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Understanding Depression -- Diagnosis and Treatment

Reviewed by Smitha Bhandari, MD on November 13, 2019

How Is Depression Diagnosed?

Although common, depression is often ignored or wrongly diagnosed and left untreated. This can be life-threatening; major depression, in particular, has a high suicide rate.

If you or a loved one have symptoms of depression, seek help from a qualified health care professional. Many primary care doctors diagnose and treat depression. Screenings for depression are now often part of a routine visit to your doctor. But if your symptoms get a lot worse or do not improve within 4 to 8 weeks of treatment, ask your doctor for a referral to a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms -- and always if you have thoughts about death or hurting yourself or someone else -- you should see a psychiatrist as soon as possible.

To diagnose depression, your doctor will ask you about your symptoms and family history. They may want you to fill out a questionnaire about your symptoms. You may get medical tests to rule out other conditions that may be causing your symptoms, such as a lack of certain nutrients, underactive thyroid or hormone levels, or reactions to drugs (either prescription or recreational) or alcohol.

What Are the Treatments for Depression?

The stigma of depression drives many people to hide it, try to tough it out, or misuse alcohol, drugs, or herbal remedies to get relief. To effectively treat depression, it is important to seek care from a health care professional such as your primary care doctor or a licensed mental health professional. They can help you get a correct diagnosis and develop a treatment plan. There are many treatments for depression, and they typically include a combination of psychotherapy and medication.

Psychotherapy teaches people how to overcome negative attitudes and feelings and helps them return to normal activities.

Drug therapy is intended to treat symptoms that are thought to result from problems in brain circuits that regulate mood, thinking, and behavior. It may take several weeks for an antidepressant to fully work to ease depression symptoms, so it's important to stay on the medication.

As with any chronic illness, getting an early medical diagnosis and medical treatment may help make depression symptoms less intense or last a shorter time. It may also reduce the likelihood of a relapse.

Medication for Depression

SSRIs and SNRIs

The group of antidepressants most often prescribed today consists of drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors (SSRIs), the group includes citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft).

Serotonin norepinephrine reuptake inhibitors (SNRIs), including desvenlafaxine (Khedezla), desvenlafaxine succinate (Pristiq), duloxetine (Cymbalta), levomilnacipran (Fetzima), and venlafaxine (Effexor), also act on serotonin and norepinephrine but in a different way than SSRIs. The drugs vortioxetine (Trintellix) and vilazodone (Viibryd) affect the serotonin receptor (like SSRIs) but also affect other receptors related to serotonin function.

Other antidepressants include bupropion (Wellbutrin), a drug that appears to affect dopamine and norepinephrine regulation, and mirtazapine (Remeron), which increases levels of serotonin and norepinephrine by a different mechanism than SNRIs.

For children and adolescents, SSRIs are among the best-studied and therefore often the drugs of choice. The FDA warns that anyone taking antidepressants should be watched closely, particularly in the first few weeks. Children, teenagers, and young adults might have more negative thoughts, possibly even suicidal thoughts or behaviors, while taking antidepressants.

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Tricyclic antidepressants (TCAs)

TCAs, which have been used to treat depression since the 1950s, are another option, although they have more side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. TCAs include amitriptyline (Elavil), amoxapine (Asendin), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil).

Because adolescents do not handle side effects well and tend to stop taking their medication, TCAs are not recommended for them as the first treatment. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine.

Monoamine oxidase inhibitors (MAOIs)

The third group of antidepressants, MAOIs like phenelzine (Nardil), tranylcypromine (Parnate), and the skin patch EMSAM, have also proved to be effective. MAOIs may sometimes work more quickly than the TCAs, but they require avoiding certain foods (such as aged meats and cheeses) and certain other medicines that can also affect serotonin or raise blood pressure. MAOIs are usually prescribed only if SSRIs and TCAs, or other depression medicines that can be simpler to take, don’t make things better.

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You may need to try a few antidepressants before you find one that works well for you. If you’ve given it a few months and your medication doesn’t seem to help, or if side effects are making it hard for you to take it, go back to your doctor. But don’t just stop taking it. That can cause more problems. When it’s time to stop, your doctor will slowly reduce your dose to let your body readjust.

Antipsychotics

Lithium carbonate (Eskalith), which is a drug commonly used for manic depression, is also sometimes used to treat depression in combination with an antidepressant. Today, atypical antipsychotics have become the most widely prescribed class of medications that are added to an antidepressant after an incomplete initial response. Three in particular, aripiprazole (Abilify), brexpiprazole (Rexulti), or quetiapine (Seroquel XR), are FDA-approved as add-on therapy for antidepressants, regardless of the presence or absence of psychosis (delusions or hallucinations). However, atypical antipsychotics can have many side effects, including weight gain, changes in blood sugar and cholesterol, sedation, and abnormal movements.

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L-methylfolate

The nutriceutical l-methylfolate (Deplin) is a prescription-strength form of the B-vitamin folate and has shown success in treatment of depression. Referred to as a medical food by the FDA, l-methylfolate helps regulate all three of the brain’s monoamine neurotransmitters associated with moods. Side effects include hives, swelling, nausea, and bloating.

