Depression (Wiki)

Medication wise, depressive disorders can be treated with antidepressants and, less frequently, antipsychotics or mood stabilisers such as lithium.

Depression is a negative affective (mood) episode, the opposite of mania and was first recorded in 1550 BC in the Ebers papyrus; at that time the condition was regarded as a demonic thing and was treated in a rather unpleasant way. In the 1950s following trials with MAOI antidepressants and the now long gone antidepressant Reserpine. Researchers are still uncertain as to what causes depressive illnesses, although there are multiple theories in this field. Depression is a blanket term for multiple disorders and states of mind, outlined below in alphabetical order.

Depression has a range of treatments, from mild to extreme. Posted below is a report into the full range of treatments by yours truly, for a variety of reasons, both academic and bitter experience.

First line treatments

If you illness is not as severe as MDD, you should first attend counselling without drug therapy. Failing that, psychotherapy would be the way to go. Remember, you do NOT want more drugs in your system than is absolutely necessary.

Drug therapy

If you do suffer from MDD, you should attend psychotherapy come what may; taking the drugs without appropriate therapy is just wrong and pretty much every study ever made pushes the point that medications and psychotherapy work better when combined.

So, what if your depression is atypical or resistant to treatment?

If you're outside of the USA, I'd recommend you try an RIMA medication (a reversible MAOI). They do not demand a strict diet and are quite effective against treatment resistant depressions. As a rule of thumb, they should always be tried, if possible, before an irreversible MAOI for the sake of safety. This treatment seems to be on a level with the new MAOI patch; just as with the RIMA, the MAOI patch doesn't demand any special diet - at low doses. It is probably the case that a high dose of the RIMA will pan out to be superior, offering more power without restrictions.

If RIMA drugs and MAOI drugs fail, you should closely consider mixing in an antipsychotic. The atypicals generally have more of an antidepressant effect, whilst the typicals are more effective against panic attacks and anxiety (Trifluoperazine especially, at a usual dose of 1-2mg when needed).

Failing that, Lithium may be called for. Here in the UK at least, blood tests are demanded for this old school medication and potential side effects can be quite nasty. A general nasty is the "flattening" effect. That's good if you're bipolar but not so great if you have a unipolar depression.

If Lithium fails, go back to last ditch antipsychotics, namely Clozapine (an atypical) and Mesoridazine (a typical), in that order. You may want to try the following therapy, TMS, before you take either of these drugs; it's up to you and your doctor.

So, what if the extreme drugs refuse to help?

The first call would be TMS (Transcranial Magnetic Stimulation). Side effects appear to be minimal and the treatment has proven to be quite effective. Headaches have been reported as well as a euphoric feeling, but these generally wear off. Limited information is available for this treatment as it is still in its infancy.

Next up is Cranial Electrotherapy Stimulation. It can sport a delayed effect and side effects aren't all that bad.

Transcranial Direct Current Stimulation is also worth mentioning, but I have very little idea about the treatment.

Your next port of call would be ECT (Electro-Convulsive Therapy). Nowadays, the procedure is a very far cry from Hollywood depiction. You're knocked under, receive mild shocks to the brain and wake up 15 minutes later probably with the side effects of confusion, fear and memory loss. These usually clear within a few hours with the exception of the memory loss which may take weeks or months to mend - sometimes, you won't get it back at all. Muscle relaxants are also administered during treatment to prevent self inflicted injury.

Now we're getting desperate. Vagus Nerve Stimulation may provide the answer to extreme disorders. Simply put, a small pacemaker like contraption is connected up to, yes, your vagus nerve. It sends frequent but mild stimulation to your brain, resulting in an antidepressant effect amongst others. It is generally regarded as more effective than drug therapy. Many people don't feel the shocks, whilst others aren't so lucky. The energy levels of the device can be toned down very easily to a more acceptable level and can be turned off altogether if it's causing unpleasantness.

Atropinic Shock Therapy, anyone? We're getting nasty here. With this treatment, the patient is subjected to an induced coma that lasts several hours. Needless to say, it's very rare, although it is still available on written consent.

Last few options now. Insulin Shock Treatment. I didn't think that this is ever legal any more, but apparently it is, albeit rarely used. Massive amounts of Insulin are injected into you, causing convulsions and coma. It was an effective treatment for all sorts of psychiatric ailment and was discovered in 1933.

Neurosurgery (Leukotomy). This is horrific and is only ever used when there is quite literally no choice for whatever reason. Basically, your prefrontal cortex is screwed up by means of knife. On last counting, the UK performs (or performed) an average of 15 leukotomies a year. The procedure often leads to a massive change in personality and that's the most benign effect. It is the ultimate, most effective method of controlling symptoms, but at a huge price. As I said, this procedure is only ever carried out when there is no choice.


