Medications for Depression: A consumer guide by Lee H. Beecher, M.D.

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Depressive disorders affect people of all ages and walks of life, including children and elderly people. About one in ten of us will suffer with clinically significant depressive symptoms in a given year. Common symptoms of depression include trouble concentrating mentally, loss of energy and enthusiasm, waking frequently or not sleeping restfully, nervousness, excessive sadness, self-critical or angry preoccupations, feelings of worthlessness, and, not infrequently, suicidal thoughts in varying degrees. Depression decreases productivity at work and heightens conflicts in personal and work relationships.

The cause of depression is an imbalance of brain chemicals, but currently there is no blood test for depression. Skillful psychotherapy can help change brain chemistry for the better, as can antidepressant medications. Depression may be associated with stressful life events such as major disappointments, separations, deaths, job loss, financial stress, and conflict with relatives. Alcohol and illicit drug use are very frequently associated with depression, and should never be overlooked or minimized as a significant factor. Other medical conditions (e.g., low thyroid hormone levels, anemia, diabetes) and prescribed medications to treat them (e.g., steroids, sedatives, chemotherapy, and blood pressure–lowering drugs), as well as herbal products containing ephedrine, can cause or contribute to depression. Clinical depression frequently accompanies any chronic medical condition that causes significant disability or threatens length or quality of life.

Diagnosing and treating depression

Successful treatment of depression requires study of the patient’s history of depression and treatment. This means you and your treating health professionals need an accurate story of your depression. To treat you effectively, your doctor needs to know answers to questions such as these: When did the symptoms of depression start? Did they begin gradually or suddenly? Has your mood changed suddenly or gradually, or gone down and up, from sadness to agitation? Has the course of your illness been associated with the use of medications, alcohol, or illicit drugs, or with definable events in your life? Have you had thoughts of suicide, and, if so, what steps are needed and taken to prevent a suicide attempt? Does your family know you are depressed, or at risk for suicide? Do you or members of your family have a history of symptoms of or treatment for depression, mental disorders, or substance abuse?

Studies have shown that if a person has severe and recurrent depression, long-term antidepressant therapy (a year or longer) is often the best treatment recommendation. Psychotherapy, which involves talking-thinking-deliberating-planning in a professional-patient relationship, is usually a vital component of optimal treatment for depression.

Who sees patients with depression?

Medical and mental health treatment professionals have different types and degrees of training. Most licensed personnel have some familiarity with the training of others, and they often work collaboratively in clinic or hospital settings. In Minnesota, all prescriptions for antidepressants are written by physicians or persons under a physician’s supervision or scrutiny.

• Psychologists (master's degree or Ph.D.) have completed graduate school in psychology, do not have medical school training, and do not prescribe medications in Minnesota. They can diagnose depression and many provide psychotherapy.
• Nurses specializing in mental health, nurse practitioners (N.P.s), and physician assistants (P.A.s) can prescribe antidepressants under supervision of a physician. Patients should contact their physician if they have unanswered questions or concerns about their prescriptions.
• Clinical social workers (L.I.S.W., L.I.C.S.W.) have training in psychotherapy. Some are licensed as family therapists.
• Primary care physicians prescribe most antidepressants in Minnesota. Primary care physicians include pediatricians, family practitioners, internists, obstetricians/gynecologists, and rehabilitation medicine specialists.
• Psychiatrists are physician specialists who have completed training residencies of three to five years in adult or child psychiatry beyond medical school and internship. Most psychiatrists are board certified by the American Board of Psychiatry and Neurology; some have board certifications in addiction or geriatrics psychiatry. Child psychiatrists have special training and clinical experience in child psychiatry; fewer than 100 child psychiatrists are available statewide.

Most patients in Minnesota get their antidepressant medications from family physicians, pediatricians, internists, and clinic nurses. Most of the state's 700 practicing psychiatrists see patients in hospitals, outpatient clinics, or private offices to provide diagnostic assessments and to prescribe or monitor psychotropic medications (including antidepressants). Medical consultants in alcohol and drug rehab programs can prescribe antidepressants for patients whose depressive or mood symptoms do not substantially improve during chemical dependency care or recovery programs.

Some psychiatrists, usually in private practice, provide a combination of psychotherapy and medication (integrated treatment) to treat depression. In split-treatment arrangements, the psychiatrist prescribes medications while others provide the psychotherapy, as is the rule in most large behavioral clinics and mental health centers. Coordination of care is very important.

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