Depression: treatment

What is it about ?

The depression

is a mental illness. The key symptoms of depression are a sad mood or a loss of interest or pleasure in (almost) all activities. These symptoms appear almost every day, for most of the day. Complaints last at least 2 weeks, and key symptoms may be accompanied by other manifestations. The sadness you may feel when a loved one has passed away is not depression.

The depression is a common ailment. Depression is classified into mild, moderate and severe form. Sometimes depression can persist for a very long time (persistent depressive disorder) and it can be difficult to get out of it.

Treatment of depression is based on 2 pillars: psychological support and medication. Whether to use one of the two pillars or both together depends on the severity of the depression. Treatment always consists of psychological support by a general practitioner, a psychologist or a psychiatrist. This support takes place individually or in groups, in consultation with the treating therapist (s) and according to the wishes of the person suffering from depression. The entourage (family, friends, colleagues, etc.) is also involved in the treatment. Scientific studies show that intensive and active support is more effective than medication alone. In the case of mild to moderate depression, this support is usually sufficient. The usefulness of the drugs increases with the severity of the depression. Treatment with medication may be necessary, especially if it is a severe form.

When is non-drug therapy indicated?

The treatment is always multidisciplinary, involving collaboration between the depressed person, the general practitioner, the psychologist and, possibly, the home nurse, the physiotherapist, the family and informal caregivers. In case of depression mild and moderate, a treatment plan is established, with a daily structure and activity plan, and is supported by a psychological support. The preferred method is the cognitive behavioral therapy, which emphasizes changing ways of behaving. The goal is to get you back to activities according to a specific schedule. In doing so, you break out of your moodiness and depression, and you revert to ordinary daily activities, which you relearn to enjoy. You are closely monitored by the doctor and / or psychologist: you are seen every 2 weeks, for example, depending on the severity of the depression.

You can also seek psychiatric care at home. There are thus mobile teams of psychiatry, which can offer a psychological support ambulatory. If the results are good, the checks will be more spaced. The goal is to get back to the normal course of your personal and professional life.

A depression mild to moderate usually does not require medication. In some depressed people with anxiety disorders or from sleeping troubles, a sleeping pill is sometimes prescribed for a short time at the start of treatment. If possible, this intake should be limited to a maximum of 4 weeks, taking into account the risk of addiction.

This treatment regimen is also applied for severe depression, but the follow-up is more intensive and of longer duration. After healing, the psychological support is usually maintained because people who have experienced severe depression often relapse. In this case, more attention will also be paid to possible problems, for exampleother psychiatric disorders such as psychosis and the suicide risk. If necessary, the help of a psychiatrist will be requested. In these situations, the psychological support is often associated with taking antidepressants.

When is drug treatment started?

In case of depression severe, an antidepressant is almost always prescribed, unless the patient refuses it. Mild or moderate depression usually does not require medication. But they are still prescribed in the following cases:

• If the mild or moderate depression lasts for more than two years;
• If you have had moderate to severe depression in the past and medication helped you get better at the time;
• If you do not respond enough to other (non-drug) treatments.

The effectiveness of antidepressants depends on the other current treatment (psychotherapy). The psychotherapy and antidepressants should preferably be combined. If you do not want this combined care, psychotherapy should be preferred. The psychotherapy is as effective in the short term as antidepressants, and even more effective in the long term. This is the reason why antidepressants should preferably not be prescribed alone.

How long does the drug treatment last?

The aim of the medication is to make the symptoms of depression. Two in three people with severe depression respond well to antidepressants. Almost half of the symptoms even go away completely.

You may have to wait up to 6 weeks to notice the effects of antidepressants. If there is no improvement, the dose is usually increased or another type of antidepressant prescribed. Once depression is under control, drug therapy should be continued at the same dose for 6 to 9 months. The dose is defined on a case-by-case basis: if it is too low, it will have no effect; if it is too strong, it will not have more effect but it will cause more side effects.

