Treatment Options 1

Medications

Antidepressants

Purpose: Reduce the number and intensity of depressive symptoms or eliminate them entirely,

enabling individuals to feel as they did prior to the onset of depression

Note: This class of drug contains many sub-categories, each targeting a different combination of neurotransmitters in the brain. Results are not typically seen until 2 or 3 weeks minimum on the medication.

Caution: If a person with bipolar disorder takes an antidepressant by itself, without a mood stabilizer, it is possible that the antidepressant could trigger a manic or hypomanic episode (characterized by excessive energy, rapid thoughts and talking, elevated mood, hypersexuality, spending sprees, possible psychosis, etc.)

Selective Serotonin Reuptake Inhibitors (SSRIs)

At a Glance: These newer medications are frequently prescribed because they are fairly effective

and have fewer side effects than some of the other antidepressants. However, warnings have

recently been issued regarding the potential for these medications to increase suicidal thoughts

and behavior, particularly among children and teenagers. This has been known to occur not only

while on the drugs, but while and shortly after discontinuing them. In general, common side

effects of SSRIs include headache, nausea, agitation, nervousness, insomnia, and sexual

problems.

Drug (Brand) Names:

citalopram (Celexa)

escitalopram (Lexapro)

fluoxetine (Prozac)

fluvoxamine (Luvox)

paroxetine (Paxil)

sertraline (Zoloft)

Tricyclics

At a Glance: While effective, these drugs are not typically the first line of treatment because of the

unpleasant side effects which may include dry mouth, constipation, blurred vision, dizziness,

drowsiness, increased heart rate, bladder problems, and sexual problems. Since tricyclics can

cause serious cardiac problems at high doses, caution must be exercised when prescribed to

suicidal individuals.

Drug (Brand) Names:

amitriptyline (Elavil, Endep)

clomipramine (Anafranil)

desipramine (Norpramin, Pertofrane)

doxepin (Adapin, Sinequan)

imipramine (Tofranil)

nortriptyline (Aventyl, Pamelor)

protriptyline (Vivactil)

trimipramine (Surmontil)

Monoamine Oxidase Inhibitors (MAOIs)

At a Glance: MAOIs can be very effective for people not responding to other treatments for

depression; they may also be used for panic disorder and bipolar disorder. However, they are not

typically a first line treatment because of the many restrictions on foods, beverages, and other

medications (as a result of the potentially dangerous hyperpyretic and hypertensive crises, which

could lead to "serotonin syndrome," stroke, coma, etc.). Precautions can be taken, including

informing yourself about the symptoms of a reaction, wearing a MedAlert bracelet, and having an

antedote (medication for acute high blood pressure); so long as the regimen is followed, the MAOIs

are fairly tolerable and effective. An MAOI patch, akin to the nicotine patches often used for

smoking cessation, has been developed and is awaiting FDA approval; the patch should eliminate

(or at least reduce the number of) dietary and medication restrictions, since medication

absorption takes place at the level of the skin, as opposed to the gastrointestinal system.

Drug (Brand) Names:

isocarboxazid (Marplan)

phenelzine (Nardil)

selegiline (Eldepryl)

tranylcypromine (Parnate)

Alternative Medical Treatments

Acupuncture

Acupuncture is based on energy principles of the human body, the needles tapping into points along "meridians" to manipulate this energy, or "qi" (pronounced "chee"). In Chinese medicine, there is no actual diagnosis of "depression"; in fact, there are quite a few diagnoses that could fit the description. Instead, the underlying cause of the symptoms is found to be related to problems such as qi deficiency, qi blockage, etc. The diagnosis typically consists of a patient interview, examination of various qualities of the tongue, palpation (or touching) of various body regions to check for temperature, moisture, and pain response, and determination of the pulse rate, rhythm, position, and quality. An actual treatment session of acupuncture might be something like the following: The practitioner checks the progress of your symptoms (comparing them to the initial diagnostic evaluation), then has you lie down or sit comfortably. Sterile needles are then placed in predetermined locations around your body and remain there for at least a 20 minute treatment session. What do the needles feel like? While some people experience strong responses, others hardly feel the needles when they are inserted. It's possible for the regions to become a little sore, hot, and tingly, as time progresses in the session; however, these feelings are alleviated upon removal of the needles. Early studies examining the use of acupuncture for depression are promising, but additional studies are necessary to confirm its benefits for this purpose.

