Diagnosing and Treating Depression: Drug Treatment

by Food and Drug Administration (FDA)

(Page 2 of 3)

Diagnosing Depression

Medical professionals generally base a diagnosis of mental illness on the presence of certain symptoms listed in the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The symptoms listed for a major depressive episode include:

• sadness
• loss of interest or pleasure in activities once enjoyed
• change in appetite or weight
• difficulty sleeping or oversleeping
• physical slowing or agitation
• energy loss
• feelings of worthlessness or inappropriate guilt
• difficulty thinking or concentrating
• recurrent thoughts of death or suicide.

A person is clinically depressed if he or she has five or more of these symptoms and has not been functioning normally for most days during the same two-week period.

Dysthymic disorder is diagnosed when depressed mood persists for at least two years (one year in children) and is accompanied by at least two other symptoms of depression.

The episodes of depression that occur in people with bipolar disorder alternate with mania, which is characterized by abnormally and persistently elevated mood or irritability. Symptoms of mania include overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk-taking. Because bipolar disorder requires different treatment than major depression or dysthymia, obtaining an accurate diagnosis is extremely important.

Treating Depression

Finding the right treatment for depression can be as difficult as convincing someone that they need help. However, according to the NIMH, clinical depression is one of the most treatable of all medical illnesses.

Because it is currently against the law in Virginia, where the Earleys live, to force someone into medical treatment, Earley must rely on his son's willingness to take his medicines. Typically, bipolar patients periodically stop taking their medications.

"Part of my son's illness," Earley explains, "is believing he is perfectly fine when he goes off his medicines.

"Even though it was obvious that my son was clearly out of his mind, the law still insisted that he was capable of deciding whether or not he needed treatment," says Earley. "In these cases, you are asking an irrational person to make a rational decision. It's like expecting a person with a broken leg to run a marathon."

Today, most people with depression can be treated successfully with antidepressant medications, "talk" therapy (psychotherapy), or a combination of the two. Experts agree that successful treatment also hinges on early intervention. And early treatment increases the likelihood of preventing serious recurrences.

Drug Treatment

Existing antidepressant drugs are known to influence the functioning primarily of either or both of two neurotransmitters in the brain — serotonin and norepinephrine. 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 significant 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 people, including older adults, 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.

"Clinicians tell us that different drugs seem to work for different people," says Thomas Laughren, M.D., team leader for the review of psychiatric drugs in the Food and Drug Administration's Division of Neuropharmacological Drug Products. "And it's difficult to predict which people will respond to which drug or who will experience what side effects." So, Laughren says, it may take more than one try to find the appropriate medication. "Now that we've made a distinction between different depression subtypes, this seems to have stimulated additional drug research. Drug companies are also conducting more longer-term studies in depression, and this is important since depression tends to be a chronic illness."

Although some improvement may be seen in the first few weeks, antidepressants usually must be taken regularly for three to four weeks (and sometimes longer) before full therapeutic benefits occur. "If we had a better understanding of the biological basis for depression, it would help in the discovery of newer antidepressants that hopefully would work faster and better," says Laughren. "Unfortunately we do not really understand the mechanism for the antidepressant drugs."

The medication most often used to treat bipolar disorder is lithium (Eskalith, Lithane, Lithobid, Cibalith-S). Lithium evens out mood swings in both directions — from mania to depression, and depression to mania. It is used not just for manic attacks or flare-ups of the illness, but also as an ongoing maintenance treatment for bipolar disorder.

About the Author

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