Interventions For Major Depressive Disorder

Clinical And Methodological Issues

Context

Depressive disorders can be serious, disabling illnesses. Major depressive disorder ,1 defined as the presence of depressed mood or loss of interest or pleasure, along with at least four additional MDD diagnosis criteria or symptoms for a duration of at least 2 weeks, is the most prevalent and disabling, affecting more than 16 percent of U.S. adults .2 The burden of depressive illnesses, in both human and financial terms, is enormous. MDD, in particular, exerts a negative impact on physical health. It reduces participation in preventive activities3 as well as adherence to medical treatment,4 and it increases the likelihood of chronic conditions such as obesity, smoking, sedentary lifestyles, diabetes, and cancer.5,6 MDD may be associated with a general increase in chronic disease. Mortality rates attributable to MDD and other depressive illnesses are high approximately 4 percent of adults with a mood disorder commit suicide, and about two-thirds of suicides are preceded by depression.7

In 2000, the U.S. economic burden associated with depressive disorders was estimated to be $83.1 billion, a number that has likely increased during the past 10 years. More than 30 percent of these costs are attributable to direct medical expenses.7

In addition to depression severity, the number of antidepressant failures can also influence the likelihood of clinical benefit.

Impetus for Review

Interventions for MDD

Pharmacotherapy for MDD

Psychotherapy for MDD

CAM for MDD

Key Points About Depression

• Depression is a serious mood disorder that affects your whole body including your mood and thoughts.

• Its caused by a chemical imbalance in the brain. Some types of depression seem to run in families.

• Depression causes ongoing, extreme feelings of sadness, helplessness, hopeless, and irritability. These feelings are usually a noticeable change from whats normal for you, and they last for more than two weeks.

• Depression may be diagnosed after a careful psychiatric exam and medical history done by a mental health professional.

• Depression is most often treated with medicine or therapy, or a combination of both.

Biological Breakthroughs In Treating Depression

The mid-20th Century also saw a revolution in major depressive disorder healthcare, when antidepressant medications were introduced as a viable treatment method. The proven efficacy of antidepressants underscored the biological and genetic factors related to this condition, while being able to offer many patients significant symptom relief.

Read more about the benefits and possible side effects antidepressant medication can cause.

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What Can I Do If I Have Depression

If you have symptoms of depression, see your healthcare provider. They can give you an accurate diagnosis, refer you to a specialist or suggest treatment options.

If you or someone you know is thinking of hurting themselves or taking their own life:

• Go to the emergency department of your hospital.
• Contact a healthcare provider.
• Speak to a trusted friend, family member or spiritual leader.

A note from Cleveland Clinic

Depression is a common condition that affects millions of Americans every year. Anyone can experience depression even if there doesnt seem to be a reason for it. Causes of depression include difficulties in life, brain chemistry abnormalities, some medications and physical conditions. The good news is that depression is treatable. If you have symptoms of depression, talk to your healthcare provider. The sooner you get help, the sooner you can feel better

Last reviewed by a Cleveland Clinic medical professional on 12/31/2020.

References

Selective Serotonin Reuptake Inhibitors

SSRIs, which include fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and fluvoxamine, have become the first-line treatment for major depression.29 There does not appear to be significant differences among SSRI brands in effectiveness for treating MDD.29 SSRIs work by selectively blocking the reuptake of serotonin to increase the amount of serotonin available in synapses in the brain. They are effective, have fewer and milder side effects, and are less toxic in overdose when compared to the TCAs.29 Patients who do not respond to one SSRI can be switched to another SSRI or other antidepressant.34 Another option is to switch to the atypical antidepressant bupropion.35-37 For some patients, an SNRI such as venlafaxine may be more effective than any of the SSRIs.38 Fluoxetine and escitalopram are the only antidepressants recommended for treatment of MDD in adolescents , and fluoxetine is also approved for children aged 8 years and older.39,40 Side effects of SSRIs include dry mouth, nausea, sleepiness, dizziness, sweating, constipation, decreased appetite, and insomnia. Taking SSRIs in the morning generally avoids the insomnia issues.41

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Questions For A Nonprescribing Clinician To Ask A Referring Physician:

1. What goals do you have for the therapy?2. How might the side effects of the medications enhance or interrupt the therapy?3. If the patient describes side effects or nonadherence to the medications, what is the best way for me to contact you?4. What is the best way for me to contact you to discuss the patients progress?

An Intersection Of Contributing Factors

Opting for a more empirically-based approach to depression over Freuds psychoanalytic theory was Swiss psychiatrist Adolf Meyer. Eventually rising to the position of President of the American Psychiatric Association, Meyer pushed the mental health community into considering biological factors, as well as mental and familial ones, as potential sources of depression.

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How Behavioral Therapy Can Help Treat Depression In Adults

Individuals with depression often disengage from their relationships and usual activities, perhaps because they perceive themselves as incompetent or as a burden to others. This self-perception and subsequent behavioral withdrawal can negatively influence their mood and lead to a confirmation bias . Behavioral therapy can help address the negative perception of ones ability to engage in activities of daily living by having the person reverse current patterns and actively participate in pleasurable activities, despite their current depressed mood. The active participation is presumed to increase his/her mood over time and improve functioning.

