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Depression: Non-psychological approaches to treatment

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TreatmentEdit

Treatment of depression varies broadly and is different for each individual. Various types and combinations of treatments may have to be tried. There are two primary modes of treatment, typically used in conjunction: medication and psychotherapy. A third treatment, electroconvulsive therapy (ECT), may be used when chemical treatment fails.

Other alternative treatments used for depression include exercise and the use of vitamins, herbs, or other nutritional supplements.

The effectiveness of treatment often depends on factors such as the amount of optimism and hope the sufferer is able to maintain, the control s/he has over stressors, the severity of symptoms, the amount of time the sufferer has been depressed, the results of previous treatments, and the degree of support of family, friends, and significant others.

Although treatment is generally effective, in some cases the condition does not respond. Treatment-resistant depression warrants a full assessment, which may lead to the addition of psychotherapy, higher medication dosages, changes of medication or combination therapy, a trial of ECT/electroshock, or even a change in the diagnosis, with subsequent treatment changes. Although this process helps many, some people's symptoms continue unabated.

In emergencies, psychiatric hospitalization is used simply to keep suicidal people safe until they cease to be dangers to themselves. Another treatment program is partial hospitalization, in which the patient sleeps at home but spends the day, either five or seven days a week, in a psychiatric hospital setting in intense treatment. This treatment usually involves group therapy, individual therapy, psychopharmacology, and academics (in child and adolescent programs).

MedicationEdit

Medication that relieves the symptoms of depression has been available for several decades. These drugs are listed in order of historical development. Typical first-line therapy for depression is the use of an SSRI, such as sertraline (Zoloft).

Monoamine oxidase inhibitors (MAOIs) such as Nardil may be used if other antidepressant medications are ineffective. Because there are potentially fatal interactions between this class of medication and certain foods and drugs, they are rarely prescribed anymore. MAOI's are used to block the enzyme monoamine oxidase which breaks down neurotransmitters such as serotonin and norepinephrine.MAOI's are as effective as tricyclics, if not slightly more effective. A new MAOI has recently been introduced. Moclobemide (Manerix), known as a reversible inhibitor of monoamine oxidase A (RIMA), follows a very specific chemical pathway and does not require a special diet.

Tricyclic antidepressants are the oldest and include such medications as amitriptyline and desipramine. Tricyclics block the reuptake of certain neurotransmitters such as norepinephrine and serotonin. They are used less commonly now because of their side effects, which include increased heart rate, drowsiness, dry mouth,constipation, urinary retention, blurred vision,dizziness, confusion, and sexual dysfunction. Most importantly, they have a high potential to be lethal in moderate overdose. However, tricyclic antidepressants are still used because of their high potency, especially in severe cases of clinical depression.

Selective serotonin reuptake inhibitors (SSRIs) are a family of antidepressant considered to be the current standard of drug treatment. It is thought that one cause of depression is an inadequate amount of serotonin, a chemical used in the brain to transmit signals between neurons. SSRIs are said to work by preventing the reabsorption of serotonin by the nerve cell, thus maintaining the levels the brain needs to function effectively, although two researchers recently demonstrated that this is a marketing technique rather than a scientific portrayal of how the drugs actually work. [1]. Recent research indicates that these drugs may interact with transcription factors known as "clock genes"[2], which may be important for the addictive properties of drugs of abuse and possibly in obesity[3][4].

This family of drugs includes fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), citalopram (Celexa), and sertraline (Zoloft). These antidepressants typically have fewer adverse side effects than the tricyclics or the MAOIs, although such effects as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite, and decreased ability to function sexually may occur. Some side effects may decrease as a person adjusts to the drug, but other side effects may be persistent.

Norepinephrine reuptake inhibitors such as reboxetine (Edronax) act via norepinephrine (also known as noradrenaline). NeRIs are thought to have a positive effect on concentration and motivation in particular.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor) and duloxetine (Cymbalta) are a newer form of antidepressant that works on both noradrenaline and serotonin. They typically have similar side effects to the SSRIs, although there may be a withdrawal syndrome on discontinuation that may necessitate dosage tapering.

On 28 February 2006, the United States Food and Drug Administration approved Emsam, a transdermal MAOI patch developed by British company Somerset Pharmaceuticals, to be marketed in the U.S. by Bristol-Myers Squibb [5].

Dietary supplementsEdit

5-HTP supplements are claimed to provide more raw material to the body's natural serotonin production process. There is a reasonable indication that 5-HTP may not be effective for those who haven't already responded well to an SSRI.

S-adenosyl methionine (SAM-e) is a derivative of the amino acid methionine that is found throughout the human body, where it acts as a methyl donor and participates in other biochemical reactions. It is available as a prescription antidepressant in Europe and an over-the-counter dietary supplement in the United States. Clinical trials have shown SAM-e to be as effective as standard antidepressant medication, with many fewer side effects.[1],[2] Its mode of action is unknown.

