After someone has been diagnosed with depression, it could be you or one of your near or dear ones, a lot of questions come to mind about the diagnosis and how the depression needs to be taken care of.
What are the lifestyle measures that needs to be taken ?
How long do I need to take medications?
Whether the medications have side-effects?
and many more questions!!
Let’s get the answers to them.
Q. What are the non pharmacological measures to take care of Depression :
Basic lifestyle measures that are shown to benefit depression symptoms are -
Regular exercises have been shown to be mood lifter and alleviate depressio.
Pursuing a hobby gives a sense of creativity and increases a sense of satisfaction.
Creating a me time where the work we do for ourselves and we try to actively create happiness for our own selves.
Creating more discipline in life in terms of physical activities and psychological balance by creating a schedule and following it diligently.
Bonding with the friends and sharing your problems and getting their perspectives.
Q. How long would I need medicines for Depression ?
In case non pharmacological is not successful and depression is still hampering social, economical life and limiting physical activities of the patient, then starting the patient on medications might bring back the patient to his/ her normalcy. Starting the medicines might actually give the necessary push to the patient to start making lifestyle changes that can help make him move forward towards a meaningful life.
Phases of Medical/ pharmacological Management :
Apart from acute management, there is maintenance phase or at times a continuation phase during which the patients needs to be on medicines so as to decrease the chances of relapse.
Acute and Continuation phase:
The duration of this phase is about 8-12 weeks. The primary goals of the acute management are :
to achieve remission
Remission is a state that comes close to being symptom free (typically remission represents a score of ≤7 on the Hamilton Rating Scale for Depression (HAM-D - Check the Hamilton score on this form here) or ≤10 on the Montgomery-Asberg Depression Rating Scale [MADRS - Check your score here ].
The duration of this phase varies between 6 months to 24 months or longer. The goal of this phase is to return to full function and quality of life and prevention of recurrence.
Regular follow-up appointments are important, particularly in the first 2 to 3 months. The first follow-up visit should generally be 2 weeks after initiating treatment, although high-risk patients with suicide intent or psychotic features should be seen sooner and more frequently.
Q. When is a good time to stop medicines in Depression patients ?
Some patients may achieve remission early in the course of treatment (2 weeks or less), the majority of those who do remit will do so after 6 to 8 weeks. Typical rates of remission are between 30 to 40 percent with most antidepressants and response rates are generally in the 50 to 65 percent range, for patients who are not considered treatment resistant.
Q. What are the treatment options available to patients ?
Treatment options available are :
Somatic treatment like Electroconvulsive therapy
An antidepressant is selected taking into account symptom profile, past history of treatment response and tolerability, potential for drug-drug interactions, and in many instances, cost.
First-line antidepressants include:
SSRIs (Selective Serotonin-Reuptake Inhibitors),
SNRIs (Serotonin and Norepinephrine-Reuptake Inhibitors),
other second generation & novel antidepressants.
Second-line options include novel antidepressants and adjunctive treatments.
MAOI (Monoamine Oxidase inhibitors) & tricyclic antidepressant (TCA) agents are considered third-line treatments for major depressive disorder.
Inadequate response to first line antidepressant
When a patient has received at least 4 to 6 weeks of treatment with a first-line antidepressant and shown no improvement despite a dose increase, the following options should be considered:
(i) further dose increase, particularly when the medication appears to be well tolerated;
(ii) switching to a different antidepressant within the same or a different class;
(iii) adjunctive therapy with an established agent such as an atypical antipsychotic, lithium, triiodothyronine or a second antidepressant with a different neurotransmitter action .
Electroconvulsive therapy(ECT): In refractory cases , ECT might be tried but only for very specific cases and indications are quite limited. Let's discuss ECT in next article.
Patients with mild to moderate depressive disorder may respond to psychotherapy alone. It is also used in combination with pharmacotherapy in some patients.
Cognitive behavioural therapy (CBT) & Interpersonal therapy are the psychotherapeutic approaches that have the best documented efficacy in the literature for management of depression. Various psychotherapeutic interventions which may be considered based on feasibility, expertise available and affordability are shown below :
Cognitive Behaviour Therapy (CBT) : Identifying problems, Identifying cognitive distortions/errors, generating alternative thoughts, problem solving, mastery and pleasure rating, activity scheduling, anxiety management strategies- relaxation exercises.
Interpersonal Therapy (IPT) : Focuses on losses, role disputes and transitions, social isolation, deficits in social skills, and other interpersonal factor that may impact on the development of depression.
Supportive psychotherapy: Allowing the patient to ventilate, providing emotional support, guidance, increasing the patient’s self-esteem, accepting feelings at face value, enhancing hope, enhancing adaptive coping.
Behavioural Therapy (BT) : Activity scheduling, social skills training and problem solving.
Marital Therapy (MT) : Marital therapy conceptualises depression as an interpersonal context such that both members of the marital dyad are included in therapy. Treatment includes behavioural exchange, communication training, problem solving, and resolution of conflict around issues such as financial, sex, affection, parenting, and intimacy.
Family Therapy : When interpersonal problems in the context of pathological family dynamics are responsible for depression, then family therapy may be considered. It would involve all the family members and include similar principles as for marital therapy.
Brief Psychodynamic Psychotherapy (BPD) : The premise of brief psychodynamic psychotherapy is that depressive symptoms remit as patient learns new methods to cope with inner conflicts. Several different approaches have been described.
Dr Nikita Rajpal
(MD - Psychiatry ( PGIMER - Chandigarh) )
Kalpavriksh Superspeciality Center, Delhi.