psychotherapy
Also known as “talk therapy,” psychotherapy involves the individual but may also involve the individual’s family. Cognitive behavioral therapy (CBT), one of the most common forms of therapy, is beneficial in patients with depression.5 CBT focuses on recognizing distorted thinking and on problem solving in the present. The goal of CBT is to change an individual’s pattern of thoughts and behaviors to better respond to challenges in a positive way.5
Electroconvulsive therapy, the use of short electrical stimulation to the brain under anesthesia, is reserved for treatment-resistant patients with severe depression. Treatment occurs 2- to 3-times a week for 6- to 12-treatments.5
Pharmacotherapy
Antidepressants utilized for the management of depression can include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic and tetracyclic antidepressants (TCAs), atypical antidepressants, monoamine oxidase inhibitors (MAOIs), and an n-methyl d-aspartate (NMDA) antagonist (not first-line therapy).6 Patients initiating antidepressant therapy should always be evaluated for any contraindications to therapy and drug interactions with existing medications, and patients should also be counseled to be aware of possible side effects when starting their medication.
Any antidepressant typically takes between 4- to 8-weeks to work in patients, so it is very important to also counsel patients regarding the importance of medication adherence.7 Generally, symptoms such as insomnia, appetite change, and inability to concentrate will resolve first before mood improves.7
In children and young adults, there may be an increase in suicidal thoughts when taking antidepressants approved for use in children and young adults. This is most likely to occur within the first few weeks of starting the medication or if the dose is changed.7
Lifestyle Modifications
Patients should be encouraged to make positive lifestyle changes during and after treatment. These include7:
• Exercising
• Setting realistic goals toward remission and improvement of mood
• Spending time with trusted family and friends for support
• Reducing isolation
• Postponing important life changes, if possible, until the patient feels better
• Continually seeking out information about depression
References:
1. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry. 2000;157(4 Suppl):1-45.
2. Chekroud AM, Foster D, Zheutlin AB, et al. Predicting barriers to treatment for depression in a U.S. national sample: a cross-sectional, proof-of-concept study. Psychiatr Serv. 2018;69(8):927-934. doi:10.1176/appi.ps.201800094
3. Olfson M, Blanco C, Marcus SC. Treatment of adult depression in the United States [published correction appears in JAMA Intern Med. 2016;176(10):1579]. JAMA Intern Med. 2016;176(10):1482-1491. doi:10.1001/jamainternmed.2016.5057
4. Treatment - clinical depression. National Health Service. Updated December 10, 2019. Accessed December 6, 2022. https://www.nhs.uk/conditions/clinical-depression/treatment/
5. What is depression?. American Psychiatric Association. Updated October 2020. Accessed December 6, 2022. https://www.psychiatry.org/patients-families/depression/what-is-depression
6. Depression medicines. US Food and Drug Administration. Updated November 18, 2019. Accessed December 6, 2022. https://www.fda.gov/consumers/free-publications-women/depression-medicines#SSRI
7. Depression. National Institute of Mental Health. Updated September 2022. Accessed December 6, 2022.
https://www.nimh.nih.gov/health/topics/depression/index.shtml