First comes the diagnosis, then comes therapy for depression. For many patients, getting on the path to treatment is the first step on the sometimes-tedious way out of the mood valley.
They learn that they are not helpless in their situation and that depression can be effectively treated. There are various therapeutic approaches available, which are recommended depending on the severity of the disease and the current disease phase.
There are basically four primary treatment strategies: watchful waiting, drug treatment, psychotherapeutic treatment and combination therapy.
Patients with very severe depression and poor general condition are often admitted to a specialist hospital for inpatient treatment, especially if there is an increased risk of suicide.
Adherence to therapy: a prerequisite for successful therapy
The success of any therapy is very much dependent on how much the patient is ready and able to adhere to the treatment plan discussed with the doctor. In medicine one speaks of adherence or compliance.
The problem of non-compliance often occurs in diseases whose extent and consequences are underestimated by the patient.
In particular, when the disease, as in the case of depression, in phases with more and sometimes less pronounced impairments, patients tend to suspend the therapy in good phases. However, this increases the risk of more serious relapses.
The best way to improve adherence is to educate. The doctor must take the time to explain what depression is, what status the therapy has and what the consequences of untreated depression can be.
The patient must also be informed about possible side effects of the antidepressant medication. In addition, he should know that the antidepressant effect can often begin only after 2 or 3 weeks.
It is important to adapt the treatment plan to the needs and living conditions of the patient.
For severely depressed people who can only cope with their everyday lives to a very limited extent, a close-knit therapeutic care is required. In many cases, it makes sense that, with the patient’s consent, relatives are informed and involved so that they can assist the patient.
The regular contact with the therapist and the exchange of information about the current state of the disease as well as the course of therapy promote adherence to therapy.
Medicines for the treatment of depression are referred to as antidepressants. They intervene in the brain metabolism. They are intended to regulate the disturbed communication between the nerve cells by influencing the quantity and activity of the messenger substances.
The various biochemical agents used are targeted to the messengers serotonin, dopamine, norepinephrine and melatonin.
According to their mechanism of action, one divides antidepressants into different classes.
Depending on the condition of the disease and the prevailing symptoms, the doctor decides which drug is best from which activity class. The side effect profile also plays a role here.
For moderate and severe depression, drug therapy is indispensable. The choice of the appropriate antidepressant depends on the individual needs and symptoms of the patient.
MASSA (melatonin agonist and specific serotonin antagonist)
This drug, which is approved for episodes of depression in adults, is referred to as a melatonin antidepressant.
It acts on the mode of action of the messenger melatonin, which is responsible for the adjustment of biological rhythms. This “melatonin agonist and specific serotonin antagonist” directly influences the internal clock of the human via melatonergic binding sites.
At the same time it inhibits certain binding sites of serotonin to the nerve cells, whereby a greater proportion of the messengers noradrenaline and dopamine is released in certain brain regions.
The interaction of these receptors on the one hand causes a normalization of the disturbed biorhythm of depressive patients, it adapts the circadian rhythm to the natural day-night rhythm, on the other hand, an improvement in depressive symptoms such as impaired mood, affect and daily activity and anxiety symptoms.
The melatonergic antidepressant has a favorable side effect profile. It is neutral in terms of body weight, heart rate and blood pressure and maintains sexual function. Temporarily, nausea and dizziness may occur after ingestion. Sleep disorders, elevation of liver function, headache and sweating are also reported.
SSRIs (Selective Serotonin Reuptake Inhibitors)
These reuptake inhibitors affect the composition of messengers between neurons in the synaptic cleft. SSRIs block specific serotonin receptors on the secretory nerve cell, thereby preventing the return of serotonin to the nerve cell. As a result, the concentration of serotonin in the synaptic cleft increases. This has a mood-enhancing, general activating and anxiolytic effect. However, there are also known undesirable side effects. These include: nausea and diarrhea, sexual dysfunction, dry mouth, headache and sleep disorders.
NARI (Selective norepinephrine reuptake inhibitors)
NARI regulate the balance of messenger substances by blocking the receptors for the reuptake of the messenger noradrenaline, thus increasing its concentration in the synaptic cleft. The therapeutic effect is reflected above all in an improved drive and an increase in motivation. As side effects constipation, dry mouth, increased sweating, bladder discomfort, headache and sleep disorders are known.
