Depression: To Medicate or Not

To take medication  or not for depression is something that there still seems to be some prejudice.  In the 28 years plus I have been in practice, it is something I see patients have confusion about in regards to their treatment.   Medication should only be considered after a detailed interview to establish a diagnosis with symptoms that warrant medication.

Every so often I will have a patient who is suffering from all the signs and symptoms of major depression, yet is very reluctant about taking any antidepressants to relieve her depression.  I can certainly understand their concern about taking any medication at all, and rightfully so, as every patient has the right to know the pros and cons of any medication.

One of the biggest problems is the misunderstanding about depression in the first place.  Clinical depression is a real syndrome of symptoms that involves neuronal dysfunction but affects the entire body.  In other words clinical depression is a sickness with multiple symptoms, both physical and emotional because of the nerve cells in the brains are not functioning in the proper way.

Clinical depression is not sadness because of a loss that occurred in your life.   Grief reactions, caused by death and loss can mimic all the symptoms of depression, but they rarely warrant being medicated.  They are diagnosed differently than depressive disorders.  Only if the patient continues to display all the symptoms of a grief reaction after a long period of time, would a clinician advocate medication.

When a patient presents with all the symptoms of depression without any particular  loss, then you are looking into classical major depression.  This is due to a genetic predisposition for neuronal dysfunctioning.  Depression, as other mental diseases runs in families.

Be aware that in this population,(with genetic predisposition) that any event of grief or loss can often be enough to derange the neuronal system and set off a phase of major depression, or make an existing depression worse.  Patients who have inherited a predisposition towards depression are more susceptible to  stressors they encounter than the ordinary person.  Therefore they will be more at risk for developing depression.

When I talk about a genetic predisposition, this is something I always investigate about in taking a family psychiatric history the first time I interview a new patient.  If any blood related relatives have suffered from mental illnesses such as depression ,psychotic symptoms, anxiety, addictive diseases,then there is a high likelihood that the patient has inherited certain predispositions.  They are especially at risk if any blood relative has attempted suicide or completed a suicide.

If my patient presents with all the signs and symptoms of major depression with a “loaded” family psychiatric history, and without any precipitating event, then they are probably suffering from inherited neuronal dysfunction.

Even if there is no known family history of mental illnesses,  patients can present with a full-blown constellation of severe depressive symptoms.  Everybody’s neuronal makeup is different and has different ways to responding to stressors in life.

In these cases the very best treatment option would be an antidepressant medication.  Especially if there is suicidal ideation, even without intent.  Just the fact that people would prefer to die than face another day is rationale enough to warrant antidepressant medication.

It is also the severity and duration of the depressive symptoms  and the patient’s previous psychiatric and family history that leads me to ascertain that this person is in need of antidepressant medication.   But one must beware that to medicate depression without a good psychiatric history of the patient is not at all advisable , and can make matters worse. .

A blatant example is that of bipolar patients, who may present during  depressive phase, but without any detailed previous psychiatric history, then antidepressant treatment alone is not warranted, and even contra indicated.

If the depressive symptoms are not really interring in the general functioning in their personal and professional life, then psychotherapy alone is usually effective.   Dysthymics(those who suffer from low-grade depression) and seasonal affective disorder patients often chose to tough it out, as for them their sub normal feelings are very “normal” to them.

From time to time I will have a patient, who despite their severe suffering, will absolutely refuse to even consider antidepressant medication.   They offer rationals that “those” medications are addictive or will “play” with their minds.   Yet they have no problems at all in taking antibiotics whenever they have a viral cold, which is totally worthless as antibiotics do not kill viruses.

Antidepressants are not addictive, nor do the have ability to change your personality.  These medicines can not make you happy.  They relieve symptoms of depression and allow you to cope with whatever stressors you have in your life.   They restore the ability to find pleasure and joy again in your life.  I have often seen them save lives.

The most popular “natural” over the counter medications for depressive symptoms would be St John’s Wort and SAME or S-adensylmethionine.  The problem with St John’s Wort is that is practically impossible to know how much of the active ingredient(hypericin) is really present in the capsules you are swallowing.   SAME might be the better choice for those who want to try the “natural” preparations as it seems more effective, but only in mild cases of depression.

If you are taking either one of those preparations, and decide later to seek an antidepressant medication, you need to stop the over the counter medications, as taking both is contra indicated.  Also St. John’s Wort may interfere with other prescription drugs you are taking, so always tell your doctor or clinician.

Frankly for all depressed patients, whether you are taking medications or not , there are some simple things that are always helpful.  First and foremost is getting outside and at least walking for as long as you can, hopefully for at least 30 minutes a day.

Any exercise is beneficial, but getting out in fresh air is much more stimulating and helpful.   Getting depressed patients out of the house is like pulling teeth though, because of the severe lack of energy and motivation.   So it helps to have someone, friend or family, to ensure that they get out on a daily basis.

Going to the seacoast and any place in nature with water for negative ions will be helpful in boosting energy and mood.   Walking in a large city like Paris(even if the air is not so fresh) is also a stimulant because of all the animations and lights.  Large cities usually have a contagious high energy and are stimulating in mood.

Being around kind understanding friends and family, who are generally positive, especially if there is laughter is always good.  Unfortunately most  depressed patients want to withdraw in their dark corners to avoid any social contact, so once again you have to use pressure to get them out.

Sometimes in dealing with depressed family members, you can’t allow a “no” answer to either getting out or being with others. If they were in a psychiatric hospital, they would have no choice but to do these things, because they are essential in the care and treatment of depression.

Another factor is eating real foods, rather than processed stuff and taking additional multiple vitamins. I could harp much more on this in a future post!

Psychotherapy is extremely helpful as a conjunctive to medication, as medication alone is not very desirable.   In another future post I will address the various antidepressants most commonly used and how one might be better for one patient over another.

The goal of treatment is to alleviate symptoms that would allow the patient to restore full capacity of living.  Thank God we have these medications today, as unwarranted suffering that clinical depression entails cripples and even kills victims everyday.