Atypical Depression - Despite it's name, approximately 40% of patients who suffer Major Depressive Disorder are subject to Atypical Depression, a subtype of Major Depressive Disorder. Atypical Depression is defined as a Major Depressive Disorder with additional or more precise symptoms, including mood reactivity and at least two of the following symptoms: hypersomnia, a minor paralysis, weight gain or overeating (known as reversed vegetative symptoms), or a hypersensitivity that negatively affects everyday life. About 70% of patients with this particular condition are women and the illness usually asserts itself in latter teenage years, earlier than other depressive disorders. Atypical Depression is considerably more likely to cause associated daughter illnesses, such as social anxiety disorder.

Treatment: Psychotherapy and drug therapy are usually used concomitantly. Sedative antidepressants are almost always avoided for obvious reasons as are drugs that typically cause weight gain. This condition may be more difficult to treat with standard antidepressants due to its nature; however, if push comes to shove, there are RIMA antidepressants (such as moclobemide) and MAOI antidepressants (such as phenelzine) that are far more reliable in this field. Combinations with Lithium or atypical antipsychotics such as quetiapine at low doses are also sometimes used, although they are avoided as much as is possible.

Catatonic Depression - This illness is another subtype or daughter illness to Major Depressive Disorder and is relatively unusual. Criteria for the disorder are a Major Depressive Disorder accompanied by at least two of the following symptoms: extreme negativity, mutism, stupor, odd yet voluntary movements, catalepsy, akathisia, motor control hyperactivity and (rarely) echolalia and/or echopraxia.

Treatment: In the early days of treatment, psychotherapy is often regarded as far less effective than if used during the recovery initiated by drug therapy. Since the condition has both sedative and stimulant properties, neutral antidepressants (such as citalopram) are often used. Benzodiazepines are very commonly used as is Electro Convulsive Therapy (ECT), which has been shown to be extremely effective with few side effects.

Dysthymia - An chronic illness perceived as less severe than Major Depressive Disorder, Dysthymia tends not to disrupt life but can sap enjoyment from everyday activities. It is defined as a regular and frequent condition that lasts for a minimum of two years, exhibiting at least two of the following symptoms: hopelessness, inactivity, changes in appetite, sleep disorders, poor concentration and reduced self image. In addition to this, these symptoms must not have been absent for more than two months, the patient must not have exhibited symptoms of mania, the illness must not be a result of a psychotic illness, must not be the result of substance use or condition suffered, must impair the enjoyment of life but must not be severe enough to be classified as a Major Depressive Disorder.

Treatment: The typical treatments lie in different facets of psychotherapy first and drug therapy last. If medication is required, stimulant antidepressant drugs such as fluoxetine are typically favoured over sedative antidepressant drugs such as sertraline. Natural remedies such as St. John's Wort unfortunately do not seem to work any more than placebo.

Major Depressive Disorder - A clinical state of a low mood so marked that it interferes with major aspects of the patient's life, such as their social life, their ability to work and so on; anxiety is often present, compounding the already present symptoms. Depression itself was first recorded in 1550 BC and usually presents itself in patients in their late 20s. Approximately two thirds of sufferers are women and according to the World Health Organisation, depressive illnesses will be second only to heart disease by 2020 as the primary cause of disability. Diagnosis of the disorder is made when the patient exhibits either a depressed mood or anhedonia for at least two weeks and must also, for the same amount of time, experience at least 5 additional symptoms out of the following: sleep disturbances, fatigue (mental or physical, resulting in an apparent reduction in energy), feelings of guilt where inappropriate and/or excessive, suicidal attempts and/or thoughts, extreme feelings of sadness and/or fear or emotional flattening, marked changes in appetite, sleep disturbances, frequent psychomotor disturbances (agitation or retardation) and poor cognition (problems with proactive thought, memory and concentration). Other symptoms which can occur but are not included in the diagnosis (usually) include poor personal care, lowered self esteem, fear of condition worsening, poor perception of time, hypersensitivity and minor physical flaws such as localised pain that can often be a source of fretting as the patient assumes or believes, incorrectly, that they are signs of a serious illness, often thought to be related to their psychiatric condition. In children, depression is harder to spot; symptoms may include changes in appetite, irritability, behavioural problems (such as aggression and social withdrawal), sleep disturbances (such as frequent nightmares), hypomania and cognitive difficulties. Meanwhile, adolescents may turn to substance abuse. This illness must not have a specific cause such as bereavement.

Treatment: Simultaneous use of psychotherapy and drug therapy is the most prevalent method of treatment today. Families of drugs referred to as antidepressants are first line treatments, whilst augmentor medications, including benzodiazepines, antipsychotics and lithium may be use to potentiate the antidepressant effect of the core treatments. If the above options prove either unfortuitous or unpleasant due to extrapyramidal symptoms (EPS) then alternative therapies may be in order, be they so-called "natural" therapies or physical therapies such as shock therapies.

