Adult Depression - Treatment and Antidepressants
What if you are diagnosed with depression? Don't be afraid; there are many methods to treat depression. It's just that ordinary people may not have enough knowledge to make choices from among them. Here, we will discuss with everyone the basic directions and plans for treating depression.
How to Treat Depression? The Four Levels of Depression Treatment
What if you are diagnosed with depression? Don't worry, there are many methods to treat depression. However, the average person may not have enough knowledge to make a choice, so here we will discuss the basic directions and plans for treating depression.
Treating depression is like climbing a ladder step by step. Suppose there is a group of patients with depression; initially, we use antidepressants, and most of them see an improvement in their condition. However, after a while, some of the patients who improved may see their condition worsen again. At this point, we have no choice but to use different antidepressants or other methods to treat the depression. These other methods may have more side effects or be more troublesome to implement.
This process repeats, with some patients recovering while others do not, so we need to continually switch to new methods. Therefore, treating depression is like climbing a ladder step by step; we start with the more convenient methods, and if they don't work, we try the less convenient or more side-effect-prone methods.
First Level
The first level is usually antidepressants, but there are many different types of antidepressants. Doctors typically choose the most suitable one based on experience and research data.
Some patients with depression resist taking medication, and for those with milder symptoms, psychotherapy can be tried. With the advancement of technology, repetitive transcranial magnetic stimulation (rTMS) is also a good option for treating depression.
Second Level
If one type of antidepressant doesn't work, then switching or adding medications is necessary. There are many types of antidepressants, with the most common being SSRIs, but there are also others like SNRIs, NDRIs, and serotonin modulators, all of which are effective against stubborn depressive symptoms.
Some people may also consider methods with greater side effects or more troublesome, such as electroconvulsive therapy (ECT). Patients usually need to be hospitalized for treatment, and each session requires general anesthesia, with both a psychiatrist and an anesthesiologist present.
Another example is esketamine, an isomer of ketamine, which is a newer type of drug and has a significant effect on reducing suicidal thoughts. However, it must be administered under the observation of a professional, and the patient cannot leave the clinic for two hours after taking it.
Third Level
The methods used at this level are more controversial. For example, MAO inhibitors are almost never used in Hong Kong now because they have significant side effects and easily interact with other medications. Another example is vagal nerve stimulation, which requires surgical intervention by a surgeon, making it highly controversial.
Fourth Level
The fourth level of treatment methods usually refers to experimental methods. The evidence and data from their studies are not very comprehensive, and prescribing doctors cannot guarantee their safety.
Are New Methods for Treating Depression Always Better? Doctors Teach You Three Analysis Directions
Many people have heard of various therapies for depression, such as antidepressants, psychotherapy, and newer treatments like Transcranial Magnetic Stimulation (TMS). Are new drugs better than old ones? Are new methods always more effective?
When doctors choose a treatment method for depression, it is not based on whether the method is new or old, but on other considerations. Below, we share three different analysis directions to consider before choosing a treatment method:
First, we must look at the research data to understand whether the new treatment method is effective. Anyone can conduct research, but the quality of the research varies. Doctors need to analyze the methodology used by the researchers to determine whether the results of the study are valid.
Second, we need to know whether the treatment method is convenient and suitable for the patient. Some newer treatment methods, such as Vagal Nerve Stimulation (VNS), require a surgical procedure before treatment can begin. The doctor must implant a metal device near the patient's neck to stimulate the vagal nerve in that area. In this situation, even if the research results show that the treatment method is very effective, we would not use it casually due to the surgical risks involved.
Third, the potential side effects and complications of the medication are also very important factors to consider. Some newer drugs must be strictly regulated when prescribed. For example, esketamine, used to treat treatment-resistant depression, requires frequent blood tests during prescription and must be taken under close medical supervision to monitor vital signs. If the clinic lacks such facilities, or if the patient has a low tolerance for risk, doctors may not choose to use such drugs casually.
Depression: Can You Avoid Medication? What Happens After Taking It? Antidepressant Q&A
Q: If a doctor diagnoses me with depression, do I absolutely have to take medication?
A: Of course not. Every individual has their own rights and freedom. Before prescribing antidepressants, a doctor will explain to each patient the reasons for prescribing them. The doctor also needs to clearly outline the risks of taking or not taking antidepressants, as well as alternative treatment options besides medication. After receiving full information, the patient should discuss it with their family before making a decision.
Q: How long does it take for symptoms to improve after starting antidepressants?
A: This varies from person to person. Generally speaking, when taking antidepressants daily, the effects typically begin to emerge after one to two weeks. This is because antidepressants don’t just replenish serotonin levels in the brain; it’s only after serotonin levels increase and structural changes occur in the brain that our mood gradually improves.
