Depression is a mental illness that can be debilitating without treatment. The Centers for Disease Control found one in 10 U.S. adults suffer from depression. Those most affected include women, people 45-64, those currently unemployed or unable to work, and people without health insurance coverage, though depression can affect people from all walks of life. Depression is not just feeling a little blue.
“We all feel down if we get a bad grade or have a break-up; that’s normal,” says Gabriela Cora, MD, MBA, a Miami-based psychiatrist. “It may not be normal if I just broke off an engagement with my boyfriend and I want to kill myself.” Most people either seek treatment on their own or are referred by their family doctor to a psychiatrist -- a doctor who specializes in mental health.
When you see your doctor for depression, you will be asked about your symptoms. Specifically, your doctor will want to know two things:
- The severity of your depression
- How long you’ve been depressed
Cora says that depression severity is tied to your level of functioning. In a mild depression, someone may feel low but still go to work or school, participate in activities but not with the level of interest or zest they had before. They may lack energy and have some difficulty with daily tasks. “I would advocate people to be as truthful as possible when speaking with the doctor so they can assess how severe it is,” says Cora.
If you’re experiencing a moderate depression, you may skip work, or go but have trouble finishing projects or concentrating, feel low most of the time, and not find pleasure in any of the activities you previously did.
If you can’t get out of bed or function well, and your cognition (thinking, memory, attention and decision making) has slowed and you’re thinking about death or dying, you are having a severe episode of depression, Cora says.
On your first visit, a psychiatrist will do a comprehensive psychological evaluation. This will include:
- A discussion of your symptoms
- An assessment of your current mental status
- A discussion of your general concerns
- A psychological, medical, social, and family history
- Questions about your education and relationship status
Your doctor may ask:
- If you have had a history of drug abuse or prior depression.
- If you are currently taking medication.
- If you’ve experienced symptoms of mania or hypomania, which if present, suggests bipolar disorder. Bipolar disorder is a condition in which people experience periods of mania and depression.
- If your depression has seasonality. This means that depression symptoms occur almost exclusively during certain times of the year. If so, you may have Seasonal Affective Disorder (SAD), a type of depression that occurs at certain times of the year -- typically in the winter -- and has been linked to reduced sunlight exposure in the colder seasons.
- If the onset of depression symptoms coincides with a medical illness like heart disease or cancer, or emotional triggers like a divorce or death of a loved one.
At the end of the session, the psychiatrist will provide a diagnosis. “Depending on symptom severity and the specific subtype of depression, I make a recommendation to the patient as to what the appropriate treatment approach should be,” says Angelos Halaris, MD, professor of Psychiatry and medical director of the department of psychiatry at Loyola University Medical Center.
Deciding on a Treatment
Finding the right treatment is not like choosing wallpaper. You’re not looking for what works best for your personality, but rather depending on the recommendation of your doctor who can customize your treatment depending on the severity, type, and triggers of your depression.
For some, lifestyle changes like exercise and relaxation may be all that’s recommended. Others may benefit from talk therapy. Still more may require lifestyle changes in combination with therapy and/or medication.
Here’s a breakdown of various types of psychotherapy:
Cognitive Behavior Therapy (CBT)
Once you’re feeling a little better or begin practicing lifestyle strategies like exercise or relaxation or start medication, your doctor may recommend cognitive behavior therapy (CBT). It’s not appropriate for everyone, but often people have long-established patterns of thinking that are dysfunctional and nonproductive. “As long as those patterns persist, they can interfere with your ability to get better,” says Halaris. Let’s say your mom criticizes you, and you feel bad about it. Your automatic response to her criticism is that you’re no good. Therapy helps you understand your feelings about the criticism, and let go of the automatic response by replacing it with a positive one like ‘I have an excellent career.’ Therapy usually lasts once weekly for three to four months.
Interpersonal therapy (IPT) is based on the idea that improving your communication skills and patterns, as well as the way you relate to others, can help your depression. Your therapist will focus on issues concerning your relationships such as disputes with friends or family, divorce, or work conflicts, and find better ways to help you deal with them. IPT analyzes how you interact with people and if your interactions cause problems, how to correct them, and how to change those behaviors. Your therapist may help you explore the triggers that influence your depression such as grief, loss, or transition. Therapy usually takes place weekly for two to four months. A maintenance phase is often recommended with monthly follow-up visits.
Psychodynamic therapy focuses on gaining insight about how your emotions affect your behaviors. Therapists and patients work very closely to find problematic patterns and help you understand and correct them. This type of therapy may be used along with CBT or IPT. Research published by the American Psychological Association found this therapy grows more powerful after treatment ends, meaning patients later discover even more meaning from their past therapy once it’s ended. These therapies can last several months to many years.
Medication and Therapy
In addition to therapy, “medications are the cornerstone of treatment for depression,” says Halaris. There are a number of antidepressant medications on the market; the most common are Selective Serotonin Reuptake Inhibitors (SSRIs), which work by increasing serotonin, a neurotransmitter in the brain.
Other classes of medications include:
- Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Sometimes, doctors will prescribe other psychiatric medications in addition to antidepressants.
Through trial and error, you can find the right combination of therapy and medication to ease your depression. Work closely with your doctor until your symptoms improve and your depression is managed.
“The brain of the psychiatrist is like a computer into which you feed data, and the computer needs to do a data integration at a very high speed and come up with the best match as far as choice of medication,” says Halaris.
Most medications take four to six weeks before you notice an affect. You may be on medication for six months, a year, or longer. It is important to discontinue antidepressant medication gradually under the supervision of your doctor since abruptly stopping an antidepressant can have serious physical and emotional withdrawal effects. If you’ve had several episodes of moderate to severe depression, you may need to remain on medication longer or indefinitely.