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Did you know... In youth the days are short and the years are long; in old age the years are short and the days long.
Source: Nikita Ivanovich Panin

Treatment Options

Treatment Options for Depression

Depression can be treated successfully with a variety of methods. There are many effective means for dealing with depression at varying stages of severity. Below are some of the best and newest methods available for treating depression:

Visit the Expert Consensus Guideline Series website to read a report on Depression in Older Adults: A Guide for Patients and Families. This report provides information on depression treatment based on research and clinical recommendations. 

Exercise Training

"The importance of physical activity to older Americans can't be stressed too much" said the 19th Secretary of Health and Human Services, Thomas Thompson. "An active lifestyle is achievable and it helps people live independently longer".

Exercise can help prevent and also treat depression in older adults. Clinical studies suggest that seniors who follow a supervised aerobic exercise program and engage in positive, goal-oriented physical habits may experience beneficial outcomes, including improved health functioning and a reduction in depressive symptoms. 

National Organizations

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Medications

Depression can be treated successfully with a variety of methods, including many new medications.  These new medications have been found to be effective in treating persons with depression, and may offer hope to depressed older adults who have not responded to other therapies.

General Medication Guidelines Patient research conducted with the antidepressant medications has shown that:

  • All appear to have been effective in treating depressed patients.
  • 65-80% of patients responded to the medications in 4-6 weeks, with the majority showing a full response.

What you should know about antidepressant medications:

  • They are non-addictive.
  • The newer antidepressants seem to have fewer side effects than traditional medications.
  • Some side effects may be felt in the first few days of taking the medication.
  • A full, effective response to the medications takes about 4-6 weeks.
  • You must stay on the medication as directed to ensure the full benefit.
  • These antidepressants may cause reactions with other medications you might be taking, including over-the-counter products, such as ginko biloba or St. John's Wort.

What you should let your doctor know before taking antidepressant medications:

  • Provide a list of all medications you are taking. You can ask your pharmacist for help. 
  • Let your doctor know about previous treatments you have had for depression, including any medications you have taken.
  • Talk openly about concerns you have about the cost of the medication. There may be special plans available to help patients with restricted incomes.
  • Remember to continue to take the medication as directed and to complete the prescribed dosage.

If you are feeling better, it means the medication is working, not that you no longer need it. To prevent a recurrence, you must stay on your medication at least 6 months to a year or as directed by your doctor.

Types of Medications

The medications below are grouped based on their chemical compositions. A few examples of each type of medications are provided, however, additional medications may exist that are not shown.

Monamine Oxidase Inhibitors (MAOIs)

  • Isocarboxazid (Marplan®)
  • Phenelzine (Nardil®)
  • Tranylcypromine (Parnate®)

Pros :  Very effective in treating depression and have been in use longer than any other antidepressants. Cons:  Strong and potentially dangerous side effects. Side Effects:  Dry mouth, constipation, weight gain, sexual dysfunction and sedation.  Some of MAOIs may lead to liver problems or may lower blood pressure.  In extreme cases there may be a dangerous hypertensive reaction (high blood pressure) when mixed with certain foods or other medications. Bottom Line:  Although highly effective, MAOI medications are rarely prescribed in the United States except in cases where other methods have failed. 

Tricylic Antidepressants (TCAs)

  • Amitriptyline (Elavil®)
  • Imipramine (Tofranil®)
  • Clomipramine (Anafranil®)

Pros:  Very effective and generally safe.  TCAs can be measured reliably in the bloodstream to assure an adequate dosage.  And, as generic drugs, they may be less expensive than other medications. Cons:  Require additional tests prior to beginning treatment. TCAs have more side effects than some other classes of antidepressants.  As a result, patients may have difficulty staying on the medication long enough for it to be effective.  Side Effects:  Dry mouth, constipation, difficulty urinating, weight gain, sedation, blurred vision, decreased blood pressure, and sexual dysfunction have been reported.  There are also effects on the heart that must be monitored while a patient is on these medications. Bottom Line:  Doctors can usually control side effects of TCAs by starting with a low dose and increasing it slowly.  However, depending on the patient, there may be more effective antidepressants available with fewer side effects.

Heterocyclic Antidepressants

  • Amoxapine (Asendin®)
  • Maprotiline (Ludiomil®)

Pros:  In certain cases, these were successful alternatives for patients who could not tolerate the side effects of some other antidepressants.  Cons:  Potentially dangerous side effects.   Side Effects: One of these medications, amoxapine, has been linked to a condition that causes symptoms similar to those of Parkinson's disease.  And another, maprotiline, may cause seizures. Bottom Line: There are newer, equally effective medications that do not have the potentially serious side effects.  For that reason, the heterocyclic antidepressants are now obsolete medications.

