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Depression; Treatment.

If you aren't sure whether to seek help for a mood disorder or emotional problem, ask yourself, "Could I use some help right now?" The questions below may help you decide:

Is the problem interfering with your work, relationships or other aspects of your personal life?

Have you been feeling less happy, less confident and less in control than usual for a period of several weeks or longer?

Have close, trusted friends or family members commented on changes in your behavior and personality?

Have your own efforts to deal with a problem failed to change your behavior or improve the situation?

Is dealing with everyday problems more of a struggle than before?

Are you having suicidal thoughts?

If you answered yes to any of these questions, talk to your health care professional about how you are feeling.

Left untreated, depression can be devastating--an estimated 15 percent of people with severe, untreated clinical depression will eventually commit suicide. What's more, depression is now known to play a major role in exacerbating existing medical conditions and may even predispose people to develop other illnesses. Depression may have adverse effects on the immune system, blood clotting, blood pressure, blood vessels and heart rhythms.

Unfortunately, many people who suffer from depression do not seek help. They believe that nothing can help, or that they can simply cure themselves. Many women and their families don't understand that depression is a medical illness. Furthermore, because some symptoms of depression are common to other medical illnesses, depression is often misdiagnosed. The tragedy of this is that in the last two decades treatments have emerged that can lead to recovery for most sufferers.

With accurate diagnosis and proper treatment, you can learn how depression affects your life and get the help you need to be productive again; in fact, 80 percent of individuals who are depressed recover with appropriate treatment.

Reaching out for help when you can't spring back from sad or depressed moods, or when emotional difficulties begin to interfere with work, relationships or other aspects of your life, is a wise step but one that's often difficult because depression typically robs your motivation and energy.

The single most important function your health care professional can perform is to distinguish between mild and severe depression. If your depression is mild, you may need an antidepressant and/or a referral to a psychologist or social worker for counseling. If your depression is severe, however, you may need to see a specialist such as a psychiatrist, who can determine the treatment. Studies find, however, that although primary care physicians and nurses treat an estimated 70 percent of those with depression, they tend to under prescribe medication for depression. They also tend to keep patients on the wrong medication for too long before trying other drugs. Thus, it's important that you communicate honestly with your health care professional about your illness, your current treatment and other treatment options. Though it can be challenging, you can find another medical professional if you are not satisfied with the care you're receiving.

Psychotherapy

Most cases of major depression can be successfully treated with psychotherapy, medication (known as antidepressants) or both. Although the exact effectiveness of psychotherapy is difficult to measure, on average, about 75 to 80 percent of depressed patients improve within a few months of starting treatment.

Psychotherapy focuses on changing negative thinking and behaviors and/or unhealthy relationships that can contribute to depression. Talking to a psychological counselor can provide relief, lead to new insights and help replace unhealthy behaviors with more effective ways of coping with problems. Most mental health professionals tailor their approach to the needs, problems and personality of the person seeking help, and they may combine different techniques in the course of therapy. The various types of psychotherapy include:

Cognitive-behavioral therapy, which focuses on identifying distorted perceptions you may have of the world and yourself, changing these perceptions and discovering new patterns of actions and behavior.

Behavior therapy, which is based on the premise that if you are depressed, you behave in ways that bring about negative consequences. Behavioral counselors help you change what you do so you can change how you feel. For instance, you might be encouraged to become more active or add pleasurable activities to your life, learn to assert yourself, relax or modify your reactions to unsettling daily experiences. Behavior therapies work best for disorders characterized by specific, abnormal patterns of acting, such as alcohol and drug abuse, anxiety disorders and phobias, and for changing destructive habits or inappropriate behavior patterns as well as depression.

Cognitive-behavioral therapy and interpersonal therapy have been shown in clinical trials to work as well as antidepressant drugs for treating mild cases of depression, although they take longer than medication to achieve results.