Using Supportive Therapy To Treat Depression In Adults

Techniques that are foundational to supportive therapy include showing empathy and unconditional positive regard toward the individuals current struggle by normalizing his/her feelings, as well as providing suggestions for how to deal with whatever difficult situations the individual might be experiencing. Supportive therapists might also include exercises from a range of therapeutic orientations, such as diaphragmatic breathing or problem-solving. In experiencing the therapists empathic listening and unconditional positive regard, the individual will generally feel heard and understood and learn to internalize the therapists accepting view of the individual, ideally leading to improved self-esteem. The flexibility to explore different perspectives strengthens an individuals inner resilience and capacity to cope.

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Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions

We will systematically search, review, and analyze the scientific evidence for each KQ. We will take the following steps to perform the literature search. To identify articles relevant to each KQ, we will begin with a focused MEDLINE® search for eligible interventions using a combination of medical subject headings and title and abstract keywords, limiting the search to English-, German-, and Italian-language and human-only studies. We will also search the Cochrane Library, the International Pharmaceutical Abstracts database, EMBASE, AMED , PsycINFO, and CINAHL using analogous search terms. These searches will include RCTs for benefits and be expanded to nonrandomized studies to assess harms. We selected these databases based on preliminary searches and consultation with content experts. The search period will go back to January 1990. We will conduct quality checks to ensure that the searches identify known studies. If we do not identify the known studies, we will revise and rerun our searches.

In addition, in an attempt to avoid retrieval bias, we will manually search the reference lists of landmark studies and background articles on this topic to look for any relevant citations that our electronic searches might have missed.

Status In The United States

In the United States, the Medicare program covers outpatient mental health services and visits with the following professionals15:

• Psychiatrist or other physician
• Nurse practitioner
• Physician assistant

Medicare covers counselling or therapy only when delivered by a health care professional who accepts assignment, which is an agreement by a health care professional to be paid directly by Medicare accept the payment amount that Medicare approves for the service and not bill the patient for more than the fee of the Medicare deductible and coinsurance.15

There are caveats around the specific amount a patient is required to pay for treatment depending on several factors, such as the following15:

• Other insurance the patient may have
• How much the health care professional charges
• Whether the provider accepts assignment
• The type of facility in which treatment is provided
• The location where the patient receives treatment

Health care professionals may recommend a patient receive treatment more often than what Medicare will cover.15 Or, they may recommend services that Medicare does not cover. In such cases, the patient may have to pay some or all of the treatment costs.15

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From Young To Old: Depression Through The Life Cycle

Though most research has focused on the adult population, depression can also occur during other stages of life. As such, special care should be given to those in additional age groups, such as children, adolescents and senior citizens, whose depression can manifest through symptom patterns of their own.

Depression Among Children: With their communication skills, introspective abilities and view of the world still in development, children often find it harder to clearly express what they are going through. As a result, they may struggle to convey their emotional world to parental or adult figures.

Rates of depression among children have been steadily rising in the last several years, with up to 3% of US children said to develop depression. Children with depression may show signs of irritability, clinginess, complain of physical aches and pains, display emotional outbursts, run away from home, be prone to accidents, refuse to go to school or underperform academically, or go through significant weight changes.

Depression Among Teenagers: Adolescence is a time when individuals transition out of the more dependent and unaware state of childhood, and begin exploring the different roles they may come to identify with later in life. This period of exploration can bring with it new passions and excitement, but it can also cause confusion, feelings of self-doubt, and for many, their first experience with depression.

Major Depressive Disorder Is A Highly Treatable Condition Whether The Mental Illness Exists By Itself Or With A Co

Major depressive disorder is a treatable mental health condition that should be taken seriously by the person with the disorder and their loved ones. Clinical depression treatment is most effective when it begins shortly after diagnosis, but it is never too late to receive medical help for a mental illness. Treatment options for major depressive disorder include psychotherapy, psychotropic medication and electroconvulsive therapy. A mental health professional may recommend a combination of psychotherapy and antidepressant medication to treat the disorder in children, adolescents and adults. Electroconvulsive therapy induces seizures and is a valid but controversial option.

Major depressive disorder treatment should be individualized based on symptom severity, co-occurring disorders and the patients history of mental illness. Individuals with severe cases of depression may portray self-harming behaviors or suicidal thoughts, thus necessitating inpatient hospitalization for stabilization and safety. Individuals with less severe cases may be responsive to weekly individual therapy as part of an outpatient rehab program.

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Improvements In Brain Stimulation

Medications aren’t the only treatment for depression. Electroconvulsive therapy has been around for more than 70 years. It remains one of the most effective ways to manage major depressive disorder, especially if you don’t respond to other treatments. While it isn’t new, scientists have fine-tuned the procedure over the past decades.

Today, electroconvulsive therapy uses less energy than it did in the past. The goal is to give you the same benefits but with less negative impact on your memory and thinking skills. “That’s been a huge improvement,” says Susan Conroy, MD, PhD, a psychiatrist and neuroscientist at Indiana University School of Medicine.

