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The three most common clinical treatments for depression are psychotherapy, medication, and electroconvulsive therapy. Psychotherapy is the treatment of choice (over medication) for people under 18. Care is usually given on an outpatient basis, whereas treatment in an inpatient unit is considered if there is a significant risk to self or others. Other treatments include light therapy, sleep deprivation, physical exercise, stopping smoking, mindfulness meditation, and music therapy. Treatment options are much more limited in developing countries, where access to mental health staff, medication, and psychotherapy is often difficult. Development of mental health services is minimal in many countries; depression is viewed as a phenomenon of the developed world despite evidence to the contrary, and not as an inherently life-threatening condition.[156] In general, the type of treatment is less important than involvement in a treatment program.[157] Psychotherapy Psychotherapy can be delivered, to individuals, groups, or families by mental health professionals, including psychotherapists, psychiatrists, psychologists, clinical social workers, counselors, and suitably trained psychiatric nurses. With more complex and chronic forms of depression, a combination of medication and psychotherapy may be used.[158][159] A 2012 review found psychotherapy to be better than no treatment but not other treatments.[160] Cognitive behavioral therapy (CBT) currently has the most research evidence for the treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy (IPT) are preferred therapies for adolescent depression.[161] In people under 18, according to the National Institute for Health and Clinical Excellence, medication should be offered only in conjunction with a psychological therapy, such as CBT, interpersonal therapy, or family therapy.[162] Psychotherapy has been shown to be effective in older people.[163][164] Successful psychotherapy appears to reduce the recurrence of depression even after it has been terminated or replaced by occasional booster sessions. The most-studied form of psychotherapy for depression is CBT, which teaches clients to challenge self-defeating, but enduring ways of thinking (cognitions) and change counter-productive behaviors. Research beginning in the mid-1990s suggested that CBT could perform as well or better than antidepressants in patients with moderate to severe depression.[165][166] CBT may be effective in depressed adolescents,[167] although its effects on severe episodes are not definitively known.[168] Several variables predict success for cognitive behavioral therapy in adolescents: higher levels of rational thoughts, less hopelessness, fewer negative thoughts, and fewer cognitive distortions.[169] CBT is particularly beneficial in preventing relapse.[170][171] Several variants of cognitive behavior therapy have been used in depressed patients, the most notable being rational emotive behavior therapy,[172] and more recently mindfulness-based cognitive therapy.[173] Psychoanalysis is a school of thought, founded by Sigmund Freud, which emphasizes the resolution of unconscious mental conflicts.[174] Psychoanalytic techniques are used by some practitioners to treat clients presenting with major depression.[175] A more widely practiced, eclectic technique, called psychodynamic psychotherapy, is loosely based on psychoanalysis and has an additional social and interpersonal focus.[176] In a meta-analysis of three controlled trials of Short Psychodynamic Supportive Psychotherapy, this modification was found to be as effective as medication for mild to moderate depression.[177] Logotherapy, a form of existential psychotherapy developed by Austrian psychiatrist Viktor Frankl, addresses the filling of an "existential vacuum" associated with feelings of futility and meaninglessness. It is posited that this type of psychotherapy may be useful for depression in older adolescents.[178] Antidepressants Zoloft (sertraline) is used primarily to treat major depression in adult outpatients. In 2007, it was the most prescribed antidepressant on the U.S. retail market, with 29,652,000 prescriptions.[179] The effectiveness of antidepressants is none to minimal in those with mild or moderate depression but significant in those with very severe disease.[4][160] Combining psychotherapy and antidepressants may provide a "slight advantage", but antidepressants alone or psychotherapy alone are not significantly different from other treatments, or "active intervention controls".[160] The effects of antidepressants are somewhat superior to those of psychotherapy, especially in cases of chronic major depression, although in short-term trials more patients—especially those with less serious forms of depression—cease medication than cease psychotherapy, most likely due to adverse effects from the medication and to people's preferences for psychological therapies over pharmacological treatments.[180][181] To find the most effective antidepressant medication with minimal side-effects, the dosages can be adjusted, and if necessary, combinations of different classes of antidepressants can be tried. Response rates to the first antidepressant administered range from 50–75%, and it can take at least six to eight weeks from the start of medication to remission.[182] Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence,[182] and even up to one year of continuation is recommended.