Other therapies that are available, but most haven't been proven effective in treating depression. These include:

Psychodynamic psychotherapy, which concentrates on working through unresolved conflicts from childhood. Some psychiatric specialists view depression as a grieving process for the loss of a parent or other significant person, or for the loss of their love. Others theorize that depressed individuals can only express rage at this loss by turning it against themselves and transforming it into depression. Psychodynamic therapists discuss their patients' early experiences and repressed feelings to provide insight into current problems and bring about behavioral change. Therapy may be brief or it may continue for several years.

Interpersonal therapy (IPT) acknowledges the childhood roots of depression but focuses on symptoms and current issues that may be causing problems. IPT does not delve into the psychological origins of symptoms; rather, it concentrates on relationships as the key to understanding and overcoming emotional difficulties. The therapist seeks to redirect the patient's attention, which has been distorted by depression, outward toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (three to four months of weekly appointments). Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes and isolation. People with major depression, chronic difficulties developing relationships, dysthymia or the eating disorder bulimia are most likely to benefit.

Supportive psychotherapy is meant to provide the patient with a nonjudgmental environment by offering advice, attention and sympathy. The goal of supportive psychotherapy, which can be brief or long-term, is to help patients who may temporarily feel unable to cope during times of great stress, such as after learning that they have a serious physical illness. Although many people think of supportive psychotherapy as simply giving comfort and advice, the process is far more complex and may include therapeutic techniques such as education, reassurance, reinforcement, setting limits, social skills training and medication. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur.

Medications

If you have major or chronic depression, you may be prescribed an antidepressant.

Antidepressants are thought to alter the action and distribution of brain chemicals and can be effective in bringing mood, appetite, energy level, outlook and sleep patterns back to normal. Up to 90 percent of patients with major depression will improve with good compliance and adequate doses of the right antidepressant drug.

To reduce or avoid side effects, you may be started on low doses that increase over time. You and your health care professional should first thoroughly discuss your medical history, including the presence of any emotional disorders in family members, and assess your overall health to rule out any illnesses that might be causing your psychiatric symptoms. You should also weigh the benefits and risks of the medication with input from your health care professional. While current antidepressants are not addictive, virtually all have side effects and sometimes serious interactions with other drugs; you should inform your health care professional of any drugs you take, including over-the-counter medications.

If you have never been treated for depression, your medications will probably be maintained for six months or longer after your depression improves. Some women, however, may require indefinite maintenance therapy. Note: The FDA has issued a black box warning indicating an increased suicide risk associated with antidepressants. If you begin to feel like hurting yourself or killing yourself, or someone close to you notices a drastic change in your behavior, be sure to get in touch with your health care provider or call a suicide hotline for help and guidance right away.

Medications used to treat depression include:

Selective serotonin reuptake inhibitors (SSRIs) are now usually the first-line treatment of major depression. They are thought to work by blocking a pump mechanism in the brain that normally moves serotonin back into brain cells. Blocking this action temporarily increases the level of serotonin outside brain cells, especially in the specialized connection zones (synapses) between the brain cells. Because they act on serotonin specifically, SSRIs have fewer side effects than tricyclic antidepressants, which affect a number of chemicals in the body. Commonly prescribed SSRIs include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram oxalate (Lexapro).

Patients taking SSRIs report not only relief of depressive symptoms, but also a higher level of efficiency, energy and better relationships.

Important note: Early results of studies on paroxetine (Paxil) suggest the drug increases the risk for birth defects, particularly heart defects, for women who take it during the first three months of pregnancy.

An SSRI usually takes two to four weeks to work in most adults, up to 12 weeks in the elderly and those with dysthymia. By 14 weeks, depression is usually in remission in those who respond to the medication. If you don't respond to one medication even after the dosage has been adjusted, your health care professional should try you on another. Lexapro, the newest antidepressant in its class, appears to offer some advantages over other SSRIs in the treatment of depression: higher potency, faster response time (one to two weeks after beginning treatment) and lower incidence of side effects. Additionally, the drug is approved for the treatment of generalized anxiety disorder.

