Treatment of depression requires more than meds

By Stephanie Hittle
For Health Care Today

Exercise. Eat right. Think positive thoughts. Stay socially connected. Not only is this good advice for healthy living; it is also part of treatment for clinical depression.

Clinical depression has multiple categories — dysthymic disorder, major depression, adjustment disorder with depressed mood and the depressive part of bipolar disorders.

Each category is based on duration, kind and severity of symptoms. People who feel "down" after a divorce, for example, may be diagnosed with an adjustment disorder, as their depression is part of their adjustment to a particular situation.

Dysthymic disorder is a longer-term version of depression where the individual can suffer from irritability, fatigue and loss of motivation among other symptoms. Persons who have major depression sometimes have problems with activities of daily living and may also have strong suicidal inclinations.

For most forms of depression, a combination of medication and counseling has been proven to be the most effective treatment. Counseling can be help the client make positive behavioral changes such as exercising, eating right and engaging socially as well as making changes in work or home environments.

Counseling can also help the client change destructive and ineffective thinking patterns that exacerbate depression. These include "all or nothing" thinking where the client sees himself/herself or life circumstances as all bad or good. Polarized thinking like this is almost always distorted and leaves the client unable to see possibilities and options outside of best- or worst-case scenarios.

Some clients "catastrophize" or think only in terms of the worst case scenario. Such negative thinking creates a "mind rut," that keeps clients stuck in depression. Other "mind ruts" include "if onlys" and "shoulds." These "regret orientations" keep persons looking to a past they can't change instead of a future they can. Even if they can't change their situation, they can change their attitude about it.

When my clients are depressed, I will often ask them, "What do you need to change?" That question is designed to stimulate thinking about what they have control over (versus what they don't) and to get them to formulate an action plan. That plan will usually include "homework" assignments to try new behaviors and perspectives. It may also include seeing a doctor or clinical nurse specialist for a medication evaluation.

"Medication for depression targets its common symptoms such as anxiety, sadness, negativity, guilt, hopelessness, irritability, sleep problems, appetite disturbances, low energy, low motivation, poor concentration and body pains," according to S. Jean Budding, CNS, BC. Budding is a board-certified psychiatric clinical nurse specialist with prescriptive authority. She is both a clinical assistant professor in the College of Nursing and Health at Wright State University and a private practitioner in Centerville.

Budding said antidepressant medications address dysregulation of neurotranssmitters in the brain such as serotonin, dopamine, GABA, acetylcholine, norepinephrine and others. Medications are chosen to correspond with particular symptoms. For example, for excessive crying and mood issues, selective serotonin reuptake inhibitors are often chosen. For problems with energy and motivation, serotonin norepinephrine reuptake inhibitors are often prescribed.

"The rebalancing of neuro-transmitters through the use of antidepressants medications is the "art" of the prescriber," said Budding, who added that any evaluation for medication must include a complete health and social history.

"Antidepressant medications speed up the process of recovery from problematic symptoms; medications do not cure or change a person's character or values. That is why counseling is so essential," Budding said. "Ideally, counseling, in conjunction with medication management, helps shape long term changes through improved coping skills, positive thinking and appropriate emotional responses. These results drive sustained improvements in a person's functioning."