These individuals may have treatment-resistant depression or refractory depression. While there’s some debate over the precise definition, treatment-resistant depression is typically thought of as failing to achieve remission after two treatments or two antidepressants, according to George Papakostas, M.D., director of Treatment-Resistant Depression Studies in the Department of Psychiatry at Massachusetts General Hospital.

Why Some People Have Treatment-Resistant Depression

People develop treatment-resistant depression for many reasons. Some struggle with severe depression, which is difficult to treat. Medical illness and comorbid psychological disorders — such as drug or alcohol abuse or eating disorders — also complicate treatment response, according to Dr. Papakostas and Yvette Sheline, M.D., professor of psychiatry and the director for the Center for Depression Stress & Neuroimaging
 at the Washington University in St. Louis. Severe stress also can impact improvement, Dr. Sheline said.

A variety of genetic, neuroimaging and electrophysiological studies have investigated the underlying causes of treatment-resistant depression. And researchers know one thing for sure: Refractory depression is not the result of one brain region or neurotransmitter system.

Preliminary research suggests that individuals with depression may have abnormalities in the frontal and temporal regions in the brain and dysfunction in serotonin modulation. Also, the subgenual cingulate (Cg25), which is located under the cortex along the midline of the brain, may play a role. Cg25 is activated when an individual experiences sadness. It also connects to other regions involved in mood, motivation and sleep. When antidepressants are effective, this area is less active. Some researchers have hypothesized that in refractory depression, Cg25 doesn’t turn off. In general, according to Papakostas, there isn’t enough evidence to show a consistent or unifying theory.

Other individuals may not have refractory depression after all. For instance, according to Sheline, a thyroid problem may mimic depression. Individuals may have bipolar disorder — though there’s recent evidence that bipolar disorder may be overdiagnosed in patients who appear to have treatment-resistant depression — or a long-term low-grade depression called dysthymia. If a treatment isn’t working, it’s critical that your physician re-evaluate your diagnosis.

Treatment Options for Refractory Depression

According to Sheline, there’s disagreement about the number of medication trials a person needs to try before moving onto more invasive interventions. While physicians determine this on an individual basis, it’s important for patients to have an adequate dose of medication for an adequate amount of time, Sheline said. “Each antidepressant has different therapeutic dose ranges, and these also vary according to individual factors, such as age,” she said. An adequate duration of treatment is usually six weeks. If there’s partial improvement, doctors may recommend patients stay on the medication for six to 12 weeks, Papakostas said.

This is why it’s especially important to take medication as prescribed. Many patients stop taking their medication after a week if they don’t get better, Sheline said. But this isn’t enough time to see improvement. Skipping or forgetting a dose can decrease a medication’s efficacy and make it look like it’s not the right medication for you. Also critical is practicing healthy habits, such as engaging in physical activities and getting enough sleep, and managing stress. Exercise boosts mood, while stress and lack of sleep exacerbate depression.

If one antidepressant truly doesn’t work, physicians will typically prescribe an antidepressant from a different drug class. Or they’ll prescribe an augmenting agent, such as lithium or an atypical antipsychotic medication to boost the effectiveness of the antidepressant.

If medication and psychotherapy are unsuccessful, these are other options:

Electroconvulsive therapy (ECT). ECT involves placing electrodes on a patient’s scalp, which sends a specific current that induces a short seizure in the brain. In the 1950s, ECT developed a bad reputation because it was administered without anesthesia and with a high voltage, Sheline said. But today, it’s a completely different treatment, she said.

ECT is administered with general anesthesia and the voltage is carefully controlled. In fact, Sheline noted that there is ongoing work to decrease the pulses to minimize side effects. There’s also been concern that ECT is involuntary, Papakostas said. He clarified that ECT is voluntary and requires a patient’s informed consent.

ECT does have various bothersome side effects, including memory loss and headaches. It’s understandable why patients would hesitate to try it, Papakostas said. However, both Papakostas and Sheline agree that a large body of research substantiates ECT’s efficacy. When compared with medication and psychotherapy, ECT appears to work faster and has a higher chance of success, according to Papakostas. It also has the most efficacy data of all the more invasive interventions.

Transcranial magnetic stimulation (rTMS). According to Papakostas, this treatment is second to ECT in quality of data. Transcranial magnetic stimulation doesn’t require anesthesia or induce a seizure like ECT. Instead it creates a magnetic field that produces an electric current in a specific area of the brain. It’s typically used for mild to moderate depression. The Food and Drug Administration has approved one device called the NeuroStar TMS to treat depression, which may be used after one antidepressant has failed.

Vagus nerve stimulation (VNS). In 2005, the FDA approved vagus nerve stimulation for treating treatment-resistant depression. The device is surgically implanted onto the vagus nerve on the left side of the neck and delivers mild electrical impulses. Think of it as a cardiac pacemaker. According to the University of Maryland Medical Center, it sends 30-second impulses to the vagus nerve every five minutes.

For over a decade, VNS has been used to treat patients with epilepsy. Researchers began studying VNS for refractory depression when they noticed that some patients’ moods improved. Whether VNS is an effective treatment for refractory depression is unclear. It appears to help some people tremendously but not others. To date, “the data [on VNS] just isn’t on par with ECT or rTMS,” Papakostas said.

Not finding a treatment that lifts your depression can be utterly frustrating and make you feel hopeless. But while it may take more time and effort, together with your physician, you can find a treatment that works for you. Remaining optimistic is important. “Being able to maintain a positive, hopeful attitude is as critical as [getting the right treatment], Papakostas said.

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

Surviving Depression traces Hamlett’s life from his early childhood until he finally received a prescription for a combination of medications that successfully keep his depression in remission.  Most of the book takes place during the Vietnam War era and shortly thereafter.  During this time, antidepressant medications were still experimental and many psychiatrists still believed that depression was solely a reaction to circumstance.  The context of the book, however, must be applied to the present day to gain any inspiration.  The hope, therefore, lies in the hands of science.  Compare the available remedies of the 1970s and 1980s to the medicines and therapies we have today, and one will find much hope that depression can be held at bay.

Throughout Surviving Depression, Hamlett emphasizes his fear of slipping into a major depressive episode and having what he calls a “meltdown.”  He writes his memories in such a way that just as the reader gets comfortable with who Hamlett is, his meltdown tears the sense of security from the reader — much like a meltdown does to its victim.  Hamlett’s first meltdown forces him to drop out of school.  Another makes him run away from life and even pushes him to the brink of suicide.  Hamlett captures his “escape to nowhere” with vivid detail:

The next morning, I shaved for the first time in several days.  I also put on the best clothes that I had brought with me.  I wanted to look like a reputable citizen.  Then, I went to a local gun shop.  I had finally convinced myself that taking my own life was the only way to end my suffering … I am not sure exactly how long I stood there staring at that weapon.  It could have been a minute or ten minutes.  I had no concept of time. Many scenes from my life crossed my mind … No, I could not kill myself … I turned and walked out of the store empty-handed.

Only after being hospitalized a second time does Hamlett break free from his depression.  His psychiatrist prescribes a combination of medications that allow Hamlett to function normally, and he remains on those antidepressants to this day.