[183] People with chronic depression may need to take medication indefinitely to avoid relapse.[6] Selective serotonin reuptake inhibitors (SSRIs) are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants.[184] Patients who do not respond to one SSRI can be switched to another antidepressant, and this results in improvement in almost 50% of cases.[185] Another option is to switch to the atypical antidepressant bupropion.[186] Venlafaxine, an antidepressant with a different mechanism of action, may be modestly more effective than SSRIs.[187] However, venlafaxine is not recommended in the UK as a first-line treatment because of evidence suggesting its risks may outweigh benefits,[188] and it is specifically discouraged in children and adolescents.[189][190] For adolescent depression, fluoxetine[189] and escitalopram[191] are the two recommended choices. Antidepressants appear to have only slight benefit in children.[192] There is also insufficient evidence to determine effectiveness in those with depression complicated by dementia.[193] Any antidepressant can cause low serum sodium levels (also called hyponatremia);[194] nevertheless, it has been reported more often with SSRIs.[184] It is not uncommon for SSRIs to cause or worsen insomnia; the sedating antidepressant mirtazapine can be used in such cases.[195][196] Irreversible monoamine oxidase inhibitors, an older class of antidepressants, have been plagued by potentially life-threatening dietary and drug interactions. They are still used only rarely, although newer and better-tolerated agents of this class have been developed.[197] The safety profile is different with reversible monoamine oxidase inhibitors such as moclobemide where the risk of serious dietary interactions is negligible and dietary restrictions are less strict.[198] For children, adolescents, and probably young adults between 18 and 24 years old, there is a higher risk of both suicidal ideations and suicidal behavior in those treated with SSRIs.[199][200] For adults, it is unclear whether or not SSRIs affect the risk of suicidality.[200] One review found no connection;[201] another an increased risk;[202] and a third no risk in those 25–65 years old and a decrease risk in those more than 65.[203] Epidemiological data has found that the widespread use of antidepressants in the new "SSRI-era" is associated with a significant decline in suicide rates in most countries with traditionally high baseline suicide rates.[204] The causality of the relationship is inconclusive.[205] A black box warning was introduced in the United States in 2007 on SSRI and other antidepressant medications due to increased risk of suicide in patients younger than 24 years old.[206] Similar precautionary notice revisions were implemented by the Japanese Ministry of Health.[207] There is some evidence that fish oil supplements containing high levels of eicosapentaenoic acid (EPA) to docosahexaenoic acid (DHA) may be effective in major depression,[208] but other meta-analysis of the research conclude that positive effects may be due to publication bias.[209] There is some preliminary evidence that COX-2 inhibitors have a beneficial effect on major depression.[59] Lithium appears effective at lowering the risk of suicide in those with bipolar disorder and unipolar depression to nearly the same levels as the general population.[210] There is a narrow range of effective and safe dosages of lithium thus close monitoring may be needed.[211] Electroconvulsive therapy Electroconvulsive therapy (ECT) is a procedure whereby pulses of electricity are sent through the brain via two electrodes, usually one on each temple, to induce a seizure while the person is under a brief period of general anesthesia. Hospital psychiatrists may recommend ECT for cases of severe major depression that have not responded to antidepressant medication or, less often, psychotherapy or supportive interventions.[212] ECT can have a quicker effect than antidepressant therapy and thus may be the treatment of choice in emergencies such as catatonic depression where the person has stopped eating and drinking, or where a person is severely suicidal.[212] ECT is probably more effective than pharmacotherapy for depression in the immediate short-term,[213] although a landmark community-based study found much lower remission rates in routine practice.[214] When ECT is used on its own, the relapse rate within the first six months is very high; early studies put the rate at around 50%,[215] while a more recent controlled trial found rates of 84% even with placebos.[216] The early relapse rate may be reduced by the use of psychiatric medications or further ECT[217][218] (although the latter is not recommended by some authorities)[219] but remains high.[220] Common initial adverse effects from ECT include short and long-term memory loss, disorientation and headache.[221] Although memory disturbance after ECT usually resolves within one month, ECT remains a controversial treatment, and debate on its efficacy and safety continues.[222][223] Other Bright light therapy reduces depression symptom severity, with benefit was found for both seasonal affective disorder and for nonseasonal depression, and an effect similar to those for conventional antidepressants. For non-seasonal depression, adding light therapy to the standard antidepressant treatment was not effective.