SNRI (serotonin norepinephrine reuptake inhibitors)
Drugs of this class of drugs inhibit both the reuptake of the messenger serotonin and the reuptake of the messenger noradrenaline. This has a mood-enhancing and in higher dosages drive-enhancing effect. Possible side effects are, similar to SSRI, nausea, sleep disorders, sexual dysfunction, dry mouth and headache. It can also cause dizziness, loss of appetite and high blood pressure.
NASSA (noradrenergic and specific serotonergic antidepressants)
These modern antidepressants stimulate the release of the messenger substances norepinephrine and serotonin and thus increase their concentration in the synaptic cleft. The list of possible side effects includes fatigue, dizziness, headache, weight gain and circulatory problems due to low blood pressure.
Modern antidepressants are more specifically involved in the activity of special messengers. This makes them much better tolerated.
Antidepressants of the first generation
Tricyclic and tetracyclic antidepressants
These antidepressants inhibit the reuptake of the messengers serotonin, norepinephrine and dopamine in the nerve cells, but are less selective than newer antidepressants. This can lead to much stronger side effects. These are in particular: tiredness, dry mouth, constipation, disorders in bladder emptying, headache, nausea, vomiting, dizziness, influence on blood pressure and heartbeat, sleep disorders, sexual disorders, weight gain, above-average sweating.
Note: Certain ingredients in grapefruit juice may inhibit the breakdown of drugs. This leads to an increased concentration of active ingredient and increases the risk of side effects.
MAO inhibitors (mono-amino-oxidase inhibitors)
Substances in this class of drugs also increase the concentration of the messengers serotonin and norepinephrine. However, they do not block the receptors of the nerve cells, but the protein called mono-amino-oxidase, which ensures the breakdown of messengers in the synaptic cleft in the cell.
Typical side effects include dizziness, sleep disorders and headaches. Since the mono-amino-oxidase is also responsible for the degradation of other substances in the body, for tyramine, the MAO inhibitors increase the tyramine concentration, which can trigger violent blood pressure crises. To avoid this, a diet and the waiver of tyramine-containing foods (including cheese, smoked fish, wine, beer) is required. In addition, the doctor must rule out possible interactions with other drugs.
Antidepressants have no addictive potential and do not become dependent even after prolonged ingestion. However, if antidepressants are discontinued very suddenly, weaning symptoms may occur. Typical withdrawal symptoms are: sleep disorders, gastrointestinal problems, agitation, irritability, headaches and muscle aches.
In mild to moderate depression, the use of some herbal medicines, especially St. John’s wort, has proven itself. These medications are pharmacy-only and not to be confused with St. John’s wort supplements, which are freely available on the market.
When taking the exact dosage must be complied with, because even natural drugs can cause side effects. In the case of St. John’s wort this can be gastrointestinal discomfort, dry mouth, tiredness or restlessness. In addition, intensive sun exposure should be avoided, as St. John’s wort increases the photosensitivity of the skin and thus increases the risk of photodamage and sunburn.
Monitoring of drug therapy
Regardless of which drug the doctor prescribes, regular contact with the doctor is important to monitor the effects and possible side effects of the preparations. The doctor will ask how the patient copes with the medication, if complaints related to the medication have occurred, and if an effect is already noticeable.
He will also perform the medical tests recommended for therapy control. On this basis, the treatment strategy can be continued, if necessary the dosage adjusted, a change or a supplement of the drug administration are considered. In the first few weeks of therapy, these checks will be close-knit. If there are no problems and the patient is well prepared for the medication, the intervals between visits to the doctor may gradually increase.
Before and during therapy various physical, technical and laboratory examinations are required. Only then can the doctor select the most appropriate drug for the patient and uncover undesirable effects at an early stage.
Various psychotherapeutic procedures are available for the treatment of depressive disorders. Decisive for the choice of the method are the individual clinical picture, the depression-inducing and -reinforcing factors as well as typical behavior patterns of the patient.
The aim of the therapy is to recognize, break up and positively change the negative attitudes, ways of thinking and behavior. Depending on the severity of depression, psychotherapy should be used as a combination treatment with drug therapy.