Surviving Depression achieved its goal, but I do have reservations with the method Hamlett chose to use.  Memoir is definitely an appropriate form of writing for a topic such as this, however, focusing on the negative aspects of his life seemed a bit overwhelming.  Certain parts of the book triggered my own depression and sent me into a meltdown-like state.  I appreciate the heart behind the work, but I would have preferred that the author focus on the solution instead of the problem.  Hamlett covers every way to deal with depression that I know: ignoring it, taking medication, talking to a therapist, and a combination of medicine and therapy.  Obviously, ignoring depression will not help to relieve it.  For Hamlett, talking to a therapist and taking antidepressants in conjunction saved his life.  When his psychiatrist restricted his medications, Hamlett slipped into another meltdown.  For some, this is a real risk.  For others, only therapy helps relieve their depression.  Still others feel that antidepressants alone suffice in treating their condition.

Overall, Surviving Depression was a good book, a quick read, and inspiring enough to convince me to consider other methods of treating my own depression.  The book really does give hope for a better future, especially when one considers that science has come a long way since the events of the book.  Treatments are more effective, cheaper, and the stigma of mental illness is dissipating.  I highly recommend this book to anyone who needs that extra push to get help.  I do caution, however, that reading this book while depressed may worsen your symptoms.

Surviving Depression: My Agonizing Struggle with Sanity
By Robert L. Hamlett
Vantage Press: July 1, 2008
Paperback, 147 pages

After the first chapter, the author describes the basics of depression, such as how it’s diagnosed, where researchers think it may come from, and the usual treasure trove of information you’d expect to find in such a book. The third chapter runs through the common and not-so-common treatments of depression.

The fourth chapter gives the reader the “inside track” on everything from how to best deal with antidepressants and their negative side effects, to what really goes on in psychotherapy. It offers explanations about a variety of issues and myths many patients face in psychotherapy, such as Psychotherapy does not always make you feel better, Psychotherapy is not like talking to a friend and Psychotherapy will not work if you have unrealistic expectations. This chapter also covers the basics of drug discount cards and programs, and how to best navigate the U.S. healthcare system to ensure you get your treatment paid for. This chapter alone makes the book more than worthwhile for its no-nonsense advice and information about these important — but often overlooked — issues.

The next chapter, “Your Depression,” walks you through what to expect in the typical course of a person’s depressive episode. While no two people experience depression in exactly the same way, Dr. Serani uses this chapter to offer tips and practical advice about how to approach treatment and psychotherapy. While much of the advice comes her professional knowledge, it’s also solidly informed with her own direct experiences in dealing with her own depression. While some of the advice borders on the over-exposed (such as the advice to “avoid toxic people”), it’s always well-intentioned.

Chapter 6 walks the reader through the “5 R’s” of depression — response, remission, recovery, relapse and recurrence. Chapter 7 gives us a wealth of information about suicide — a topic often not covered very well in other self-help depression books. Why? Probably because it scares some people to talk about it, but suicidal thoughts are fairly common among people with depression (not to be confused with actual suicidal actions).

The next chapter describing the societal stigma that still exists in many parts of the country regarding depression is important. But I prefer the term “prejudice” nowadays, because it makes the issue more personal. However, this is a very good chapter because it prepares a person to better understand and deal with the various responses they may receive from family members, friends and coworkers whom with they share their diagnosis with. The responses can be all over the board, and this chapter is a great guide to not only better understand the reasons why, but provides some useful ideas on what a person can do about it too.

The last chapter is entitled “Living with Depression” and offers a nice bookend to the first chapter in the book, with the author describing her own personal battles in living with depression. She also relates her own personal discovery in gaining more insight into depression through reading other people’s personal accounts:

One of the most moving accounts of depression for me came from American author William Styron, whose descent into a “dank joylessness” is vividly worded in his 1990 memoir Darkness Visible. Truth be told, the movie adaption of Styron’s Sophie’s Choice left me so hollowed out and emotionally depleted, that I resisted reading his memoir for fear that it would weaken me further. What I found in his pages, however, was quite different. The textures of his experiences offered me consolation. Again, I wasn’t alone.

The book finishes on page 114, but carries on for another 85 pages of appendices. The first 14 pages is of a list of celebrities, authors and other famous people who’ve had a mood disorder. I suppose the author finds such a list both comforting and eye opening, but such lists don’t do much for me. Since most people grapple with depression at some point in their lives — to one degree or another, whether it’s a full-blown clinical depression or not — I would argue most anyone could go on that list.

Another 15 pages list depression resources and organizations that may benefit the reader. The remainder of the book is filled with notes — mostly research references from the chapters — as well as a helpful glossary.

Insight and perspective comes in droves in this book, but for me, the best chapters were the first one and the last one, in which Dr. Serani recounts her personal failures and successes in battling depression. In short, personal stories move me more than facts and data; but I’m a biased reader, since my depression knowledge is likely greater than the average layperson this book is targeted toward. My only wish was that there was more of this personal narrative throughout the entire book, because all too often the book felt like it was more of a textbook rather than a personal account intertwined with the kind of information one might expect from a depression self-help book.

Nonetheless, this is a thoughtful book about depression and would be recommended for anyone who has just been recently diagnosed with depression, or knows someone who has and wants to better understand this illness. It left me with a very real sense of hope. Because it is up-to-date and well-written, it will give you (or your loved one) everything you’ll need to know, understand and find a path toward recovery from depression.

Hardcover: 208 pages
Publisher: Rowman & Littlefield Publishers (May 31, 2011)
Language: English
ISBN-10: 1442210567
ISBN-13: 978-1442210561
Product Dimensions: 8.4 x 5.7 x 1 inches

Side effects are a normal part of taking virtually any prescription medication. Although the drugs are intended to treat the specific condition — in this case, depression — they also cause unwanted physical symptoms that are usually an annoyance.

You shouldn’t feel abnormal, awkward or self-conscious if you have any of these side effects. You should, however, talk to your doctor about them — especially if they make you feel worse or the side effects themselves are unbearable:

• Decreased sex drive or no sex drive at all
• Dry mouth — your mouth feels very dry and cannot produce the same amount of saliva as usual
• Mild to moderate nausea
• Insomnia — inability to get to sleep, or difficulty staying asleep
• Increased anxiousness or restlessness
• Daytime sleepiness or drowsiness
• Weight gain
• Constipation or diarrhea
• Headaches
• Increased sweating
• Dizziness

Whatever you do, do not try and manage your medication — the dose, frequency or amount you take — on your own. You need to talk to your doctor before making any changes to your medication. Do not suddenly quit taking your medication, because it could cause intense withdrawal symptoms or even a return of your depression.

Keep in mind that some side effects can also be managed in conjunction with your doctor. There are remedies for dry mouth, for instance, and additional medications for other things (such as sexual dysfunction, a common side effect of many antidepressant medications).

Helping to Manage the Common Side Effects of Antidepressants

1. Decreased sex drive or no sex drive at all

Ask your doctor whether another medication is available that doesn’t have such strong sexual side effects, or if a lower dose may help with the problem. Talk to your doctor about other options, such as taking a medication for erectile dysfunction.

