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Adult Psychiatry
Depression - Treatment

In the event of a confirmed diagnosis of depression, don't worry, there are numerous methods for treating depression. However, everyday individuals might lack the necessary knowledge to choose among these options. In this article, we will discuss with you the fundamental approaches and strategies for managing depression.


Treating Depression: The Four-Tiered Approach

If you've been diagnosed with depression, don't worry—there are many treatment options available. However, the average person may not have enough knowledge to make informed decisions about these treatments. In this article, we'll explore the basic principles and strategies for treating depression.

Treating depression can be likened to climbing a ladder, one step at a time. Imagine a group of patients with depression who initially receive antidepressant medication, which leads to improvement for the majority. Over time, however, some patients may experience worsening symptoms, necessitating the use of different antidepressants or other treatment methods, which may have more side effects or be more challenging to implement.

As some patients recover and others don't, it's essential to continually explore new approaches. Treating depression is like climbing a ladder step by step, starting with more convenient methods and moving to more inconvenient or side effect-prone methods if necessary.

Tier 1:

The first tier mainly consists of antidepressant medications, which come in various types. Doctors typically select the most suitable antidepressant for their patients based on experience and research data.

Some patients may resist medication, and those with milder symptoms can consider psychotherapy. With advances in technology, transcranial magnetic stimulation (rTMS) is also a viable option for treating depression.

Tier 2:

If the initial antidepressant is not effective, it may be necessary to switch or add medications. There are many types of antidepressants, including SSRIs, SNRIs, NDRIs, and Serotonin Modulators, all of which can effectively combat stubborn depressive symptoms.

Some individuals may consider more invasive or side effect-heavy methods, such as electroconvulsive therapy (ECT). This requires hospitalization and general anesthesia, with both psychiatrists and anesthesiologists present.

Another example is esketamine, a newer medication and a derivative of ketamine, which has been shown to significantly reduce suicidal ideation. However, it must be administered under professional supervision, and patients cannot leave the clinic for two hours after taking it.

Tier 3:

The treatments in this category are more controversial. For example, MAO inhibitors are hardly used in Hong Kong due to their severe side effects and potential interactions with other medications. Another example is vagal nerve stimulation, which requires surgery performed by a surgeon, making it more controversial.

Tier 4:

The fourth tier of treatment generally refers to experimental methods. These methods may lack sufficient evidence and data to support their use, and prescribing physicians may not be able to guarantee their safety.

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New vs. Classic Treatments for Depression: A Comprehensive Comparison




Depression is a complex mental health disorder that affects millions of people worldwide. Various treatments have been developed to address it, ranging from antidepressant medications and psychotherapy to newer techniques such as transcranial magnetic stimulation (TMS). But are newer treatments necessarily better or more effective than traditional ones? When doctors choose a treatment approach for their patients, they consider factors other than the novelty of the method. In this article, we will explore three key analytical directions that doctors take into account when selecting a treatment for depression.

Research Data and Methodology

The first step in evaluating a treatment method is to examine the research data and determine whether the new approach is effective. While anyone can conduct research, the quality of the studies can vary greatly. Doctors must analyze the methodology used by researchers to assess the validity and reliability of the study's results. Only by scrutinizing the methods and outcomes of the research can medical professionals determine if a treatment is likely to be beneficial for their patients.

Convenience and Suitability for Patients

Another crucial factor to consider when choosing a treatment for depression is its convenience and suitability for patients. Some newer treatment methods, such as vagal nerve stimulation, require invasive procedures, including surgery, to implant a device near the patient's neck to stimulate the vagus nerve. In these cases, even if the research indicates that the treatment is highly effective, doctors may not recommend it due to the risks associated with surgery.

Side Effects and Complications

The potential side effects and complications of a treatment are also essential considerations. Some newer medications require strict regulation and monitoring during prescription. For example, esketamine, a drug used to treat treatment-resistant depression, requires frequent blood tests and close supervision by a doctor while the patient is taking the medication. If a clinic lacks the necessary resources or a patient has a lower risk tolerance, doctors may be hesitant to prescribe such drugs.


In conclusion, when it comes to treating depression, the decision between using newer or more classic treatment methods is not solely based on their novelty. Instead, doctors consider factors such as the quality of the research data, the convenience and suitability of the treatment for patients, and the potential side effects and complications. By carefully weighing these factors, medical professionals can select the most appropriate treatment for each individual patient, ensuring the best possible outcome in their battle against depression.

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Antidepressants Q&A

Q: If I am diagnosed with depression, do I have to take medication?

A: No, you don't have to. Every individual has the right to make their own decisions regarding their treatment. Before prescribing antidepressants, doctors will discuss with each patient the reasons for using the medication, the risks associated with taking or not taking it, and alternative treatment options. Patients should be provided with complete information, discuss the options with their families, and then make their decision.

