Depression Symptoms Treatment

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Factors involved in treatment failure

Several questions must be asked when assessing a patient who has failed to respond to treatment. Is the diagnosis of depression correct? Has the subtype of depression been correctly identified? Are there underlying physical factors? Are there underlying psychosocial factors? Has the current treatment been adequate?

Correct diagnosis.Several psychiatric illnesses can have accompanying depressive symptoms and be mistakenly diagnosed as primary depression. These include obsessive-compulsive neurosis, panic disorder or generalized anxiety disorder with demoralization, post-traumatic stress disorder (particularly in adults who have been sexually abused as children), schizophrenic defect state with apathy, uncomplicated grief, and dementia (such as early Alzheimer’s disease) with cognitive decline causing distress.

Correct identification of subtype. Several subtypes of depression have implications for treatment. Unless these subtypes are recognized, a standard approach to depression will likely be ineffective and make the patient appear treatment resistant. These subtypes are briefly discussed. More detailed information can be found in the literature.

Bipolar affective disorder (depressedphase): Although, clinically, the depressed phase of bipolar disorder is much like a major (unipolar) depressive episode, introducing lithium as a therapeutic agent becomes much more important. Rapid onset of symptoms, hypersomnia, a postpartum trigger, a past history of manic or hypomanic episodes, and a positive family history can all be clues to bipolarity

Delusional (psychotic) depression: A major depressive episode in which psychotic features, such as mood-congruent delusions or auditory hallucinations, are present usually responds poorly to tricyclics alone (about 20%) and requires the addition of an antipsychotic agent. Electroconvulsive shock therapy is the treatment of choice.

Major depression with obsessional features: Major depression that presents clinically with obsessions and compulsions responds better to strongly serotonergic antidepressants, such as the tricyclic clomipramine and selective serotonin reuptake inhibitors, such as fluoxetine or fluvoxamine.

Atypical depression: Atypical depression has vegetative features, such as an increased need for sleep, initial insomnia, and increased appetite. Symptoms such as panic attacks, severe generalized anxiety, agoraphobia, or social phobia also make a depression atypical. Monoamine oxidase inhibitors (MAOIs) rather than tricyclics are the agents of choice.

Postpartum depression: About 80% of depressions that occur in the postpartum period are bipolar and tend to resist treatment. Psychosocial factors, such as bonding with the infant and the marital relationship, are of great importance and need to be addressed as part of the treatment plan. If the mother is hospitalized, hospitalizing the infant should be considered as well.

Double depression: As its name suggests, double depression is a major depression superimposed on chronic dysthymia. Chronic dysthymia usually requires psychotherapy and lifestyle changes, although pharmacotherapy can be helpful. Chronic dysthymia can make a major depression seem unresolved.

Seasonal affective disorder. This subtype of affective disorder has been adequately described only in the last few years. It probably is a variant of bipolar disorder. The patient suffers from a winter-onset depression for at least 4 consecutive years with either normal mood or mild hypomania during the summer. Seasonal depression sometimes responds to traditional antidepressants or lithium; however, the most effective treatment appears to be light therapy. To complicate matters, seasonal affective disorder can have variants, such as summer depression (and winter highs), which respond to temperature manipulation.