Ketamine

Ketamine can be given through a vein (intravenously) or through an inhaled nasal mist to treat severe depression. It is becoming more widely available for depression that is not treatable with conventional means.

Psychotherapy for Depression

Psychotherapy is an important part of treatment for depression. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression.

Commonly used forms of psychotherapy are cognitive, behavioral, and interpersonal therapies.

  • Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively.
  • Behavior therapies concentrate on changing patterns of behavior.
  • Interpersonal therapies help you examine how relationships affect your moods.

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You may need to try a few therapists to find one you’re comfortable sharing your feelings with. You’ll meet on a regular schedule, maybe once or twice a week depending on what you need. This type of therapy can take months or more than a year, but some patients feel better in a matter of weeks. You and your therapist will decide when you’ve made enough progress to stop.

Your doctor may also suggest you join a support group. They can put you in touch with people who are facing the same thing. They may be able to offer you advice and fellowship when you hit a rough patch.

Other Treatments for Depression

Electroconvulsive therapy (ECT)

ECT involves the application of an electric current through electrodes on the head. The patient is asleep under general anesthesia and doesn’t feel anything. Although doctors are still uncertain exactly how ECT works, it is thought that by producing a brief seizure, a course of several treatments of ECT over a few weeks can bring about relief from depression. The methods have been refined in the past 20 years in order to minimize side effects. Today, ECT is considered as safe or safer than many drugs used to treat depression and for some people, more effective.

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ECT is usually considered after a number of other options because it may require hospitalization and general anesthesia. It's also considered if rapid results are vital, as with people who are suicidal or who refuse to eat or drink. ECT should not be thought of as a "last resort"; it is very effective and may work before other treatments have been tried and failed.

Possible side effects include headaches, nausea, confusion, disorientation, and memory loss, which can last for several months.

Usually given three times a week for 2 to 4 weeks, treatments generally involve six to 12 sessions and are sometimes followed by a “taper down” in frequency over several weeks. Some people benefit from ongoing “maintenance” treatment over longer periods to prevent relapse when medicines alone may be ineffective.

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Repetitive transcranial magnetic stimulation (rTMS)

RTMS, which involves passing strong magnetic currents through the brain, is another option for treating depression. rTMS has been used effectively at times to treat major depression and depression that does not respond to other forms of treatment (treatment-resistant depression). However, to date, studies have not found rTMS to be as effective as ECT.

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Vagus nerve stimulation (VNS)

VNS is used to treat select cases of severe or recurrent chronic depression that does not respond to at least two antidepressants. This surgical treatment involves the use of a pulse generator implanted under the collarbone that sends out pulses of electricity to stimulate the vagus nerve in an attempt to affect the brain's mood centers. It typically takes at least several months for VNS to begin to show a benefit for depression.

Deep brain stimulation (DBS)

DBS is an experimental procedure that puts thin electrodes deep within the brain to directly stimulate areas that handle emotions.

Exercise for Depression

Exercise should be a part of any therapy for depression. It improves blood flow to the brain, boosts mood, and relieves stress. Even if used alone, it can often help. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20 to 30 minutes three to four times a week.

Nutrition and Diet for Depression

Because symptoms of depression can be made worse by a lack of nutrition, a healthy diet is important. Eat a well-balanced diet. Some people have noticed an improvement of depression symptoms when they eliminated wheat, dairy, alcohol, sugar, and caffeine from their diets. But this is not proven to treat depression. You can try eliminating those foods one at a time from your diet and note whether your symptoms improve. It may help to keep a symptom diary. Quitting smoking is also advised.

Alternative Medicine for Depression

As with any alternative or complementary medicine, check with your doctor before starting it, especially if you are taking other medications or treatments.

Herbal Remedies for Depression

Several studies show that the herb St. John's wort is as successful at improving symptoms of mild to moderate depression as prescription medications, often with fewer side effects. However, other reports show that the herb isn't any better than placebo (or sugar pill) in treating depression. Although it is considered safe, St. John's wort can be potentially dangerous if taken with other antidepressants (especially SSRIs), including certain medications used for treating HIV, cyclosporine, a drug used in organ transplant patients, or anticoagulant drugs. It can also interfere with the efficacy of oral contraceptives and medications used for heart disease and seizures.

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S-adenosyl-methionine (SAM-e), another herbal remedy, is also sometimes considered to be a useful treatment option for depression, although medical studies have not been conclusive.

Although ginkgo biloba is typically used as an "alternative medicine" strategy that might help improve memory and ease confusion, it has proved in some cases to work better than placebo for the symptoms of depression and is approved by the German government's Commission E for this purpose.

Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to talk with your doctor first, especially if you’re taking prescription medications for the same or other conditions.

Mind/Body Medicine for Depression

Many mind/body practices can be helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you, and practice often.

Massage for Depression

Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed teens got massage therapy, their stress hormone levels changed, their brain activity was positively affected, and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program. However, by itself, massage is not considered to be a proven or evidence-based treatment for depression.

Acupuncture for Depression

The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown that it markedly lessens symptoms of depression. Acupuncture may be a viable alternative if you can’t take antidepressants or have not found them helpful.

WebMD Medical Reference

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