Presented by Kenneth Nelson, M.D., September 8, 2003
Dr. Nelson has been a practicing psychiatrist since 1981 and also is a Board Certified addictions psychiatrist. He does some psychotherapy and a lot of psychopharmacology (medication management) with patients who have a variety of psychiatric problems and also addictions.
Dr. Nelson spoke of the “spectrum” of depression from mild to extreme. Some people have a “reactive depression,” a response to a personal loss like a death in the family, loss of a job, or a disappointment like not getting into graduate school. These people benefit from counseling but rarely need medication. Often depressed people begin by seeing a counselor or therapist, then if their problems are more severe, they are referred to a psychiatrist, or more commonly to their family doctor. About two/thirds of cases of depression are treated by family doctors. The psychiatrists see the more complex cases.
Psychiatrists view patients from the biological, psychological and social perspective. And diagnoses can be made on several levels. Axis I gives a label for an illness – Depression, Schizophrenia, etc. Axis II designates what kind of personality the individual has. Is the individual’s personality maladaptive? Have there been problems long before the current depression? Has this depression gone on so long that it has affected the person’s development over years, or has the condition just developed? Then Axis III notes physical problems – thyroid disease which often is seen in depression, endocrine problems, asthma, diabetes, etc. If the person has depression that is resistant to counseling and has persisted for some time, s/he probably has physical reasons for the condition as well as emotional.
Sometimes people have many physical symptoms but do not know they are depressed. They have aches and pains, dizziness, stomach problems, racing heartbeat, etc. and have “somaticized” their depression, directing the symptoms into physical ailments. These depressions are the hardest to diagnose. Family doctors may try unsuccessfully to treat those depressed people for various physical conditions. Other people with depression may show just emotional symptoms like crying, having poor sleep and eating habits, but not have physical symptoms. For people who have a predisposition for depression, stress is an important component. They “take life hard” and have trouble retaining emotional balance and perspective on themselves in stressful situations.
There is a spectrum of depressive reactions, from mild reactive depression to total debilitating depression. And there are different kinds. The depression of bipolar illness is very hard to treat. If the doctor prescribes an anti-depressant, it can initiate a mania. Dysthymic disorder is depression that “waxes and wanes” through the years. Major depression is the deep sadness but it is accompanied by other factors that can indicate more about how to treat it.
Dr. Nelson explained in great detail how the brain is affected by specific neurotransmitters. Out of hundreds of them, serotonin is linked with many cases of major depression. People with that condition respond well to SSRI medications. Other types of depression are related to the norepinephrine or dopamine neurotransmitter and don’t respond well to SSRIs. There is a class of medications that can help balance a person’s level of calmness/excitability. In the geriatric population, a dopamine enhancer often is effective for depression. A person with a “serotonin” depression usually shows symptoms of nervousness and worry, may have obsessive-compulsive disorder, panic disorder and eating disorders, and may respond well to SSRI medications. A person with “norepinephrine” depression, showing symptoms of lethargy, irritability and eating and sleeping a lot, won’t respond well to SSRIs. They will need another class of medications.
With the new Functional MRI and PET scans, very specific information about the brain is becoming available that will help doctors know how to prescribe medication for each individual patient. Too little medication, and the person stays depressed; too much and the person develops mania. Getting the right balance depends on trial and error. Hopefully in the future treatment will be based more on knowledge about the brain.
Another treatment challenge is, for example, when one part of the brain needs more serotonin and it is given in medication, all other parts of the brain get extra serotonin as well. The other parts get “too much,” which causes the side effects of weight gain, sexual problems, low energy level. Some people have depression with anxiety disorder. When a medication is given for the depression, it may cause “activation” in another part of the brain and increase anxiety. Some of the newer medications are being more area-specific; they treat just one part of the brain and don’t flood the rest of it with an overdose, so side effects are less severe.
“Therapy, without medications, is the preferred method of treating depression,” stated Dr. Nelson. It is very effective, and it actually can change the brain in the same way that medication does. For instance, for treatment of OCD (obsessive compulsive disorder), a Functional MRI can show that the part of the brain that’s over-active with that condition can be calmed with therapy, in the same way that it is calmed by medication. Of course, therapy takes longer and its effectiveness is harder to measure. A combination of therapy and medication is the most effective treatment for cases of severe depression.
A first depression may last up to 6 months, a second 6-9 months. With a third depression, “all bets are off.” With a depression that begins when a person is over 55 years of age, it is likely more serious and chronic. Some people can be stable on a medication for years and then find it doesn’t work any more. They will have to taper off it and try something else. With other people, if they go off a medication and then back on it again later, they may find that it is less effective the second time. This is particularly true of prozac and lithium.
Dr. Nelson answered many questions about specific medications. Regarding MAOs (monoamine oxidase inhibitors), he said that most clinicians have mixed feelings about them. They are one of the most effective antidepressants and also one of the most dangerous, because of bad reactions people can have when eating certain foods or taking other medications along with MAOs.
ECT is a very effective treatment for major depression. Two people Dr. Nelson recommends for giving that procedure are Dr. Richard Jaffe at Belmont Hospital and Dr. John Worthington at Abington Hospital. After ECT treatment, an antidepressant can be given to maintain the improved brain functioning.
How about taking anti-depressants while pregnant? There are different schools of thought. One is that the fetus doesn’t benefit from any medication. The other is that a very depressed pregnant mother might do damage to the fetus by being depressed. The safest antidepressant for a pregnant woman is wellbutrin which has a category B for safety, meaning that no birth defects have been found in offspring of either animals in research or children whose mothers took it during pregnancy. Medications definitely to avoid during pregnancy are depacote and other anti-convulsants. Postpartum depression is hard to treat and often needs antipsychotic medication along with an antidepressant. For breast-feeding mothers, there is the question of what and how much medication they can safely take without having detrimental effects on the baby.
For bipolar disorder, the three most commonly used medications are lithium, depacote and zyprexa. For anyone taking lithium, kidney and thyroid tests should be given regularly.
Mental illness of any kind in one member of a family can cause other family members to become depressed. Entire families experience “ups and downs” along with the ill person. It is a form of “co-dependency,” and virtually impossible to avoid. If you care about a family member, you’re going to be affected by his/her moods and functioning. Family members need treatment too – counseling, information and support. They need to learn coping skills for managing the stress in their lives and helpful responses to the ill person. (The free NAMI Family-to-Family 12-week series offers this information and support.)
For additional advice, we recommend Depression Survival Guide (https://www.nami.org/Blogs/