2. Dry mouth

Eat more water-laden snacks, like celery sticks, and consider chewing sugarless gum, or suck often on sugarless candy. The sugarless part is important, because otherwise the sugar of constant gum chewing or candy sucking can harm your teeth and cause future cavities. You can also consider increasing your daily water intake by drinking at least 8 to 10 glasses of water a day and cutting back on some of the caffeine-laden drinks, such as coffee, tea and alcohol. As a last resort, you can also try a specially formulated rinse for your mouth that may help, such as Biotene or Orazyme.

For the bad breath that often accompanies dry mouth, consider munching on these herbs: parsley, aniseed, fennel, rosemary and cayenne pepper (individually, not all together!). See this article for more details.

The different classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), norepinephrine (noradrenaline) reuptake inhibitors, atypical antidepressants, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Different classes of antidepressants take different amounts of time before you will start to feel their anti-depressant effects.

The most commonly prescribed modern antidepressants include SSRIs — such as Prozac, Lexapro, Celexa and Paxil — and SNRIs — such as Pristiq, Cumbalta and Effexor. Although the claim is made that some people may be able to start to feel less depressed within 2 weeks of taking one of these kinds of antidepressants, most people won’t start experiencing the full positive effects of the medication until 6 to 8 weeks after beginning it.

In addition to feeling less depressed from antidepressant medications, people will often experience the side effects of antidepressants first. While these side effects vary from person to person and from medication to medication, the most commonly observed side effects in antidepressants are:

• Decreased sex drive or no sex drive at all
• Dry mouth — your mouth feels very dry and cannot produce the same amount of saliva as usual
• Mild to moderate nausea
• Insomnia — inability to get to sleep, or difficulty staying asleep
• Increased anxiousness or restlessness
• Sleepiness
• Weight gain
• Constipation or diarrhea
• Headaches
• Increased sweating
• Tremors or dizziness

You shouldn’t be overtly concerned if you experience any of these side effects while taking an antidepressant, but you should still tell your psychiatrist or doctor about them. Some side effects may go away on their own once your body adjusts to the medication. Others may not, and may be addressed through an adjustment of your medication dose or when you take it.

Antidepressants don’t work for everyone. Sometimes the first antidepressant a doctor prescribes may not work for you (as they don’t in 50 percent of people who try an antidepressant). Don’t get frustrated, just accept that either another medication may need to be tried, or the doctor may suggest a higher dose may be required. Talk to your doctor about adjusting your medication if you’re not feeling any positive effects of the medication after 6 to 8 weeks.

Older classes of antidepressants — MAOIs and tricyclic antidepressants — take about the same amount of time to work — anywhere from 2 to 6 weeks for most people, while most people will start to feel a benefit within 3 to 4 weeks. It is not well understood why antidepressant medications appear to take longer to work than other types of psychiatric medications.

For decades, the dominant hypothesis of depression has been that low levels of monoamines in the brain cause this debilitating disorder.

In the ‘80s, the selective serotonin reuptake inhibitor (SSRI) fluoxetine (brand name: Prozac) heralded a new era of safer drugs which also target the monoamine system. Since then, various SSRIs and serotonin-norepinephrine reuptake inhibitors (or SNRIs) have been developed as new antidepressants. While these drugs aren’t more effective than older antidepressants, they are less toxic.

But SSRIs and SNRIs don’t work for everyone, so MAOIs and TCAs still are prescribed.

Two out of three patients with depression do not fully recover on an antidepressant medication according to findings from STAR*D, the largest clinical trial study of treatments for major depressive disorder, funded by the National Institute of Mental Health. (One-third of patients do have a remission of their depression symptoms.)

These results “are important because previously it was unclear just how effective (or ineffective) antidepressant medications are in patients seeking treatment in real-world settings,” said James Murrough, M.D., board-certified psychiatrist and a research fellow at the Mount Sinai School of Medicine Mood and Anxiety Disorders Program.

As Murrough explained, depression treatment can be thought of in thirds: “for one third of patients, symptoms remit; another third don’t have as good of an outcome, experiencing residual symptoms and waxing and waning course or chronic course and are at risk for relapse whether they’re on or off medication; and then a third don’t get much benefit at all.”

He added that around “10 to 20 percent have persistent clinically significant symptoms that aren’t decreased by current treatment — these are the patients that we are the most worried about.”

So there’s a real need to find treatments that work for these patients. Since the 1950s and 1980s breakthroughs, researchers haven’t discovered drugs that target chemical systems in the brain other than the monoamine system.

“We haven’t been able to find any new systems, because we don’t understand the underlying biology of depression,” Murrough said.

But researchers are studying other mechanisms of depression and various drugs have recently been approved to treat depression. Below, you’ll learn about these drugs along with several chemical systems research is exploring.

Recently Approved Drugs for Depression

Recently approved drugs for depression are generally “me-too” drugs. A “me-too drug is a drug whose mechanism of action (what it does at the molecular level in the brain) is not meaningfully different than its predecessor,” Dr. Murrough said.

Prime examples of me-too drugs are desvenlafaxine (Pristiq), an SNRI, and escitalopram (Lexapro), an SSRI, he said. Pristiq is simply Effexor’s main metabolite. Lexapro is essentially a close relative derivative of citalopram (Celexa). Interestingly, sales still skyrocketed when Lexapro came out.

As Murrough said, there is value in some me-too drugs. Generally, all drugs within the classes SSRIs and SNRIs are me-too drugs. But the side effect profiles for each drug have slight differences, which can help patients.

For instance, Prozac tends to be more activating, so a doctor may prescribe it for patients with low energy, Murrough said. In contrast, paroxetine (Paxil) makes people more tired, so it’s prescribed to patients who have trouble sleeping, he said.

The drug Oleptro was approved this year for depression. It doesn’t target new mechanisms, and it isn’t even a me-too drug, Murrough said. It’s a reformulation of trazodone, an atypical antidepressant that’s been used as a sleeping aid by psychiatrists and other doctors. Because it’s so sedating, its earlier form would just put patients to sleep. “It is unclear if the new formulation will offer any benefit for patients over the original,” Murrough said.

These recently approved medicines “characterize the state of drugs in psychiatry,” Murrough said, and speak to “what’s wrong with antidepressant drug development today.” Novel treatments just aren’t on the market.

Augmentation of Depression Drugs

Recently, the biggest development in depression treatment has been the use of augmenting agents, said David Marks, M.D., assistant professor at the Department of Psychiatry & Behavioral Sciences at the Duke University Medical Center.

Specifically, some research has found that adding atypical antipsychotic drugs, like aripiprazole (Abilify) and quetiapine (Seroquel), to an antidepressant can boost its effectiveness.

Atypical antipsychotics are used to treat schizophrenia and bipolar disorder. “Abilify has three strong studies that show how well it works in patients that have partially responded to antidepressants,” Marks said. According to Murrough, augmentation has become a common strategy in depression treatment.