Q: What should I do if I experience side effects after taking antidepressants?
A: If you’ve never taken this type of antidepressant before and suddenly feel unwell after starting it—experiencing symptoms like headaches, dizziness, sweating, or shaky hands—you must stop taking the medication immediately. Then, arrange a follow-up appointment with your doctor as soon as possible. The doctor will decide whether to switch you to a different type of antidepressant.
Q: What harm does long-term use of antidepressants do to the body?
A: Generally speaking, even with long-term use, antidepressants don’t cause serious harm to the body. However, among the various types of antidepressants, there may be two or three that require special attention. Before prescribing these, the doctor will definitely explain everything clearly to the patient.
Exploring Types of Antidepressants (Part 1): Serotonin SSRIs
When it comes to antidepressants, many people only know about serotonin. However, in reality, there are many different types of antidepressants. Doctors prescribe different kinds based on a patient’s specific needs. As a user of antidepressants, it’s naturally important to have a good understanding of the medication you’re taking before starting it.
Since serotonin has come up, let’s start by talking about it. The name "serotonin" is deeply ingrained in people’s minds and is quite distinctive, often raising the question: Is serotonin really extracted from human blood serum?
Of course not. The full name of serotonin in this context is "Selective Serotonin Reuptake Inhibitor," or SSRI for short. So why is it called serotonin? This stems from the fact that among the many neurotransmitters in our brain, serotonin is one of them. The amount of serotonin present, whether too much or too little, affects the brain’s ability to regulate emotions.
The mechanism of SSRIs is to inhibit the reuptake of serotonin by brain neurons. Under normal circumstances, neurons in the brain both release serotonin and reabsorb it, much like a recycling process. By inhibiting this reuptake, SSRIs increase the concentration of serotonin in the brain, leading to structural changes in the receptors of the neurons, which ultimately helps regulate emotions.
SSRIs include Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram, and Fluvoxamine. Each of these medications has slightly different clinical uses and side effects. For example, Fluoxetine is more commonly used for children, while Sertraline is considered safer for pregnant and breastfeeding women. Doctors will choose the most appropriate SSRI based on the patient’s specific condition.
Exploring Types of Antidepressants (Part 2): Motivation-Boosting SNRIs
Depression comes with many symptoms, one of which can significantly impact a patient’s daily life, work, and studies.
Some people with depression not only experience low mood but also a lack of motivation. They may spend all day lying in bed, avoiding going out. Even if they once enjoyed socializing, they push others away; activities they used to love no longer interest them, and they’d rather stay home doing nothing.
The SSRIs (Selective Serotonin Reuptake Inhibitors) we discussed earlier are effective for many depression symptoms. However, sometimes their effect on the specific symptom of low motivation isn’t particularly pronounced. This is where SNRI, the "sister" of SSRI, comes into play.
While SSRIs are called Selective Serotonin Reuptake Inhibitors, SNRIs are Serotonin-Norepinephrine Reuptake Inhibitors. Compared to SSRIs, SNRIs have an additional effect: they inhibit the reuptake of norepinephrine (also known as noradrenaline).
In other words, SNRIs not only increase serotonin levels in the brain but also boost norepinephrine levels. Higher norepinephrine concentrations can enhance motivation in people with depression, reducing the impact of depressive symptoms on work, studies, and daily life.
Sometimes, after taking SNRIs, the expected increase in motivation may not be very noticeable. This can happen because certain SNRIs require a higher dose to effectively raise norepinephrine levels. So, if symptoms don’t fully improve after starting the medication, it might simply be a matter of insufficient dosage.
The side effects of SNRIs are generally similar to those of other antidepressants, but there’s one point to note: SNRIs can affect blood pressure. If someone already has high blood pressure, they should discuss this thoroughly with their doctor before starting an SNRI.
Common SNRIs include Duloxetine, Venlafaxine, Desvenlafaxine, and Milnacipran. Each of these medications has slightly different clinical uses and side effects, and a doctor will select the most suitable SNRI based on the patient’s condition.
Counting the Types of Antidepressants (Part 3): No S, but More? NDRI
Previously, we introduced SSRI and SNRI, and this time, we’ll talk about NDRI. Attentive readers might notice that NDRI lacks the "S" but has an extra "D." This is exactly what makes NDRI unique. The "S" stands for Serotonin, which is a neurotransmitter. Both SSRI and SNRI can increase serotonin levels in neurons, but for some patients, elevated serotonin concentrations can lead to uncomfortable side effects, such as sweating, stomach pain, or weight gain. Since NDRI doesn’t involve "S," it can avoid these particular side effects.
