Anxious depression typically poses a treatment dilemma for doctors. Many seek to use antidepressants that have sedating properties, although it’s not clear that they need to, said Dr. Fava. Studies show that all of the antidepressants work equally well against this type of depression, although high doses may be needed. Still, in practice physicians tend to prescribe a combination of drugs for such patients, usually a tranquilizer along with an antidepressant.
Given their anxiety quotient, depressives of this type are unusually sensitive to bodily sensations. As a result, common drug side effects — such as gastrointestinal distress — are often cause for discontinuing treatment. Even when treatment continues, remission can be a long time coming. Cognitive therapy can be very helpful.
Melancholic depression is often a synonym for severe depression, and it is far more common among those hospitalized for depression than among those in the community. Affected persons lack pleasure in almost all activities and do not react to pleasurable stimulation. They may experience extreme slowness of movement or agitation. Their depression is regularly worse in the morning and is accompanied by lack of appetite and weight loss.
Melancholic depressives may also ruminate over the same thoughts and experiences, and feel excessive guilt. Their depression takes on a life of its own: the more episodes they have, the more autonomous such episodes seem, less likely to be set off by stressful events. And patients do not respond to psychotherapy, at least not before successful drug treatment, reported J. Craig Nelson, M.D., of Yale.
Studies he and others have conducted show that the most helpful drugs for this type of disorder are not the SSRIs but agents that block the reuptake of norepinephrine as well as of serotonin. “Some drugs,” he said, referring to dual-action agents like venlafaxine and mirtazapine, “may treat more symptoms.”
Psychotic depression was once another term for severe depression, but the more refined the tools scientists apply to dissect the disorder, the more distinctive this variety appears, especially biologically. Not only is this type of depression severe, life-impairing and marked by suicide attempts, it is accompanied by delusions that reflect the depressed mood and guilt patients feel.
Biological tests show the patients have a distinct abnormality in the system that controls production of stress hormones, said Linda L. Carpenter, M.D., of Brown University. Imaging studies reveal significant brain atrophy. The decrease in brain tissue likely reflects the toxic effects of excess stress hormones, namely cortisol.
Despite the proliferation of antidepressant drugs, the best treatment for psychotic depression is electroshock therapy. But drugs now in development may offer some advantage. Dr. Carpenter specifically cites agents that interfere with cortisol by blocking receptors for it.
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Last reviewed: By John M. Grohol, Psy.D. on 15 Aug 2007
