Treatment for Unipolar Depression

I realised today that I have addressed the physiology, causes, definitions, etc of depressive disorders, but not very much about how they are treated, so I shall address that problem in this post. There are a lot of different treatment options for people with mood disorders. The same treatments won't necessarily work for everyone, and many people find that a combination of two or more different approaches is best for them. This post explores treatment options for those diagnosed with Depression (Major Depressive Disorder). Treating Bipolar Disorder is somewhat different and will be dealt with separately, although the sections about therapy and looking after your mental health apply to bipolar patients as well. So with that said, I'm going to try and take you through step-by-step.

Finding a doctor
The first doctor you should see if you think you are suffering from depression is your GP. Many people find this step to be the most difficult, because they fear that their doctor won't take them seriously. Although each doctor is different, depression is the most common ailment that GP's deal with, so the majority will be experienced in looking for symptoms and giving you any advice or information you need. A few tips on going to your GP:

• Make an appointment in advance, so that you have time to prepare. It should preferably with a GP you are familiar with and whom you trust, but if you are feeling desperate and need help ASAP then tell the receptionist this. Most practices have emergency appointments within 24 hours for problems needing immediate attention.
• Think about what you're going to say. Write down how you've been feeling, for how long, and what you want out of the appointment. E.g. 'I've been feeling really low for the last few months, and I want to know if you think I might be depressed'.
• Make a note of any questions you want to ask the doctor in advance so you don't forget them.
• If you're nervous, ask a friend or family member to go with you for emotional support. Most GP's will welcome this, because often people you know well have a more realistic understanding of how your mood is affecting your life than you do yourself.

If the first doctor you see doesn't take you seriously, don't give up. Try another GP. It's not always easy to find a sympathetic doctor whom you feel comfortable with, but when you do find one, they are immensely helpful, so it's worth sticking with it. You can search for a GP near you on the NHS website.

Mental Health Professionals
If your GP feels that you are suffering from a mental illness, the logical next step is usually to refer you to an NHS specialist mental health service in your area, where you will be allocated a keyworker, who assess your needs and co-ordinate your care plan. They will then refer you to whichever mental health professional(s) suit your needs. I've summed up the different types below, with the most qualified professionals at the top.

• Psychiatrist: Doctor who specialises in prescribing psychiatric medication, diagnosing psychiatric disorders and assessing patients level of risk to themselves or others. Everyone who takes psychiatric medication should see their psychiatrist regularly, so that the psychiatrist can check on how the patient is responding to the drug, and if necessary adjust their dosage or change or stop their medication.
• Clinical Psychologist: Specialist psychologists, trained to give clinical therapy to patients either individually or in groups.
• Community Psychiatric Nurse: Usually visit patients in their own homes. Offer support, make sure the patient is taking their medication correctly, and talk to the patient's family, to help them understand and cope with the illness.
• Occupational Therapist: Help patients with practical and occupational difficulties. E.g. help patients set goals for themselves, take better care of themselves etc.
• Psychotherapist: Therapist with an interest in a particular form of psychotherapy, which they offer to patients either in individual sessions, group sessions or a mixture of the two.
• Counsellor: Has a degree or diploma in counselling - i.e. helping people identify and talk through their problems to help them cope better with them.

Mental health teams also include social workers, although they are employed by social services rather than the NHS. Although specialist mental health services are the ones recommending and providing treatment, your GP will still oversee your primary care and usually you will have to see them regularly to see how you're doing and to get your medication etc. So now, on to the actual treatment options.

Psychotherapy
Therapy is probably the most common treatment for depression, because although medication can help alleviate some of the symptoms, it doesn't treat the underlying psychological problems. Nor can it teach the patient how to manage their illness and prevent relapses. People with Bipolar Disorder should also receive some kind of therapy, although sometimes their psychiatrist will fill this role as opposed to an actual psychotherapist or clinical psychologist. There are many different kinds of therapy, and there isn't any hard evidence to suggest that one is better than another, so a lot of the time finding the right therapy is a case of trial-and-error. Here are some of the different kinds of therapy:

