Major Depressive Disorder - Recurrent episode

Finding The Right Treatment

Treatment

Treatment for Recurrent MDD is extremely important. Without treatment, depression lingers, and symptoms can intensify over time. Some individuals lose interest in their jobs, their families, and everything else they once cared about. In such a pit of despondency, they cannot imagine ever feeling better. The good news is that most people can recover from depression with a combination of therapy, medications, and lifestyle modifications, and lead normal, fulfilling lives.

Recurrent MDD often accompanies other conditions

Sometimes one condition is the result of another that was left untreated. For example, individuals with ADHD have a higher likelihood of experiencing symptoms of anxiety and depression. As a result, in most cases a healthcare provider will focus on treating one diagnosis first, and if the other symptoms do not resolve, proceeding to treat the next diagnosis. As an example, when individuals struggle with ADHD in addition to anxiety or depression, treating the underlying ADHD tends to improve all other symptoms. An exception may be when a person’s depression or anxiety is so severe that they need immediate relief, and at that point, other interventions must be considered.

Finding a therapist

While medications are often a catalyst for change in individuals with Recurrent MDD, therapy has been proven to yield major improvements in the lives of those struggling. Whether it be early recognition of symptoms that lead to a depressive episode, an understanding of how the past might impact an individual, or a simple awareness of thoughts and triggers, therapy can help people become more content versions of themselves. Most therapists have experience working with adults with Recurrent MDD.

There are different kinds of professionals that can provide effective therapy, including:

• Clinical psychologists (PhD)
• Licensed clinical social workers (LCSW or LMSW)
• Licensed professional counselors (LPC)
• Licensed clinical professional counselors (LCPC)
• Licensed Marriage and Family Therapists (LMFT)
• National certified counselors (NCC)

There are several styles of therapy that can be helpful for Recurrent MDD including psychodynamic, interpersonal, and supportive therapy. In recent years, more therapists employ cognitive behavioral therapy (CBT), which is a method that helps the individual identify unhelpful thought patterns, challenge self-destructive cognitions, and replaces them with more constructive thinking. Therapists will also help the individual identify behaviors that may help bring increased pleasure or a return to a sense of confidence.

Many individuals with Recurrent MDD find therapy to be one of the best ways to prevent future depressive episodes. Recognizing the triggers and signs of an oncoming episode can be critical to helping detect an oncoming episode, and therapy can help detect such triggers and signs. The natural ups and downs of life can often be triggers for depressive episodes. A good therapist will partner with an individual to plan accordingly and may even aid an individual in his or her advocacy for antidepressant dosing adjustments through such difficult periods.

The decision to start therapy

Many people try to cope with their distress on their own, and then feel disappointed when they find that this is very difficult to do. Deciding to start therapy can be hard; it takes courage.

For some people, it can take time to warm up to the idea of sharing one’s intimate thoughts or disclosing details of one’s life, especially for those who grew up in a culture where seeking psychological help was frowned upon.

Psychotherapy is increasingly accepted as not only a way to improve mental health symptoms, but also a means for self exploration and personal growth. No problem is too small for a trained therapist: an individual need not worry that others may have it worse. The willingness to reach out for help is increasing: in 2020, one out of every six Americans (men and women) reported seeing a therapist.

Seeing a therapist with whom one feels comfortable, and a sense of connection, and who also participates in their insurance network, is essential. It may take a couple tries to find a therapist who feels like the right fit. If therapy didn't help the first time around, it can be helpful to give another therapist a try because therapeutic styles vary so much from therapist to therapist.

Where to start

Requesting one’s physician to make a referral is often a good place to start. Many health insurance cards have websites or 1-800 numbers to call for a list of in-network providers.

To find a therapist who takes one's insurance, the National Institute of Mental Health offers a comprehensive list of resources.

Psychology Today also lists therapists by type, location and insurance.

Determining whether medications will play a role in treatment

Medications often play a central role in the lives of people with depression. Finding the right medication is not straightforward, as individuals metabolize and react to medications differently. Adjusting dosages to manage and prevent depressive episodes can add an additional layer of complexity for those with depression.