The Glutamate System and Depression

Researchers have looked at the role of the glutamate system in depression. Glutamate is abundant in the brain and is one of the most common neurotransmitters. It’s involved in memory, learning and cognition.

Some research has implicated the dysfunction of the glutamate system in medical conditions, such as Huntington’s chorea and epilepsy, and psychological disorders, such as schizophrenia and anxiety disorders.

Recent research suggests that drugs targeting a specific type of glutamate receptor in the brain — called the NMDA receptor — may have antidepressant effects.

Studies have explored ketamine, an NMDA antagonist, in treating treatment-resistant depression and acute suicidal ideation. Ketamine has a long history in analgesia and anesthesiology.

Currently, when a person is at imminent risk for attempting suicide or has attempted suicide, they’re admitted to a psychiatric hospital and closely monitored. But, as Murrough explained, medically, there’s nothing doctors can do to help with suicidal ideation or intense depressed mood. Antidepressants typically four to six weeks to work.

Ketamine appears to have fast antidepressant effects — within hours or a day. Thus, it may help protect patients from suicidal thinking or acute dysphoria when they’re in the hospital. Unfortunately, its effects only last seven to 10 days.

This research is “highly experimental, and probably less than 100 patients in the country have participated in controlled depression studies of ketamine,” Murrough said. The patients in these studies typically have treatment-resistant depression: They haven’t responded to several antidepressants and have moderate to severe symptoms of depression.

They’re admitted to the hospital and receive ketamine intravenously from an anesthesiologist, while their vital signs are closely monitored.

Ketamine is a drug of abuse, known by such street names as “Special K.” It induces trance-like or hallucination states. It also produces mild to moderate cognitive side effects, like other anesthetics. People report feeling “out of it,” intoxicated and disconnected in general.

These side effects actually “introduce a potential bias to the study design” because participants know they’re getting the treatment (when saline is given in the placebo condition), Murrough said.

To eliminate this bias, Murrough and his team are conducting the first-ever study to compare ketamine to a different anesthetic — the benzodiazepine midazolam (Versed) — which has similar transient effects as ketamine, he said. The study is currently recruiting participants.

Murrough cautioned that ketamine isn’t meant to be a treatment administrated at your doctor’s office. In a recent article in the journal Nature Medicine, he said ketamine treatment may be “akin to electroconvulsive shock treatment.”

Studying ketamine may reveal mechanisms underlying depression and help to find drugs that can be prescribed as antidepressants to a wider patient population.

Pharmaceutical companies have started exploring other NMDA receptor antagonists for treatment-resistant depression. For instance, in July 2010, the pharmaceutical company Evotec Neurosciences began testing a compound in a Phase II study, which evaluates the safety and efficacy of a drug.

The reality is that it is possible to safely discontinue any medication, including psychiatric ones.

Stop your medication for the right reasons.

“Timing is everything,” according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of the book Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting. Just because someone wants to stop taking their medicine doesn’t mean they’re actually ready, he said.

There are many reasons individuals decide to stop taking medicine. For instance, they might feel better and think they don’t need treatment anymore. Their family might be pressuring them to stop, they read something about a drug that scares them, or they’re afraid that the drug will affect their personality, Banov said. Sometimes people want to stop after making major changes in their lives, such as getting a divorce, moving or changing jobs. But, according to Dr. Banov, this is actually “the worst time” to stop.

Also, some mental health conditions require taking medicine indefinitely. Ultimately, how long a person takes a psychotropic drug depends on his or her individual illness, its responses to treatment and their personal situation, according to Dr. Ross J. Baldessarini, professor of psychiatry and neuroscience at Harvard Medical School and director of the psychopharmacology program at the McLean Division of Massachusetts General Hospital. For instance, some individuals struggling with depression may take an antidepressant for nine months to a year and get better; others may need two to five years; and still others, may be “so genetically loaded for depression, that they may need to stay on them indefinitely,” Dr. Banov said.

Don’t stop your medication abruptly.

“Stopping abruptly is especially dangerous,” Baldessarini said.

Depending on the medicine, stopping abruptly or “cold turkey” can cause a variety of distressing reactions, ranging from mild to moderate early discontinuation symptoms with antidepressants, rapid return of the illness being treated, or even potentially life-threatening seizures with a high dose of benzodiazepines.

Consult your doctor before stopping any medicine, and never attempt to do it on your own.

Consider if you’ve received a thorough assessment.

A comprehensive assessment is required prior to stopping medicine. Among other indicators, your doctor needs to consider “your current clinical condition and life circumstances, your past clinical history, reasons to consider stopping versus continuing treatment, side effects and the presence of stressors and supports, as well as the dose and the length of time you’ve been taking a medicine,” Baldessarini said. You and your doctor should talk about these indicators along with how he or she plans to discontinue the drug.

There are no firm, established rules for discontinuing psychiatric medicines. However, there is one major rule of thumb: Reduce the dosage gradually whenever possible. “We still do not know for sure how long is long enough to reduce doses safely,” Baldessarini said. Still, the “slower the dose-reduction, the greater the chances of preventing return of symptoms of the illness for which treatment was started. Very slow discontinuation is especially important when a person has been taking high doses of a medicine over a long time,” he said.

Discontinuing multiple drugs is like peeling an onion, Baldessarini said. He usually leaves the most essential medicine for last. He then reduces doses of one or more optional or supplemental drugs slowly and gradually. Stopping all medicines at once is not safe.

Dealing with small final doses is tricky when dropping from a low dose to nothing. Sometimes doctors decrease the dose to one pill a day or one every two days or split the pill in half, he said. Pill-splitting can be very helpful. You can find pill splitters at your pharmacy.

Don’t expect stopping medication to be a quick process.

Gradually and safely discontinuing a drug doesn’t happen in a few days. Some drugs, including antidepressants, don’t show benefits for several weeks when they’re started; it seems best to avoid discontinuing faster than over several weeks, Banov said.

If you’ve been taking a medicine for years, Banov recommended reducing the dose, stepwise, over at least six weeks. While this may be a conservative practice, he said that “sometimes, you might not detect a change for a few weeks, but later, problems may arise.” Discontinuation symptoms usually occur within days of stopping a medicine, but relapse of the illness being treated can be delayed for weeks after initially feeling well.

In bipolar disorder, Baldessarini and his research team found years ago that the rate of discontinuing ongoing treatment determines the risk and timing of relapse, he said. Initially, their research found that risk for relapse after discontinuing lithium was reduced by one half or more when slow dose-reduction over several weeks was compared to abrupt discontinuation (Baldessarini et al., 2006). Gradual discontinuation of antipsychotic drugs also resulted in lower risk of relapse in schizophrenia (Viguera et al., 1997). In a recent study, he and his colleagues found that stopping an antidepressant abruptly or only over several days resulted in a much greater risk for depression or panic than gradual discontinuation over two weeks or more (Baldessarini et al., 2010).

If you’re switching from one medicine to another, you can be more aggressive than when discontinuing altogether, Banov said. Usually you switch drugs because of ineffectiveness or side effects, and commonly a new drug is introduced as the previous one is gradually removed. This way, there’s little concern about either withdrawal symptoms or relapse, assuming that both drugs have similar effects or belong to the same class, he said. If you’re switching classes, it’s usual to “cross-taper” the medicines: You take both drugs for a while, and then, the doctor reduces the dose of one and ups the dose of the other.