Omega-3 fatty acids (found naturally in oily fish, flax seeds, hemp seeds, walnuts, and canola oil) have also been found to be effective when used as a dietary supplement (although only fish-based omega-3 fatty acids have shown antidepressant efficacy) [6].

Magnesium has gathered some attention [7][8].

St John's Wort [Hypericum Perforatum] Traditionally used by 'wise women' and midwives for hundreds of years, to 'chase away the devil' of melancholia and anxiety. It is a mood-enhancing antidepressant supplement that increases the availability of serotonin, norepinephrine and dopamine at the neuron synapses. Also popular for treating insomnia, mood swings, fatigue, PMS and menopause.[3] [9]

Ginkgo Biloba Effective natural antidepressant said to stabilise cell membranes, inhibiting lipid breakdown and aiding cell use of oxygen and glucose - so subsequently a mental and vascular stimulant that improves neaurtransmitter production. Also popular for treating mental concentration (eg for Alzheimer's and post-strokes). [3]

Siberian Ginseng [Eleutherococcus Senticosus] Although not a true panax ginseng it is a mood enhancement supplment against stress. Also popular for treating depression, insomnia, moodiness, fatigue, poor memory, lack of focus, mental tension and endurance. [3]

Zinc: 25mg per day have had an antidepressant effect in an experiment [10].

Biotin: a deficiency has caused a severe depression. The patient's symptoms improved after the deficiency was corrected. [11]

The amino acids phenylalanine and tyrosine have also a favourabele effect by easy forms of depression. They enhance the neurotransmitters dopamine and noradrenalin.

Augmentor drugsEdit

Some antidepressants have been found to work more effectively in some patients when used in combination with another drug. Such "augmentor" drugs include tryptophan (Tryptan) and buspirone (Buspar).

Tranquillizers and sedatives, typically the benzodiazepines, may be prescribed to ease anxiety and promote sleep. Because of their high potential for fostering dependence, these medications are intended only for short-term or occasional use. Medications often are used not for their primary function but to exploit what are normally side effects. Quetiapine fumarate (Seroquel) is designed primarily to treat schizophrenia and bipolar disorder, but a frequently reported side-effect is somnolence. Therefore, this drug can be used in place of an antianxiety agent such as clonazepam (Klonopin, Rivotril).

Antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa), and Quetiapine (Seroquel) are prescribed as mood stabilizers and are also effective in treating anxiety. Their use as mood stabilizers is a recent phenomenon and is controversial with some patients. Antipsychotics (typical or atypical) may be also prescribed in an attempt to augment an antidepressant, to make antidepressant blood concentration higher, or to relieve psychotic or paranoid symptoms often accompanying clinical depression. However, they may have serious side effects, particularly at high dosages, which may include blurred vision, muscle spasms, restlessness, tardive dyskinesia, and weight gain.

Antidepressants by their nature are stimulants. Antianxiety medications by their nature are depressants. Close medical supervision is critical to proper treatment if a patient presents with both illnesses because the medications tend to work against each other.

Lithium remains the standard treatment for bipolar disorder and is often used in conjunction with other medications, depending on whether mania or depression is being treated. Lithium's potential side effects include thirst, tremors, light-headedness, and nausea or diarrhea. Some of the anticonvulsants, such as carbamazepine (Tegretol), sodium valproate (Epilim), and lamotrigine (Lamictal), are also used as mood stabilizers, particularly in bipolar disorder.

Failure to take medication or failure to take it as prescribed is one of the major causes of relapse. Should one feel a change or discontinuation of medication is necessary, it is critical that this be done in consultation with a doctor.

Transcranial magnetic stimulationEdit

Repetitive transcranial magnetic stimulation (rTMS) is under study as a possible treatment for depression. Initially designed as a tool for physiological studies of the brain, this technique shows promise as a means of alleviating depression. In this therapy, a powerful magnetic field is used to stimulate the left prefrontal cortex, an area of the brain that typically shows abnormal activity in depressed people.

rTMS has been proposed as an alternative to ECT that would have fewer side effects. No sedation is needed, and the only reported side effects are a slight headache in some patients and facial muscle contraction during treatment. However, clear evidence that it is effective is still awaited.[4]

Recent work in Poland suggested that weak, variable magnetic fields may offer relief from depression in those who have not responded to medication. However, some of the existing work has been questioned, with claims that the effect is not as significant once environmental conditions are controlled for.

Vagus nerve stimulationEdit

Vagus nerve stimulation therapy is a treatment used since 1997 to control seizures in epileptic patients and has recently been approved for treating resistant cases of clinical depression. The VNS device is implanted in a patient's chest with wires that connect it to the vagus nerve, which it stimulates to reach a region of the brain associated with moods. The device delivers controlled electrical currents to the vagus nerve at regular intervals.

