Depression Treatment in Seattle

Treatment for Depression

Are you suffering with fear, sadness, sleeplessness, tiredness, weakness, loss of interest, decreased concentration, thoughts of dying, or low sex drive? It may be depression.

Depression affects approximately 121 million people worldwide.  The total cost of depression for Americans has risen to over 40 billion dollars each year for direct and indirect costs. Direct costs, such as hospitalization, outpatient care, and drug treatment, account for $12.4 billion, while indirect costs incurred by lost productivity, absenteeism, and suicide-related losses in productivity comprise the remainder.

When a person is depressed, it interferes with his or her daily life and routine, such as going to work or school, taking care of children, and relationships with family and friends. The illness causes pain for the person who has it and for those who care about him or her. Loss of a loved one, divorce, bereavement, social isolation, stress and hormonal changes, or traumatic events may trigger depression at any age.

Women are twice as likely to be diagnosed with Major Depressive Disorder as men. It occurs most often between the ages of 25 and 44. At any given time, up to 9 percent of women and 4 percent of men may have the disorder.

The clinical course of major depressive disorder is quite variable. The disorder typically has its onset when the patient is in his or her mid-20s or 30s,  but a later onset is not uncommon.

Most patients who have major depressive disorder will eventually recover, but some patients will never have a remission (two months or more with no symptoms, or one or two symptoms to a mild degree) and others may have many years in which they have no signs and symptoms of depression.

Patients who have had severe depression or who have had an onset at a relatively young age are more likely to have recurrent depression, and depression accompanied with anxiety, personality disorders, or psychotic features has a poor prognosis for remission. Gender and age do not seem to affect the progression of major depressive disorder.

Major depressive disorder is associated with a high mortality risk and most of this risk is from suicide. Major depressive disorder is considered to be a significant risk factor for suicidal behavior, and suicide attempts or threats of suicide are considered to be consistent risk factors for suicide in patients who have major depressive disorder.

Major depressive disorder is a risk factor for the development of chronic diseases (and it negatively influences the progression of these diseases) such as cardiovascular diseases, diabetes, and neurological disorders.

People who have major depressive disorder are more likely to smoke, abuse alcohol and use drugs.  Drinking as little as two drinks per day may reduce or cancel an anti-depressant’s benefits. Stimulant abuse with cocaine, crack, methamphetamine, or diet pills use may cause depressive symptoms or mood swings. Using pain medications and abusing narcotics commonly cause some depression symptoms, and withdrawal from them causes even more depression.

Depressed people report a lower quality of life, and the disorder has a profound effect on your family life, personal relationships, and career.

“Your worst enemy cannot harm you as much as your own thoughts.”

Diagnostic Criteria
for Major Depressive Disorder

Everything You Want to Know About Depression – EAP – Africa

The American Psychiatric Association’s diagnostic criteria for major depressive disorder, located in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

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Types of Depression

Major Depressive Disorder

MDD is a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person’s lifetime, but more often, it recurs throughout a person’s life.

Dysthymia

Dysthymia, also called Persistent Depressive Disorder, is characterized by long-term (two years or longer), but less severe, symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes. In fact, up to 25 percent of people who develop unipolar depression have been previously diagnosed with dysthymic disorder. Both dysthymic disorder and major depressive disorder can exist at the same time.

Bipolar Disorder

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (e.g., mania or hypomania) to extreme lows (e.g., bipolar depression).

Bipolar Disorder: Signs, Symptoms, Causes, Treatment and more

Postpartum Depression

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Seasonal Affective Disorder

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

“Mental pain is less dramatic than physical pain, but is more common and also more hard to bear. The frequent attempt to conceal mental pain increases its burden: It is easier to say ‘My tooth is aching’ than to say ‘My heart is broken.'”

C.S. Lewis

Causes of Depression

Genetic
Depression is to some degree an inherited disease. People who have major depressive disorder are three times more likely to have a first-degree relative (parent or sibling) who has or had depression than people who do not, and twin studies have estimated that the risk of developing depression is approximately 30%-50% associated with genetic variations.

However, despite a consistent body of evidence that indicates people inherit a susceptibility to depression, genome-wide association studies and gene-environment interaction studies have not yet clearly defined the role and contribution of genetics in the development of depression.

Biological
Biological causes of major depressive disorder include abnormal changes in brain structures, impaired and/or abnormal neurotransmitter function, and immune system dysfunction that can cause inflammation and oxidative stress.Whether these changes in structure and function are cause or effect has been difficult to determine, given the heterogeneity of major depressive disorder and the treatments for the disease.

