Treatment of Depression
Most people suffering depression find it hard to choose from the menu of depression treatments. Should one choose to make lifestyle changes, use natural remedies, attend psychotherapy or use medications?
Some individuals prefer to use medications whereas others would prefer talking therapies. But the general guiding principle based on evidence is that, mild to moderate depression would respond to psychotherapy alone , whereas moderate to severe depression requires medical intervention. Initial phase of treatment would be aiming at reducing the severity of the symptoms. After symptoms are under control, the aims of the continuation phase of treatment are to get one back to living a fulfilling life, and to stop their symptoms from coming back again.
What anti-depressant medication is best for me?
The choice of anti-depressant is generally pre-determined, most doctors would start with an SSRI as it is generally safe and effective. Some might prefer an SNRI such as Venlafaxine or Duloxetine if lack of energy, attention or pain are the main presenting problems. Those with Sleep problems may respond well to Mirtazapine or Valdoxan. Some individuals with chronic low mood (Dysthymic) which can be traced back to their childhood tend not to have any change in mood with anti-depressants whereas those with prior hyperthymic ( highly active) or Cyclothymic (cyclical mood changes) temperament tend not to agree with conventional anti-depressants at all. Moreover, some of these individuals with depression tend to have multiple co-morbidities such as generalised anxiety, OCD, Bipolar, Eating disorder, Body image issues, Gambling, Panic attacks, Substance use , Borderline personality, ASD and ADHD. Hence I would like to propose a theoretical model to understand this complexity and to make informed treatment decisions called the “inverted iceberg hypothesis”.
The Inverted Iceberg Hypothesis
This empirically construed model tries to simplify the complexity of an individuals emotional experience and their actions by focusing on their core traits rather than the number of different and often changing psychiatric diagnosis.
People with long history of psychological problems often get confused about the number of psychiatric diagnosis given to them over the years by various medical practitioners. It is not uncommon to be diagnosed with Autism spectrum disorder (ASD), Attention deficit hyperactivity disorder (ADHD) or Tourette’s in childhood only to be re-diagnosed as Borderline, Anti-social, Anxiety disorder, eating disorder, substance use, adjustment disorder or with body image issues in adolescence and then to be diagnosed with depression, anxiety, bipolar, OCD or panic attacks in adulthood. To me, this indicate a developmental trajectory rather than misdiagnosis.
All of us seem to share the same traits but in varying shades. These are genetically determined entities called temperamental traits. It can be subdivided into impulsive and compulsive traits. This division is arbitrary as most people tend to have a combination of both. Nonetheless, those with predominant impulsivity tend to be energetic from the very beginning, they are physically active, pleasure driven, need immediate gratification and usually show low persistence or harm avoidance. Their attention span is generally low and they tend to react physically to stress. Classical pathological version of this is ADHD. Those with significant compulsivity on the other hand, are usually introverted, cautious, anxious and reassurance seeking. They tend to show high level of persistence and task completion, they usually have attention to detail but often has a low self esteem. They prefer to be by themselves, are kind to others and take up altruistic pursuits. They can have rigid rules for themselves or others. Again, the classical pathological counterpart for this would be ASD.
As discussed above, most people with minor variations of these traits never get to the attention of health providers until some new behaviours start to come up. These could be self harm behaviour , uncontrollable anger, bullying at school, excessive checking or cleaning, repeated offending or excessive recreational substance use. During the late adolescence, these basic genetic traits are shaped by the environment into socially adaptive behaviours. Unfortunately some individuals fail to modify these adequately due to either an adverse environment, poor upbringing , trauma, early substance use or pathological traits(neuroticism). The final product of these changes, adaptation , coping and resulting patterns of behaviour are described as an individuals “personality”. Majority of these individuals do identify that there is a problem, but more often than not does not seek treatment or therapy as these are generally considered a part of growing up. Hence the usual presentation is for treatment of one of the adult mental health conditions such as depression, bipolar disorder, anxiety disorder etc.
Very few individuals present with pure forms of anxiety or depression because of the above reason. Co-morbidities are usually high. From the surface, it might appear like someone has a complex presentation with multiple disorders but it could be the final product of only couple of basic genetically determined traits. Now, the question is whether we can use this model to predict treatment response or prognosis?
There is no compelling research evidence at present to support this. However, usually those with Aspergerian traits (Compulsivity) without prominent impulsivity, tend to have chronic low mood which gets worse after inter-personal failures. Such individuals may not respond adequately to SSRI’s and sometimes to SNRI’s. Usually their anhedonia, lack of motivation and energy is more severe and less responsive to treatment. It is likely that these individuals might respond to dopaminergic drugs.
Similarly those with prominent impulsivity tend not to tolerate SSRI’s as they feel blunted on these medications or feel more anxious or agitated. Some may switch to Mania or have panic attacks. Once again glutaminergic, dopaminergic or nor-adrenergic agents seem to work better for the individuals.
Although, such distinctions are probable, practically most individuals respond to conventional treatment. Hence such considerations are relevant only when you are not getting better.
What if I’m not getting better?
Inform your psychologist or GP about your concerns. Discuss your options, if needed get a referral to a psychiatrist for a detailed evaluation. Your psychiatrist may be able to provide a perspective on your problem, factors causing treatment resistance and will be able to guide you through your treatment options. Usually this treatment regimen may involve anti-depressant medications , augmentation strategies or medication free options such as r TMS. Some individuals might require hospitalisation and a course of ECT.
Newer treatments for depression
There are newer medication free- options that are available for treatment of resistant depression. TMS(repetitive Transcranial magnetic stimulation) is a novel and effective treatment for depression especially for those who either did not have good response to medications or who could not tolerate medication side effects. TMS does not need anaesthesia and can be administered in an outpatient set up. Usually there are no after effects, sedation or pain. Most people are able to drive back to their homes or work. TMS is available in many centres across Australia.
A promising novel treatment claiming rapid relief from depression uses Esketamine. Esketamine is a nasal spray which can be administered under clinical supervision. It is generally considered safe and effective and is FDA approved for clinical use in United States. However, it is still under clinical research in Australia.
Mindoc a clinic based out of Melbourne that provides effective treatment for mental illness, treating each patient with individual, empathic attention. You are welcomed to bring in your family or a friend for an appointment. Do get in touch with us and we will guide you systematically through the whole treatment process.