Electroconvulsive therapyEdit

Electroconvulsive therapy (ECT), also known as electroshock or electroshock therapy, uses short bursts of a controlled current of electricity (typically fixed at 0.9 ampere) into the brain to induce a brief, artificial seizure while the patient is under general anesthesia.

ECT has acquired a fearsome reputation, in part from its use as a tool of repression in the former USSR and its fictional depiction in films such as One Flew Over the Cuckoo's Nest, but remains a common treatment where other means of treatment have failed or where the use of drugs is unacceptable (as in pregnancy). Also, in contrast to direct electroshock of years ago, most countries now allow ECT to be administered only under anaesthesia. In a typical regimen of treatment, a patient receives three treatments per week over three or four weeks. Repeat sessions may be needed. Short-term memory loss, disorientation, and headache are very common side effects. In some cases, permanent memory loss has occurred, but detailed neuropsychological testing in clinical studies has not been able to prove permanent effects on memory. ECT offers the benefit of a very fast response; however, this response has been shown not to last unless maintenance electroshock or maintenance medication is used. Whereas antidepressants usually take around a month to take effect, the results of ECT have been shown to be much faster. For this reason, it is the treatment of choice in emergencies (e.g., in catatonic depression in which the patient has ceased oral intake of fluid or nutrients).

There remains much controversy over electroshock. Advocacy groups and scientific critics, such as Dr Peter Breggin[12], call for restrictions on its use or complete abolishment. Like all forms of psychiatric treatment, electroshock can be given without a patient's consent, but this is subject to legal conditions dependent on the jurisdiction.

Other methods of treatmentEdit

Light therapyEdit

Bright light (both sunlight and artificial light) is shown to be effective in seasonal affective disorder, and sometimes may be effective in other types of depression, especially atypical depression or depression with "seasonal phenotype" (overeating, oversleeping, weight gain, apathy).

Important note: An antidepressant effect is caused by stimulation of the retina by the visible light, not by the ultra-violet portion. Thus, it is not necessary (and may be even dangerous in some cases) to get sunburn. It can be enough just to walk at daytime or to take light therapy using a light box. However, recent discoveries of the existence and importance of the third kind of photoreceptor in our eyes, the intrinsically photosensitive retinal ganglion cells (ipRGC), critical to human chronobiology, strongly suggest that bluish light is more helpful, and manufacturers are beginning to respond to this finding.[How to reference and link to summary or text]

ExerciseEdit

It is widely believed that physical activity and exercise help depressed patients and promote quicker and better relief from depression. They are also thought to help antidepressants and psychotherapy work better and faster. It can be difficult to find the motivation to exercise if the depression is severe, but sufferers should be encouraged to take part in some form of regularly scheduled physical activity. A workout need not be strenuous; many find walking, for example, to be of great help. Exercise produces higher levels of chemicals in the brain, notably dopamine, serotonin, and norepinephrine. In general this leads to improvements in mood, which is effective in countering depression.

Note that before beginning an exercise regime, it is wise to consult a doctor. He or she can establish whether a person has any health problems that could contraindicate some types of exercise.

MeditationEdit

Meditation is increasingly seen as a useful treatment for depression. The current professional opinion on meditation is that it represents at least a complementary method of treating depression, a view that has been clearly underscored by the Mayo Clinic. Since the late 1990s, much research has been carried out to determine how meditation affects the brain (for more information see the main article on meditation). Although the effects on the mind are complex, they are often quite positive, encouraging a calm, reflective, and rational state of mind that can be of great help against depression. Although many religions include meditative practice, it is not necessary to be a member of any faith to meditate.

Old methodsEdit

Insulin shock therapy is an old and largely abandoned treatment of severe depressions, psychoses, catatonic states, and other mental disorders. It consists of induction of hypoglycemic coma by intravenous infusion of insulin. The treatment is potentially unsafe and can be lethal in some cases (about 1% of patients undergoing insulin coma), even with proper monitoring. In contrast, ECT is considered to be very safe.

Nevertheless, insulin shock therapy is still officially used in Russia and some other countries and can be administered to a very treatment-resistant patient with written consent in many Western countries.

Atropinic shock therapy, also known as atropinic coma therapy, is an old and rarely used method. It consists of induction of atropinic coma by rapid intravenous infusion of atropine.

Atropinic shock treatment is considered safe, but it entails prolonged coma (4-5 hours), with careful monitoring and preparation, and it has many unpleasant side effects, such as blurred vision. It can be used with written consent in Western countries in very treatment-resistant patients and is still officially used in Russia and some other countries.

Adverse reactionsEdit

Aspartame was associated with a significant difference in number and severity of symptoms for patients with a history of depression in an experiment [13].

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