Evidenced-based Treatment

Depression Treatment in Seattle

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.

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.

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.

 

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.

Depression Symptoms

The disorder can be very different in different people or in the same person over time.  The official DSM-5 symptoms are:

  1. Depressed mood nearly every day for most of the day
  2. Marked reduction or loss of interest or pleasure in all, or nearly all, activities for most of the day, nearly every day
  3. Significant non-dieting weight loss or weight gain (more than 5% change in body weight)
  4. Insomnia or hypersomnia nearly every day
  5. Psychomotor agitation or slowing (should be observable by others)
  6. Fatigue/loss of energy nearly every day
  7. Feelings of worthlessness or excessive/inappropriate guilt (possibly delusional) nearly every day
  8. Diminished cognitive function (reduced ability to think or concentrate, or indecisiveness) nearly every day
  9. Recurrent thoughts of death and/or suicide, suicide planning, or a suicide attempt

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 trail, 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.

Antidepressants

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.