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    Learning About Your Health

    Patients' Frequently Asked Questions (PFAQ): Depression

    If you are diagnosed with depression, do you have to be on medication for the rest of your life?

    Not necessarily. Depression is thought to be a recurrent illness which means that it comes and goes. When you are in the midst of an episode of depression, it is very important to stay on your medication until you have a period of at least 6-12 months without symptoms. Basically, this means that it is important to stay on an antidepressant for a period, on average, of one year. At this point, it may be entirely reasonable to go off the medication.

    As I mentioned, depression tends to be a recurrent illness so it tends to recur in individuals. If a person has had one episode of depression, he or she carries a 50% chance of having a second episode at some time in the individual's life. If the person has had 2 episodes of depression, the individual carries a 75% chance of a third episode. After a 3rd episode, the individual carries a 90% chance of having a recurrence. And, after this point, the standard of care requires lifetime treatment.

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    There are many different kinds of new medications that deal with depression - what guidelines do doctors use to determine what someone should be on?

    Example: Prozac® (Fluoxetine) versus Zoloft® (Sertraline) versus Lexipro™ (Escitalopram), etc.? should be on a particular antidepressant?

    There are a variety of antidepressant medications for the treatment of depression. The selection of which drug to use can be a complicated matter. One of the most potent indicators for selecting the appropriate drug to use would be an individual's prior history of successfully being treated with an antidepressant. That is, if one has had a prior episode of depression and it was successfully treated by a particular drug, then in subsequent episodes of depression the use of the same drug again may make sense. In absence of such a history, then a family history of successfully treated depression becomes a possible indicator. That is, if someone in the family has had a prior episode of depression and was treated by a particular drug, it might be reasonable to consider using that drug in the individual being seen by the clinician. In the absence of any particular personal or family history, then the clinician is faced with a difficult selection of matching the appropriate drug to the appropriate patient. Certain medications tend to be invigorating, that is, give the individual more energy. Other antidepressants are somewhat sedating. Every effort is made to match these characteristics of the patient with the symptoms of a particular individual's period of depression.

    Let's say an individual is having substantial trouble sleeping. It would make sense to choose an antidepressant that is somewhat sedating in order to provide immediate relief to the insomnia. On the contrary, for an individual who may be excessively sedated or lethargic, as a manifestation of their depression, a choice of an antidepressant with some invigoration properties may be indicated.

    In general, the entire class of antidepressants, whether the older antidepressants, the tricyclidies (tricyclic), or the newer drugs, such as some of the SSRIs, all, in general, have approximately an 80% (success rate when used in combination with psychotherapy) in effectively treating an episode of depression.

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    How do antidepressants work?

    The exact mechanism of action of antidepressants is not completely understood. However, there is general consensus that the mechanism by which antidepressants works involves a change in neurotransmitters in the brain. Neurotransmitters are molecules in the brain that the neurons or nerve cells use to communicate with each other. The general theory of depression involves the concept of aberrations in these neurotransmitter levels in the brain. So antidepressants correct an abnormality in the levels of neurotransmitters in the brain.

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    How can you determine what is normal depression that will pass and significant depression that needs medical assistance?

    The diagnostic criteria for many psychiatric conditions have been established by consensus in the field of psychiatry in the form of a document entitled The Diagnostic and Statistics Manual of Mental Disorders. This book is currently in its 4th edition. One diagnostic criteria for all psychiatric diagnoses involves an assessment of duration of symptoms. Any symptoms that have been in place less than 2 weeks are not thought to meet the threshold of a diagnosis. So, first of all, for symptoms to be considered problematic, it is necessary that they are present for more than 2 weeks.

    Other criteria that are involved in a diagnosis of depression include changes in basic body functioning on parameters, such as sleep, appetite, libido, and concentration. Obviously, changes in mood may predominate. Sometimes, depression is characterized by a sad mood. In other individuals, depression may be more clearly manifested with irritability, agitation, or a change in one's usual demeanor.

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    How can a parent, spouse, sibling, or the designated family member of someone with depression best communicate with the patient's doctor?

    On the one hand preserving patient confidentiality, but on the other hand keeping the parent or other family member involved for the patient's benefit? So often these illnesses render adolescents or adults dependent in ways that make family involvement important, but especially with psychiatric illnesses, the patient's privacy is often paramount.

    Family members should feel a complete freedom to provide any and all information to the treating clinician. Patient confidentiality is vital, but it is, in fact, a one-way street. The patient's confidentiality is required on the part of the clinician. This essentially means that the clinicians can receive information from anyone, but can provide information to an individual other than the patient only with the patient's consent. The maintenance of family involvement is always important. Additional information is always important to a clinician who is attempting to treat and understand a patient. So through whatever mechanism — electronic, voicemail, or face-to face contact — family members need to feel free to provide information that they believe would be helpful to the treating clinician. Also, it is important that family members continue to communicate with their loved one about their concerns.

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    The patient is depressed about his life threatening disease and has lost his appetite - what can his wife do to encourage him to eat?

    Also, the depression has affected his compliance to medications.

    The combination of a decrease in appetite and a change in an individual'hs willingness to comply with medical advice may indicate a more pervasive problem. In other words, these two symptoms could be components of an underlying depression. The best remedy to a decreased appetite due to depression is treatment of the depression.

    For the individual with the two symptoms described above, a family can offer its best support by encouraging the patient to receive an evaluation of these symptoms. Non-critical, well-intentioned support is always helpful to family members. Unfortunately, an individual who is depressed may experience well-intentioned advice as excessive. If someone has not eaten an adequate amount of food, offer to provide them with additional food that they like. If someone is not taking medications, as directed, one might offer to bring medications to them at the appointed time. Whether or not the individual is able to benefit from these acts, they remain normal healthy expressions of support within a family.

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    Are there resources for people who need counseling and do not have the resources to pay? Where would one go to learn of these resources?

    Recent changes in health care coverage have had a significant impact on the ease with which individuals can obtain mental health assessment and treatment. California has established a certain group of psychiatric diagnoses, the treatment for which cannot be restricted by insurance carriers. This is, in general, a positive development. Despite this positive action by our state legislature, many individuals have found it even more difficult to access mental health clinicians since the passage of this law. Here at CPMC, we offer mental health services on a sliding scale through our outpatient mental health clinic. Although a minimum fee does exist, variations from that fee are based on an individual's ability to pay. It is always important to remember that, on an emergency basis, anyone can receive treatment in the Emergency Room at a nearby health facility regardless of his or her ability to pay.

    For additional information, please see the American Psychiatric Association's Opens new windowWeb site.

    Authored By: Joe A. Walker, MD
    Reviewed By: Michael Valan, MD

    Produced by the Center for Patient and Community Education in association with the staff and physicians at California Pacific Medical Center. Created: 2003

    Funded by: A generous donation from the Mr. and Mrs. Arthur A. Ciocca Foundation.

    Note: This information is not meant to replace any information or personal medical advice which you get directly from your doctor(s). If you have any questions about this information, such as the risks or benefits of the treatment listed, please ask your doctor(s).

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