Your doctor may prescribe another medication.

If you’re taking a relatively short-acting antidepressant, such as paroxetine (Paxil) or venlafaxine (Effexor), and you experience bothersome symptoms, “your doctor may prescribe a long-acting antidepressant such as Prozac for a time, and then gradually discontinue the long-acting drug to limit risk of discomfort of withdrawing,” Baldessarini said. “The principal byproduct of the metabolism of fluoxetine has an extraordinarily long half-life or duration of action,” he said, and can take weeks to leave your system.

This method is not well established for discontinuing other classes of psychotropic drugs, including antipsychotics and mood stabilizers, so the best option usually is to “discontinue such drugs gradually, with close clinical monitoring by your doctor,” Dr. Baldessarini said.

This common phenomenon is known as SSRI discontinuation syndrome. (It may also be known as SSRI withdrawal syndrome.)

Discontinuation symptoms typically arise within days after stopping the medication, particularly if it was stopped abruptly. Stopping a high dose of a relatively short-acting drug also can bring on symptoms. In addition to the previously-mentioned symptoms, “anxiety and depressed or irritable mood are common features that may make it hard to differentiate SSRI discontinuation syndrome from early return of symptoms of depression,” Baldessarini said.

About 20 percent of people experience discontinuation symptoms, according to Dr. Michael D. Banov, medical director of Northwest Behavioral Medicine and Research Center in Atlanta, and author of Taking Antidepressants: Your Comprehensive Guide To Starting, Staying On and Safely Quitting. About 15 percent experience mild to moderately bothersome symptoms while fewer than five percent experience more severe symptoms, he said.

However, the risk for discontinuation syndrome is generally greater with potent, short-acting SSRIs —particularly paroxetine (Paxil and others) and venlafaxine (Effexor and others), Baldessarini said.

Discontinuation symptoms can happen with any antidepressant, but seem to be more common with the following classes of drugs:

• SSRIs. These include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac and others), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft)
• Inhibitors of inactivation of both norepinephrine and serotonin (SNRIs). These include chlompramine (Anafranil), venlafaxine (Effexor) and desvenlafaxine (Pristiq). Such drugs are prescribed more often for depression or severe anxiety disorders, so the withdrawal phenomenon is more common.

Whether you experience discontinuation syndrome after stopping an SSRI depends on several factors. These include the amount of time you’ve taken the medication, your dosage level, and the pill’s half-life (how quickly it is eliminated from your body). For instance, Prozac, which has about a five-week half-life, appears to cause discontinuation much less often than drugs with shorter half-lives, such as Paxil.

If discontinuation symptoms last more than a week or two, call your doctor. You may be in the early stages of a relapse.

Preventing Discontinuation Syndrome

There are ways that you can prevent or reduce discontinuation symptoms.

• Don’t stop a psychotropic medicine abruptly. People may stop their medicine abruptly for various reasons, including feeling better or experiencing unpleasant side effects, as well as simply forgetting to refill a prescription. But stopping some medicines abruptly or “cold turkey” can cause discontinuation or withdrawal symptoms.

• Talk to your doctor. If you’d like to stop your antidepressant, first talk it over with your prescribing clinician. Voice any concerns you have, and do not attempt to stop on your own. “It’s a collaborative venture between patient and doctor,” Baldessarini said. “Don’t be afraid to ask your doctor tough questions.”
• Consider if you’ve received a thorough clinical assessment. Before stopping an antidepressant — or any medicine — your doctor should assess whether this is an appropriate time to do so. He or she should consider various factors, “including your past clinical history and current stress level,” Baldessarini said.
• Discontinue slowly. One of the best ways to minimize discontinuation syndrome is by reducing doses of medicines, including SSRIs, slowly. Together, you and your doctor should decide how to reduce, then stop, the dose. Based on his and others’ clinical research, Baldessarini said that reducing the dose of an SSRI to zero gradually over two weeks or longer is prudent. Even slower discontinuation may be required if you’ve taken high doses for a long time.
• Practice healthy habits. If you’re under a lot of stress, not sleeping well, not eating nourishing foods, or not sticking to a consistent schedule, stopping medicine successfully may be unrealistic. It can increase anxiety and depression, which can make stopping harder.

Is It Discontinuation Or Depression?

Discontinuation reactions are not dangerous. According to Banov, “the bigger concern when stopping your antidepressant is making sure your depression does not return.” Typically, “this risk follows SSRI-discontinuation reactions by considerable time (weeks to a few months), but when depression re-emerges quickly, it can be tough to tell whether you’re experiencing discontinuation symptoms or a recurrence of depression,” Baldessarini said.

If you’re experiencing these symptoms soon after stopping an antidepressant, then the reaction likely is discontinuation syndrome. However, as Banov noted, symptoms such as mood swings, anxiety and depression can make it tricky to distinguish between discontinuation reactions and depression. He suggests that patients and their clinicians consider the symptoms that led to starting the treatment. “If anxiety was initially part of your symptoms, that’s a clue that new symptoms of anxiety during discontinuation of treatment may represent depression, especially if they arise after several weeks after stopping the medicine,” he said.

Risk of discontinuation or withdrawal reactions appears to be greater after stopping prolonged treatment, especially with high doses of an antidepressant, according to Baldessarini. “Although the duration of treatment is less clearly a predictor of relapse of depression or anxiety, symptoms arising many weeks after discontinuing most likely represent relapse.”

In addition to slowly reducing the dose of an antidepressant, Baldessarini emphasized the importance of “thoughtful monitoring by yourself and your doctor, and communicating” with your doctor to limit risks of relapse after stopping an antidepressant.

Credit: JOHN GREIM / SCIENCE PHOTO LIBRARY

So, in short, starting, staying on and safely quitting antidepressants are topics that aren’t easy to make sense of. Fortunately, Taking Antidepressants gives readers a balanced, up-to-date and jargon-free look at the pros and cons of taking this class of medication. Written by Michael D. Banov, M.D., a triple board-certified medical director at Northwest Behavioral Medicine and Research Center in Atlanta, this book dispels common myths, discusses the latest research and provides the tools for readers to become smart consumers and active participants in their treatment.

Aptly, the book is divided into three parts: Starting Antidepressants, Staying on Antidepressants and Stopping Antidepressants. In each chapter, Dr. Banov answers common questions and concerns about depression and its treatment. Toward the end, there’s a short section on antidepressants in children and teens, a glossary and list of Internet resources. You’ll also find an appendix section with valuable tools, including short questionnaires to help you assess your mood and health, a list of commonly prescribed medications and their side effect risk and a self-test to see if you can successfully taper off a medication.

In section one on starting antidepressants, Dr. Banov introduces readers to four individuals who are suffering from some type of depression. Their stories appear throughout the book, and serve as a great illustration of diagnosing, treating and living with depression. He also discusses what to do when considering an antidepressant, such as making sure that you’re seeing a professional who specializes in depression and can offer suggestions for non-medication treatments. He includes various questions that your doctor may ask so you can prepare for your appointment, and helps you determine your own attitude about antidepressants.