Conroy also uses transcranial magnetic stimulation to treat depression, which has fewer side effects than electroconvulsive therapy. It works by sending magnetic pulses around your skull.

Brain tissue translates these signals into electrical energy, Conroy says, which changes the way areas of your brain talk to each other. “By changing that circuitry, we think that’s how transcranial magnetic stimulation gets people better from depression.”

These and other forms of brain stimulation aren’t right for everyone. But tell your doctor if other treatments don’t help and your depression keeps you from doing daily activities, you aren’t eating, and you have constant suicidal thoughts.

“These are all signs your treatment needs to be escalated and pretty quickly,” Conroy says.

Data Abstraction And Data Management

Two trained research team members will independently review all titles and abstracts identified through searches for eligibility against our inclusion/exclusion criteria. Studies marked for possible inclusion by either reviewer will undergo a full-text review. For studies without adequate information to determine inclusion or exclusion, we will retrieve the full text and then make the determination. All results will be tracked in an EndNote® bibliographic database .

We will retrieve and review the full text of all titles included during the title/abstract review phase. Two trained team members will independently review each full-text article for inclusion or exclusion based on the eligibility criteria described above. If both reviewers agree that a study does not meet the eligibility criteria, the study will be excluded. If the reviewers disagree, conflicts will be resolved by discussion and consensus or by consulting a third member of the review team. All results will be tracked in an EndNote database. We will record the reason that each excluded full-text publication did not satisfy the eligibility criteria so that we can later compile a comprehensive list of such studies.

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How Is Depression Treated

Treatment for depression may include one or a combination of the following:

• Medicine. Antidepressants work by affecting the brain chemicals. Know that it takes 4 to 6 weeks for these medicines to have a full effect. Keep taking the medicine, even if it doesnt seem to be working at first. Never stop taking your medicine without first talking to your healthcare provider. Some people have to switch medicines or add medicines to get results. Work closely with your healthcare provider to find treatment that works for you.

• Therapy. This is most often cognitive behavioral and/or interpersonal therapy. It focuses on changing the distorted views you have of yourself and your situation. It also works to improve relationships, and identify and manage stressors in your life.

• Electroconvulsive therapy . This treatment may be used to treat severe, life-threatening depression that has not responded to medicines. A mild electrical current is passed through the brain. This triggers a brief seizure. For unknown reasons, the seizures help restore the normal balance of chemicals in the brain and ease symptoms.

With treatment, you should feel better within a few weeks. Without treatment, symptoms can last for weeks, months, or even years. Continued treatment may help to prevent depression from appearing again.

Ketamine And Related Molecules

In intravenous sub-anesthetic doses, ketamine has very quick effects on resistant unipolar depression and acute suicidal ideation. The antidepressant effect of ketamine can persist for several days but eventually wanes. A few reports are have cited oral and intranasal formulations of ketamine for treatment-resistant depression, but there is still no data about the potential link between the onset of action and the route of administration.

Common adverse effects of ketamine include dizziness, neurotoxicity, cognitive dysfunction, blurred vision, psychosis, dissociation, urological dysfunction, restlessness, headache, nausea, vomiting, and cardiovascular symptoms. Such adverse effects tend to be brief in acute, low-dose treatments, whereas prolonged exposure may predispose patients to neurotoxicity and drug dependence. Lastly, since ketamine is associated with a higher risk of drug abuse and addiction, it cannot be recommended in daily clinical practice.

Ketamine is not a miracle drug, and many important factors still need to be defined, such as the most effective dose and the optimal administration route. The current lack of guidelines about the therapeutic monitoring of ketamine treatment for depression further complicates the expanding use of this treatment. Even though ketamine might never reach the market, it has stimulated research in the neurobiology of depression, including studies on potential fast and long-lasting antidepressants.

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Using Cbt To Treat Depression In Adults

Treatment begins with the therapist educating the patient about how thoughts, feelings and behaviors interact with each other to influence mood and well-being. The therapist introduces the idea that there are ways to modify thinking and behavioral patterns that could have a positive benefit on emotions and behaviors. Therapists teach patients how to use a variety of techniques to reduce symptoms and improve functioning.

The patient might be encouraged to complete a mood diary outside of sessions, noting the situations that triggered the thoughts that then influenced feelings and behaviors in the moment. The patient and therapist then work together to identify common themes that influence the unhelpful thinking and behavior patterns in a particular situation.

The therapist might have the patient challenge his/her beliefs about himself/herself , the world, and the future by exposing the patient to a fearful situation .

Patients are often encouraged to complete homework assignments to fully develop new skills and build confidence to work through stressful situations.

Pearls And Other Issues

MDD is one of the most prevalent mental health disorders and causes of disability in the United States. Risk factors for MDD include internal factors, external factors, and adverse life events. Treatments for MDD include medications, psychotherapy, lifestyle modifications, and brain stimulation therapies. Nurses play an important role in the interdisciplinary team with screening and recognizing the signs and symptoms of MDD, making referrals to healthcare team members, and providing education about the disease and the medications prescribed.

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