Depression is treatable. But that doesn’t mean that treatment is simple, or that many of the current treatments are incredibly effective. In fact, a huge proportion of people do not respond to the first treatment they receive.
While we develop better treatments for depression, I want to propose an ideal approach based upon the best science we currently have. I have not seen any studies that have tested this holistic approach. However, I do know many physicians and therapists who draw upon many of the principles outlined below. Incorporating every aspect of this treatment would be nearly impossible. I’m open to suggestions on how to package this treatment for maximum benefit.
Are you ready? These are the components that I would include in an ideal treatment for depression:
An appropriate workup
On paper, the criteria for diagnosing major depressive disorder are straightforward. A person must meet 5 of 9 criteria, and the presentation can’t be better explained by another disorder. Counting up the criteria is easy, and there is a simple mnemonic that medical students learn to rattle off in their sleep. However, ruling out other causes of depression is much more difficult. Sometimes depression has a physical cause that can be determined with laboratory tests. For example, low thyroid hormone often presents with symptoms of depression. But there are other mimics of major depressive disorder than can only be distinguished through subtle questioning. In some cases, ruling out other diagnoses cannot be done in a single visit. For example, bipolar disorder often begins with depressive episodes, and it is not uncommon for it to take many years before the correct diagnosis is established. Each of the different mimics of depression requires a different treatment approach, and in some cases, the wrong treatment can have catastrophic results. Diagnosis by a competent professional is absolutely critical.
People with depression should receive close follow-up–especially in the first few weeks of treatment. Frequent return visits allow for quick treatment adjustments, and also allow clinicians to ensure that thoughts of suicide can be kept in check. On occasion, some people respond to certain treatments by becoming more depression, agitated, or suicidal, and it is critical that changes are made quickly.
An evidence-based treatment is one that has been repeatedly shown to work in well-designed human studies. This doesn’t mean that the treatment makes a huge difference for everyone who uses it. However, evidence-based treatments should form the foundation for an ideal treatment of depression.
Antidepressant medications provide a small but beneficial impact on depression. Even though they work through different mechanisms, they all tend to provide a similar benefit, and so the choice of which antidepressant to use is largely based on side effects and comorbid conditions. If the first one doesn’t work, a second one is usually tried. These drugs are not perfect, but in most cases, the benefits strongly outweigh the risks.
Psychotherapy has also been shown to be effective for the treatment of depression. There are many different forms of psychotherapy, and each has it’s proponents and detractors. For depression, cognitive-behavioral therapy seems to be the most well-studied treatment. The effect tends to be modest with initial treatment, but the odds of success increase if the patient connects well with the therapist. For this reason, I make sure that my patients keep trying until they find someone they work well with. Notably, the combination of psychotherapy and antidepressants is much more effective than either treatment alone.
Electroconvulsive therapy is a treatment where a seizure is induced through electrical current. The patient is under general anesthesia and does not experience any pain. Electroconvulsive therapy is far and away the most effective treatment for major depressive disorder. However, it does entail considerable risks, and so it is generally not recommended as first-line treatment of depression. The treatment carries an unfortunate stigma, but it is incredibly impactful. An ideal treatment plan for depression must include electroconvulsive therapy as an option for severe depression that does not improve after an adequate trial of therapy and medicine.
Theoretically effective treatments
There are many treatments that might be successful based upon theoretical or anecdotal evidence. In some cases, small studies may have shown some benefit. Unfortunately, a lot of these treatments don’t have a sponsor with the funding to prove or disprove their efficacy. However, those with minimal risk should absolutely be considered as adjuncts to the evidence-based therapies found above.
Obtaining and maintaining meaningful work
Spirituality and meditation
Nutritional supplements may also be effective. It’s really not fair to lump all nutritional supplements into one category. Most products that have been tested aren’t any better for you than a placebo. However, there are some supplements that show encouraging results in smaller studies. As with any other medication, talk to your doctor before taking a nutritional supplement.
Addressing socially mediated risks for depression
People who live in poverty, have a history of abuse, or suffer from chronic medical conditions are also at risk for depression. There is no easy answer to any of these problems, but it seems clear that finding effective methods to fight poverty, protect people from the horrors of abuse, and provide affordable, high-quality healthcare are critical elements for preventing and treating depression.
There must be a better way to treat depression. I’m grateful that we have antidepressants and psychotherapy, but I believe that there is so much more that can be done to help people overcome depression. I look forward to innovation that can help us produce and implement better treatments for depression!
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