Next, he demystifies depression by outlining the various types. He discusses how depression affects the brain and body, the types of antidepressants and how doctors choose medications for patients. These are complex concepts that can confuse many readers. However, Dr. Banov provides straightforward and easy-to-read explanations, whether he’s discussing brain receptors or drug research.

In the second section, staying on antidepressants, you’ll learn how to tell if your medication is working, what to do to boost its effectiveness, the safety of antidepressants, overcoming side effects and what to do when your medication stops working. Dr. Banov provides a frank discussion of everything from how clinical research works to which medications have the greatest risk for dangerous side effects to whether antidepressants are addictive. Again, you’ll find this refreshing frankness throughout the book.

The third section addresses a much-neglected topic: stopping antidepressants. Dr. Banov talks about the right and wrong reasons to stop taking antidepressants along with the factors that may create successful or unsuccessful discontinuation. He lays out the safe ways people can stop or switch antidepressants with the help of their doctor.

The final chapter focuses on life post-medication, including what you can do to prevent another episode of depression.

Taking Antidepressants features a wealth of science-based and expert information. Dr. Banov talks candidly about the limits of depression treatment and the research to date. For instance, in Chapter 4, he reveals how pharmaceutical companies can manipulate studies to give their drug the upper hand.

Dr. Banov provides the facts without taking either sides of the medication debate. He emphasizes the importance of choosing treatments based on a person’s specific needs. He empowers readers to educate themselves, ask their doctors questions and to seek second and third opinions. In Chapter 1, for example, he writes, “If your provider takes offense at this [getting a second opinion], then you may be dealing with someone whose ego is too inflated to serve you well.”

Books on medication tend to be dry and read like jargon-filled textbooks; however, Dr. Banov has created an engaging and well-written text that simplifies dense subjects.

Overall, Taking Antidepressants is a must-read for patients, loved ones, caregivers and even mental health professionals. Amid the misinformation, confusion, mystery and stigma that surround psychiatric medications, this book provides a clear-cut, compassionate, well-researched and insightful look into treating depression and making informed choices about your treatment.

Taking Antidepressants: Your Comprehensive Guide to Starting, Staying On, and Safely Quitting
By Michael D. Banov, MD
Sunrise River Press: July 2010
Paperback, 304 pages
$16.95

Depressive symptoms also are thought to increase the risk of further heart problems and mortality.

Dr. Michael Rapp from St. Hedwig’s Hospital, Berlin, and his team enrolled 22 patients three months after hospitalization for acute coronary syndrome. The patients had brain scans to highlight any cerebral deep white matter changes or structural abnormalities in areas called the anterior cingulate cortex and the dorsolateral prefrontal cortex. They also completed the Beck Depression Inventory.

Results showed that, after three months, patients with persistent depressive symptoms had “more advanced deep white matter changes” than patients who were not depressed.

Details are published in the journal Psychotherapy and Psychosomatics. The authors believe, “this study provides the first evidence that persistent depressive symptoms after acute coronary syndrome are associated with brain changes.”

They call for long-term studies to see whether depression develops in advance of these brain changes or afterward and which aspects of depression are worthy of further investigation.

Dr. Rapp writes, “Elevated depressive symptoms appear to be a robust risk and prognostic marker of cardiovascular disease. This has led to conjectures that depression is a causal risk factor, and that depression treatment may alter the course of cardiovascular disease.”

In February this year, researchers from the Royal College of Surgeons in Ireland again found that depression predicts the onset and recurrence of heart disease. They looked at which depressive symptoms in particular were linked to poorer outcomes, and found that “fatigue/sadness,” but not other symptoms, were associated with increased risk of having a major cardiac event.

They write that in the context of heart disease, “Depression should be considered as a multidimensional, rather than a unidimensional, entity.”

A 2006 study again highlighted the complexity of the link between depression and heart problems. It found that the Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, is able to identify heart patients with a raised risk of mortality in the following year.

Previous studies also have found that depression is a strong predictor of future heart disease in healthy people. A 2004 review summed up the evidence. It concluded that depression can double the risk of developing cardiovascular disease, due to a number of plausible reasons such as lifestyle risk factors and differences in the nervous system.

The team also looked at the effects of treating depression in heart patients. They write, “There are currently several empirically validated treatments for depression. However, to our knowledge, there have been only two completed clinical trials treating depression in cardiac patients.”

One of these trials took heart attack patients with depression and gave them either usual care or a psychosocial intervention consisting of at least six sessions of individual cognitive behavior therapy, group therapy, and antidepressants. But the intervention was not effective at reducing rates of mortality or recurrent cardiac events.

The second trial compared the effects of sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI) antidepressant and placebo for patients with depression alongside heart problems. In this case, there was a tendency for the patients treated with sertraline to have fewer serious adverse events (death or rehospitalization for heart problems) than those on placebo. This may be because, in addition to reducing symptoms of depression, SSRIs act as an anticoagulant or blood thinner.

The researchers conclude that the effectiveness of depression treatment to improve outcomes for depressed cardiovascular disease patients is still unclear.

Nevertheless, Dr. Hannah McGee of the Royal College of Surgeons in Dublin, Ireland, believes that depression symptoms in heart patients should be measured by health practitioners. Her research leads her to believe, “Routine assessment would identify those at increased risk of poorer outcomes. Short-form depression questionnaires are an acceptable substitute for clinical interviews in a setting where depression would not be routinely assessed.

“Identification of depressed patients is advisable for both service providers and patients. The prevalence of depression and the poorer outcomes seen in this group provide support for the treatment of depression to enhance patients’ quality of life, and to reduce the negative outcomes associated with depression.”

References

Rapp, M. A. et al. Persistent Depressive Symptoms after Acute Coronary Syndrome Are Associated with Compromised White Matter Integrity in the Anterior Cingulate: A Pilot Study. Psychotherapy and Psychosomatics, Vol. 79, April 2010, pp. 149-55.

Davidson, K. W., Rieckmann, N. and Rapp, M. A. Definitions and Distinctions Among Depressive Syndromes and Symptoms: Implications for a Better Understanding of the Depression-Cardiovascular Disease Association. Psychosomatic Medicine, Vol. 67, May/June 2005, S6-S9.

Doyle, F. et al. Depressive symptoms in persons with acute coronary syndrome: specific symptom scales and prognosis. The Journal of Psychosomatic Research, Vol. 68, February 2010, pp. 121-30.

Lett, H. S. et al. Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosomatic Medicine, Vol. 66, May-June 2004, pp. 305-15.

Doyle, F. et al. The Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, identifies patients with acute coronary syndrome at elevated risk of 1-year mortality. Journal of Psychosomatic Research, Vol. 60, May 2006, pp. 461-67.

McGee, H. M. et al. Impact of briefly-assessed depression on secondary prevention outcomes after acute coronary syndrome: a one-year longitudinal survey. BMC Health Services Research, Vol. 6, Feb 2006, article 9.

