What Can Be Done About Depression

The first part of this article comprised definitions and a little epidemiology, pretty much factual and inarguable. It was easy to write. This part is hard. The facts are not as solid or well defined. Some of the conclusions are simplified versions of complex issues. First, a little more about the nature of depression, presented in glorious oversimplification. This section is in the treatment portion because the treatment modalities have cast light on the nature of the underlying disorder.

There have been several classes of drugs that have shown clear efficacy in treating the symptoms that define depression. All of these drugs have something in common. They all affect the action of one or more of a few neurotransmitters in the brain, specifically, norepinephrine, serotonin, and dopamine. Although these transmitters are closely related to each other and, in fact, convert from one to another, they stimulate somewhat different receptor sites in the brain. It appears that increasing the responses of the receptors to these transmitters has effects on many of the symptoms of depression. Different transmitters affect different symptoms, to a greater or lesser degree. All of the chemicals (drugs) that affect the symptoms of depression, appear to increase the available amount of one or more of these chemicals in the brain. In fact, various drugs that are also known to affect these transmitters have somewhat predictable effects on the symptoms, too. Some drugs, used for hypertension, block these receptors and are liable to cause depression in the patient. Similarly, stimulants, used for treatment of attention deficit or hyperactivity (among other things) cause an amelioration of depressive symptoms. They are known to increase the activities of these neurotransmitter receptor cells. They are rarely used as antidepressants, though, for a number of reasons, including the fact that their effect on depression tends to be short lived.

For the reasons above, it is difficult to escape the belief that these neurotransmitters (and the cells they stimulate) are intimately involved in the symptoms of depression. This evidence, alone, does not prove that the origin of depression is an "imbalance" in these substances, however, or even that it is biological in nature, because the changes in the transmitters could be an effect of depression, and not the original cause. However, there is more evidence of the biological connection that comes from the heritability studies. In brief, depression, particularly the more serious forms, show a high heritability. That is, there appears to be a substantial genetic or hereditary link.

Whatever the cause, it is useful to treat the activity of the neurons that respond to these transmitters. In general, antidepressant medications work on norepinephrine, serotonin, or both. Stimulating dopamine receptors can have some rather serious undesirable side effects as dopamine receptors are involved in more than just symptoms of depression. So, all of the effective antidepressants increase the activity of serotonin and/or norepinephrine receptors. There are numerous such drugs on the market. There are different ways to achieve this result, so there are different classes of antidepressant drugs. Interestingly, although there have been many attempts to pick drugs based on the particular target symptoms that are prominent in the depressed person, these have had limited success and the choice of drug is based on simply trying to see what works and choosing the particular side effects that are least disruptive to the patient. There is very little overall difference among the antidepressants in the sense that some are 'better' than others. Such differences, overall, are relatively small and the choice of therapy is a 'cut and try' proposition steered by what may have worked for the patient before or for close relatives. The rest is matching the adverse drug effects (so called side effects) to the patient. To be simplistic, different drugs work for different people. The question, of course, is what I mean by "work." Do they help everybody? No. Do they cure anybody? No. So what do they do? Well, when used properly, they have about a 70% chance of materially improving the symptoms of depression in any person. Somewhat over 70% of people with depression can be helped by drugs.

The single most important reason for drug failure is compliance failure, that is, the drugs are not being taken properly or at all. And the single most important reason for compliance problems is the adverse (side) effects. Some of the drugs are sedating, some are not, and a few can even increase activity level a little. Many of the drugs have effects on appetite, and the older ones tend to cause weight gain. However, that is not true of many of the newer ones, a couple of which actually decrease appetite a little. Note that people who have decreased appetite from the depression, will tend to gain weight when the depression is improved, also, not from any direct effect of the drugs. Unfortunately, most of them have sexual side effects, and not generally in any desirable direction. Although the severity (and even presence) of these effects varies greatly from person to person, sexual side effects are far more common than the companies' official literature suggests. There are several strategies or combinations of medications that can minimize or even overcome these effects, however, and they do tend to diminish with time (usually).

One important area of concern is the possible long term effects of taking these drugs over periods of years. Two thirds of patients who are benefited by the drugs will benefit from keeping on taking them indefinitely. Most of the agents do not require any increasing dosing over the years. (There are a couple of exceptions to that.) But neither do they cure anyone so that they can be stopped. In the minority of cases when the drugs can be discontinued, it was a remission of the underlying depression that allows this, not a cure. So, if most people will need to take them indefinitely, do they have long term deleterious effects? The general answer to this is, "no." Do they make the underlying depression worse? The general answer to this question is also, "no." In fact, there is some recent evidence that some of them might promote improvement. Assuming that this is true, however, it is not necessarily a direct pharmacologic effect, but possibly the fact that the individual gains some life skills that serve well to reduce the depressive reaction.

Psychotherapy; what about psychotherapy? Does it help? Yes. As a matter of fact, the probability that psychotherapy helps is roughly equal to the likelihood that medication will be useful. Somewhere around 70% or a bit more, of people are significantly improved by psychotherapy. Just as there are several types of medications, there are several types of psychotherapy, ranging from the intensive analytic therapy of psychoanalytic (Freudian) treatment to purely behavioral therapies and many types in between or different combinations of 'insight' oriented therapy and behavioral techniques. Is there one type that is clearly superior to the others? Also, pretty much the same as with pharmacologic treatments, the answer is, no, not really, certainly not for everyone. There is some demonstrable advantage of behavioral or cognitive-behavioral therapies, overall, but the data do not clearly identify any one therapy that is substantially better than any of the rest for all people.