[224] For non-seasonal depression where light was used mostly in combination with antidepressants or wake therapy a moderate effect was found, with response better than control treatment in high-quality studies, in studies that applied morning light treatment, and with people who respond to total or partial sleep deprivation.[225] Both analyses noted poor quality, short duration, and small size of most of the reviewed studies. There is a small amount of evidence that skipping a nights sleep may help.[226] Physical exercise is recommended for management of mild depression,[227] and has a moderate effect on symptoms.[228] It is equivalent to the use of medications or psychological therapies in most people.[228] In the older people it does appear to decrease depression.[229] Smoking cessation has benefits in depression as large as or larger than those of medications.[230] Prognosis Major depressive episodes often resolve over time whether or not they are treated. Outpatients on a waiting list show a 10–15% reduction in symptoms within a few months, with approximately 20% no longer meeting the full criteria for a depressive disorder.[231] The median duration of an episode has been estimated to be 23 weeks, with the highest rate of recovery in the first three months.[232] Studies have shown that 80% of those suffering from their first major depressive episode will suffer from at least 1 more during their life,[233] with a lifetime average of 4 episodes.[234] Other general population studies indicate that around half those that have an episode (whether treated or not) recover and remain well, while the other half will have at least one more, and around 15% of those experience chronic recurrence.[235] Studies recruiting from selective inpatient sources suggest lower recovery and higher chronicity, while studies of mostly outpatients show that nearly all recover, with a median episode duration of 11 months. Around 90% of those with severe or psychotic depression, most of whom also meeting criteria for other mental disorders, experience recurrence.[236][237] Recurrence is more likely if symptoms have not fully resolved with treatment. Current guidelines recommend continuing antidepressants for four to six months after remission to prevent relapse. Evidence from many randomized controlled trials indicates continuing antidepressant medications after recovery can reduce the chance of relapse by 70% (41% on placebo vs. 18% on antidepressant). The preventive effect probably lasts for at least the first 36 months of use.[238] Those people experiencing repeated episodes of depression require ongoing treatment in order to prevent more severe, long-term depression. In some cases, people must take medications for long periods of time or for the rest of their lives.[239] Cases when outcome is poor are associated with inappropriate treatment, severe initial symptoms that may include psychosis, early age of onset, more previous episodes, incomplete recovery after 1 year, pre-existing severe mental or medical disorder, and family dysfunction as well.[240] Depressed individuals have a shorter life expectancy than those without depression, in part because depressed patients are at risk of dying by suicide.[241] However, they also have a higher rate of dying from other causes,[242] being more susceptible to medical conditions such as heart disease.[243] Up to 60% of people who commit suicide have a mood disorder such as major depression, and the risk is especially high if a person has a marked sense of hopelessness or has both depression and borderline personality disorder.[1] The lifetime risk of suicide associated with a diagnosis of major depression in the US is estimated at 3.4%, which averages two highly disparate figures of almost 7% for men and 1% for women[244] (although suicide attempts are more frequent in women).[245] The estimate is substantially lower than a previously accepted figure of 15%, which had been derived from older studies of hospitalized patients.[246] Depression is often associated with unemployment and poverty.[247] Major depression is currently the leading cause of disease burden in North America and other high-income countries, and the fourth-leading cause worldwide. In the year 2030, it is predicted to be the second-leading cause of disease burden worldwide after HIV, according to the World Health Organization.[248] Delay or failure in seeking treatment after relapse, and the failure of health professionals to provide treatment, are two barriers to reducing disability.[249] Epidemiology Main article: Epidemiology of depression Disability-adjusted life year for unipolar depressive disorders per 100,000 inhabitants in 2004.[250] no data <700 700-775 775-850 850-925 925-1000 1000-1075 1075-1150 1150-1225 1225-1300 1300-1375 1375-1450 >1450 Depression is a major cause of morbidity worldwide.[251] It is believed to currently affect approximately 298 million people as of 2010 (4.3% of the global population).[252] Lifetime prevalence varies widely, from 3% in Japan to 17% in the US.[253] In most countries the number of people who have depression during their lives falls within an 8–12% range.[253] In North America, the probability of having a major depressive episode within a year-long period is 3–5% for males and 8–10% for females.[254][255] Population studies have consistently shown major depression to be about twice as common in women as in men, although it is unclear why this is so, and whether factors unaccounted for are contributing to this.