This book will challenge the prevailing “medical model” of depression and the widespread, even epidemic, use of chemical antidepressants. This narrow model of diagnosis and treatment insists that those who feel helpless and hopeless, unhappy and uncertain, have a disease, like insulin-dependent diabetes, that requires a pharmacologic treatment. I’ll offer you evidence that strongly suggests that this model is poorly justified, largely inappropriate, limited and limiting, and, often enough, dangerous to your physical, emotional, and spiritual health.

A non-drug approach to the treatment of depression is the focus of Unstuck: Your Guide to the Seven-Stage Journey Out of Depression. In his latest book Gordon outlines his preferred depression treatment—a “healing journey” that includes “mind-body” techniques such as meditation, guided imagery, physical exercise, and acupuncture.

Gordon’s expertise in using mind-body medicine to heal depression is influenced by his work with leading physicians and researchers at the National Institute for Mental Health (NIMH) and The Center for Mind Body Medicine. Some techniques recommended in the Unstuck approach—such as the soft belly—are borrowed from those individuals.

Gordon suggests a comprehensive alternative approach to treating depression. In the first step, “The Call,” Gordon instructs the reader to acknowledge his depression and investigate its cause. This investigation begins with a trip to the reader’s primary care physician for a physical exam, complete medical history, and routine lab tests. If the “conventional workup” does not reveal the cause, Gordon suggests consulting with a naturopath.

During “The Call” the reader also examines his diet. Gordon suggests using an elimination diet to identify food sensitivities. He also offers suggestions for vitamin and mineral supplements.

In the “Guides on the Journey” stage the reader is given instructions for “meeting and choosing the men and women who can help.” Gordon doesn’t always refer to these men and women as therapists, but it is fairly clear that he is asking the reader to consider psychotherapy. “False guides”—people who “got the answers, not only for themselves but for you as well”—are identified as well.

The third stage, “Surrender to Change,” acknowledges that “the journey through and beyond depression requires a balance of action and acceptance.” During this stage Gordon asks the reader to let go of control and move forward. Movement is emphasized during this stage in the form of walking, yoga, dancing, and dynamic meditation.

The fourth stage, “Dealing with Demons” focuses on addressing the habits that keep the reader stuck. In this stage Gordon recommends meditation and Chinese medicine to address these issues.

In the fifth stage, “The Dark Night of the Soul,” Dr. Gordon addresses suicidal feelings. According to Gordon these feelings signal “a turning point, not an end point.” Readers are encouraged to seek out their guide and meditate. Gordon says he considers using antidepressants during “dark nights,” but recommends SAM-e, 5HTP, and Saint John’s Wort first.

Spirituality is the focus of the sixth stage. Gordon is careful to note the difference between religion and spirituality—“the connection between ourselves and something greater than ourselves.” Meditation and prayer are recommended.

The last step, “The Return,” is a celebration that depression has lifted. Gordon offers 10 simple suggestions to the reader to practice as they move forward with their lives: T

• relax
• move
• be aware
• practice acceptance
• have patience
• take time out
• fear not
• ask for help
• trust your inner guide
• celebrate everything

The Unstuck approach may be a valuable treatment option for mildly depressed individuals who have the drive to exercise on a regular basis, cook healthy food, and participate in psychotherapy. Most individuals with severe depression, however, lack the kind of energy and motivation that are necessary to make Gordon’s mind-body approach effective.

Antidepressants may have side effects, but sometimes the benefits outweigh the risks. The right antidepressant produces a response fairly quickly, making them the preferred treatment option for individuals with intractable depression or suicidal ideation.

What’s missing from Gordon’s approach to depression is the acceptance that other treatment options—namely antidepressants—can work in some individuals. His opposition to the use of antidepressants is so strong that he recommends them only after trying the Unstuck approach—even with patients having suicidal thoughts. This kind of all-or-nothing thinking does little to help a patient on his journey out of depression.

Unstuck: Your Guide to the Seven-Stage Journey Out of Depression
By James S. Gordon, M.D.
Penguin Books: Reprint edition, May 2009
Paperback, 448 pages
$16

This husband-and-wife team also has authored several other books, including Overcoming Anxiety For Dummies.  As part of the super-successful and ever-growing Dummies franchise, this offering has the same simple, orderly layout with plenty of tips, reminders, and special boxes to explain any technical jargon.  The first thing you see upon opening the cover is the usual useful tearout sheet; this time it’s a depression checklist and resource list for getting help, as well as do’s and don’ts and how to deal with it if it’s just a bad mood.  This would be very helpful for someone picking this book up because they are not sure if they, or a loved one, are struggling with depression or just the blues.

After the typical title pages and such, you find yourself at Contents At A Glance and the ensuing Table of Contents.  They are basically the same, differing only in length and detail, but both of them make it easy to see what subjects the book deals with and where to find just the information you need.

The body of the book is broken down into 22 chapters over five sections.  The first section deals with learning about depression, including general facts and more specific information on how it affects different groups, including children, the elderly, and minorities.  It also covers how to seek help, as well as reasons why people choose not to seek help and how to get past those ideas.

The second section covers depression’s effect on thought processes, how we view ourselves and the world around us, and memory.

Section three is about methods of behavior therapy.  The fourth section focuses on building and repairing relationships.

The fifth section is about biological methods of treating depression, such as medication, ECT, and several of the more popular alternative treatments people are using.

Section six covers the issue of relapse.  How do you decide when your depression is behind you?  What happens if it comes back?  It also covers the growing field of positive psychology, which focuses on how we can be happy, rather than the problems that rob us of those feelings.

Section seven, the final one, is the standard For Dummies parting shot, The Part of Tens.  Each chapter is a list of ten things in a topic.  This book has three: ways to deal with a bad mood, helping depressed children, and helping a loved one who is depressed.

This book is designed for those who are depressed or think they might be, and those with people in their lives struggling with depression whom they want to support.  It contains a great deal of information organized simply and clearly, with plenty to get your started on your own or getting professional help, if that is what you need.  It can be read cover to cover or in any order you choose.  Throughout the book they point you to other sections that deal with the topic at hand, as well as suggest where to start reading if you are severely depressed.  They also recommend other books that might be of interest in various areas, both their own books and those of other professionals.  A list of all their recommended reading is included in back for easy reference.

Being sensitive to their audience, the authors included in the introduction a note to readers, explaining the title and that the humor they used hopefully would “lift their spirits a little“ — it was not meant to belittle their experience in any way.  I thought this was a nice touch.  Several people I mentioned this book to thought the title was a little odd.  Who wants to be labeled a “dummy” when you’re depressed?

The book’s information is grounded in research and clinical success. A few alternative treatments mentioned were specifically presented as having only anecdotal evidence and no scientific basis to recommend them.  In presenting positive psychology they offer the idea that I can go on to feel “better than good.” While that may be difficult for a someone in the midst of a depressive episode to believe, the authors were prepared for that, too.  Section six on life after the depression is introduced with the caveat that it should not be read until you have “succeeded in defeating your depression.”