Drug treatment is gradually stopped, slowly reducing the dose. During this process, symptoms that may mark a relapse of depression are watched closely. If you have ever had a depression and that at the time you responded well to treatment, a background treatment may be necessary. This treatment may even need to be continued for several years, especially if you have already experienced several depressions. The doctor will discuss with you the need for continued treatment. Stopping drugs is always done gradually, by small successive decreases. If you cannot take the medicine, the dose will be increased again.

What medications can you take?

There are several types of antidepressants. In depression, the most commonly prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).

• The SSRIs drugs are usually the first choice because they are easy to use, have few side effects (especially in patients with the elderly) and are relatively harmless. They do not require a titration phase, during which the dose must be gradually adapted. The initial dose is therefore immediately the appropriate dose.
  Since SSRIs do not induce sleep, it may be necessary, in exceptional cases, to add a sleeping pill at the start of treatment. These drugs should be used for the shortest time possible.
  The most common side effects of SSRIs are nausea, loss of appetite, diarrhea, the sleeping troubles, nervousness, restlessness andanxiety. In people under the age of 30, suicidal thoughts may increase at the start of treatment. The doctor will pay particular attention to this.
• The tricyclic antidepressants have been available for a long time. They have been the subject of numerous studies and benefit from a great deal of practical experience. They can be administered every evening as a single dose.
  A major problem among the elderly is the fact that they often do not cope well with this type of antidepressant. Therefore, the dose should be gradually increased until the effective dose is reached.
  Side effects are, for example, a dry mouth, a constipation, a inability to urinate, weight gain, drowsiness and drop in blood pressure when you go from sitting or lying down to standing. For this reason, tricyclic antidepressants are not prescribed for patients. the elderly that in the absence of any other alternative.

There are still other antidepressants such as MAOIs, mirtazapine, mianserin and trazodone. However, these drugs are not the first choice for the treatment of depression due to the high risk of side effects and interactions with other drugs.

St. John’s Wort is sometimes used for depression mild to moderate. However, there is limited knowledge about the effectiveness of the plant, especially in severe depression, as well as its long-term safety and what doses to use. St. John’s Wort may reduce the effectiveness of medications used at the same time (including the birth control pill, certain antibiotics, and blood thinners).

What should you do before starting to take medication?

Always ask your doctor for advice before taking any medicine for depression. It sometimes happens that it cannot be combined with certain medicines that you are already using. Also, the dose often needs to be adjusted in people with liver or kidney disease. People who suffer fromepilepsy They too should always seek advice from their doctor before taking an antidepressant, as some medicines can trigger more seizures.

Want to know more?

• Depression – let’s talk about health
• Depression: drugs or psychotherapy? – mongeneraliste.be – SSMG – Scientific Society of General Medicine

• Cognitive Behavioral Therapy (CBT) – AEMTC – Association for the Study, Modification and Therapy of Behavior

• Selective serotonin reuptake inhibitor antidepressants – CBIP – Belgian Center for Pharmacotherapeutic Information
• Tricyclic antidepressants – CBIP – Belgian Center for Pharmacotherapeutic Information
• St. John’s Wort – CBIP – Belgian Center for Pharmacotherapeutic Information

• Sleeping pills and sedatives, think before consuming – FAMHP – Federal Agency for Medicines and Health Products

Are you looking for more specialized help?

• Mental Health Services – The Social Guide
• Find a therapist – AEMTC – Association for the Study, Modification and Therapy of Behavior
• Find a psychologist – Commission des psychologues

Sources

• Belgian practice guide ‘Depression in adults’ (2016) – SSMG – Scientific Society of General Medicine
• Belgian practice guide ‘Major depression (in adults): long-term efficacy of psychotherapy, alone or in combination with antidepressants’ (2014) – KCE – Federal Center for Expertise in Health Care
• CBIP – Belgian Center for Pharmacotherapeutic Information