When Depression Is Severe

Written By Maia Szalavitz, Contributing Writer

Severe depression is life threatening. So it is worth every effort you make and every resource it may take to get depression under control and make life more manageable. For most people, that means some combination of antidepressant drugs and talk therapy.

One big challenge is that even the most effective treatments typically take four to six weeks to improve depression. But anti-depressant medications tend to have their worst side effects immediately, before it becomes clear whether they will work. The right treatment, however, can work wonders—it just may take some time to find it.

The range of options can be bewildering with more than two dozen medications and even more types of talk therapy available. But there's an upside here too: though it may take some perseverance in a time when it's hard to hold onto hope, the variety of options increases your odds of finding effective care.

Antidepressant drugs are classified or grouped by how they affect a patient's brain chemistry. Their ingredients are designed to address specific areas of brain functioning. These are the major classes of antidepressants now on the market:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs)
  • Tricyclics
  • Monoamine oxidase inhibitor (MAOIs) or MAO inhibitors

"Unfortunately, we have no way of telling which drug will do what for what person," says John W. Williams, M.D., a professor of medicine and psychiatry at Duke University.

Some research finds that people who show some improvement early on when taking an antidepressant are more likely to achieve complete recovery with that particular medication, says Peter Shapiro, M.D, professor of clinical psychiatry at Columbia University.

He adds that ideally, people show some improvement within two to three weeks—but if not, and if raising the dose and waiting another few weeks doesn't work, "you're probably not magically going to have headway eight to 10 weeks later."

Finding What Works

The first medication prescribed for Bosari was an early SSRI drug. "It did improve my mood but it was not what I would call a cure," she says. "It helped me to function better. It was not as hard to get out of bed. I did kind of have a sense of 'Oh, this is different.'"

Bosari took the drug for a few years, eventually stopping because it didn't seem to be helping much and because her husband questioned the need for her to be on medication. Over time, she adds, her husband grew to understand that treatment—the right treatment—really was important.

It helps to realize that the course of depression treatment is rarely smooth or straightforward. The road is often bumpy and you might have to change directions—but that's typical of the process.

Tracking Your Recovery

Because symptoms often naturally wax and wane, it can sometimes be hard to tell whether treatment is working optimally. "The aim for treatment is not reduced misery; it is normalcy," says Eric Goplerud, a professor of health policy at George Washington University, who himself has suffered depression.

He recommends using a questionnaire called the Patient Health Questionnaire-9 (PHQ-9).

"About a year ago, I was concerned that I was getting into real funk," he says, describing how he sought both therapy and medication. "Every two weeks, I took the PHQ-9 before I went in for counseling and was able to chart my improvement." If treatment is working, research shows that you should see about a 50 percent reduction in symptoms within six weeks.

Mark Zimmerman, M.D., director of outpatient psychiatry at Rhode Island Hospital and his colleagues developed another method to track depression and anxiety symptoms, available at www.outcometracker.org. "Any patient can use it as long as their doctor registers and it's free for doctors to register," he says.

According to the largest trial of multiple medication treatment for depression, conducted by the National Institute of Mental Health, about one-third of patients will completely recover with the first drug they try and up to 93 percent will recover by the time they've tried four different medications.

If multiple medications fail, see an experienced psychiatrist rather than a general practitioner—or even a psychopharmacologist, who is a psychiatrist specializing in the use of medications.

In Bosari's case, when her depression returned, she eventually found the drug combination that provided the best results. "I finally felt 'normal,'" she says. "It just felt right and natural and suddenly it made sense that people would enjoy living and want to make their lives longer. It clicked, like it was the missing piece of the puzzle."

How Long?

The good news is that the vast majority of people suffering depression can be helped with currently available treatments—and sometimes, even a medication that has previously failed will work.

"There has been a consensus for a while that if you have had a significant episode of depression and been treated and gotten better, you should stay on your effective dose for at least six months," Shapiro says. "The risk of relapse is clearly greater for those who discontinue compared to those who maintain for at least six months. And the more episodes of depression you have had in the past, the more likely it is that if you're not on maintenance medication, you will have a relapse going forward."

Bosari has decided to stick with this combination indefinitely—and given her life and family history, it's clear that her depression is chronic and requires long-term treatment. She says that finding the right therapist and exercising have also been critical to her recovery.

Reviewed September 2014


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