Depression is an uncomfortable complex mind-body state that almost everyone has experienced to one degree or another. Most people recognize that they have good days and bad days, cheerful days and down days. Major Depressive Disorder (MDD) can severely impair our functioning and can become a real emergency. In the last TLC issue, MDD was defined and explored in depth.
A Major Depressive Episode can be just as lethal as a stroke or heart attack. A suicide attempt is a true emergency. In 2001, 30,622 people in America killed themselves. 24,672 of them were men and 5,950 were women. Every day 1,500 people make suicide attempts that do not result in death. That’s 547,500 attempts per year.
A relative, or close friend of someone who is depressed will usually know that something is wrong. Their loved one doesn’t seem the same. His motivation is a shadow of what it used to be. Much of what he talks about is negative, he’s “down,” and may express feeling hopeless. A close relative may wonder what is wrong, if it is something serious or just a low period that will soon pass. It’s difficult for many people to ask the depressed person if they’re feeling suicidal. Many people fear that, if they ask a person if they are feeling suicidal, it might upset the individual and make him suicidal.
Bringing Up the Question
You can’t predict how someone will respond to being asked if they are feeling suicidal. Some people who are suicidal will initially deny it when asked about it, while others will feel a sense of relief. They realize that someone has noticed, cares, and is concerned. By bringing the question of suicide into the open, the opportunity is created for people to open up, share how they are feeling and why they are considering suicide. Do not think that asking about suicide will result in suicide. Your concern needs to lead to psychiatric evaluation. While the lay person is usually afraid to ask about suicide, it’s part of what psychiatrists do, in the same way that a cardiologist evaluating someone with chest pain will ask a host of questions to sort out if that person is having a heart attack.
I’ve treated more than 1,000 people who attempted suicide, and countless more who were depressed and considering suicide. Once you’ve learned that your spouse/partner is depressed and considering suicide, regard the situation as an emergency and get a psychiatric evaluation immediately. Probably 95% of the people I’ve treated (often in the hospital) for a suicide attempt, recover fairly quickly in the hospital.
We’re in an era in which primary care doctors are treating depression, and it is usually with an SSRI (selective serotonin re-uptake inhibitor) medication like Prozac (fluoxetine), Paxil (paroxetine), and Zoloft (sertraline). This has become dangerous business. During medical school, like everyone else, I had rotations in surgery, internal medicine, neurology, etc, but I never thought for a moment that I could do what a surgeon does. Likewise, non-psychiatric physicians, with their 3-month psychiatry rotation in medical school, should not be stepping into the very complicated arena of mental illness. Yet primary care physicians prescribe more than half of the anti-depressant orders.
If someone is suffering from moderate to severe depression that is potentially life-threatening, there are several main emergency treatments. Whether or not a depressed person is treated in the office or in a hospital depends on whether or not it’s safe and practical to treat in the office. Let’s first look at medications. Anti-depressants (whether medication or natural approaches) raise the levels of serotonin, norepinephrine, or both. These two brain neurotransmitters are associated with mood.
There are nutritional/metabolic tests that map out brain chemistry, telling us if a depression is caused by too little serotonin or insufficient norepinephrine. These tests are easy to do, but are known by a very small percentage of psychiatrists. With that said, most doctors will use a serotonin drug as their first choice for depression, without any lab work to support their decision.
The most commonly used serotonin medications are Prozac, Paxil and Zoloft. Wellbutrin (bupropion) treats depression caused by a deficiency in norepinephrine. Effexor (venlafaxine) and similar drugs treat both serotonin and norepinephrine. Over decades of testing for neurotransmitters, my experience is that at least 60% of depressed people are deficient in norepinephrine and not serotonin. Such testing leads to accurate treatment, whether conventional or alternative. If depression is accompanied by significant cognitive problems, like decreased memory, focus, and concentration, chances are that the problem is with norepinephrine and not serotonin.
What follows are guidelines for prescribing anti-depressant medication. I’ll use Paxil to illustrate treatment. If Paxil, which raises serotonin, helps an individual, stay with Paxil. If, after a period of relief the depression starts to come back, increase the dose of Paxil. Be careful of a psychiatrist who puts you on Paxil 20 mg, doubles it to 40 mg a few days later, and increases it to 60 mg within a couple of weeks. That is dangerous. I know of one young woman who went from zero to 60 mg of Paxil in 10 days, and shortly after that had to be hospitalized because of the negative effects of how Paxil was prescribed.
Let’s say that Jane Doe is taking 40 mg of Paxil. It helped but the benefits maxed out and she is relapsing. This is where a big mistake occurs. Many doctors, given this situation, will stop Paxil and switch the patient to another SSRI, such as Prozac, Zoloft, or Celexa. The fact is that all SSRI anti-depressants are close first cousins, and they all cause decreased libido in a sizable percentage of people. Therefore, it’s very unlikely that switching to a different SSRI will help, with the exception that one SSRI may not affect your libido as badly as another one.
So, Jane Doe is taking 40 mg of Paxil, but it’s not enough. The doctor has several choices: 1) A medication that increases norepinephrine (like Wellbutrin) can be added to the treatment. The patient will be treated with Paxil and Wellbutrin, 2) Paxil can be discontinued and a drug, like Effexor (venlafaxine), that treats both serotonin and norepinephrine can be started, or 3) a tricyclic antidepressant such as Tofranil or Elavil.
While primary care physicians mainly prescribe SSRI’s for depression, psychiatrists still use tricyclic anti-depressants (TCA) frequently as a second-line approach after an SSRI and Wellbutrin.
Psychiatry residencies stopped training in psychotherapy 15 to 20 years ago, even though solid data has been around for 35 years that showed that treating depression with a medication and psychotherapy is much more effective than treatment with medication only. In working with a depressed person, I want to get to know him or her on a very deep level, examining every aspect of their life, treating their brain chemistry as well as dealing with conflict in their life, their sense of purpose, stressors, long-term effects of child abuse, and much more. That’s why my session don’t last 15 minutes!
If treatment with anti-depressant medication fails to adequately treat a Major Depressive Episode, Electroconvulsive therapy (ECT) may be added to treatment. ECT, first introduced in 1938, remains a controversial modality in which seizures are electrically induced in anesthetized patients for therapeutic effect. Throughout my career two patients of mine with severe depression were treated with ECT with excellent improvement. However, its mode of action still remains unknown. In reviewing the scientific literature, it’s clear that ECT remains controversial. Two-thirds of people who have had ECT believe that it’s possible for ECT to cause cognitive impairment. There remains a great deal of mystery and misinformation about ECT, and it’s not easy to sort out fact from fiction. Clearly, for many people ECT has been highly beneficial. Others consider it to be voodoo medicine. My advice is this. If you or a loved one are suffering from Major Depression and have not improved with any kind of treatment, be open minded to non-drug treatments.
Amino Acid Therapy
The nutrients, the foods that make neurotransmitters are amino acids. L-tyrosine makes norepinephrine and L-tryptophan makes serotonin. While it takes several weeks to get the lab work back, this approach is powerful and scientifically targets the kind of depression a person has. If someone needs relief today, then he might want to start with medications. Amino acid therapy can then either be: 1) added to an anti-depressant, or 2) used to taper off medication. If someone’s MDD requires hospitalization, amino acid therapy won’t be an option until he’s discharged from the hospital.
Severe Major Depression can be fatal, so it needs to be diagnosed and treated with the same urgency of any other serious illness. While there are many other treatments for depression, before we explore numerous natural approaches, we have to make sure to treat a suicidal depression with the most powerful and fast-acting modalities available.