There are multiple categories, or classes, of medications that the Food & Drug Administration (FDA) has approved to treat depression. Each class is often prescribed for a different scenario or type of depression. In order to understand the full roadmap for treatment, individuals should gain a sense of the major classes of antidepressants. Treatment protocols and insurance companies often call for “step-therapy,” or trying medications in a certain order, usually starting with inexpensive options. Insurance companies usually restrict access to more expensive medications. When an individual’s previous treatments are organized, it may help their provider to better advocate for the brand name medication if needed.

Medications

First-line treatment

For most types of depression, the first step is to try a medication in the category of selective serotonin reuptake inhibitors (SSRIs or SRIs), which include fluoxetine (Prozac), escitalopram (Lexapro), and a few others. Research has shown that there is a relationship between depression levels and the amount of serotonin available in the brain; So, these medications prevent serotonin from being taken out of the system too quickly (reuptake inhibition). The other group of commonly used medications are classified as serotonin norepinephrine inhibitors (SNRIs). Both of these classes of drugs modulate the levels of these neurotransmitters in the brain.

As a class of medications, antidepressants often take 10 days to two weeks to begin working. The full effect of the medication is not realized for two months.

If one of the “first-line” medications does not initially work, a prescriber has many options. The first is to ensure that the SSRI/SNRI is dosed adequately. Before abandoning a “first-line” treatment, a provider may suggest that these high doses are given a chance. Sometimes, however, high doses are not tolerated due to side effects. And, in those situations, a provider may employ other strategies.

Second-line treatment

A large percentage of people who take antidepressants either do not tolerate the SSRIs/SNRIs or do not see clinical benefit. In these situations, prescribers may turn to bupropion (Wellbutrin). Bupropion is a dopamine and norepinephrine reuptake inhibitor (DNRI). It has significant antidepressant properties, particularly as the dose increases from the starting dose of 150 mg to the maximum dose of 450 mg. Bupropion does not have serotonin properties, and for this reason, it does not cause sexual side effects. On the downside, bupropion is not as effective against anxiety as some of the SSRIs/SNRIs.

Bupropion can be used alone, and in situations of Recurrent MDD, a provider may recommend a higher dose. Not uncommonly, a provider may add bupropion to an SSRI/SNRI.

Next-level treatment

The strategies discussed above are considered “first-line” treatments. Most of the medications described are generic, and consequently, they are less expensive than new “brand name” medications. The techniques of combining the medications are well established, and can be done in the primary care setting. The majority of patients receiving treatment for depression are given one of these “first-line” options. Fortunately, other options exist for the large swath of individuals who don’t respond to them.

Vortioxetine (Trintellix) works by a combination effect of decreasing serotonin reuptake and interacting with selective serotonin receptors, thus increasing the level of circulating serotonin. Just remember this: more serotonin generally = better mood. Vortioxetine is highly effective in combating symptoms of depression. It is distinguished because it is associated with less weight gain and sexual dysfunction than the SRIs/SNRIs. A small number of individuals taking vortioxetine (Trintellix) notice significant nausea early on, and the medicine should be taken with one's largest meal of the day. While its effectiveness and minimal side effects are noteworthy, vortioxetine (Trintellix) is a more expensive agent, and therefore, protocols suggest trials of SSRIs/SNRIs first.

Vilazadome (Vybriid) also works as a serotonin reuptake inhibitor, and a selective serotonin agonist. It is distinguished from the SSRIs/SNRIs in that it causes less emotional blunting, meaning the people who take it report experiencing a full range of emotions. Like Tryntellix, it has a favorable side effect profile, causing less weight gain and sexual dysfunction than SSRIs/SNRIs. Nausea is associated with Vybriid, although it typically diminishes within the first week. The medication should not be discontinued abruptly.

Psilocybin, Medical Marijuana & CBD

Some physicians are achieving promising results with formerly-maligned drugs such as ketamine and psilocybin as well as with cannabinoids and medical marijuana. Recently, researchers are looking at micro-doses of psilocybin, a hallucinogenic drug, for patients with addictions who are depressed and not responsive to standard antidepressants.

In addition, the active ingredient of tetrahydrocannabinol (THC) in marijuana (the substance that gives people a euphoric “high”) may relieve depression in some patients when antidepressants have been ineffective. Many states have approved the use of “medical marijuana” for adults over age 21, and some states have approved the recreational use of the drug for all adults. However, the laws of each state, including neighboring states, vary greatly. In some states, it is relatively simple for an adult to obtain marijuana or medical marijuana while in other states, possession of these drugs is a crime.

