How to treat Depression?

Pic: Vincent van Gogh's 1890 painting; Sorrowing old man ('At Eternity's Gate')

By Dr. Panchajanya Paul, MD

Depression can be a serious and debilitating illness. The World Health Organization (WHO) reports that around 350 million or 4 percent of the world's population suffers from depression. This makes Depression the second leading cause of disability worldwide. Depression can impair social, family, and work life; and worse can lead to death by suicide. Hence it is important to diagnose and treat depression at the earliest. Depression can be a part of many psychiatric conditions; the most common one is called Major Depressive Disorder (MDD). It contains other symptoms in addition to being sad or depressed. In the common media the terms depression and major depressive disorder are used synonymously. The Diagnostic and Statistical Manual V (DSM V) lists the following symptoms for MDD namely:
DSM- V Symptoms for Major Depressive disorder :
1. Depressed mood most of the day, almost every day, indicated by your own subjective report or by the report of others. This mood might be characterized by sadness, emptiness, or hopelessness.
2. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day.
3. Significant weight loss when not dieting or weight gain.
4. Inability to sleep or oversleeping nearly every day.
5. Psychomotor agitation or retardation nearly every day.
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.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
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.

The exact cause of depression is unknown. It is believed to be a result of complex interaction between one's environment and one's genes. Any factor increasing stress like trauma, abuse, injury, loss of job, death in family, divorce, alcoholism etc. can increase the risk of depression. Also medical conditions like anemia, thyroid problems, cancer, cardiovascular and neurological diseases can predispose one to depression. Also people with pessimistic personality types are more prone to depression. Loneliness and lack of social contact, especially among the elderly in the industrialized countries is a risk factor for depression. Untreated depression can increase the risk of other medical illnesses and reduce life span.

Pic: Vincent van Gogh's 1890 painting; Sorrowing old man ('At Eternity's Gate')
The good news is that the treatment of depression has been an intense field of research. We now have many evidence based treatment available for depression. Two commonly used treatments are psychotherapy and psychotropic medications. Psychotherapy or counseling can be used with benefit in mild to moderate depression. Several types of therapy options are available namely cognitive behavioral therapy, psychodynamic psychotherapy, and interpersonal therapy. The success of therapy depends on finding the right fit between the patient's needs and therapists' expertise.
Severe depression requires the use of combination treatment using therapy plus medication or use of one or more psychotropic medications called the antidepressants. Commonly used psychotropic medications work through serotonin, norepinephrine, and dopamine pathways. One popular class of medications called selective serotonin reuptake inhibitors (SSRI) like Prozac and Zoloft increases the availability of serotonin in the brain. Another group called selective norepinephrine reuptake inhibitors (SNRI) like Effexor and Cymbalta increases the availability of norepinephrine in the brain. For many who don't get well with one anti-depressant, they may need an adjunct medication like the antipsychotics. The psychotropic medications can cause serious side effects and should only be taken after weighing the risks and benefits in consultation with a psychiatrist.
Natural remedies like exposure to bright light or sun has shown to improve the mood. St John's Wort or hypericum extracts also helps with depression. Other lifestyle changes like regular exercise, healthy diet, mindfulness and adequate sleep can also boost mood and alleviate depression. However, inspite of all the above, about one third of patient continues to suffer from one or more symptoms of depression despite trying different medications. For them more aggressive treatment modalities like Deep brain stimulation, Electro-convulsive therapy, Transcranial Magnetic Stimulation, Vagus Nerve Stimulation, and Ketamine might be considered.

Depression is a complex and heterogeneous entity. Each patient is depressed for his/her unique condition. What works for one person may not work for the other. Thus having more treatment options is better. The art of medicine comes in finding the right treatment match for the particular patient. In summary, depression or major depressive disorder is a serious illness which can cause disability and death. Early diagnosis and treatment can save lives. Many treatment options exist. If you suffer from any of the symptoms of MDD, consult your clinician and seek appropriate help.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 2013, by American Psychiatric Association.

Dr. Panchajanya 'Panch' Paul, MD, ABIHM, ABPN, FAPA - is an American Board certified - Child, Adolescent, and Adult Psychiatrist. He is a diplomat of the American Board of Integrative and Holistic Medicine, and a Fellow of the American Psychiatric Association. He holds an adjunct faculty position at Emory University School of Medicine; University of Georgia, and University of Central Florida School of Medicine. Call 7704541252 or email to schedule an appointment with Dr.Paul at Georgia Behavioral Health Professionals. He is also the author of 2 books- Stress Rescue and Sleep Coaching available at Amazon.