Major Depressive Disorder - Single episode

Finding The Right Treatment

Treatment

Getting treatment for MDD can be life changing for those who are struggling. Without treatment, the experience of depression can linger, and symptoms can intensify over time. The good news is that most people can absolutely recover from depression with a combination of therapy, medications, and lifestyle modifications, and lead normal, fulfilling lives.

Finding a therapist

In addition to (or sometimes in lieu of) medications, psychotherapy has been proven to yield major improvements in the lives of those struggling. Therapists can intervene in many meaningful ways, including:

  • Educating an individual (and their family) about depression
  • Assessing one’s risk of self-harm or suicide
  • Helping one to identify and challenge negative thought patterns and replace them with healthier, more adaptive thoughts and behaviors
  • Working with an individual to re-build their self-esteem Exploring the impact of one’s depression on their work and home life, and developing strategies to mitigate these effects By working with an individual to develop these insights and tools, a skilled therapist can have a profound impact on the life of someone struggling with depression. Most therapists have experience working with adults with MDD.

There are different kinds of professionals who 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)

There are several styles of therapy that can be helpful for 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 (as referenced above).

Many individuals with MDD find therapy to be one of the best ways to prevent future depressive episodes. It can help them to recognize the triggers and signs of an oncoming episode, allowing them to intervene earlier. The natural ups and downs of life can often be triggers for depressive episodes, and a good therapist can help an individual to weather these storms.

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 can play a central role in the lives of many people with depression. As individuals metabolize and react to medications differently, the process can take some time and energy.

There are multiple categories, or classes, of medications that the Food & Drug Administration (FDA) has approved to treat depression. In order to understand the full roadmap of possibilities for one's treatment, it makes sense to go over the major classes of antidepressants. Treatment protocols and insurance companies often call for “step-therapy,” or a certain order for trying medications, usually starting with inexpensive options. Insurance companies usually restrict access to more expensive medications.

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, higher doses are often given a chance. Sometimes, however, high doses are not tolerated due to side effects. And, in those situations, other strategies can be employed.

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 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 these situations, a higher dose is recommended (300 mg - 450 mg). Not uncommonly, bupropion is added to an SSRI/SNRI. When used in combination, dosages are usually between 150 mg to 300 mg.

Next-level treatment

The strategies discussed above are considered “first-line” treatments. Most of the medications described are generic, and less expensive. 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. It 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.

Antidepressant medications used for sleep

Since sleep issues often accompany depression, psychiatrists 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.

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.