Melancholic Depression - From the Greek, μελανχολια, literally meaning melancholy. Melancholic Depression, regarded more as a biological illness, is a highly distressing condition exhibiting the standard symptoms of a Major Depressive Disorder accompanied by either anhedonia or a non-reactive mood as well as at least three of the following symptoms: excessive and/or inappropriate feelings of guilt, anorexia or associated eating disorders, a distinct depression disassociated with normal grief, psychomotor disturbances (agitation or retardation), sleep disturbances (usually awakening very early) and a higher morning intensity of the depression.

Treatment: Although placebo is extremely ineffective, Melancholic Depression typically reacts well to certain psychiatric drugs. Broad spectrum medications that act on a broader range of chemicals within the brain are almost always superior to narrow spectrum medications that operate on a selective basis; therefore, MAOIs, RIMAs and TCAs work best whilst NARIs and SSRIs work the least; this characteristic increases with age. Certain antipsychotics can augment antidepressants and failing that, Electro Convulsive Therapy (ECT) has been shown to be highly effective.

Postpartum Depression - Also known as postnatal depression. A daughter illness to Major Depressive Disorder, Postpartum Depression is a treatable condition that occurs after childbirth; interestingly, men can also experience this illness, although it is quite rare. A fusion of the so-called "baby blues" (or "maternity blues") with Major Depressive Disorder, Postpartum Depression has the same criteria for diagnosis as does Major Depressive Disorder but has to last at least one month after postpartum, essentially to differentiate between between baby blues (which can last for hours or days and affects 80% of postpartum women) and a true clinical depressive illness.

Treatment: As with Major Depressive Disorder, but with care given to drug selection if the mother intends to breastfeed.

Psychotic Depression - Psychotic Depression is an extreme chronic affective disorder of the depressive type in which patients experience moderate to severe psychotic episodes. Usually, once experiences particular psychotic symptoms such as paranoia, hallucinations (usually audible and visual) and erratic episodes. The condition is particularly exacerbated by severe stress and chemical abuse and is cyclic in nature. Approximately one in four patients who are hospitalised for an extreme depressive illness suffer from Psychotic Depression and suicide is sadly all too frequent. Interestingly, unlike primarily psychotic illnesses, patients who suffer from Psychotic Depression are conscious to the fact that their psychosis induced experiences are farce.

Treatment: Whilst psychotherapy is very effective in this field, it is prudent to provide said treatment alongside drug therapy. Typically patients react best to a combination of tricyclic antidepressants and atypical antipsychotics whose doses are tailored to the individuals requirements. Electro Convulsive Therapy (ECT) is extremely effective, but is not a first line treatment due to longer lasting side effects, be they more trivial or more damaging than the side effects induced by psychiatric drugs of choice. Interestingly, the so called "morning after" [contraceptive] pill also appears to be very effective in the short term.

Reactive Depression - An affective disorder induced by traumatic events in the normal course of life. Depending on the event and the person involved, this condition may deteriorate into a more serious disorder, such as Major Depressive Disorder.

Treatment: Psychotherapy is extremely effective for most patients with this disorder, as is counselling. Drug therapy is, of course, available but may be ineffective in these cases. A novel treatment known as (repetitive) Transcranial Magnetic Stimulation (rTMS), an offshoot of the God Helmet experiments) has been shown to be extremely effective in cases where a depressive illness has a focal point or cause.

Seasonal Affective Disorder - An extension (more serious case) of winter depression, Seasonal Affective Disorder (or, rather appropriately, S.A.D.) is an affective (mood) disorder that affects mainly people who live in changeable climates, usually 30° North or South of the equator and may affect people who are otherwise completely healthy; the condition lies dormant during long daylight hour seasons. The illness presents itself when days are shorter and therefore when daylight hours are in short supply. The condition was first described by the scholar Jordanes in the 6th century and has since been re-examined countless times. It was proposed as a psychiatric disorder in the USA in 1984 after a doctor noticed that his mood seemed to depend on the environment he was in; he subsequently experimented with artificial light and discovered a correlation with mood levels.

Treatment: The primary method of treatment is known as light therapy, where patients are exposed to full spectrum or infa-red lights; research now indicates that blue light is highly potent. Approximately 10,000 lux a day should be administered for 30 to 60 minutes per day and whilst one should not look at the light source, it seems that one's eyes must remain largely open. Alternatively, a family of antidepressants called SSRIs have proven effective, usually at low doses.

Substance Induced Depression - Illegal substance use or legal substance abuse is highly likely to lead to psychiatric illnesses, including Major Depressive Disorder. For example, according to Andrew Johns' text "Psychiatric effects of cannabis", published in 2001, asserts that Cannabis use, even in moderate amounts, can lead to an affective (mood) disorder; for more information, refer to the condition "C.I.P." on this site, meaning Cannabis Induced Psychosis (this article deals with the many affects caused by Cannabis use).

Treatment: As with Major Depressive Disorder, but with care given to the withdrawal of the drug used or abused; inpatient status would be prudent within the first few days of treatment.