• Psychodynamic Therapy: Based on Freud's psychoanalysis, psychodynamic therapies work around the theory that mental illnesses are caused by unconscious desires, conflicts and traumatic experiences in very early life. Therapy works by uncovering the original problem and working through it. The patient voices their thoughts as they occur to them without censoring them, and the therapist analyses this for signs of repressed memories, thoughts, fears and conflicts. Psychodynamic therapy is an intensive, long-term treatment, and is often criticised for being time-consuming, expensive and for ignoring a patient's immediate problems in preference for unconscious past conflicts.
• Cognitive Behaviour Therapy (CBT): Works around the idea that mental health problems are not caused by negative events, but rather how the person distorts the meaning of those events through self-defeating thought patterns and negative beliefs. The therapist's job is to help you to identify and correct these negative patterns of thinking and behaving. CBT has widely been shown to be at least comparable to drug treatments in treating all but the most severe cases of depression. The advantage of CBT is that it is a short-term treatment which also helps prevent relapse in the long-term.
• Interpersonal Therapy: Focuses on interpersonal relationships. The therapist helps the patient to learn to communicate better and develop good interpersonal skills, which improves their relationships to other people.
• Humanistic-Experiential Therapy. Centres on the idea that we have both the freedom and the power to control our own behaviour and influence our own lives. The main goal of therapy is to increase the patient's self-awareness, self-acceptance and self-fulfilment, which may be frustrated by irrational tendencies, dehumanising mass society and existential anxiety. There are various types of therapeutic approaches:
  1. Client-centred Therapy aims to create a psychological climate in which the patient feels unconditionally accepted, understood and valued as a person, so that they can explore their true feelings and accept anger, hate and unpleasant thoughts as a part of themselves.
  2. Gestalt Therapy teaches patients to identify feelings they have been blocking off and hiding. It is often done in group therapy, but the focus is always on one person at a time, with the group and therapist offering insight into the individual's life which they are not accepting.
  3. Existential Therapy encourages patients to acknowledge and accept their own mortality, and that their existence is a coincidence, not the result of fate, destiny or a divine will. Although there is a tragic element to this, it celebrates the freedom of the individual (as opposed to the 'herd mentality' of mass society) and encourages free expression, similar to the French concept of 'joie de vivre'.
• Integrative therapies: Types of therapy which combine different aspects of different kinds of therapy. E.g. 'Cognitive Analytic Therapy', which involves some analysis of early traumas and the impact those have on the individual's life, but with a cognitive behavioural approach. I.e. Repressed early experiences, family dynamics in infancy etc can affect an individual's mental health, but in the sense that they cause negative and self-defeating beliefs, which can be changed.
• Couples therapy and Family therapy. Pretty much self-explanatory.

Medication
Psychiatric drugs are an essential part of treatment for some sufferers of depression. The most common drug treatment is the use of antidepressants. Antidepressants should only be used in cases of severe depression, or moderate depression which has not responded to psychological therapy and lifestyle changes. There are two reasons for this. Firstly, recent research has shown that unless you are very severely depressed, antidepressants do not work any better than placebos. Secondly, like any drug, antidepressants can have unwanted side-effects. In particular they are associated with an increase in suicide risk, so unless the patient is severely depressed, the risks of antidepressant drugs outweigh the potential benefits. You can find a guide to 'what you need to know' about antidepressants in this post.

Antidepressant treatment is usually offered in addition to psychological therapy, not instead of it. As for which antidepressant is right for you, it is impossible to tell. Basically it's a case of trial-and-error. In young adults and teenagers, psychiatrists will usually begin antidepressant treatment by prescribing fluoxetine (Prozac), due to its relative safety compared with other drugs it is the only one approved for treating under-18's, who are at an increased risk compared to adults of committing suicide as a result of antidepressants. In adults, citalopram (Celexa) is often the first drug prescribed. Whichever particular drug it is, SSRI's are generally the first line of treatment for unipolar depression. Most doctors begin by prescribing a very low dose and gradually increase it until it's high enough to work. If after 4-6 weeks you don't feel any better, your doctor will usually increase your dosage further.

If after a couple of months you are still experiencing symptoms, or if you can't tolerate the side-effects of the antidepressant there are several options. Your psychiatrist can switch you to a different SSRI or to one from a different class of antidepressants, or they can suggest that you add a second medication to supplement your current one. If you responded partly to the first drug, it makes sense to try a different SSRI or add another medication to it. If you didn't respond at all, it's probably more sensible to switch to a different class. This process continues until you the drug or combination of drugs which works for you, and which you tolerate well. Psychiatric patients sometimes call this the 'med-go-round'. It can be frustrating, and the side-effects can sometimes be unpleasant, but ultimately for the severely ill it's a worthwhile process, because the right drug (or combination thereof) can help you turn your life around.

Electro-Convulsive Therapy (ECT)
ECT has a bad reputation because it has a history of being abused by doctors to punish or control uncooperative patients but when properly administered, ECT is actually a very safe, effective treatment. In fact the only form of treatment available for:

1. Those who have not had an adequate response to other forms of treatment
2. Pregnant women for whom drug treatment may be problematic
3. Those who have medical conditions which are contraindicative for antidepressant therapy
4. Bipolar patients who have not responded to pharmacological treatment

It is usually administered bilaterally. That means that electrodes are placed on either side of the head. Brief electrical pulses of either high or low intensity are then passed from one side to the other for up to about 1.5 seconds. Anaesthetic is used so that the patient in unconscious throughout the procedure, and these days muscle relaxants are always used to stop the violent convulsions which ECT is sometimes known for. Psychiatry has come some way since One Flew Over The Cuckoo's Nest, people.

