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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 or psychologist.

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 the supplement.

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