Some report improvement in depressive symptoms with CBDs or cannabinoids, which do not contain THC. It is unclear, however, how much oversight there is by the Food and Drug Administration (FDA) and other federal agencies with regard to quality control over these drugs.

Adjunctive treatments

When the discussed medications are not effective, a provider might prescribe an adjunctive treatment, which are sometimes referred to as augmentation strategies. For the treatment of depression, adjunctive medications are always prescribed with an SRI or an SNRI. Usually, adjunctive treatments are added only after the SRI or SNRI has been taken for at least a month without benefit. Providers may use these medications at higher doses for other mental health conditions.

Treatment-resistant depression/depression and suicidal ideation

The diagnosis of treatment-resistant depression is used when first-line, second line, next level, and adjunctive treatments have not been effective. Spravato was approved in 2019 for treatment-resistant depression. The next year, Spravato was also approved for depression with suicidal ideations, when taken with other antidepressants. Spravato is a nasal spray administered twice weekly for the first month, and then weekly during the second month. This medicine is notable because it offers rapid relief of depression, sometimes as soon as 24 hours after administration. Most people tolerate this medication well, but individuals need to be monitored for two hours after the drug is given, as they are likely to have short-lived sedation and dissociation.

Treatment resistant depression is one of the most common presentations of depression that psychiatrists see. If an individual is not getting better on antidepressant medications, it is important to re-evaluate the diagnosis. For many individuals with treatment-resistant depression, depression is only one element of their diagnosis. In these situations, it is important to consider and address any less obvious co-occuring conditions. These conditions include:

1. Active substance use disorder
2. Obstructive sleep apnea
3. Bipolar disorder
4. ADHD
5. A medical illness

Neuromodulation therapy

Another option for treatment resistant depression is neuromodulation therapy. A common method of neuromodulation is repeated transcranial magnetic stimulation (rTMS). This is a non-invasive technique whereby the doctor places an electrode on the skull resulting in the transmission of magnetic waves to a specific part of the brain. This treatment has been shown to relieve anxiety and depression with a different side effect profile than most medications. For instance, sexual side effects do not result from rTMS, and many patients who cannot tolerate medications migrate towards this option. This is a highly specialized approach to treatment resistant depression, and most of the treatment centers are located in large cities. Individuals should be aware that there are many companies promoting their own specific neuromodulation technology, but many of these have not been proven to be effective.

Electroconvulsive therapy

Electroconvulsive therapy, once called “shock treatments,” is still a feared treatment by many people. But the ECT of today uses much lower dosages of electroshocks than in past years and does not cause pain in the individual, nor does it result in major memory loss.

Antidepressant medications used for sleep

Since sleep issues often accompany depression, providers often use other antidepressant medications to reduce insomnia and augment the antidepressant effect. There are other medications that are not specifically antidepressants which directly improve sleep. This category of medications may be used in tandem with SRIs and SNRIs.

Healthcare providers that can prescribe medications

Psychiatrists, psychiatric nurse practitioners, and physician assistants are practitioners who are trained to diagnose and treat mental health conditions by prescribing medications. Sometimes it's hard to find a psychiatric provider because there are so many people who need them. So, individuals often choose to see a different kind of provider who can prescribe. This could be a doctor they already see, like a primary care doctor, family doctor or OB/GYN, or a new primary doctor.

FDA warning about suicide risk with antidepressants

Some research exists that, occasionally, newly initiated anti-depressants may increase the risk of suicide. If an individual begins to have these thoughts after starting an anti-depressant, please stop this medicine and contact a prescriber immediately. This risk is more evident in children, adolescents, and young adults.

Dietary supplements

There are an increasing number of supplements, such as an herb, vitamin, mineral, and other supplements claiming to improve sleep, depression, stress, restlessness, or anxiety. While it is possible for a supplement to improve one’s symptoms, their effects are often unproven.

Be aware that dietary supplements are not controlled by the FDA and, therefore, are not subject to the standards of quality, uniformity, and testing for efficacy and safety as regulated medications. It is important to share a list of all medications and supplements with one's treating provider because some of them may interact with the medications they prescribe.