For many people, admitting that they have depression can be difficult. Some regard it as a sign of weakness, while others think they should be able to simply “pull themselves up by the bootstraps”. Acknowledging this treatable psychiatric disorder is the first step towards getting better. The second step is getting treatment. Traditionally, there are three types of treatment for depression:
In many cases of depression, psychotherapy alone is effective. Others need the addition of medication as well. Medication is often used as the sole treatment for most types of depression – primarily because it’s easy to take and convenient. However, many (if not most) mental health professionals do not regard this as the best approach to treating depression – for reasons that will be discussed below. For severe cases of depression – when a person is so depressed that he is barely able to function or is a danger to himself due to suicidal thoughts – hospitalization must be considered. If you’re not sure which type of treatment is best for your depression, there are several factors you should consider including:
- The severity of your symptoms
- Your willingness and desire to address the issues in your life that are contributing to and / or causing your depression
- Your willingness to commit to several weeks or months of psychotherapy
- Your financial resources (e.g. whether or not you have health insurance, what it will cover, and what you can afford to pay out of pocket if needed)
- Your personal preferences with regards to the type of treatment
- Your ability to stick with a medication regimen
- How well you tolerate medications in general
- The mental health services that are available to you (e.g. do you live in a rural area where the nearest therapist is 60-90 minutes away?)
- Prior treatment history, if applicable (e.g. what was effective, what wasn’t, etc.)
- Any medications or health conditions that could make taking antidpressant medication problematic (e.g. being pregnant or breast-feeding)
Following is a brief overview of each type of treatment, including the pros and cons associated with each one.
Psychotherapy for Depression
Many people believe that going to a “shrink” or therapist is only necessary for those who are “seriously mentally ill” or truly crazy. The reality is, everyone has difficult times in life when talking to a highly trained, objective professional could be really beneficial – regardless of whether or not you have a mental health disorder. Getting past the perceived stigma of seeing a therapist is often the biggest hurdle when considering psychotherapy. There are numerous therapeutic approaches to treating depression. One of the most effective (based on research) is Cognitive Behavioral Therapy (CBT). CBT identifies and addresses the negative, irrational thoughts that typically play a major role in depression. It also targets the core beliefs (e.g. “I’m worthless”) that may be feeding your depression. A skilled cognitive behavioral therapist can help you change these detrimental beliefs and thought patterns to ones that are healthy and beneficial. Pros: In terms of treating depression, psychotherapy has several advantages over medication. It can help you identify and change thought patterns, beliefs, and lifestyle habits that play a big role in depression. Depending on the type of therapy, you will also learn how to manage your symptoms, and ultimately reduce them significantly or overcome them altogether. The “tools” you gain from psychotherapy can last a lifetime, which is one of the greatest advantages over medication. Another advantage of psychotherapy is the therapeutic relationship itself. It can be very empowering to feel supported, genuinely heard, and encouraged each step of the way. For some people, this is an entirely new experience, particularly if they’ve experienced a lot of criticism from others. Also, as you try out new behaviors you can discuss them with your therapist, “fine tuning” them under his or her guidance as you go. Cons: You may need to go to therapy for at least a few months – and sometimes much longer – to get the results you desire. It’s not a magical process – it takes time and effort. Many people are not aware of (or ready to face) the real issues when they first start therapy. This is part of the reason therapy takes time. Not everyone can tolerate the slow pace – they want things fixed now, not months from now. Also, psychotherapy is expensive. Insurance will often cover only a few sessions, and only a percentage of the cost even then. The cost of the co-pay (and expense for additional sessions not covered) must be considered as well. While fees can vary considerably, it is not uncommon for a one hour session to cost between $100 and $150. Some therapists do offer sliding fees, and mental health clinics (if available in your area) may also offer lower fees. Another downside of psychotherapy is that it may not be helpful. This is often due to one or more factors including:
- An inexperienced therapist
- The wrong therapy approach
- Quitting therapy prematurely (due to discomfort, impatience, lack of funds, etc.)
- Resistance to change
- Unwillingness to do the work
- Having unrealistic expectations
Medication for Depression
Many people opt for medication because, quite frankly, it’s easier to take a pill than making the time for weekly therapy sessions in which you bare your soul. Antidepressant medications are often easily obtained from primary care doctors and other healthcare professionals. Many advertisements for antidepressants give consumers the impression that merely popping a pill will make them happy again. Antidepressant drugs can be very helpful in the treatment of depression, although they do not work for everyone. Currently, there are numerous antidepressants available, with more coming on the market all the time. Each works slightly differently, but all of them target chemicals in the brain that affect your mood and other factors associated with depression (e.g. sleep and appetite). There are several categories of antidepressants:
- SSRIs (selective serotonin reuptake inhibitors): Examples include Zoloft, Celexa, and Paxil. Viibryd (vilazodone) is the newest SSRI, approved by the FDA in January of 2011 for the treatment of major depression.
