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6411 E Thomas Road Scottsdale, AZ 85251 Phone (480) 994-4407

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6411 E Thomas Road Scottsdale, AZ 85251 Phone (480) 994-4407

     6411 E. Thomas Road

    Scottsdale, AZ 85251

    Phone: (480) 994-4407 Toll Free: (800) MHA-9277 www.mhaarizona.org

    DEPRESSION

    Diagnostic Evaluation and Treatment

The following information has been provided by the National Institute of Mental Health (NIMH). This is an excerpt

    of the NIMH publication “Depression.” NIMH publications are in the public domain and may be reproduced or

    copied without permission from NIMH. Citation of the National Institute of Mental Health as a source is appreciated.

A good diagnostic evaluation will include a complete history of symptoms, i.e.,

    when they started, how long they have lasted, how severe they are, whether the

    patient had them before and, if so, whether the symptoms were treated and what

    treatment was given. The doctor should ask about alcohol and drug use, and if the

    patient has thoughts about death or suicide. Further, a history should include

    questions about whether other family members have had a depressive illness and,

    if treated, what treatments they may have received and which were effective.

Last, a diagnostic evaluation should include a mental status examination to

    determine if speech or thought patterns or memory have been affected, as

    sometimes happens in the case of a depressive or manic-depressive illness.

Treatment choice will depend on the outcome of the evaluation. There are a variety

    of antidepressant medications and psychotherapies that can be used to treat

    depressive disorders. Some people with milder forms may do well with

    psychotherapy alone. People with moderate to severe depression most often benefit

    from antidepressants. Most do best with combined treatment: medication to gain

    relatively quick symptom relief and psychotherapy to learn more effective ways to

    deal with life’s problems, including depression. Depending on the patient’s diagnosis

    and severity of symptoms, the therapist may prescribe medication and/or one of

    the several forms of psychotherapy that have proven effective for depression.

Electroconvulsive therapy (ECT) is useful, particularly for individuals whose

    depression is severe or life threatening or who cannot take antidepressant

    medication.1 ECT often is effective in cases where antidepressant medications do

    not provide sufficient relief of symptoms. In recent years, ECT has been much

    improved. A muscle relaxant is given before treatment, which is done under brief

    anesthesia. Electrodes are placed at precise locations on the head to deliver

    electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within

    the brain. The person receiving ECT does not consciously experience the electrical

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stimulus. For full therapeutic benefit, at least several sessions of ECT, typically

    given at the rate of three per week, are required.

     Medications

There are several types of antidepressant medications used to treat depressive

    disorders. These include newer medicationschiefly the selective serotonin

    reuptake inhibitors (SSRIs)the tricyclics, and the monoamine oxidase inhibitors

    (MAOIs). The SSRIsand other newer medications that affect neurotransmitters

    such as dopamine or norepinephrinegenerally have fewer side effects than

    tricyclics. Sometimes the doctor will try a variety of antidepressants before finding

    the most effective medication or combination of medications. Sometimes the

    dosage must be increased to be effective. Although some improvements may be

    seen in the first few weeks, antidepressant medications must be taken regularly for

    3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect

    occurs.

Patients often are tempted to stop medication too soon. They may feel better and

    think they no longer need the medication. Or they may think the medication isn’t

    helping at all. It is important to keep taking medication until it has a chance to work,

    though side effects (see section on Side Effects on page 13) may appear before

    antidepressant activity does. Once the individual is feeling better, it is important to

    continue the medication for at least 4 to 9 months to prevent a recurrence of the

    depression. Some medications must be stopped gradually to give the body time to

    adjust. Never stop taking an antidepressant without consulting the doctor for

    instructions on how to safely discontinue the medication. For individuals with

    bipolar disorder or chronic major depression, medication may have to be

    maintained indefinitely.

Antidepressant drugs are not habit-forming. However, as is the case with any type

    of medication prescribed for more than a few days, antidepressants have to be

    carefully monitored to see if the correct dosage is being given. The doctor will check

    the dosage and its effectiveness regularly.