The most common side effects of SSRIs are nausea and gastrointestinal problems. Other possible side effects include anxiety, drowsiness, sweating, headache, difficulty sleeping and mild tremor. All usually wear off over time. During the first few weeks of treatment, some patients lose a small amount of weight but, in general, they regain it. Sexual dysfunction, including delay or loss of orgasm and low sexual drive, occurs in up to 70 percent of patients and is a major reason people quit taking their medicine. However, these side effects can usually be managed or reduced with a different medication or by prescribing an additional medication.

More rarely, SSRIs may cause bruising or bleeding in those who are predisposed to bleeding, such as the elderly. SSRIs can also cause dry mouth, which increases the risk of oral health problems. You can increase salivation by chewing sugarless gum, using saliva substitutes and frequently rinsing your mouth.

Some people taking SSRIs report a group of side effects known as extrapyramidal symptoms, which are similar to those in Parkinson's disease and affect the nerves and muscles controlling movement and coordination. They are very uncommon, however. If they develop, it tends to be in the first month of treatment.

Contact your health care professional if you experience any intolerable side effects. Don't discontinue your medication without guidance from a health care professional who is familiar with your health history.

Serotonin-norepinephrine reuptake inhibitors (SNRIs). This class of antidepressants works on two neurotransmitters in the brain important in mood--norepinephrine and serotonin. Drugs in this class include venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta). These drugs tend to have fewer adverse effects on sexual function than SSRIs and some people even report enhanced sexuality. Common side effects include drowsiness, nausea, dizziness and dry mouth.

Rare cases of life-threatening liver failure have been reported in a few patients treated with nefazodone, a drug in a class of antidepressants known as piperazine antidepressants, so call your health care professional if you have any of the following symptoms: yellowing of the skin or white of eyes, unusually dark urine, loss of appetite that lasts for several days, nausea or abdominal pain.

Tricyclic antidepressants had been the standard treatment for depression prior to the introduction of SSRIs. Some of the most frequently prescribed tricyclics are amitriptyline (Elavil), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), imipramine, (Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil) and trimipramine (Surmontil). Tricyclics are as effective as SSRIs and may still offer benefits for many people with chronic depression who do not respond to SSRIs or other antidepressants. Imipramine seems to be of particular benefit for those with dysthymia.

Tricyclic antidepressants may also be used to treat chronic pain-related symptoms, even when a patient is not depressed. These medications help restore the body's normal perception of pain.

Side effects are fairly common with these medications and include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty urinating, constipation, disturbances in heart rhythm, drowsiness and dizziness. Blood pressure may drop suddenly when sitting up or standing. Tricyclics can also have serious, although rare, side effects and can cause fatal overdose.

Monoamine oxidase inhibitors (MAOIs) are usually indicated when other antidepressants don't work. They include phenelzine (Nardil), isocarboxazid (Marplan) and tranylcypromine (Parnate).

There is also an antidepressant patch (Emsam), which delivers the MAO inhibitor selegiline, into the bloodstream through the skin. In its lowest strength, Emsam can be used without the dietary restrictions (described below) that are needed for all oral MAOIs approved for treating major depression.

MAOIs take up to six weeks to become effective. They commonly cause a sudden drop in blood pressure upon standing that can make you dizzy, drowsiness, sexual dysfunction and insomnia. The most serious side effect is severe hypertension that could lead to stroke brought on by eating certain foods that have high levels of the amino acid tyramine, such as aged cheese, red wine, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans and concentrated yeast products. This class of drugs also can cause birth defects and should not be taken by pregnant women. They may also interact with other drugs, including common over-the-counter cough medications stimulants such as Ritalin), and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. You should take at least a two- to five-week break between taking an MAOI and any other form of antidepressant.

Aminoketone antidepressants: bupropion (Wellbutrin, Wellbutrin SR, Zyban) appears to work by blocking dopamine uptake. The side effects of are similar to those of other antidepressants. Bupropion does not, however, have the degree of sexual side effects common with other antidepressants. People with a seizure disorder or at risk of a seizure disorder should not use bupropion.