The "S" (serotonin) can also sometimes cause sexual dysfunction, such as erectile difficulties or reduced libido. Some patients taking SSRI or SNRI may find it takes longer to ejaculate, or even after a long time, they might not be able to ejaculate at all. In such cases, doctors might consider switching medications for the patient, and NDRI becomes a good option.
The "D" stands for Dopamine. NDRI can simultaneously increase the levels of Norepinephrine and Dopamine in neurons. The combined effect of these two neurotransmitters ("N" and "D") is similar to that of SNRI, as it can boost a person’s motivation and reduce the impact of depressive symptoms on their life.
NDRI has a particularly notable side effect: although the risk is low, some people taking it might experience seizures. When prescribing NDRI, doctors need to adjust the dosage gradually and avoid increasing it too quickly. Extra caution is required if the patient has a history of seizures.
Counting the Types of Antidepressants (Part 4): Directly Targeting Serotonin Receptors - Serotonin Modulator
Many patients with depression, in addition to experiencing symptoms like low mood and lack of motivation, may also face cognitive issues, such as reduced concentration and memory decline. If these symptoms are particularly prominent and severe, many doctors will recommend the use of a Serotonin Modulator.
The mechanism of a Serotonin Modulator is quite unique—it’s not an SSRI, SNRI, or NDRI, yet it is closely tied to serotonin. From a pharmacological perspective, a Serotonin Modulator doesn’t just increase serotonin levels in neurons; it also directly interacts with various serotonin receptors in the brain, including 5-HT3, 5-HT7, 5-HT1D, 5-HT1B, and 5-HT1A. By targeting multiple pathways, it produces its antidepressant effects.
Another advantage of Serotonin Modulators is that they tend to have fewer side effects. Common antidepressants often cause drowsiness, weight gain, or sexual dysfunction, but Serotonin Modulators are less likely to produce these issues.
Currently, the only Serotonin Modulator available on the market is Vortioxetine. As a relatively new type of antidepressant, it’s important to discuss it thoroughly with your doctor and understand it well before starting treatment.
Counting the Types of Antidepressants (Part 5): Regulating Sleep - MT Agonist
Have you ever heard of Melatonin?
The human body naturally secretes melatonin, which induces drowsiness at night. However, sometimes due to a reversed sleep schedule or jet lag, melatonin secretion becomes disrupted, making it difficult to fall asleep at night.
There’s another class of antidepressants closely related to melatonin, known as Melatonin receptor agonists (MT Agonists). These drugs directly interact with melatonin receptors. In other words, like melatonin itself, they can be used to regulate a person’s sleep.
Beyond that, stimulating melatonin receptors can also trigger a cascade of downstream reactions, promoting the release of dopamine and norepinephrine in the brain. This helps improve a person’s mood and motivation, achieving an antidepressant effect.
Currently, the only Melatonin receptor agonist available is Agomelatine. This drug generally doesn’t have significant side effects, but it does have a downside: it can potentially affect liver function. Therefore, before starting this medication, blood tests are required for the patient. After beginning treatment, regular blood tests are also necessary to monitor whether liver function is impacted by the drug.
One common thing to note when taking Agomelatine is that for the first few nights, sleep may be lighter. During the initial stages of sleep, it might feel like a half-dreaming, half-awake state (Hypnagogia), and sleep duration may be shorter than usual. However, for most patients, this tends to normalize after about a week.
Antidepressant Side Effects Tour: Which Antidepressants Are More Likely to Cause Drowsiness?
Do you feel sleepy after taking medication? In fact, many antidepressants can cause varying degrees of drowsiness. Fortunately, since many depression patients also suffer from insomnia, taking antidepressants that induce drowsiness can, to some extent, help address their sleep problems. For some patients with relatively severe insomnia, doctors may prescribe antidepressants that are more likely to cause drowsiness, such as Trazodone, Mirtazapine, and Agomelatine, among others. In some cases, these medications can even be used as alternatives to sleeping pills, helping those addicted to sleeping pills break their dependency. However, these drugs should absolutely not be taken during the day, or you might not be able to go to work. On the other hand, some depression patients experience excessive sleep or a lack of energy. In such cases, prescribing antidepressants that cause drowsiness could make things worse. Under these circumstances, doctors might opt for antidepressants less likely to cause drowsiness, such as Vortioxetine from the Serotonin Modulator class, or even medications that boost energy and motivation, like SNRIs or NDRIs.
Suspect You Have Depression? The PHQ-9 Questionnaire Can Help!
We might worry about whether we have depression. Before seeing a doctor, complete the following questionnaire, and the computer will automatically calculate your score, giving you an additional reference point.