Unicyclic Aminoketone

  • Bupropion (Wellbutrin®)

Pros:  Unlike some antidepressant medications, they do not cause weight gain or sedation and are not harmful to the heart.  Patients report only a low incidence of sexual dysfunction. Cons:   Have been linked to seizures in patients who have not been carefully monitored to assure the proper dosage.  They also are not advised for patients with bulimia. Side Effects: In addition to the serious conditions listed above, there are rare occurrences of headaches, anxiety, agitation, and sleep disturbance. Bottom Line:  These medications may be appropriate for patients whose dosage can be closely supervised, and if administered within the recommended guidelines, do not cause seizures more than other antidepressants. The newer longer acting Bupropion SR is associated with a lower risk of seizures than other antidepressants.

Piperazine Antidepressants

  • Trazodone (Desryel®)
  • Nefazodone (Serzone®)

Pros:  Do not cause many of the side effects associated with other antidepressants such as constipation or more serious conditions such as aggravated glaucoma, urinary tract difficulties, sexual dysfunction and heart problems. Cons:  May not be as effective in the treatment of depression.  In fact, they are only effective in fairly high doses and their side effects (particularly sedation) may limit their use in the elderly. Side Effects:  Sedation.  In addition,  Trazodone may cause dizziness because of abrupt drops in blood pressure.  Nefazodone is one of the few antidepressants that has a low incidence of sexual side effects and is less sedating than Trazodone. Bottom Line:  The sedative effect of these medications may prove a problem for elderly patients who need to be maintained on fairly large dosages to achieve a therapeutic effect.

Serotonin Selective Reuptake Inhibitors (SSRIs)

  • Fluoxetine (Prozac®)
  • Sertraline (Zoloft®)
  • Paroxetine (Paxil®)

Pros:  As effective as other antidepressants but have  few minor side effects.  Weight gain, a common side effect of most antidepressants, is not a problem. And, there are no serious effects on the heart or blood pressure. Cons: Expensive but financial assistance may be available.  Ask your doctor about patient prescription assistance information. Side Effects:  One in 10 patients may report diarrhea, nausea, headaches or rashes, agitation, sedation,  and a feeling of apathy.  Four in ten may report sexual side effects, usually a lack of desire. Bottom Line:  Although comparatively expensive, SSRIs have been a significant development in the treatment of depression because of their effectiveness and relatively benign side effects.  The cost of these medications is offset by  their improved side effect profile.

Serotonin and Norepinephrine Modulators

  • Venlafaxine (Effexor®)
  • Mirtrazapine (Remeron®)

Pros:   Similar in side effects to the SSRI class medications. May have minor side effects, but because they work therapeutically on both neurotransmitters affected by depression (norepinephrine and serotonin) medications in  this class may be more effective on patients who failed SSRIs. Cons:  A minority of patients develop high blood pressure on Venlafaxine depending on the dose they take.   Some patients experience weight gain and sedation on Mirtazapine. Side Effects:  Nausea, headaches, agitation, insomnia and sexual side effects are occasionally reported with some of the medications. Bottom Line:  These medications are very effective, with few side effects.  More serious problems with increased blood pressure or sedation can be controlled by modifications to the dosage.

Electroconvulsive Therapy (ECT) 

Electroconvulsive Therapy (ECT), also know as Electroshock Therapy (EST), is a medical procedure used to treat various psychiatric disorders including depression, manic depressive illness and schizophrenia. The reputation of ECT often precedes it, bringing to mind negative images of an antiquated and barbaric treatment. Electroconvulsive therapy also has been touted as a "cure-all" for many psychiatric illnesses. In fact, the truth lies between the two extremes.

ECT is one of the most effective treatments for depression, is usually well tolerated but does carry some potentially serious side effects. The modern ECT suite such as the one at Wesley Woods of Emory University is equipped to provide general anesthesia during the treatment, and monitoring and post-ECT care that is comparable to any outpatient surgical clinic found in any state of the art hospital in the United States. Patients are monitored during the treatment by a team of medical providers that includes a psychiatrist, anesthesiologist, nurse anesthetist, nurse practitioner and postoperative nurses. Patients sleep throughout the treatment and are monitored using a continuous electrocardiogram, blood pressure, oxygenation, and electroencephalogram (EEG). During the treatment, medications are administered to limit the amount of muscle movement and to control heart rate and changes in blood pressure.