Environmental
Major life stressors are considered to be a strong predictor for the development of major depressive disorder. Chronic diseases such as cancer, chronic obstructive pulmonary disease, diabetes, heart disease also increase the risk for developing depression, as do acute illnesses such as stroke.

Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease. People who have depression along with another medical illness tend to have more severe symptoms of both mood and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression. Treating the depression can also help improve the outcome of treating the co-occurring illness.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.

Goals of Depression Treatment

The goal of depression treatment is remission, which is the resolution of essentially all symptoms.  Approximately 1/3 to 1/2 of depressed patients will achieve remission during the first trial with any antidepressant.  Unfortunately, for those who fail to remit, the likelihood of remission with another antidepressant goes down with each successive trial.

For example, in the famous STAR*D trial, only 2/3 of patients achieved remission after 1 year of treatment of 4 antidepressants (each taken 12 weeks each).

Patients who do not achieve remission not only experience ongoing impairment despite treatment, but are also at increased risk for a full return of symptoms compared to those who have achieved remission.

For example, the relapse rate at one yar for patients who achieved remission following their first antidepressant treatment is 33%, while the relapse rate for those who fail to achieve remission is 60%.  In general, the likelihood of relapse increased with the number of treatments it takes to achieve remission.

It is very important to achieve remission as early as possible.  Strategies to optimize outcomes include combining medications earlier in treatment, quick attention to residual symptoms, addressing all side effects, psychotherapy, and behavioral changes.

Treatments for Depression

Depression can be treated successfully in most cases.  However, an estimated 50% of the population that has experienced a major depressive episode will have a recurrence. Early recognition and treatment and a short duration of depressive symptoms are associated with spontaneous recovery, a better response to treatment, and a higher chance of remission

Medications and psychotherapy are the primary treatments for major depressive disorder. In many cases, you can start improving the first day with medication targeting anxiety and/or insomnia. However, antidepressant medications can take several weeks to start helping with mood.

When the depression is difficult to treat, Electroconvulsive Treatment (ECT) or Trans-magnetic Stimulation (TMS) can be used.

Antidepressants

Although the SSRIs share the same mechanism of action, therapeutic profiles, and overall side effect profiles, individual patients often react very differently to one SSRI versus another.

Selective Serotonin Re-Uptake Inhibitors (SSRIs)

  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Fluvoxamine (Luvox)
  • Paroxetine (Paxil)
  • Sertraline (Zoloft)
  • Vilazodone (Viibryd)

Serotonin-Norepinephrine Re-Uptake Inhibitors (SNRIs)

  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)
  • Milnacipran (Ixel)
  • Venlafaxine (Effexor)

Atypical Antidepressants 

  • Bupropion (Wellbutrin)
  • Mirtazapine (Remeron)
  • Nefazadone (Serzone)
  • Trazodone (Desyrel)
  • Vilazodone (Viibryd)

Tricyclic and Tetracyclic Anti-Depressants

  • Amitriptyline
  • Amoxapine
  • Clomipramine
  • Desipramine
  • Doxepin
  • Imipramine
  • Maprotiline
  • Nortriptyline
  • Protriptyline
  • Trimipramine

Monoamine Oxidase Inhibitors (MAOI)

MAOIs are one of the oldest and most effective treatment options for depression, but dietary and drug interactions have restricted their use, especially as new agents with fewer interactions have become available.  Tyramine content in food can cause a hypertensive crisis in patients taking MAOIs.  The average persona can ingest approximately 400 mg of tyramine before their blood pressure is elevated.  However, with as little as 10 mg of dietary tyramine, high blood pressure can occur if taking a MAOI.

  • Isocarboxazid
  • Phenelzine
  • Selegiline, transdermal
  • Tranylcypromine

Psychotherapy

There are many types of psychotherapy that are available for the treatment of major depressive disorder. Several reviews indicate that no type of psychotherapy is superior in effectiveness. Psychotherapy alone can be an effective treatment, but there is considerable evidence that psychotherapy combined with an antidepressant is superior to either psychotherapy alone or  antidepressants alone for treating major depressive disorder.

The effectiveness of psychotherapy appears to be associated with the number of sessions per week, with more sessions generally being more effective.

Electro-convulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is considered to be an effective therapy for treatment-resistant depression, i.e., patients who have not responded to two drugs from a different class used for a sufficient length of time or patients who have not responded to four or more different therapeutic regimens.

It can also be used for geriatric patients, patients who have depression and Parkinson’s disease, patients who have severe major depression those whose depression is accompanied by catatonia or psychotic features, or patients who have been, or may be non-compliant with medication regimens.