The advantage of ECT over other treatments is that it produces dramatic improvements almost immediately. However, ECT is still controversial. Many people are understandably uncomfortable with the idea of passing electric current through a person’s head, particularly because nobody is sure why it actually works. It remains a last-resort treatment because it carries potentially serious side-effects such as short-term and long-term memory loss, disorientation and confusion. Plus, although improvement can be drastic, it is usually temporary. The NHS says that "The NICE recommendations are that ECT should only be used with caution, and that a balance of risks and benefits for each individual should be made. Doctors are called on to keep strictly to guidelines on consent and encourage the involvement of both carers and ‘advocates’ who speak on the patient’s behalf." (NHS website)

Alternative Therapies
Some people choose to try alternative, holistic treatments instead of the conventional ones. My personal opinion is that unless you are only mildly depressed (i.e. NOT clinically depressed), this is a bad idea. Alternative therapies can be complementary to conventional treatments, but they are not a replacement for medical help. Listen to your doctor and always ask his or her advice before opting for an alternative treatment. Some examples are:

• St. John's Wort: an unlicensed herbal medicine used to help alleviate mild to moderate depression. While some clinical trials have found positive results, there is considerable variation in the preparations of St. John’s wort available over the counter, and one does not necessarily work as well as another. It is essential to consult your GP and/or psychiatrist before taking St. John's Wort, or with any herbal medicine, because they can have serious interactions with a large number of commonly used medications (e.g. warfarin). St. John's Wort should never be used alongside an antidepressant drug.
• Expressive therapies which encourage artistic expression as an emotional outlet, e.g. art therapy, drama therapy, dance therapy, writing therapy, music therapy.
• Hypnotherapy
• Acupuncture
• Aromatherapy
• Etc.

Looking After Your Mental Health
Looking after your general physical and mental health on a day-to-day basis is an essential part of treating and living with depression. For some people with mild to moderate depression, these things alone can be enough to make you feel better. The Mental Health Foundation suggests 10 ways you can look after your mental health:

1. Talk about your feelings with friends and family. Just being listened to can help you feel less alone.
2. Be Active. The NHS recommends that exercise be a part of treatment for everybody who suffers from depression. It lifts your mood, alleviates stress and improves your self-esteem. Ask your GP about exercise referral schemes in your area.
3. Eat Well. Even if you don't feel like eating due to depression, try to eat three balanced meals a day and make an effort to include a variety of fruits, vegetables, protein etc. For more information, visit the Feeding Minds webguide
4. Drink Sensibly. Don't drink to feel better. Overall it actually makes you feel more depressed. Always ask your doctor if it's okay before you mix your meds with alcohol. Stay within your daily limit.
5. Keep in touch. Isolation makes depression worse, and support from family ties can make you feel cared for and included, plus they can offer advice if you need it.
6. Ask for help. If you're struggling, talking to a therapist, counsellor or people in a support group can help. Ask your GP or psychiatrist to refer you. For a list of organisations which run support groups for people with depression, click here.
7. Relax. Ask your GP about relaxation techniques, or try yoga or meditation, or just do whatever relaxes you, either with a friend or alone. Disaster movies work great for me. Some support groups and mental health charities run relaxation classes you can go to. You can also download relaxation podcasts from the Mental Health Foundation. Finally, if you're having problems sleeping, talk to your GP.
8. Do something you're good at. Find an activity you enjoy, or learn a new skill. Achieving something boosts your self-esteem, and concentrating on something you love doing distracts you from negative thoughts or feelings.
9. Accept who you are. Recognise and accept your flaws as part of you, but try to focus on what you can do well and what you like about yourself.
10. Care for others. Looking after your friends, a pet or volunteering for a charity are all good for your self-esteem because it makes you feel valued and needed. But don't take responsibility for a pet unless you are absolutely sure you have the time and money to care for it properly. If you do decide to get a pet, please consider adopting from a rescue center. Your love will be even more valuable to a rescued animal. Find out more about volunteering at the do-it website.

References:
1. The section about looking after your mental health borrows and paraphrases from the guide 'How to look after your mental health', which is a copyright of the Mental Health Foundation. Parts of it reproduced here are done so on an educational, strictly not-for-profit basis according to the Copyright, Designs and Patents Act 1988, and remain the intellectual property of the MHF.
2. As always, crazymeds
3. NHS guide to treating depression
4. Personal experience.