Treatment for Major Depression
Antidepressants, Electroconvulsive Therapy, and Other Modalities
Major depressive disorder is a devastating, disabling psychiatric condition. Fortunately, various treatments can help those who suffer from it.
Depression is a mood disorder that affects millions of Americans. It is not simply a state of having sad feelings and thoughts; rather, the condition is characterized by such negative emotions along with prolonged functional impairment. Depression can be severe and become major depressive disorder, characterized not only by depressed mood and diminished interest in life's pleasures but also by symptoms like sleep disturbances, weight changes, decreased energy level, inability to concentrate, and thoughts of death or suicide. Given the risk of suicide and that these symptoms may occur almost daily, it is important to know that treatments for major depression do exist.
Antidepressants
The physical symptoms of major depression are believed to arise from alterations in neurotransmitters, the chemicals produced by neurons for transmitting signals to other cells. Antidepressant medications work by correcting this imbalance. Several classes of antidepressants are available, all of which have their own risks and benefits.
- Tricyclic Antidepressants: The tricyclic antidepressants (TCAs), including imipramine and amitriptyline, work by inhibiting the reuptake of norepinephrine, dopamine, and serotonin. When these neurotransmitters do not return to the neuron, they continue to stay outside the neuron and exert their effects. While TCAs are efficacious, they do have a number of side effects, including heart rhythm abnormalities, weight gain, dry mouth, urinary hesitancy, and constipation.
- Selective Serotonin Reuptake Inhibitors: The selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), sertraline (Zoloft), and citalopram (Celexa), work by inhibiting only the neuronal reuptake of serotonin. The result is a side effect profile different from that of the TCAs. Nevertheless, SSRIs are associated with sexual dysfunction, nausea, vomiting, and weight changes.
- Monoamine Oxidase Inhibitors: The monoamine oxidase inhibitors (MAOIs), including phenelzine and isocarboxazid, inhibit the breakdown of norepinephrine, dopamine, and serotonin. These drugs are so notable for their side effects that they are reserved for treating depression if other classes of antidepressants fail. MAOIs should not be taken with SSRIs because their mechanisms together dramatically elevate serotonin levels; the result is serotonin syndrome, which can involve flushing, diarrhea, sweating, skeletal muscle breakdown, kidney failure, and possibly death. MAOIs can also interact with stimulant drugs, spoiled foods, wines, and fava beans and cause dangerously high blood pressure (hypertensive crisis) associated with severe headache, perspiration, stroke, and death.
- Other Antidepressants: The antidepressants venlafaxine, mirtazapine, bupropion, trazadone, and nefazadone are drugs that do not fit into the other classes because of their molecular structure and mechanism of action, but they do have their own established efficacies and side effect profiles.
Electroconvulsive Therapy
Electroconvulsive therapy (ECT) is offered for patients who fail multiple antidepressants and/or have life-threatening depression. The procedure involves putting a patient under general anesthesia, introducing electrical currents through the brain, and inducing a seizure. ECT has a response rate of about 80% to 90%. Its side effects are mainly cognitive, with confusion and memory disturbances that may be temporary or permanent. After the procedure, patients still need to be maintained on antidepressants or with additional ECT sessions.
Investigational Options
Other treatments for depression have been explored. However, because their safety and efficacy have not been proven, they are not yet widely available in clinical practice.
- Vagus Nerve Stimulation: The vagus nerve runs down from the brainstem through the neck to the chest and abdomen. A pulse generator is surgically implanted in the chest with a wire threaded to the left vagus nerve. Pulses of a set duration and frequency are sent through the vagus nerve to the brain.
- Deep Brain Stimulation: This procedure involves two separate surgical procedures. One places electrodes within the brain and the other places a stimulator device within the chest. The two are connected via wires under the skin.
- Transcranial Magnetic Stimulation: Transcranial magnetic stimulation (TMS) delivers magnetic pulses to the brain through a coil attached to the patient's head. Unlike ECT, it does not require anesthesia and it can, in fact, be done without hospitalization.
Final Words
Please note that antidepressants and ECT are for individuals with more severe and life-threatening depression. Milder depression may not necessarily require such measures, and such patients may benefit from psychotherapy, either alone or with antidepressants. Anyone suffering from depression should consult a medical doctor, especially a psychiatrist.
References
- American Psychiatric Association - Practice Guideline for the Treatment of Patients With Major Depressive Disorder
- Mayo Clinic - ECT and Other Brain Stimulation
