There are various treatments for depressive disorders. The most common treatments include different therapies and medications. In this post, the most common outpatient therapies and medications are discussed.

Therapies

Talk therapy has been shown in research to be just as effective, if not more effective, than medication treatment alone for depression. Common therapies utilized to help treat depression include:

• Cognitive Behavioral Therapy (CBT)- CBT focuses on how one’s thoughts impact their emotions and their behaviors (and vice versa). CBT helps individuals recognize and replace their maladaptive thought distortions and behavioral patterns in order to decrease depressive symptoms. A therapist oriented in CBT will help individuals uncover their core beliefs and automatic thoughts that contribute to their depressive state. CBT is a more structured and directive approach to therapy. CBT can also be short-term or long-term.

• Psychodynamic Therapy- This type of therapy is very much past oriented. It helps individuals explore and process their unconscious thoughts and emotions. This type of therapy typically correlates depression to past experiences and unresolved conflicts. Through psychodynamic therapy, clients move forward in their lives by resolving their past.

• Acceptance and Commitment Therapy (ACT)- This is a form of mindfulness based therapy that helps clients to accept the difficulties that arise in life and better cope with circumstances in order to live a more quality life. ACT is based on the client’s values in life and helps the client to live a more values-based lifestyle. The ultimate goal of ACT is psychological flexibility. ACT helps to reduce avoidant coping styles by teaching the client how to cognitively defuse psychologically heightened experiences.

• Interpersonal Therapy- This modality is based on the idea that relationships are at the forefront of depressive symptoms. It stems from the belief that our social/romantic relationships, when toxic or maladaptive, create a depressive state. This is a short-term therapy that is highly structured. The goal of treatment for this therapy is to help clients with communication skills and conflict-resolution skills.

Medications

There are 2 classes of antidepressants that are considered “first-line” treatments for depression; selective serotonin reuptake inhibitors (SSRIs), and serotonin and norepinephrine reuptake inhibitors (SNRIs). Other forms of psychopharmacologic treatments include TCAs and MAOIs, but these medications are often reserved for patients who do not see the benefits of the more modern treatments.

Overall, SSRIs are considered the “real” first-line of antidepressants and would be my go-to choice for depression treatment that requires a medication augmentation. There are many advantages to using a SSRI initially. SSRIs can be started at a therapeutic dose, there are fewer daily side effects compared to other treatment medications which is helpful with attrition, and SSRIs are much safer in overdose. Common SSRIs include Citalopram, Escitalopram, Fluoxetine, and Sertraline.

• Selective Serotonin Reuptake Inhibitors (SSRIs)- Increase the chemical serotonin in the brain. Some disadvantages to consider with SSRIs are therapeutic benefits can take longer to be noticed, about 4-6 weeks, with the full range at 12 weeks. Worsening of anxiety can occur during the first 2 weeks of treatment. Flu-like symptoms can occur after abrupt discontinuation of SSRIs. Can also be expensive.

• Monoamine Oxidase Inhibitors (MAOIs)- These medications work to decrease the activity of the MAO enzyme. This results in an increase in norepinephrine, serotonin, and dopamine (the feel good chemicals). Common MAOIs include nardil, parnate, marplan, emsam. Side effects associated with MAOIs are nausea, insomnia, dizziness, weight gain, dry mouth, diarrhea and sexual dysfunction. If you are taking a MAOI, it is important to discontinue St. John’s Work, as it can result in serotonin syndrome and can be life-threatening.

• Tricyclic Antidepressants (TCAs)- These were some of the first developed antidepressants. These medications have more side effects compared to newer medications. TCAs work to increase the serotonin and norepinephrine in the brain. TCAs are used with depression, anxiety, and even neurological disorders and chronic pain. Common TCAs are amitriptyline, despiramine, imipramine, and nortriptyline. Common side effects of TCAs are anxiety, drowsiness, constipation, nausea, sweating, and weight gain.

• Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)- Examples of SNRIs are Effexor, Pristiq, and Cymbalta. These medications work by increasing both serotonin and norepinephrine (involved in stress response) in the brain. These medications are also useful for chronic neuropathic pain, fibromyalgia syndrome and menopausal symptoms. They are effective for both depression and anxiety. Some disadvantages of SNRIs are they need to be started gradually and they have side effects such as dry mouth, insomnia, drowsiness, headache, sexual difficulties, loss of appetite. Overdose possible. Some drug interactions can be very dangerous

• Esketamine- This is also known as Spravato, which was FDA approved for depression in March of 2019. I mention this treatment here, because it is gaining popularity with ketamine clinics popping up across the country. This treatment is particularly useful for adults with treatment-resistant depression. This means at least 2 other medications have not been able to help the individual’s depressive symptoms. This is a nasal spray that works within hours. However, since Esketamine is a variant of a hallucinogenic drug (ketamine), it may cause sedation or out of body experiences. You can only receive the drug at a certified location, and you must be monitored for a few hours afterwards.

Of course there are various other modalities that can be utilized to help decrease depressive symptoms, such as exercise, a healthy diet, supplements, and other self-help behaviors. More of these will be covered in the upcoming blog posts!

References

Stahl, S. M. (2017). Prescriber's Guide: Stahl's Essential Psychopharmacology-6th Edition. New York: Cambridge University Press. ISBN-13: 978-1316618134

Koenig, A. M., & Thase, M. E. (2009). First-line pharmacotherapies for depression-what is the best choice. Pol Arch Med Wewn, 119(7-8), 478-486.

https://www.healthline.com/health/depression/cognitive-behavioral-therapy

https://www.psychologytoday.com/us/blog/two-takes-depression/201102/introduction-acceptance-and-commitment-therapy

https://www.bmj.com/content/366/bmj.l5572