[256] The relative increase in occurrence is related to pubertal development rather than chronological age, reaches adult ratios between the ages of 15 and 18, and appears associated with psychosocial more than hormonal factors.[256] People are most likely to suffer their first depressive episode between the ages of 30 and 40, and there is a second, smaller peak of incidence between ages 50 and 60.[257] The risk of major depression is increased with neurological conditions such as stroke, Parkinson's disease, or multiple sclerosis, and during the first year after childbirth.[258] It is also more common after cardiovascular illnesses, and is related more to a poor outcome than to a better one.[243][259] Studies conflict on the prevalence of depression in the elderly, but most data suggest there is a reduction in this age group.[260] Depressive disorders are more common to observe in urban than in rural population and the prevalence is in groups with stronger socioeconomic factors i.e. homelessness.[261] History Diagnoses of depression go back at least as far as Hippocrates Main article: History of depression The Ancient Greek physician Hippocrates described a syndrome of melancholia as a distinct disease with particular mental and physical symptoms; he characterized all "fears and despondencies, if they last a long time" as being symptomatic of the ailment.[262] It was a similar but far broader concept than today's depression; prominence was given to a clustering of the symptoms of sadness, dejection, and despondency, and often fear, anger, delusions and obsessions were included.[81] The term depression itself was derived from the Latin verb deprimere, "to press down".[263] From the 14th century, "to depress" meant to subjugate or to bring down in spirits. It was used in 1665 in English author Richard Baker's Chronicle to refer to someone having "a great depression of spirit", and by English author Samuel Johnson in a similar sense in 1753.[264] The term also came into use in physiology and economics. An early usage referring to a psychiatric symptom was by French psychiatrist Louis Delasiauve in 1856, and by the 1860s it was appearing in medical dictionaries to refer to a physiological and metaphorical lowering of emotional function.[265] Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance, a hazard of contemplation and creativity. The newer concept abandoned these associations and through the 19th century, became more associated with women.[81] Although melancholia remained the dominant diagnostic term, depression gained increasing currency in medical treatises and was a synonym by the end of the century; German psychiatrist Emil Kraepelin may have been the first to use it as the overarching term, referring to different kinds of melancholia as depressive states.[266] Sigmund Freud likened the state of melancholia to mourning in his 1917 paper Mourning and Melancholia. He theorized that objective loss, such as the loss of a valued relationship through death or a romantic break-up, results in subjective loss as well; the depressed individual has identified with the object of affection through an unconscious, narcissistic process called the libidinal cathexis of the ego. Such loss results in severe melancholic symptoms more profound than mourning; not only is the outside world viewed negatively but the ego itself is compromised.[79] The patient's decline of self-perception is revealed in his belief of his own blame, inferiority, and unworthiness.[80] He also emphasized early life experiences as a predisposing factor.[81] Meyer put forward a mixed social and biological framework emphasizing reactions in the context of an individual's life, and argued that the term depression should be used instead of melancholia.[267] The first version of the DSM (DSM-I, 1952) contained depressive reaction and the DSM-II (1968) depressive neurosis, defined as an excessive reaction to internal conflict or an identifiable event, and also included a depressive type of manic-depressive psychosis within Major affective disorders.[268] In the mid-20th century, researchers theorized that depression was caused by a chemical imbalance in neurotransmitters in the brain, a theory based on observations made in the 1950s of the effects of reserpine and isoniazid in altering monoamine neurotransmitter levels and affecting depressive symptoms.[269] The term Major depressive disorder was introduced by a group of US clinicians in the mid-1970s as part of proposals for diagnostic criteria based on patterns of symptoms (called the "Research Diagnostic Criteria", building on earlier Feighner Criteria),[270] and was incorporated into the DSM-III in 1980.[271] To maintain consistency the ICD-10 used the same criteria, with only minor alterations, but using the DSM diagnostic threshold to mark a mild depressive episode, adding higher threshold categories for moderate and severe episodes.[271][272] The ancient idea of melancholia still survives in the notion of a melancholic subtype. The new definitions of depression were widely accepted, albeit with some conflicting findings and views. There have been some continued empirically based arguments for a return to the diagnosis of melancholia.[273][274] There has been some criticism of the expansion of coverage of the diagnosis, related to the development and promotion of antidepressants and the biological model since the late 1950s.[275] |
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