- SNRIs (serotonin-norepinephrine reuptake inhibitors): Popular SNRIs include Pristiq, Effexor, and Cymbalta.
- TCAs (tricyclic antidepressants): These are older antidepressants, which are often very effective but typically have more challenging side effects than SSRIs and SNRIs. Anafranil, Elavil, and Pamelor are examples of TCAs.
- MAOIs (monoamine oxidase inhibitors): MAOIs have also been around for a long time, but due to interactions with many common foods as well as numerous medications, they are usually only prescribed when others haven’t worked. Parnate and Nardil are both MAOIs.
- Atypical antidepressants: These are the antidepressants, like Wellbutrin and Remeron, that don’t fit in the categories listed above.
Other types of medications may also be used in the treatment of depression, particularly bipolar depression, such as antipsychotic drugs (e.g. Abilify, Seroquel) and mood stabilizers (e.g. lithium). Pros: For many individuals, medication can be very effective. When depression significantly interferes with functioning, medication is often necessary, at least initially. Sometimes an individual is not able to participate in psychotherapy without it. Medication is also usually a lot less expensive than psychotherapy. In fact, health insurance will often continue to pay for medication as long as a person takes it, but pay for only a limited number of therapy sessions. Another reason many people prefer medication is that, compared to psychotherapy, the benefits are often felt much sooner. Of course, this depends a lot on finding the right medication and dose early on. Medication also spares people the discomfort of confronting their issues – so it feels much “safer” than therapy, which requires a significant degree of vulnerability. Cons: Unlike psychotherapy, which focuses on the underlying issues and helps provide tools and skills for managing and even overcoming symptoms, medication treats only the symptoms themselves. In many cases, after the medication is stopped, the symptoms return. Also, medication requires you to rely on something external to feel better. This can reinforce the dependency and helplessness that often accompany depression. These are two of the primary reasons why medication alone is generally not regarded as the best treatment for depression. Another significant downside of medication is the side effects – some of which can be difficult to tolerate. Additionally, scientists don’t know the potential long-term effects of some of the newer medications. You always have to decide if the benefits outweigh the various costs. There is often a lot of trial and error involved in finding the right medication, as well as the right dose. Every person responds differently, so this aspect can be very frustrating for many people who just want relief. And for some people, medication simply doesn’t work.
Hospitalization for Depression
Long gone are the days when people had the luxury of spending several weeks in a psychiatric hospital for the treatment of mild to severe depression. In recent years, inpatient stays rarely last for more than a few days except in the most severe cases. Inpatient psychiatric treatment is usually necessary for individuals who are suicidal and at imminent risk of hurting themselves, or who are so depressed that they are unable to function. Depending on the situation, hospitalization may be involuntary. Hospitalization provides intensive treatment which includes both psychotherapy (usually group and individual) and medication. Once stabilized, the patient is usually discharged and will continue treatment at an outpatient level. Pros: Besides keeping a suicidal person safe, hospitalization also gives them a “break” from all the stress that is part of their day to day life. Sometimes just a few days of this type of respite is very beneficial. Also, over the course of a few days, patients participate in many group and individual therapy sessions. These can help jump start the process of getting better. Cons: The cost of inpatient treatment is very high. For individuals without insurance, this can add another burden to an already challenging situation – sometimes making the depression worse in the long run. Involuntary hospitalization can also be quite traumatic, stigmatizing, and humiliating – three additional blows to someone who is already severely depressed. Each of these three types of treatment – psychotherapy, medication, and hospitalization – can be very effective for depression. One of the biggest keys is your willingness to work with your treatment provider and stick with the treatment once you start.
Residential Treatment for Depression
A step down from hospitalization, residential treatment can take place in a much more comforting, less institutional setting. Some depression treatment programs offer small home-like environments with six to eight people in treatment at a time. Often these treatment programs will be gender-specific, that is, women-only treatment or men-only treatment. If depression has not responded to outpatient treatment but the patient is not so severely depressed as to require hospitalization, this type of residential treatment can be a powerful way to work through obstacles and begin to develop strategies to live a fuller life. Many of these residential treatment programs for depression will offer specialized therapy such as equine-assisted psychotherapy. In cases where past abuse or trauma may be an underlying cause for depression, they may use neurofeedback or EMDR (eye movement desensitization and reprocessing).