Treatment of Major Depression

Hospitalization

The first and most critical decision the therapist must make is whether to hospitalize a patient with major depression, or to attempt outpatient treatment. Clear indications for hospitalization are: (1) risk of suicide or homicide, (2) grossly reduced ability to care for food, shelter, and clothing, and (3) the need for medical diagnostic procedures. A patient with mild to moderate depression may be safely treated in the office if the therapist evaluates the patient frequently. The patient's support system should be strengthened and involved in treatment whenever possible.

Antidepressants

Studies have show that antidepressant therapy for major depression can dramatically reduce suicide rates and hospitalization rates. Unfortunately, very few suicide victims receive antidepressants in adequate doses, and - even worse - most receive no treatment for depression whatsoever.

One of the biggest problems with antidepressant therapy is that most patients don't stay on their antidepressant medication long enough for it to be effective. A recent study found that only 25% of patients started on antidepressants by their family physician stayed on it longer than one month. Antidepressant therapy usually takes 2-4 weeks before any significant improvement appears (and 2-6 months before maximal improvement appears).
First Line Antidepressants

The SSRI antidepressants, escitalopram (Lexapro), Fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), or sertraline (Zoloft), are considered excellent choices as the patient's first antidepressant because of their low incidence of side-effects (especially weight gain) and their low lethality if taken in an overdose. All SSRI antidepressants are equally effective.

Because many patients with major depression also suffer with intense anxiety, your doctor may also give you Fluvoxamine (Luvox) or lorazepam (Ativan) to reduce anxiety in mixed anxiety-depression.

Both Fluoxetine (Prozac) and paroxetine (Paxil) tend to be stimulating (elevate your mood); thus patients with mixed anxiety-depression can often dramatically benefit from the addition of clonazepam (Klonopin) to the Fluoxetine (Prozac) or paroxetine (Paxil) therapy.

Keep in mind, prescribing the right antidepressant is not an exact science. It may take some experimentation on the part of the doctor (make sure you're seeing a psychiatrist, a specialist in psychiatric medications) to find the right antidepressant and right dosage for you. Do not give up if everything doesn't come together right away.