What if common depression treatments don’t work?

There are many standard treatments for depression. If initial treatments do not work, there  are also a number of effective options. First, an important issue. Depression can occur in the context of unipolar disorder or bipolar. These disorders are very different. Treatments that are effective with unipolar depression often do not work with bipolar disorder, and visa versa. In fact any treatment that may reduce depressive symptoms can provoke manic episodes in bipolar disorder (especially bipolar I). Having the correct diagnosis is extremely important and misdiagnoses are a common cause of treatment failure. Here I’ll outline treatment options only for unipolar major depression.

Medical illnesses and certain drugs can cause depression. This must be evaluated. Hypothyroid may account for up to 10% of severe depressions but often is not screened for. The most common drugs that can cause depression are: beta blockers, clonidine, estrogen, tranquilizers (e.g. Xanax, Ativan, Klonopin), interferon, alcohol.

If the diagnosis is unipolar major depression the following are recommended treatments:

1. Psychotherapy: in particular these forms of psychotherapy: cognitive therapy, behavior therapy and interpersonal therapy for depression.
2. Prescription antidepressants. It’s very common that failures occur because of doses being too low and/or treatment does not last long enough. A list of antidepressants are available on my web site (free download): www.Psyd-fx.com
3. Over-the-counter antidepressants: SAMe, St. John’s wort, 5-HTP (available OTC but should never be taken except under medical supervision) !
4. Augmentation: here other drugs are added to antidepressants. Many types of augmentation are available; here are the most common and effective: thyroid hormone, atypical antipsychotics (Seroquel; Abilify), lithium, BuSpar, and 2 antidepressants added together such as Prozac and Wellbutrin.
5. The medication Clozaril should always be considered if nothing else works.
6. Exercise: best approach: 2 ten minute periods of exercise a day (aerobic: must huff and puff, but ok to do brisk walking if not very fit).
7. Make sure sleep is adequate: common reasons for impaired sleep: sleep apnea, excessive caffeine use (more than 2 cups of coffee a day), alcohol can destroy sleep, staying up too late.
8. Bright light therapy
9. ECT (shock therapy): for treatment resistant cases and psychotic depressions