Electroconvulsive ("Shock") Therapy (ECT)

ECT, or "shock" therapy, is typically reserved for severe cases, including those patients not responsive to other methods of treatment. Although it is nothing like the treatment depicted in One Flew Over the Cuckoo's Nest, it is still at the center of much controversy--particularly over whether or not ECT causes permanent loss of memory and cognitive functioning. ECT is the administration of low "doses" of electrical shocks to the brain in order to induce seizures. It's typically given in a series of 6-12 treatments over the course of a month, after which time maintenance treatments are sometimes used. If unilateral treatment is used (where only one side of the brain is shocked), it's typically

administered to the right hemisphere of the brain, since the left side interferes more with language and memory. The temporal lobe of the brain is a common region for ECT to be performed; however, there are some facilities and studies also using the frontal lobes. During the treatment, patients are hooked up to monitors (including the pulse ox--to determine blood oxygen levels, heart monitor, etc.), given a short-acting general anesthetic (so that they're not awake during the procedure), a muscle paralyzer (so that bones are not broken during the seizure lasting approximately a minute), a mouth guard (to protect the tongue and provide access for an airway, if necessary), and anti-nausea medication (if the patient is prone to post-procedure nausea). During the procedure, the person feels nothing and is not aware of his or her surroundings, as a result of the general anesthesia. However, they may wake up feeling groggy, confused, fatigued, nauseous, headachy, dizzy, etc. Memory loss and confusion may get worse as treatments continue; however, they typically dissipate upon conclusion or discontinuation of the treatments. Why even bother with ECT? As it turns out, ECT is considered the "gold standard" for measuring treatment efficacy because it is so successful. If someone is otherwise treatment-resistant or acutely suicidal, ECT can "shock" them back into a healthy brain pattern. In fact, ECT may even be the treatment of choice for conditions such as catatonia, psychotic depression, and depression in Parkinson's patients. Shocking the brain may sound barbaric and is typically difficult for people to digest, but consider the following: We shock the heart in order to save lives...Why can't we shock the brain in order to save people as well?

This purpose of this section is to provide you with an overview of the many available medications and alternative medical treatments. Keep in mind that research studies are always coming out with information about treatments--both new and old. (This information was compiled in the year 2005.)

Note: The following information was not written by a medical professional. Always discuss options with your own physician, using the following list only to serve as a general guide.

Other Antidepressants

Drug (Brand) Names:

amoxapine (Asendin) - tetracyclic antidepressant

maprotiline (Ludiomil) - tetracyclic antidepressant

nefazodone (Serzone) - serotonin antagonist

trazodone (Desyrel) - serotonin antagonist

bupropion (Wellbutrin) - norepinephrine and dopamine reuptake inhibitor (NDRI)

duloxetine (Cymbalta) - serotonin and norepinephrine reuptake inhibitor (SNRI)

venlafaxine (Effexor) - serotonin and norepinephrine reuptake inhibitor (SNRI)

mirtazapine (Remeron) - Alpha-2 receptor blocker

Mood Stabilizers

Purpose: Although some drugs in this class also contain antidepressant qualities, they are typically prescribed in an attempt to balance out the mood swings between depression and (hypo)mania, common in bipolar disorders. Lithium and anticonvulsants are both used as mood stabilizers.

Lithium

At a Glance: It has the potential to reduce severe manic symptoms within two weeks, however

it's long-term effects generally take much longer to build up (weeks to months). Because there is a

delicate range between an effective dose and a toxic dose of lithium (a salt) in the body, frequent

blood tests need to be ordered to check blood levels of the drug. (In the beginning of treatment,

this is typically checked every couple of weeks.) Anything that lowers the level of sodium in the

body--a low salt diet, heavy sweating, vomiting, fever, diarrhea, etc.--has the potential to cause

lithium toxicity. In general, common side effects of lithium include nausea, fatigue, weakness,

drowsiness, increased thirst and urination, weight gain, and hand tremor.

Drug (Brand) Names:

lithium (Cibalith, Eskalith, Lithane, Lithobid, Lithonate)

Anticonvulsants

At a Glance: Although commonly used to treat seizures, these medications have often proven fairly

effective as mood stabilizers as well. Side effects vary among the anticonvulsants, but may

include things like headache, dizziness, double vision, anxiety, confusion, cognitive and memory

impairment, and balance or motor problems.

Note: Studies have shown that in young, female patients anticonvulsants may elevate testosterone

levels and cause a condition called POS (polycystic ovary syndrome), characterized by obesity,

body hair (hirsutism), and loss of period (amenorrhea).

Drug (Brand) Names:

carbamazepine (Tegretol)

gabapentin (Neurontin)*

lamotrigine (Lamictal)**

oxcarbazepine (Trileptal)

topiramate (Topamax)

valproic acid, divalproex sodium (Depakene, Depakote)

*isn't very good mood stabilizer on its own, but works well with other mood stabilizers; useful for anxiety & pain syndromes

**carries risk of potentially serious rashes, but this risk can be minimized by increasing dosage slowly

Antianxiety Medications

Purpose: General anxiety or anxiety disorders can accompany depression, so medications specifically geared towards the reduction of anxiety symptoms may be prescribed in concert with other drugs. Some antidepressants actually have anxiety reduction properties, as well.