OK, therapy helps the majority of depressed people; antidepressant drugs help a majority of depressed people, are these the same people who are helped by either one? No, not entirely; in fact, the percentage of the depressed population that can helped by drugs, therapy, or a combination of both climbs to approximately 85%. The combination of both therapy and medications is clearly superior to either one alone. Therapy obviously takes more time and effort. In terms of expense, medications have become so prohibitively costly that the direct costs are often close to the expense of therapy. Therapy, though, has one clear advantage over medications. It does aim for long term improvement and does not require continuation for an indefinite length of time. It actually aims for 'cures', and sometimes even achieves them. A combination, particularly at the outset of treatment, however, is the best strategy for the depressed person. The expense is less than the cost in pain and effectiveness that the depression itself can have.

Is there anything that depressed people can do to help themselves? Absolutely ! Spending money for medical or psychological professionals is one choice, or doing what a good shrink is likely to tell you to do, anyway, without bothering with the fee, is another. There may be advantages in seeking professional help. This might identify other factors that need to be considered, such as physical illnesses that mimic or cause depression, but there are several very effective things that people can do for themselves under most circumstances.

Perhaps the most important behavior for helping to defeat depression is physical activity. There are two very important aspects to this. First is just exercise itself. Sedentary lifestyles are not only unhealthy in a physical sense, they are emotionally unhealthy. Not only is exercise the most consistent factor that is common to most weight loss programs, it is a very potent antidepressant. Unfortunately, torpor is a symptom of many depressions and, even if the depressed individual knows it is important to exercise and intends to do so, it is often hard to put this into practice without help. The other benefit of activity suffers from the same difficulty, a general disinclination to do what is necessary. One needs to stay active in pursuits that have been enjoyable in the past. Often, the first things to go in depression are the activities of play and entertainment, those activities that the depressed individual enjoyed doing when not depressed. It is important to engage in these activities but this often requires the active intervention of another person. Severely depressed people are unlikely to be able to benefit from so simple a plan, but those suffering from mild, or even moderate levels of depression can often benefit by being virtually forced into doing things that were enjoyed previously.

Another factor that is relevant to some depressions is simply daylight (or a good substitute). A lack of sufficient exposure to light appears to produce depressive symptoms in some people. In fact, there is a type of depression (seasonal affective disorder) that is attributed primarily to this factor. It is not clear to me how many depressions will respond to 'light therapy', but some do and it is worth a try.

I feel obliged, for sake of completeness, to mention ECT (shock treatments). In many quarters, electroconvulsive therapy is considered the treatment of choice for severe or profound depressions. I do not agree, although it has a place. In the landmark cases in Frank Johnson's federal court, in which the right to treatment was established for involuntarily hospitalized people, ECT was declared an unusual treatment that required court permission to use. At the time that I testified in those trials, the type of ECT was damaging and dangerous. It was bilateral hemisphere, high voltage treatment that was often carelessly applied. The data were hidden (just plain lied about) but some deaths and many injuries resulted. Moreover, all claims to the contrary, long treatment protocols caused measurable brain damage, brain damage that I saw and measured when apponted by the court to evaluate the involuntarily committed patients. Moreover, its beneficial effects were temporary.

Since then, the techniques have improved and the danger and damage have lessened considerably. However, the results, while marked on severely depressed patients are generally temporary. In cases of time limited depressions, such as during menopause, the critical time during which suicide is a high risk can be materially alleviated. In these cases, ECT is often warranted. However, it is my posture that it is not the first line treatment for most depressions and should be considered only after more conservative therapies have failed. I must note, in honesty, that this is not everyone's opinion and that ECT is becoming more common again.

One last issue needs to be addressed. Depression is, of course, a major risk factor for suicide. Not all depressed people commit suicide, or even consider it, and not all people who do commit suicide are depressed, but most of them are. The strongest predictor of suicide risk in depressed people is the reported feeling of hopelessness. The most effective preventive of suicide in these people is the active interest and intervention by people who care about them. Nothing is more effective than the perception that someone else cares whether one lives or dies. There is nothing more useful than the simple expression of concern and desire that the person live and get better. Of course it is important that this ministration be virtually continuous during the times of highest risk Unfortunately, at the beginning of therapy, particularly drug treatment by some antidepressants, the risk of suicide actually rises slightly. There are probably multiple reasons for this, but one of them is that at the lowest point of severe depressions, people tend to not feel that anything, including killing oneself is worth the effort. Sometimes it requires a little improvement, and the consequent increase in energy to bother to actually commit suicide. Therefore, it is particularly important for concerned friends and relatives to be vigilant and actively engaged in support at the early stages of treatment for depression.

In summary, medication is a usually effective choice for improving depressive symptoms, it helps most depressed people. Psychotherapy is, also a usually effective way to improve depressions. Each of these alone is over 70% likely to have a beneficial effect; the combination of the two, raises that percentage significantly and has a generally better chance of helping more. Simple physical exercise is a very effective antidepressant. The actual percentage of people it can help has not (to my knowledge) been established, but it is my clinical sense that it is more effective than most medications. The problem is that it is harder to put into effect for a depressed person than taking a pill. Several hours of daylight every day can also prevent or help some types of depression. Concerned people around the depressed person can also often be of assistance by attempting to engage the sufferer in activities that used to be enjoyed when the person was not depressed. This can be effective, primarily in the milder depressions.