 

Psychosocial Therapy

Support and education are an important part of treatment for depression.  Psychosocial therapy, or group therapy, for depressed patients provides a communal experience of counseling, guidance and education that can greatly aid the healing process. In group therapy, a patient expresses his/her  feelings with people who share similar experiences.  A group experience provides an opportunity to improve how we communicate with others, gain a deeper understanding of how others perceive us and how we interpret life events.  There is no better place than a structured group to release all kinds of feelings such as anger, frustration, helplessness, love and compassion. The restoration of meaning in everyday living is an inevitable outcome of a structured group experience.

There are currently two group therapy programs offered through Emory Healthcare:

Transitions Senior Program offers hope by promoting a group atmosphere for older adults to discuss their feelings with others. Program benefits include

  • Free transportation
  • Case management services
  • Most insurance accepted
  • Friendly, caring atmosphere

For a free phone consultation, please call: (404) 728-6975.

Families in Transition is a monthly education and support group for family, friends, and caregivers of older adults who are challenged with:

  • Mental or physical illness
  • Memory loss
  • Role changes
  • Changing living arrangements
  • Grief and loss
  • Anger
  • Communication difficulties
  • Changing emotional needs
  • Understanding resource needs and availability

For more information, please call: (404) 728-6975. 

Natural Remedies 

NOTE:  Even though natural remedies are seen as wholesome, some natural medications once thought to be benign later proved to have sometimes serious side effects. For the most effective treatment of depression, your doctor can prescribe a variety of antidepressants that have minimal side effects and proven results.    

 

  • Hypericum or St. John's Wort

Pros: As an over-the-counter product, St. John's Wort is inexpensive and is believed to have very mild side effects. It has received media attention lately as a natural treatment for anxiety and depression. In 2008, the National Center for Complementary and Alternative Medicine (division of NIH; NCCAM) funded researchers to review the scientific literature on the effectiveness of St. John’s Wort on depression. The majority of studies included participants with minor to moderately severe depressive symptoms. The researchers concluded that St. John’s Wort appeared to be superior to placebo, as effective as a standard antidepressant, and had fewer side effects. However, the researchers’ noted that these results were heavily skewed towards positive findings in German-speaking countries and, thus, further research is necessary to determine the true impact of St. John’s Wort. In 2011, Carpenter conducted a literature review and found that 71% of reviewed studies reported positive changed in depressive symptoms in participants with mild to moderate depression. However, in participants with severe depression, St. John’s wort was no more effective than the placebo. Cons: The National Institute of Mental Health funded a study that evaluated the effectiveness of St. John´s Wort on major depression. The study results found St. Johns Wort to be no more effective than placebo. Since it is an herbal medication, St. John's Wort has not undergone testing by the Federal Drug Administration (FDA). Without FDA scrutiny the product's various brands may be inconsistent in purity and dosage instructions. Side Effects: Minor side effects include digestive complaints and sensitivity to light. This product is not monitored by the FDA and it may weaken the effects of prescription medication such as birth control and blood thinners. Serotonin syndrome (agitation, sweating) has been noted with patients on St. John’s Wort and SSRI’s.  Bottom Line:  Some natural medications once thought to be benign later proved to have sometimes serious side effects.   

  • S-adenyl-L-methionine or SAM-e 

Pros: It is an over-the-counter supplement in the United States but is used effectively as a prescribed medication in Europe. The product's key compound, nicknamed Sam-e, is found naturally in the body and often is deficient in depressed patients. A recent study found SAM-e to be beneficial for individuals with depression that do not respond to standard antidepressant medications (Papakostas et al., 2010). Cons: As with St. John's Wort, the medication has not been monitored by the FDA. In addition, SAM-e may interfere with the effectiveness of other prescribed medications. This medication is very expensive and is often more expensive than the new antidepressant medications. Side Effects: Minor side effects, such as gas and nausea, sometimes have been reported. Bottom Line: While SAM-e has been tested successfully in Europe, tests in this country have just begun. Early results are encouraging.

References:

Carpenter, D. J. (2011). St. John’s wort and S-adenosyl methionine as “natural” alternatives to conventional antidepressants in the era of the suicidality boxed warning: What is the evidence for clinically relevant benefit? Alternative Medicine Review: A Journal of Clinical Therapeutic, 16(1), 17-39.

Linde K, Berner MM, Kriston L. St. John's wort for depression. Cochrane Database of Systematic Reviews. 2000; (4):CD000448.

Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association. ; 287(14):1807–1814 

Papakostas, G. I., Mischoulon, D., Shyu, I., Alpert, J. E., & Fava, M. (2010). S-adenosyl methionine (SAMe) augmentation of serotonin reuptake inhibitors for antidepressant nonresponders with major depressive disorder: A double-blind, randomized clinical trial. 

 

 

 

 

 

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