In cognitive therapy, it is assumed that people with depression are fixated on negative thought patterns. With the help of the therapist, patients first have to analyze their own perception, which leads to self-devaluation and depression.
The next step is to learn to distance oneself from these negative feelings or to reevaluate them, so that the patient does not automatically fall into a mood depression in future crisis situations. Cognitive therapy is often used in combination with behavioral therapy.
The psychotherapy can be done by a medical psychotherapist or a psychologist. Since the success of the therapy is based on good cooperation, it is important that a relationship of trust can be built.
The behavioral therapy is based firstly on the knowledge that every behavior can be learned, and secondly on the knowledge of the positive reinforcement in learning processes.
It is an aid to building active positive behaviors, the implementation of which is gradually being practiced. In combination with cognitive therapy, negative mental and behavioral patterns can be changed.
This therapy focuses on interpersonal and psychosocial experiences that may have a triggering or reinforcing effect on depression. These must be analyzed and managed through discussions or role-plays.
With the help of depth psychology, the patient should deal with unconscious fears, insecurities or anxieties, the causes of which lie mostly in experiences and conflicts in the past. The goal here is to expose these causes and to work through discussions to develop solutions to problems and new patterns of behavior.
In some depressive disorders, group therapies have been proven. They convey the awareness of not being alone with the disease.
In severe depression, in addition to drug therapy and psychotherapy, other supportive therapies are often used. They should also affect a regulation of the neurotransmitters with different methods.
Sleep deprivation or guard therapy
Especially patients, in which the depression is subject to greater daily fluctuations, experience an improvement of the symptoms after a specific sleep deprivation. Sleep deprivation is carried out on an inpatient basis either over a whole night and the following day or only over the second half of the night and the following day.
The patient sits here for up to one hour a day in front of a strong light source. The light enters through the eyes and is transmitted from the optic nerves to the inner clock. Through the light impulse, the internal clock adjusts the inner biorhythms to the light-dark rhythm of the day. The flattened in depression and disordered rhythms are synchronized and the sleep-wake rhythm is stabilized. The incident light also increases the availability of serotonin. The therapy has proven itself particularly with seasonal depressions such as the winter depression.
Electroconvulsive Therapy (ECT)
Treatment is only used in patients with major depressive disorder where other therapies have no effect. On one side of the head applied electrodes, the patient who is under a short anesthetic, receives an electrical impulse. This triggers artificially a seizure, which causes various neurochemical changes and regulates the imbalance of messengers.
Transcranial magnetic stimulation
In this procedure, a magnetic field is applied to the forehead of the patient. It builds up an electric field, which stimulates the nerve cells similar to the ECT.
Following the acute therapy, mistakes are often made. Patients neglect to take the medication or take off the antidepressants on their own.
Therapy course and control
Depression sufferers have every reason to hope. Your chances of recovery are good. In most patients, thanks to medication and psychotherapy, symptoms improve within a few months.
Of concern, however, is the high relapse rate, especially in the case of severely depressed patients. The risk of later developing depressive episodes is between 50 and 85 percent. The patient himself can do a lot to prevent relapses.
On the one hand, it is essential that he adheres to the prescribed therapy plans in all phases of treatment, on the other hand he should also take into account his illness in his everyday life, respond to mood lows early and, if necessary, consult a doctor. For self-monitoring and also as an aid to the doctor and therapist, it makes sense that the patient keeps a therapy diary in which he notes when and for what occasion mood changes occur.
treatment of acute depression until a significant improvement in symptoms occurs. This takes about 4-8 weeks. Components of the therapy are: patient education, drug therapy, psychotherapy.
After the symptoms have resolved, the antidepressants successfully used in acute therapy are continued for a minimum period of 6 months in order to stabilize the state of health. Therapy continues to be monitored regularly by the doctor to detect early warning signs of a possible relapse.
Prevention of recurrence (relapse prevention)
The aim of prevention is to prevent long-term new relapses. During this time, which is between 3 and 5 years, depending on the severity of the disease, the medical treatment continues. At the same time, a regular everyday rhythm should be achieved and maintained. If the state of health remains stable during this period, the doctor will gradually reduce the dose of antidepressants.