Electroconvulsive therapy has been shown to achieve a substantial remission rate, and a review of randomized controlled trials indicates that ECT combined with medications is superior to the use of medications alone for preventing relapse. Anterograde and retrograde memory deficits and other cognitive deficits are relatively common after ECT, but fortunately these are in most patients of short duration.

Natural Remedies for Depression

 St. John’s Wort

A well-known botanical product, St. John’s wort has historically been used for management of mental health issues, including depression and anxiety. St. John’s wort comes from the flowering plant Hypericum perforatum.   It is reportedly named as such because the plant tends to bloom on or around June 24th, which is traditionally known as the birthdate of St. John the Baptist.

It contains hypericin and pseudohypericin, both of which may be responsible for its activity, as well as its essential oils and flavenoids, which may also be beneficial.  The specific components of St. John’s wort that make it effective are not entirely known. St. John’s wort has been shown to be effective in the treatment of depression, and some studies have shown it to be as effective as some selective-serotonin reuptake inhibitor antidepressants.

It is possible that St. John’s wort works because it impacts levels of neurotransmitters, including serotonin and dopamine. In addition to management of depression, St. John’s wort may also be effective in the management of other conditions, including symptoms associated with menopause and premenstrual syndrome, seasonal affective disorder, and obsessive-compulsive disorder.

As a precaution, St. John’s wort has been shown to cause some negative side effects in certain patients, particularly when it is taken with other drugs. The FDA has issued warnings about interactions of St. John’s wort with medications. Specifically,  it should not be taken with other antidepressants. St. John’s wort has also caused problems with the effectiveness of some types of drugs, including warfarin, asthma medications, and birth control pills.

Depression in Men

Depression is often regarded as a “woman’s disease” because it is diagnosed more frequently in women than men. However, researchers and the health community at large now realize that depression is of serious concern in men and is underdiagnosed. According to data from 2017, the prevalence of depression was 5.3% among men and 8.7% among women.

Despite the lower rates of depression in men compared with women, the rate of completed suicide is nearly four times higher for men (21.9 vs. 6.3 per 100,000). Suicide is a leading cause of death for men in many age groups and across all racial/ethnic populations, except for the black population [25].

The underdiagnosis of depression in men involves clinician-related and patient-related factors. Clinicians’ lack of appropriate training and discomfort with dealing with depression contribute to a low rate of diagnosis, estimated to be about 50%. In addition, no screening instrument for suicide risk has been shown to reliably detect suicide risk in primary care populations. This is unfortunate, as primary care providers appear to be in a position to intervene. As many as 83% of people who died by suicide had contact with their primary care physician in the year before death, with approximately 20% seeing their physician one day before death. In addition, 50% to 66% of individuals who committed suicide saw their primary care physician within one month of their death, with 10% to 40% committing suicide within one week of the visit. Thus, better recognition of depression and suicide risk by primary care providers may help reduce suicide rates.

Many patient-related factors in the underdiagnosis of depression are primarily related to gender issues, including:

  • Reluctance of men to seek help
  • Lack of men’s recognition of the symptoms of depression
  • Hesitancy of men to express emotions
  • Tendency for men to see depression as a weakness
  • Men’s misconceptions about mental illness and its treatment

Diagnosis
Because men are less likely to express their emotions, they may recognize and discuss only the physical symptoms of depression, making diagnosis a challenge . A carefully taken history can elicit information about risk factors, which include a family history of depression, the use of some medications (beta blockers, histamine H2-receptor antagonists, benzodiazepines, and methyldopa), chronic illness or other comorbidity, lack of social support, recent life stressor, and single marital status . Substance misuse frequently occurs concomitantly with depression, more often in men than women, but the direction of the causal relationship is not clear .

Many of the symptoms of depression reported by women are the same for men: depressed mood, changes in appetite and sleep habits, problems with concentration, and an inability to find pleasure in once pleasurable activities. It has been proposed that the symptoms of depression in men represent a male depressive syndrome, characterized by such symptoms as irritability, acting-out, aggression, low tolerance of stress, low impulse control, tendency to blame others, and a greater willingness to take risk. Men with depression may thus present with a very different symptom profile.

Identification of suicide risk is an essential component of the evaluation of a man with depression. Many of the risk factors for suicide are similar to those for depression; when the circumstances surrounding completed suicides were reviewed, the following were found to be factors:

  • Loss of a partner (through death or other means)
  • Loss of job
  • History of mental illness
  • Depressed mood
  • Previous suicide attempts
  • Physical health problems
  • Intimate partner problem
  • Preceding or impending crisis (within two weeks)
  • Financial problem