Depression: Diagnostic Evaluation and Treatment

by National Institute of Mental Health (NIMH)

(Page 4 of 7)

"Your tendency is just to wait it out, you know, let it get better. You don't want to go to the doctor. You don't want to admit to how bad you're really feeling."

— Paul Gottlieb, Publisher

The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection, thyroid disorder, or low testosterone level can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If no such cause of the depressive symptoms is found, the physician should do a psychological evaluation or refer the patient to a mental health professional.

A good diagnostic evaluation will include a complete history of symptoms: i.e., when they started, how long they have lasted, their severity, and whether the patient had them before and, if so, if 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 if they were effective. Last, a diagnostic evaluation should include a mental status examination to determine if speech, thought patterns, or memory has been affected, as sometimes happens with depressive disorders.

Treatment choice will depend on the patient's diagnosis, severity of symptoms, and preference. There are a variety of treatments, including medications and short term psychotherapies (i.e., "talk" therapies), that have proven effective for depressive disorders. In general, severe depressive illnesses, particularly those that are recurrent, will require a combination of treatments for the best outcome.

Medications

There are several types of medications used to treat depression. These include newer antidepressant medications-chiefly the selective serotonin reuptake inhibitors (SSRIs)-and older ones, the tricyclics and the monoamine oxidase inhibitors (MAOIs). The SSRIs (and other newer medications that affect neurotransmitters such as dopamine or norepinephrine) generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications for the patient. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first couple of weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication, or they may think it isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects (see section on Side Effects, pages 19 20) may appear before antidepressant activity does. Once the person is feeling better, it is important to continue the medication for at least four to nine months to prevent a relapse into depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. Therefore, you should never discontinue your medication without first talking to your doctor. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.

Recently, concerns have been raised that the use of antidepressant medications themselves may induce suicidal behavior in youths. In fact, following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the FDA has adopted a "black box" label on SSRI medications to warn the public about an increased risk of suicidal thoughts (suicidal ideation) or behavior ("suicidality") in children and adolescents treated with these medications. However, studies show that there are substantial benefits from medication treatment for adolescents with moderate and severe depression, including many with suicidal ideation. Parents and children should work with their health care provider to determine the best and most appropriate treatment.

Medications for depressive disorders are not habit forming. Nevertheless, as is the case with any type of medication prescribed for more than a few days, doctors must carefully monitor these treatments to determine if the patient is getting the most effective dosage. The doctor should check regularly the dosage of each medicine and its effectiveness.

For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, including many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis (a sharp increase in blood pressure) that can lead to a stroke. The doctor should furnish a complete list of prohibited foods, and the patient should carry it at all times. Other forms of antidepressants require no food restrictions. Efforts are underway to develop a "skin patch" system for one of the newer MAOIs, selegiline. If successful, this may be a more convenient and safer medication option than the older MAOI tablets.

Medications of any kind- prescribed, over the counter, or borrowed- should never be mixed without consulting a doctor. Health professionals who may prescribe a medication, such as a dentist or other medical specialist, should be told of all the medications the patient is taking. Some medications, although safe when taken alone, can cause severe and dangerous side effects if taken in combination with others.

Alcohol-including wine, beer, and hard liquor-or street drugs may reduce the effectiveness of antidepressants and should be avoided. However, doctors may permit people who have not had a problem with alcohol abuse or dependence to use a modest amount of alcohol while taking one of the newer antidepressants.

About the Author

www.nimh.nih.gov
The National Institute of Mental Health (NIMH) is one of 27 components of the National Institutes of Health (NIH), the Federal government's principal biomedical and behavioral research agency. NIH is part of the U.S. Department of Health and Human Services.