Although uncommon, some people have experienced withdrawal symptoms when stopping an antidepressant too abruptly. Therefore, when discontinuing an antidepressant, you should gradually withdraw under your health care professional's supervision.

Other treatments for depression include:

Estrogen therapy (ET). This menopausal hormone therapy is sometimes used with other treatments to relieve mood-related symptoms such as irritability, mood swings and depression, particularly during the transition to menopause. Some women become depressed because of sleep deprivation caused by night sweats. In this situation, estrogen may be prescribed to reduce night sweats and improve sleep which may, in turn, improve depression. Estrogen therapy also has some benefits when used to relieve depression in elderly women who don't respond to standard antidepressants and to relieve symptoms of postpartum depression.

However, the U.S. Food and Drug Administration now recommends that health care professionals prescribe the lowest dose and the shortest treatment duration for all hormone therapies that contain estrogen. Studies generally find that estrogen's antidepressant affect is relatively mild, and that it primarily works on mild depression mood-related symptoms or in combination with an antidepressant.

Additionally, ET may make moods worse in some women who are clinically depressed. Likewise, some formulations of progestin (the synthetic form of progesterone used in some forms of hormone therapy) may make mood-related symptoms worse.

St. John's wort (Hypericum perforatum) is an herbal remedy that may help relieve mild to moderate depression in some patients. It is widely prescribed in Germany, and one short-term British study reported that it was effective and had fewer side effects than standard antidepressants. However, studies find little to no effect in treating major depression.

Hypericin, the active substance in St. John's wort, is manufactured in tablet and liquid form. However, this herbal substance is not regulated and there is no guarantee of quality in any brands currently available. Nor have any and effective dose levels been established. In clinical trials, 300 mg of St. John's wort administered three times daily seems to have the greatest effect.

Common side effects of St. John's Wort include gastrointestinal problems, dry mouth, allergic reactions and fatigue. It may also increase sensitivity to the sun, and some people have reported temporary nerve damage after sun exposure. People with severe depression, pregnant or nursing women and children should not take St. John's wort. It should never be combined with other antidepressants. Because this herbal substance may be similar to MAOI inhibitors, some experts suggest avoiding foods and substances that have high amounts of tyramine, such as red wine, dried meat and aged cheese.

Augmentation strategies generally involve drugs not typically thought of as antidepressants in combination with an antidepressant. Such strategies are being used for patients who fail standard therapies or to speed up the response to the antidepressant. Augmentation therapies include lithium, stimulants such as Ritalin, thyroid hormones and anti-anxiety drugs. Additionally, estrogen is sometimes used to augment antidepressant therapy in postmenopausal women. More recently, pindolol and buspirone have also been used. Anti-anxiety drugs or sedatives are not antidepressants, however, and they are not effective when taken alone for a depressive disorder.

You should start feeling better within about four to 14 weeks of starting drug therapy. If you do not experience any relief within that amount of time, talk to your health care professional or therapist, or seek a second opinion. A change in your therapy approach, medication or dosage may make a significant difference. If a particular psychiatric drug does not help, there are many alternatives. Psychiatrists with an expertise in drug therapy can usually find a medication that works even if it means switching drugs several times.

Often, however, a physician may write a prescription but not follow up to see if it's working or if the dosage is correct. So it's up to you to keep the lines of communication open with your health care professional.

While your health care professional will most likely begin treatment with psychotherapy and/or antidepressants or other medications, there are other treatments for depression, including:

Electroconvulsive therapy (ECT). Commonly called shock treatment, ECT has, unfortunately, received bad press since it was introduced in the 1930s. However, ECT has been refined over the years and now successfully works in more than 80 percent of mood-disorder patients who undergo this treatment. (However, some studies show that the relapse rate in these patients is high.) It is recommended for people with severe depression who do not respond to medication.

Before receiving ECT, you get a muscle relaxant and short-acting anesthetic. Then a small amount of current is sent to your brain, causing a generalized seizure that lasts for about 40 seconds. The practice remains controversial, however, with some critics saying its positive benefits don't last or that it causes memory impairment.

