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What are the best options for severe depression treatment?
It might first be important to define severe depression before discussing severe depression treatment. Depression is defined by five or more of the symptoms below.
Severe depression is defined by seven or more. You may also have some psychosis that accompanies your depression such as hearing voices that berate you or tell you that you are bad or delusions such as thinking you are guilty or deserve to be punished.
Here are the symptoms you need to have to meet the criteria of a major depressive episode:
1. Depressed mood most of the day, nearly every day ( by self report or observation by others).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss or weight gain or change in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day. Sleeping too much or not being able to sleep enough.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Being slowed down or keyed up. Many of my clients report this as feeling as if they are moving through quick sand.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific symptoms of depression.
You need to have had them every day for at least two weeks. One of these symptoms must be a depressed mood or diminished interest in previously enjoyed activities. These symptoms must cause you distress in your life. If you have severe depression you likely have more.
These symptoms can’t be due to the effect of drug use or a medical condition.
These symptoms can’t be due to schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
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For Major Depressive Disorder, these three kinds of therapy have the most evidence.
Cognitive Behavioral Therapy
The most extensively researched form of psychotherapy is Cognitive Behavior Therapy (CBT).
CBT helps you to get space from your thoughts so you can weigh the accuracy of them challenge them, and modify the thoughts that help to reinforce and perpetuate your depression. New behaviors are also learned to replace those behaviors that are maintaining the depression and to increase more positive and pleasant activities. It can be delivered in a group or individually.
It is important to note that CBT is the most widely researched therapy, and that is one of the reasons we say it has the most evidence.
Interpersonal therapy (IPT)focuses on the person’s relationships and roles and how difficulties in those roles can lead to depression. Resolving the patterns in those relationships, often with family, partners and peers, can help alleviate depression. Therapist focuses on those issues in therapy, although there is more evidence that those with more moderate depression are able to respond better to this therapy.
Problem Solving Therapy
Problem Solving Therapy (PST) is another form of therapy for depression. It essentially is designed to help a person identify issues contributing to their depression, evaluate and weigh the pros and cons, decide upon a solution and implement it. This has also been shown to be effective with depression.
We are learning more and more about mindfulness based cognitive therapies every day. There is specific evidence that mindfulness based cognitive therapy helps depressed people deal with relapse. And also, we are gathering a research base that suggests there is a role for yoga and tai chi in treating depression(Yassar).
There are several different categories of medicines for Antidepressants, and they are all essentially effective with major depressive disorder.
Selective serotonin reuptake inhibitors(SSRIs) serotonin and noradrenaline reuptake inhibitors (SNRIs) tricyclic antidepressants(TCAs) and monoamine oxidase (MAO) inhibitors. When you have depression, selection by your doctor is individualized based on different factors such as your specific symptoms, side effects, what other diagnoses you may have , how you are tolerating the medications prescribed, drug interactions and cost. Doctors have a specific protocol they follow based on how you respond to your medication. For example, they may increase your medication if you have a partial response, or they may switch your medicine if you have no response, or they may add a medicine in the same or a different category based on how you are feeling.
For some people, their depression is not alleviated with this standard treatment.
Before you move on to different choices for severe depression treatment it’s important that you:
If severe depression treatment of antidepressants and psychotherapy are ineffective the next section lists some alternatives.
Electroconvulsive therapy (ECT) remains the most effective approach for treatment-refractory depression. It was first introduced in the US in the 40s and although people usually think of ECT as barbaric it is now relatively safe and painless. The side effects however can be undesirable. It introduced memory loss and confusion and possible long term cognitive dysfunction.
Vagus Nerve Stimulation
This is a somewhat invasive procedure. It consists of implanting a device through surgery into your chest. A wire is threaded under your skin which connects the device to your vagus nerve. The device when activated sends signals t your brain. There is a new non surgical device approved in Europe but not yet approved in the US.
This is usually tried after ECT and carries several possible complications
Deep Brain Stimulation
Deep brain stimulation (DBS) also involves surgery. Electrodes are implanted into certain areas of your brain. The electrodes regulate and impact cells and chemicals in the brain. A pacemaker device in your chest is connected to the electrodes in your brain and control them. DBS is used to treat a number of other neurological conditions.
Transcranial magnetic stimulation
During a Transcranial magnetic stimulation (TMS) session, an coil is placed against your scalp. A pulse is delivered to your brain that targets places related to depression.
This seems to impact how the brain works and change mood. Treatment for depression involves delivering repetitive magnetic pulses, it is sometimes called rTMS.
TMS is used when medications and psychotherapy don’t work.
Ketamine is considered one of the new fast acting antidepressants that has shown great promise. Some people report it can almost immediately decrease suicidality and symptoms of depression. Insurance doesn’t cover it, it is quite expensive and we don’t fully understand the long term impact of it. It is an option to consider it for severe depression treatment if you have exhausted other approved treatment options.
References for severe depression treatment
Deep brain stimulation - Mayo Clinic. (2018). Retrieved from https://www.mayoclinic.org/tests-procedures/deep-brain-stimulation/about/pac-20384562
Transcranial magnetic stimulation - Mayo Clinic. (2018). Retrieved from https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625
Vagus nerve stimulation - Mayo Clinic. (2018). Retrieved from Vagus nerve stimulation - Mayo Clinic. (2018). Retrieved from https://www.mayoclinic.org/tests-procedures/vagus-nerve-stimulation/about/pac-20384565
Treatment of depression in the 21st Century. Presentation, Ascent TMI and CMS Center.