Benzodiazepines

At a Glance: Benzodiazepines have the ability to reduce symptoms rapidly, and may be taken as a

daily dose or simply "as needed." They have relatively few side effects, although common ones can

include drowsiness, loss of coordination, mental slowing, and confusion. Because of their addictive

properties, lengthy treatment on benzodiazepines is typically not recommended; however, there are

people for whom more long-term treatment is indicated. Abrupt discontinuation of benzodiazepines

can cause severe withdrawal reactions, which may include seizures or even death.

Drug (Brand) Names:

alprazolam (Xanax)

chlordiazepoxide (Librium)

clonazepam (Klonopin)

diazepam (Valium)

lorazepam (Ativan)

temazepam (Restoril)

triazolam (Halcion)

Other Antianxiety Medications

Drug (Brand) Names:

buspirone (BuSpar) - (mechanism of action unknown)

propranolol (Inderal, Inderide) - beta blocker

Antipsychotics

Purpose: The antipsychotics are used to enhance the effects of mood stabilizers (particularly during severe manic episodes) as well as for treatment of psychosis (which could include hallucinations, delusions, paranoia, etc.). Side effects vary from drug to drug in this class; however, the newer versions ("atypical antipsychotics") tend to have fewer side effects.

Note: Because of a potentially serious blood disorder, agranulocytosis (loss of the white blood cells that fight infection), patients on clozapine (Clozaril) should have blood tests drawn every 1-2 weeks.

Caution: Long-term use of antipsychotics, particularly the older antipsychotics, has the potential to cause tardive dyskinesia (TD), a movement disorder characterized by involuntary movements ranging from mild to severe. This is a possibly irreversible condition upon onset.

Antipsychotics (Older)

Drug (Brand) Names:

chlorpromazine (Thorazine)

fluphenazine (Prolixin)

haloperidol (Haldol)

Atypical Antipsychotics

Drug (Brand) Names:

aripiprazol (Abilify)

clozapine (Clozaril)

olanzapine (Zyprexa)

quetiapine (Seroquel)

risperidone (Risperdal)

ziprasidone (Geodon)

Magnetic Seizure Therapy (MST)

MST (in which high-intensity magnetic stimulation is used to induce seizures, as opposed to electricity) is one of the latest alternative treatments being studied. Already, research is indicating that MST may be able to reproduce the beneficial effects of ECT with fewer side effects, including less retrograde amnesia, attention difficulties, etc. However, MST is still in the clinical trials phase and is not yet available to the general public as a treatment modality.

Transcranial Magnetic Stimulation (TMS, rTMS)

Although it is not yet an FDA-approved treatment in the United States, TMS has been used in research as a treatment for depression since 1985 and is currently approved for use in certain parts of the world (including Canada, Europe, and Israel). Like ECT, TMS is proving to be an effective treatment for otherwise treatment resistant depression, only it does not cause many of the side effects associated with ECT. It works by stimulating nerves of the brain using a powerful electromagnetic field; it does not cause seizures (unless there is a complication), as ECT strives to do. TMS may be given in a series of approximately 10-30 treatments, each treatment lasting only about 30 minutes. If called for, maintenance treatments may take place after the initial series. The experience of TMS treatments may differ depending upon the patient and treatment facility, however the following is an example of the experience: The patient is seated while the technician determines the location on the head that causes hand twitching. The location is then marked with a marker, and the patient is free to make him or herself more comfortable while the machine is being set up for treatment. During the treatment itself, the machine maintains contact with the person's head and emits the electromagnetic field in an "on for 10 seconds, off for 20 seconds" pattern. Some patients report the sensation as being only a mild tingling around the brain, whereas others find the actual stimulation to be fairly painful--like "having your head banged repeatedly with a hammer at sewing machine pace, all the while creating a severe ice cream headache." Once the session is completed, the few side effects (headache being the main one) can be alleviated with some over-the-counter medication and rest. While TMS is awaiting FDA-approval, treatment facilities in the United States offering TMS are extremely rare. There IS one in Atlanta, Georgia, that performs TMS off-label (so chances are your insurance will not pay for the treatments); if you're interested, you can visit their website for more information: The Center for TMS

Vagus Nerve Stimulation (VNS)

While not a common procedure, VNS is now an option for treatment resistant depression (in addition to epilepsy), although it's success rates for depression are not nearly as good as ECT or TMS. Vagus nerve stimulation requires the surgical implantation (under general anesthesia) of a pacemaker-like device in the upper left chest region. A wire is then run under the skin from the device to the vagus nerve in the neck, where 3 leads are attached to the nerve. The purpose of the device is to stimulate the vagus nerve at intervals throughout the day (for example, for 30 seconds every 5 minutes). During the repetitive stimulation, patients have noted hoarseness, coughing, difficulty swallowing, and a tingling sensation in the throat. The possible complications of the surgery itself include damage to the vagus nerve, carotid artery, and/or jugular vein. If VNS is unsuccessful, the device typically remains (de-activated) in the chest, since surgery to remove it would be an unnecessary risk.