Although ECT has been performed for decades, researchers still don't know precisely how it works to combat depression. It's theorized that it works like antidepressant medication to change the activity of neurotransmitters; that it dampens abnormally active brain circuits, stabilizing mood; or that it causes the brain to release a substance called a neuropeptide that regulates mood. Most patients receive treatments three times a week for approximately one month. Hospitalization is not necessary for the treatment.

Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness and heart disturbances. Many experts urge that ECT be used earlier in the course of major depression, although most insurers or HMOs will not pay for early treatment. ECT may be beneficial for patients who cannot, for any reason, take antidepressant drugs, for suicidal patients and for elderly patients who are psychotic and depressed. Some health care professionals feel it is safer to use ECT than many antidepressants for patients who are pregnant or have certain heart problems, and it may also be helpful for young patients who fit the adult criteria for ECT.

Researchers are developing better ways to provide this treatment with fewer side effects.

Tryptophan-boosting foods and supplements. Some people report relief from depression by eating foods or taking diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. Vitamin B3 (niacin) is important in the production of tryptophan. Dietary sources of niacin include oily fish such as salmon or mackerel, pork, chicken, dried peas and beans, whole grains, seeds, and dried fortified cereals. The omega-3 polyunsaturated fatty acids found in fish oil may also independently reduce depression. While there's no proof that these foods improve depression, they are healthful dietary choices. These methods should not be used to self-treat depression without first consulting with your health care professional.

Exercise may reduce mild to moderate depression. Either brief periods of intense training or prolonged aerobic workouts can raise feel-good chemicals in the brain like endorphins, adrenaline, serotonin and dopamine, which produce the so-called runner's high. It also appears to elevate the body's levels of phenylethylamine, a natural chemical linked to energy, mood and attention. Meanwhile, physical activity, particularly rhythmic aerobic and yoga exercises, helps combat stress and anxiety. And, of course, weight loss and increased muscle tone can boost self-esteem.

Phototherapy is recommended as the first-line treatment for seasonal affective disorder (SAD). You sit a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) 10 to 20 times brighter than ordinary indoor light for 30 minutes or more every morning. Up to 80 percent of people experience an improvement in their symptoms as a result of phototherapy. Some people report mood improvement as early as two days after treatment; in others, depression may not lift for two to four weeks. If no improvement is experienced after that, then the depression is probably caused by factors other than lack of sunlight. Side effects include headache, eye strain and irritability, although these symptoms are usually minimal and tend to disappear within a week. Severe SAD may require both phototherapy and antidepressant medications. Stress management and exercise can also help relieve symptoms of seasonal affective disorder.

Vagus nerve stimulation (VNS). This epilepsy treatment was approved in 2005 for the treatment of resistant mood disorders. It involves a device that sends a 30-second electrical impulse to the left vagus nerve every five minute via connecting leads. The generator is surgically placed in a pocket under the skin below the left collarbone. Studies find that up to 40 percent of patients treated with this device showed at least a 50 percent or greater improvement in their condition.

Support. Support is particularly important for anyone seeking treatment and relief from depression. Typically, support comes from family members, but can also be provided by friends, relatives, co-workers or members of a shared faith based community. If you know someone who is struggling with depression, ask how you might be able to provide support. In addition, while treatment for women who experience postpartum depression (PPD) includes medication as well as therapy, support and early intervention are also important. Mothers' support groups, or groups specifically designed for women with PPD, may be worth exploring to give the woman with PPD a place to share her feelings. Other critical interventions include approaches that any mother with a newborn needs: nutritious, regular meals; light exercise; a few hours without childcare responsibilities; and extra sleep to combat exhaustion. However, support is an important component in the road to recovery for all forms of depression.

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Keywords: depression, treatment, treatment of depression, antidepressants, antidepressant medication, psychotherapy, severe depression, side effects, serotonin, selective serotonin reuptake inhibitors, ssris, sexual dysfunction, tricyclic antidepressants, monoamine oxidase inhibitors, maois, pregnant, hormone therapy, st. john's wort, electroconvulsive, therapy, ect
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