Q: How long does it take for antidepressants to improve symptoms?

A: The duration varies from person to person. Generally speaking, when taking antidepressants daily, it may take one to two weeks for the medication to gradually take effect. This is because the function of antidepressants is not only to replenish serotonin in the brain but also to wait for an increase in serotonin levels and structural changes in the brain, leading to gradual improvement in mood.

Q: What should I do if I experience side effects from taking antidepressants?

A: If you have never taken this type of antidepressant before and suddenly feel unwell after taking it, such as experiencing headaches, dizziness, sweating, or hand tremors, you should stop taking the medication immediately and arrange a follow-up appointment with your doctor as soon as possible. The doctor will then decide whether you should switch to another type of antidepressant.

Q: Are there any long-term harmful effects of taking antidepressants?

A: Generally speaking, even with long-term use of antidepressants, the body will not suffer any severe damage. However, there may be two or three types of antidepressants that require special attention. Doctors will explain these concerns to patients before prescribing these medications.

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Understanding SSRIs: A Closer Look at a Common Antidepressant


When it comes to antidepressants, many people are familiar with the term "serotonin." However, there are several different types of antidepressants available. Doctors prescribe various types of antidepressants based on patients' individual needs. As a user of antidepressants, it is essential to have a thorough understanding of the medication you are taking.

The Role of Serotonin

Since serotonin is a well-known term, let's discuss it first. Serotonin is a neurotransmitter found in the brain, and its levels can impact our ability to regulate mood. The question arises: is serotonin extracted from human serum? The answer is no. The full name for these medications is Selective Serotonin Reuptake Inhibitors (SSRIs).

How SSRIs Work

SSRIs work by inhibiting the reuptake of serotonin in brain neurons. Under normal circumstances, our brain neurons simultaneously secrete and reabsorb serotonin in a recycling process. By inhibiting serotonin reuptake, SSRIs increase the concentration of serotonin in the brain, leading to structural changes in the neuron receptors. These changes ultimately help regulate mood.

Different Types of SSRIs

There are several types of SSRIs, including Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram, and Fluvoxamine. Each medication has slightly different clinical uses and side effects. For example, Fluoxetine is more commonly used in children, while Sertraline is considered safer for pregnant and breastfeeding women. Doctors choose the appropriate SSRI based on the patient's specific situation.


Selective Serotonin Reuptake Inhibitors (SSRIs) are a common type of antidepressant that helps regulate mood by increasing serotonin levels in the brain. There are various SSRIs available, each with its clinical uses and side effects. Understanding the function and differences between these medications can help patients make informed decisions about their treatment and work closely with their doctors to find the most suitable option for their individual needs.

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Boosting Energy with SNRIs: A Second Type of Antidepressant


Depression can manifest in various ways, with one symptom significantly impacting a patient's daily life, work, and education. In addition to feeling low, some individuals with depression may lack motivation and spend their days lying in bed, avoiding going out. They may withdraw from social activities they once enjoyed and prefer to stay at home, disinterested in things they used to find appealing.

Previously, we discussed SSRIs (Selective Serotonin Reuptake Inhibitors), which are effective in treating many depression symptoms. However, in some cases, the treatment may not be as effective in addressing the lack of motivation. This is when SNRIs (Serotonin Norepinephrine Reuptake Inhibitors) come into play.

SNRIs work similarly to SSRIs but have an additional mechanism of action. While SSRIs increase the concentration of serotonin in the brain, SNRIs also increase the concentration of norepinephrine. Higher levels of norepinephrine can help boost motivation in individuals with depression, reducing the impact of depressive symptoms on work, education, and daily life.

In some instances, patients taking SNRIs may not experience significant increases in motivation. This could be because certain types of SNRIs require higher dosages to effectively increase norepinephrine concentrations. Therefore, if symptoms do not improve after starting SNRI treatment, it could simply be due to insufficient dosage.

The side effects of SNRIs are generally similar to those of other types of antidepressants, but there is one particular aspect to be aware of. SNRIs can affect a person's blood pressure, so if an individual already has high blood pressure, they should discuss this with their doctor before starting treatment.

Common SNRIs include Duloxetine, Venlafaxine, Desvenlafaxine, and Milnacipran. Each medication has slightly different clinical uses and side effects. Doctors will choose the most appropriate SNRI for each patient based on their specific needs and circumstances.

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NDRIs: Antidepressants with a Twist

In previous articles, we discussed SSRIs and SNRIs as types of antidepressants. Now, let's explore a different class of medication called NDRIs (Norepinephrine-Dopamine Reuptake Inhibitors).

Astute readers may notice that NDRIs lack the "S" found in SSRIs and SNRIs but have an additional "D." This is a unique feature of NDRIs.

