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DIAGNOSIS EVALUATION AND TREATMENT
The first step to getting appropriate treament for depression is a complete
physical examination by a family physician or internist. Certain medications
as well as some medical conditions such as a viral infection can cause the same
symptoms as depression, and the physician should rule out these possibilities
through examination, interview, and lab tests. If a physical cause for the depression
is ruled out, a psychological evaluation should be done, usually by a psychiatrist
A good diagnostic evaluation will include a complete history of symptoms, i.e.,
when they started, how long they have lasted, how severe they are, whether the
patient had them before and, if so, whether the symptoms were treated and what
treatment was given. The doctor should ask about alcohol and drug use, and if
the patient has thoughts about death or suicide. Further, a history should include
questions about whether other family members have had a depressive illness and,
if treated, what treatments they may have received and which were effective.
Last, a diagnostic evaluation should include a mental status examination to
determine if speech or thought patterns or memory have been affected, as sometimes
happens in the case of a depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the evaluation. There are a
variety of antidepressant medications and psychotherapies that can be used to
treat depressive disorders. Some people with milder forms may do well with psychotherapy
alone. People with moderate to severe depression often benefit from antidepressants.
Most do best with combined treatment: medication to gain relatively quick symptom
relief and psychotherapy to learn more effective ways to deal with life's problems,
including depression. Depending on the patient's diagnosis and severity of symptoms,
the therapist may prescribe medication and/or one of the several forms of psychotherapy
that have proven effective for depression.
Electroconvulsive therapy (ECT) is useful, particularly for individuals whose
depression is severe or life threatening or who cannot take antidepressant medication.
ECT often is effective in cases where antidepressant medications do not provide
sufficient relief of symptoms. In recent years, ECT has been much improved.
A muscle relaxant is given before treatment, which is done under brief anesthesia.
Electrodes that deliver electrical impulses are placed at precise locations
on the head to deliver electrical impulses. The stimulation causes a brief (about
30 seconds) seizure within the brain. The person receiving ECT does not consciously
experience the electrical stimulus. For full therapeutic benefit, at least several
sessions of ECT, typically given at the rate of three per week, are required.
Antidepressant medications are widely used, effective treatments for depression.
Existing antidepressant drugs are known to influence the functioning of certain
neurotransmitters (chemicals used by brain cells to communicate), primarily
serotonin, norepinephrine, and dopamine, known as monoamines. Older medications
tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) -
affect the activity of both of these neurotransmitters simultaneously. Their
disadvantage is that they can be difficult to tolerate due to side effects or,
in the case of MAOIs, dietary and medication restrictions. Newer medications,
such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side
effects than the older drugs, making it easier for patients to adhere to treatment.
Both generations of medications are effective in relieving depression, although
some people will respond to one type of drug, but not another. Medications that
take entirely different approaches to treating depression are now in development.
Electroconvulsive therapy (ECT), although not generally used as a first-line
treatment, is one of the effective treatments for severe depression.
Psychotherapy is also effective for treating depression. Certain
types of psychotherapy, cognitive-behavioral therapy (CBT) and
interpersonal therapy (IPT), have been shown to be particularly
useful. More than 80 percent of people with depression improve
when they receive appropriate treatment with medication, psychotherapy,
or the combination. Recently there has been enormous interest
in herbal remedies for various medical conditions including depression.
One herbal supplement, hypericum or St. John's Wort, has been
promoted as having antidepressant properties. However, no carefully
designed studies have determined the antidepressant efficacy of
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