Management

Managing depression is challenging due to the marked variability in biological contributors, the heterogeneity of the illness, psychosocial history, current stresses exacerbating the condition, medical and psychiatric co-occurring conditions, lifestyle, and motivation and willingness to accept and engage in treatment recommendations.¹  Less than 30% of those experiencing depression receive any care at all. Of those who do seek treatment, less than 21% receive help consistent with treatment guidelines.²  Most of those with untreated depression have visited a primary care physician within the last year. Many are unaware that they are experiencing depression or are reluctant to discuss their symptoms with their physician. In the United States, the population most likely to be treated had public insurance and was separated, widowed, or divorced. The least likely to get help were uninsured adults, racial and ethnic minorities, and men.³

Management of depression often involves a combination of pharmacological and psychological therapy.⁴ Most patients, between 80% to 90%, respond well to treatment for MDD and achieve relief from their symptoms.⁵

Mild Depression

Patients diagnosed with mild depression may be able to take the “wait and see” approach. In some cases, mild depression will resolve on its own and watchful waiting is recommended by the physician.⁴ Exercise is considered one of the main treatments for mild depression.⁴

Mild to Moderate Depression

Therapy, including cognitive behavioral therapy and counseling, can be very beneficial in patients who have not improved with the “wait and see” approach or in patients with moderate depression.⁴

Moderate to Severe Depression

Antidepressants, in combination with therapy, is beneficial in patients with moderate to severe depression. The combination of medication and therapy works better than either treatment alone.⁴

Also known as “talk therapy”, involves the individual but may also involve the individual’s family. Cognitive behavioral therapy (CBT), one of the most common forms of therapy, is beneficial in patients with depression.⁵ CBT focuses on recognizes distorted thinking and problem solving in the present. The goal of CBT is to change an individual’s pattern of thoughts and behaviors in order to better respond to challenges in a positive way.⁵

Electroconvulsive therapy, the use of short electrical stimulation to the brain under anesthesia, is reserved for treatment resistant patients with severe depression. Treatment occurs 2 to three times a week for 6 to twelve treatments.⁵

Antidepressants

Selective Serotonin Reuptake Inhibitors (SSRIs)⁶

SSRIs should not be taking concomitantly with monoamine oxidase inhibitors (MAOIs) as it can increase the risk for serotonin syndrome.⁶ Signs and symptoms of serotonin symptom include

Common side effects include nausea, tremor, nervousness, insomnia, sexual dysfunction, sweating, agitation, and fatigue.⁶

Serotonin and Norepinephrine Reuptake inhibitors (SNRIs)⁶

SNRIs should not be taken with MAOIs due to increased risk for serotonin syndrome. Caution should be used in patients with liver or kidney dysfunction, as well as narrow-angle glaucoma.⁶

Common side effects include nausea, vomiting, dry mouth, constipation, fatigue, dizziness, sweating, and sexual dysfunction.⁶

 Tricyclic and Tetracyclic Antidepressants (TCAs)⁶

* indicates tetracyclic

TCAs should not be taken with MAOIs as this increases the risk for serotonin syndrome. Use TCAs with caution in patients with narrow-angle glaucoma.⁶

Common side effects of TCAs are dry mouth, constipation, blurred vision, drowsiness, and low blood pressure.⁶

Atypical Antidepressants⁶

Any antidepressant typically takes between 2 to four weeks to work in patients, so it is very important to counsel patients on medication adherence.⁷ Generally, symptoms such as insomnia, appetite change, and inability to concentrate will resolve first before mood improves.⁷

In children and young adults, there may be an increase in suicidal thoughts when taking antidepressants. This is most likely to occur within the first few weeks of starting the medication or if the dose is changed.⁷

Monoamine Oxidase Inhibitors (MAOIs)⁶

MAOIs should not be administered with other depression medications or with medications that affect the central nervous system (stimulants or depressants).⁶ Patients should be educated to avoid eating tyramine containing foods – cheese, wine, aged meats – as well as avoid taking decongestants.⁶

Common side effects of MAOIs are nausea, restlessness, insomnia, dizziness, and drowsiness.⁶

N-methyl D-aspartate (NMDA) Antagonist⁴

Spravato (esketamine)

Esketamine should only be used in patients who have failed other depression medications and must be taken in combination with an oral antidepressant.⁶ A REMS program exists for esketamine due to tiredness and dissociation that can occur following administration. Esketamine is administered in a healthcare setting, certified by the REMS program, to allow for two hour monitoring following each dose.⁶

Common side effects include dissociation, dizziness, nausea, sleepiness, spinning sensation, decreased feeling, and anxiety.⁶

Patients should be encouraged to make positive lifestyle changes during and after treatment. These include⁷:

• Exercise
• Setting realistic goals towards remission and improvement of mood
• Spending time with trusted family and friends for support
• Reducing isolation
• Postponing important life changes, if possible, until the patient feels better
• Seek out continual education about depression

1. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry. 2000;157(4 Suppl):1-45.
2. Wang PS, Berglund P, Kessler RC. Recent care of common mental disorders in the United States : prevalence and conformance with evidence-based recommendations. J Gen Intern Med. 2000;15(5):284-292. doi:10.1046/j.1525-1497.2000.9908044.x
3. Olfson M, Blanco C, Marcus SC. Treatment of Adult Depression in the United States [published correction appears in JAMA Intern Med. 2016 Oct 1;176(10):1579]. JAMA Intern Med. 2016;176(10):1482-1491. doi:10.1001/jamainternmed.2016.5057
4. Treatment clinical depression. National Health Service. Updated December 10, 2019. Accessed January 29, 2021. https://www.nhs.uk/conditions/clinical-depression/treatment/
5. What is depression? American Psychiatric Association. Updated October 2020. Accessed January 29, 2021. https://www.psychiatry.org/patients-families/depression/what-is-depression
6. Depression medicines. US Food and Drug Administration. Updated November 18, 2019. Accessed January 29, 2021. https://www.fda.gov/consumers/free-publications-women/depression-medicines#SSRI
7. Depression. National Institute of Mental Health. Updated February 2018. Accessed January 29, 2021. https://www.nimh.nih.gov/health/topics/depression/index.shtml