The "S" represents serotonin, which is increased by both SSRIs and SNRIs. While increasing serotonin levels can be helpful for many patients, it may also lead to uncomfortable side effects such as sweating, stomach pain, or weight gain in some individuals. By not affecting serotonin levels, NDRIs avoid these side effects.

Serotonin can also contribute to sexual dysfunction, such as erectile issues or reduced libido. Some patients taking SSRIs or SNRIs may require more time to reach climax or may be unable to do so. In these situations, doctors may consider switching the patient to an NDRI, which can be a good alternative.

The "D" in NDRI stands for dopamine. NDRIs increase the concentration of both norepinephrine and dopamine in neurons. The combined effect of these two neurotransmitters can boost a person's energy and reduce the impact of depressive symptoms on their lives, similar to SNRIs.

One notable side effect of NDRIs, although relatively rare, is the risk of seizures. When prescribing NDRIs, doctors need to be cautious and gradually adjust the dosage to avoid increasing it too quickly. This is especially important for patients with a history of convulsions.

In summary, NDRIs offer a unique approach to treating depression by targeting both norepinephrine and dopamine, without affecting serotonin levels. This can make them a suitable option for patients experiencing side effects from SSRIs or SNRIs, particularly those related to serotonin. However, due to the potential risk of seizures, doctors must be cautious when prescribing NDRIs and carefully monitor their patients for any adverse effects.

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Targeting Serotonin Receptors with Serotonin Modulators

Many individuals suffering from depression experience not only emotional lows and lack of motivation but also cognitive symptoms such as decreased concentration and memory. If these symptoms are significant and severe, many doctors will recommend the use of Serotonin Modulators.

Serotonin Modulators have a unique mechanism of action. They are neither SSRIs, SNRIs, nor NDRIs, yet they are closely related to serotonin. From a pharmacological classification perspective, Serotonin Modulators not only directly increase the concentration of serotonin in neurons but also directly interfere with various serotonin receptors (Receptor) in the brain, including 5-HT3, 5-HT7, 5-HT1D, 5-HT1B, and 5-HT1A. This multifaceted approach produces their antidepressant effects.

One advantage of Serotonin Modulators is their relatively fewer side effects compared to other antidepressants. Common antidepressants often cause drowsiness, weight gain, or sexual dysfunction, while Serotonin Modulators are less likely to cause these side effects.

Currently, the only Serotonin Modulator available on the market is Vortioxetine. This is a newer type of antidepressant, and it is essential to discuss its use thoroughly with your doctor before starting treatment to understand its effects and potential risks.

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Regulating Sleep with MT Agonists

Have you ever heard of melatonin?

Melatonin is a hormone that the human body naturally produces, which induces sleepiness at night. However, sometimes due to a disrupted sleep cycle or jet lag, melatonin secretion can become irregular, leading to difficulty falling asleep at night.

There is another class of antidepressants closely related to melatonin, known as Melatonin Receptor Agonists (MT Agonists). These medications directly target melatonin receptors, meaning they can help regulate a person's sleep patterns, just like melatonin.

In addition, when melatonin receptors are stimulated, it can trigger a downstream chain reaction, leading to the release of brain neurotransmitters dopamine and norepinephrine. This process results in increased mood and energy levels, ultimately producing an antidepressant effect.

Currently, the only Melatonin Receptor Agonist available is Agomelatine. This medication generally has minimal side effects. However, it can potentially affect liver function. As a result, before starting treatment, patients are required to have blood tests to monitor their liver function regularly while taking the medication.

One common aspect to be aware of when taking Agomelatine is that, during the first few nights, sleep may be lighter than usual. Initial sleep may feel like being in a state between wakefulness and dreaming (hypnagogia), and the duration of sleep may be shorter than usual. For most patients, this situation typically returns to normal within about a week.

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Which Antidepressants Are More Likely to Cause Drowsiness?

Experiencing drowsiness after taking medication? In reality, many antidepressants can cause varying degrees of drowsiness. Fortunately, many individuals with depression also experience insomnia, so taking antidepressants that cause drowsiness can help address their sleep issues to some extent.

For patients with more severe insomnia, doctors may prescribe antidepressants that are more likely to cause drowsiness, such as Trazodone, Mirtazapine, and Agomelatine. In some cases, these medications can even be used as substitutes for sleeping pills, assisting those who misuse sleeping pills in overcoming their addiction. However, it is crucial not to take these medications during the day, as it may impact work performance.

On the other hand, some individuals with depression may have issues with excessive sleep or lack of energy. Prescribing drowsy-inducing antidepressants might worsen the situation for these patients. In such cases, doctors may prescribe antidepressants that are less likely to cause drowsiness, such as Vortioxetine, a Serotonin Modulator, or even medications that boost energy and alertness, like SNRIs or NDRIs.

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