The case is made that depression is a manageable problem with commitment to treatment, whether you choose medication or therapy or both.  They offer several methods of working through the various issues associated with depression such as altered thought processes and a warped sense of self.  These are mostly made up of various ways to challenge your assumptions, with a mix of writing things down and talking them out.

This is certainly a book I would recommend to anyone who wants to know more about depression.

Softcover
384 pages

In recent literature regarding depression, it is often discussed either as a purely “chemical” disease or one that involves the entire body.  Bragin is a huge proponent of the latter and promotes a decidedly holistic approach in treatment.  He urges readers to understand the ways in which this illness can affect the entire body and provides comprehensive methods for treating symptoms:

Many of our patients using the program quickly alleviate the symptoms of depression and begin feeling better.  Our system goes well beyond prescribing medications and providing psychotherapy.  The program features relaxation training, physical exercises, attention and memory training, diet recommendations and much more.

Conquering Depression in the Golden Years begins with a discussion of the ways that depression can manifest itself in seniors.  Bragin describes symptoms in a thorough and easy-to-read manner.  This section also stresses the fact that depression is closely tied to other ailments common to geriatric patients such as high blood pressure, cancer, diabetes, cardiac problems and Alzheimer’s and explains how these problems can exacerbate depression and vice versa.

Bragin then moves to an explanation of depression and the brain by highlighting ways in which depression can affect thought, behavior, emotion, cognition and the senses.  The book finishes with detailed instructions for exercises to be completed at home that include ways to promote stress management, sensory activation, physical exercise, cognitive training and even ways to improve digestion.

I appreciate the author’s frankness when he explains that depressed people largely are responsible for their own course of treatment:

Every depressed patient has to take a proactive approach to battling depression, 24/7.  In other words, your participation is critical to your recovery.

The author never claims this to be a self-help book but stresses that many factors, including his program, contribute to overcoming depression.  It is a many-faced disease and requires adherence to your doctor’s treatment plan that could include taking medications or vitamins, psychotherapy, as well as the various exercises described above.  Through the author’s own experience and practice he has found that medications coupled with nonpharmacological interventions have proven successful in the vast majority of his patients.

It’s a seriously flawed plan for a depressed individual to rely on medication treatment only.  Being a strong believer in the body’s natural healing capacity, I recommend using everything possible to increase the body’s natural restoration power and reserves.  To win the fight against depression, both the brain and the body should be in sync, fully mobilized.  I call this integrative treatment of depression “the battle for life.”

While the information in this book is a great resource for seniors or those who are interested in helping seniors overcome depression, it is important to note that the exercises in the books are designed for those readers who not only suffer from depression, but who spend their time mostly at home and are unable to visit a gym or participate in other high-energy activities.

With that being said, if this book set out to educate the reader on the many aspects of depression as well as to provide an encouraging platform for hope that depression overcome, it has done its job.  The solid suggestions and recommendations for treatment that Bragin provides only contribute to the fact that I would be quick to recommend Conquering Depression in the Golden Years to any senior, caregiver or health professional in my life who I felt could benefit from his insight and advice.

Conquering Depression in the Golden Years (A Practical Guide for Older Adults)
By Valentin Bragin, M.D., PhD
Langdon Street Press: January 2009
Paperback, 180 pages
$15.95

In essence, we are our own worst enemy, and despite the marvels of modern science and new-era technology, we are constantly generating new ways to render ourselves obsolete. Modern times have forced us to give up our minds and bodies to the zombie-inducing effects of television and the Internet, our lives enslaved to wonderful gadgets and gizmos that are meant to make life easier, but instead seem to be bringing us down. Ilardi mentions that “human beings were never designed for the poorly nourished, sedentary, indoor, sleep-deprived, socially isolated, frenzied pace of twenty-first-century life.” The lifestyle Ilardi speaks of has left many battling bouts of severe depression, but in this book, he has truly concocted “the depression cure.”

Using the TLC (Therapeutic Lifestyle Change) program that he established at the University of Kansas, with the help of graduate students, Ilardi illuminates six steps to breaking the habits of our fast-paced lifestyle to ensure that we remain healthy in mind, body, and soul. It is a method of defeating depression without the use of medication. Instead, Ilardi insists, through much research and case studies of real people suffering from different forms of depression, that the use of “dietary omega-3 fatty acids, engaging activity, physical exercise, sunlight exposure, social support, and sleep,” combine to create the healthiest cure for this disease.

Ilardi tells the story of how, while teaching a class on abnormal psychology, he asked his students “What’s the most effective treatment for depression?” The unanimous answer was “antidepressant medication.” The idea that medication is the first idea for treatment of any type of illness and disease is another problem prevalent in today’s society. It is almost as if humanity has increasingly become complacent with the fact that we are powerless over everything that goes wrong in our lives, so when it does, the first thought is to get a prescription for the “flavor of the week” drug to make all our pains and emotions go away. Essentially, we are only numbing ourselves to the point we are not functioning at the capacity we should, while some are simply trading away one problem for another, such as addiction.

The biggest question Ilardi poses — the same thought that spearheaded the creation of the TLC program — is with the increased use of antidepressant medications and life-simplifying technologies, “How can people possibly be so much more vulnerable to depression now?”

According to Ilardi, the answer lies in the dynamics of our culture and how our roles as humans have changed over generations. Speaking more in terms of Americans, we have turned our backs on the “hunter-gatherer” tendencies that humanity was based on. Mentioned many times throughout The Depression Cure is the modern-day hunter-gatherer band known as the Kaluli people of the New Guinea highlands, where “clinical depression is almost completely nonexistent.” Their culture still works as a cohesive unit of purpose, for survival. They obtain their physical activity through hunting and gathering, are constantly exposed to the outdoors and the elements, abide by a strict diet based on seasonal availability, and are never alone due to their constant involvement with their community. The Kaluli people lived the steps of Ilardi’s TLC program, and because of that lifestyle, depression was rarely an issue.

This speaks volumes of what The Depression Cure brings to the realm of psychology and the ability to live a happy and healthy life. The six steps that Ilardi discusses may seem simple, but who truly takes the time to worry about their diet, fitness, social interaction, and sleep patterns? Perhaps everyone does think, or ruminates, as Ilardi declares to be another roadblock to happiness, but not everyone takes the time to actually do something about it. With all the advantages of living in this modern age, most of us are afforded the options to just forge on in our lives in a walking coma, believing we either own or have achieved all that life has to offer. At the same time, we are ignoring the true needs of our bodies and minds, thus leading to depression.

The Depression Cure is truly enlightening, and Stephen Ilardi’s TLC program is something that should not just be thought about, but utilized as a tool for a healthier way of life. Most important, everyone — not just those suffering from depression — should use this program. If you follow the six steps that Ilardi explains in great detail and read the case studies that prove its success, you will not only find your life fuller with happiness, but may actually prevent the onset of future depression. The Depression Cure is a must read and a book that should be read outside of the house, on a sunny day off from work, surrounded by nature, and in the company of a great companion.    

The Depression Cure
By Stephen S. Ilardi, Ph.D
Da Capo Lifelong Books: June 2010 (reprint edition)
Paperback; 304 pages
$14.95