For the small number of people for whom MAO inhibitors are the best treatment, it

    is necessary to avoid certain foods that contain high levels of tyramine, such as

    many cheeses, wines, and pickles, as well as medications such as decongestants.

    The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp

    increase in blood pressure that can lead to a stroke. The doctor should furnish a

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    complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.

    Medications of any kindprescribed, over-the counter, or borrowedshould

    never be mixed without consulting the doctor. Other health professionals who

    may prescribe a drugsuch as a dentist or other medical specialistshould be told

    of the medications the patient is taking. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.

    Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants; however, they are not effective when taken alone for a depressive disorder. Stimulants, such as amphetamines, are not effective antidepressants, but they are used occasionally under close supervision in medically ill depressed patients.

    Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

    Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol?) and valproate (Depakote?). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal?) and gabapentin (Neurontin?): their role in the treatment hierarchy of bipolar disorder remains under study.

    Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

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     Side Effects

Antidepressants may cause mild and, usually, temporary side effects (sometimes

    referred to as adverse effects) in some people. Typically these are annoying, but

    not serious. However, any unusual reactions or side effects or those that interfere

    with functioning should be reported to the doctor immediately. The most common

    side effects of tricyclic antidepressants, and ways to deal with them, are:

     Dry mouthit is helpful to drink sips of water; chew sugarless gum; clean

    teeth daily.

     Constipationbran cereals, prunes, fruit, and vegetables should be in the

    diet.

     Bladder problemsemptying the bladder may be troublesome, and

     the urine stream may not be as strong as usual; the doctor should be

    notified if there is marked difficulty or pain.

     Sexual problemssexual functioning may change; if worrisome, it should

    be discussed with the doctor.

     Blurred visionthis will pass soon and will not usually necessitate new

    glasses.

     Dizzinessrising from the bed or chair slowly is helpful.

     Drowsiness as a daytime problemthis usually passes soon. A person

    feeling drowsy or sedated should not drive or operate heavy equipment.

    The more sedating antidepressants are generally taken at bedtime to help

    sleep and minimize daytime drowsiness.

The newer antidepressants have different types of side effects:

     Headachethis will usually go away.

     Nauseathis is also temporary, but even when it occurs, it is transient

    after each dose.

     Nervousness and insomnia (trouble falling asleep or waking often during

    the night)these may occur during the first few weeks; dosage reductions

    or time will usually resolve them.

     Agitation (feeling jittery)if this happens for the first time after the

    drug is taken and is more than transient, the doctor should be notified.

     Sexual problemsthe doctor should be consulted if the problem is

    persistent or worrisome.

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     Herbal Therapy

    In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John’s wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John’s wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses.

    Because of the widespread interest in St. John’s wort, the National Institutes of Health (NIH) conducted a 3-year study, sponsored by three NIH componentsthe

    National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the Office of Dietary Supplements. The study was designed to include 336 patients with major depression of moderate severity, randomly assigned to an 8-week trial with one-third of patients receiving a uniform dose of St. John’s wort, another third sertraline, a selective serotonin reuptake

    inhibitor (SSRI) commonly prescribed for depression, and the final third a placebo (a pill that looks exactly like the SSRI and the St. John’s wort, but has no active ingredients). The study participants who responded positively were followed for an additional 18 weeks. At the end of the first phase of the study, participants were measured on two scales, one for depression and one for overall functioning. There was no significant difference in rate of response for depression, but the scale for overall functioning was better for the antidepressant than for either St. John’s wort or placebo. While this study did not support the use of St. John’s wort in the treatment of major depression, ongoing NIH-supported research is examining a possible role for St. John’s wort in the treatment of milder forms of depression.

    The Food and Drug Administration issued a Public Health Advisory on February 10, 2000. It stated that St. John’s wort appears to affect an important metabolic

    pathway that is used by many drugs prescribed to treat conditions such as AIDS, heart disease, depression, seizures, certain cancers, and rejection of transplants. Therefore, health care providers should alert their patients about these potential drug interactions.

    Some other herbal supplements frequently used that have not been evaluated in large-scale clinical trials are ephedra, gingko biloba, echinacea, and ginseng. Any

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    herbal supplement should be taken only after consultation with the doctor or other health care provider.

Psychotherapies

    Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. “Talking” therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with “homework” assignments between sessions. “Behavioral” therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.

    Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioral therapies. Interpersonal therapists focus on the patient’s disturbed personal relationships that

    both cause and exacerbate (or increase) the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.

    Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient’s conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

     How to Help Yourself if You Are Depressed

    Depressive disorders make one feel exhausted, worthless, helpless, and

    feel like hopeless. Such negative thoughts and feelings make some people giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

     Set realistic goals in light of the depression and assume a reasonable

     amount of responsibility.

     Break large tasks into small ones, set some priorities, and do what you

     can as you can.

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     Try to be with other people and to confide in someone; it is usually

     better than being alone and secretive.

     Participate in activities that may make you feel better.

     Mild exercise, going to a movie, a ballgame, or participating in

     religious, social, or other activities may help.

     Expect your mood to improve gradually, not immediately. Feeling

     better takes time.

     It is advisable to postpone important decisions until the depression

     has lifted. Before deciding to make a significant transitionchange

     jobs, get married or divorceddiscuss it with others who know

     you well and have a more objective view of your situation.

     People rarely “snap out of” a depression. But they can feel a little

     better day-by-day.

     Remember, positive thinking will replace the negative thinking that is

     part of the depression and will disappear as your depression responds

     to treatment.

     Let your family and friends help you.

How Family and Friends Can Help the Depressed Person

The most important thing anyone can do for the depressed person is to help him or

    her get an appropriate diagnosis and treatment. This may involve encouraging the

    individual to stay with treatment until symptoms begin to abate (several weeks), or

    to seek different treatment if no improvement occurs. On occasion, it may require

    making an appointment and accompanying the depressed person to the doctor. It

    may also mean monitoring whether the depressed person is taking medication.

The depressed person should be encouraged to obey the doctor’s orders about the

    use of alcoholic products while on medication. The second most important thing is

    to offer emotional support. This involves understanding, patience, affection, and

    encouragement. Engage the depressed person in conversation and listen carefully.

    Do not disparage feelings expressed, but point out realities and offer hope. Do not

    ignore remarks about suicide. Report them to the depressed person’s therapist.

    Invite the depressed person for walks, outings, to the movies, and other activities.

    Be gently insistent if your invitation is refused. Encourage participation in some

    activities that once gave pleasure, such as hobbies, sports, religious or cultural

    activities, but do not push the depressed person to undertake too much too soon.

    The depressed person needs diversion and company, but too many demands can

    increase feelings of failure.

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Do not accuse the depressed person of faking illness or of laziness, or expect him or

    her “to snap out of it.” Eventually, with treatment, most people do get better. Keep

    that in mind, and keep reassuring the depressed person that, with time and help,

    he or she will feel better.

     Where to Get Help

If unsure where to go for help, check the Yellow Pages under “mental health,”

    “health,” “social services,” “suicide prevention,” “crisis intervention services,”

    “hotlines,” “hospitals,” or “physicians” for phone numbers and addresses. In times

    of crisis, the emergency room doctor at a hospital may be able to provide

    temporary help for an emotional problem, and will be able to tell you where and

    how to get further help.

    Listed below are the types of people and places that will make a referral to, or

    provide, diagnostic and treatment services.

     Family doctors

     Mental health specialists, such as psychiatrists, psychologists, social

    workers, or mental health counselors

     Health maintenance organizations

     Community mental health centers

     Hospital psychiatry departments and outpatient clinics

     University- or medical school-affiliated programs

     State hospital outpatient clinics

     Family service, social agencies, or clergy

     Private clinics and facilities

     Employee assistance programs

     Local medical and/or psychiatric societies

    For More Information

For more information on depression and organizations from NLM’s MedlinePlus,

    please see the following website:

    http://www.nlm.nih.gov/medlineplus/depression.html

To see the website in Spanish please use the following link:

    http://www.nlm.nih.gov/medlineplus/spanish/depression.html

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     References

1. Frank E, Karp JF, Rush AJ (1993). Efficacy of treatments for major depression.

    Psychopharmacology Bulletin, 1993; 29:457-75.

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