In treating depression, doctors often have three goals.
- The first is to relieve the symptoms of depression.
- The second is to restore the person's ability to function socially and in the workplace.
- And the final goal is to reduce the likelihood of a recurrence.
The goals for bipolar disorder are somewhat different. Doctors primarily strive to reduce the frequency and severity—and the social and psychological impact—of episodes. Improving social and mental functioning between episodes is the other major goal of treatment.
When a person seeks treatment for a mood disorder, the first step is a complete evaluation, which includes a detailed psychiatric and medical history, and a mental status examination. Because treatment varies considerably based on the diagnosis, it is crucial to have this comprehensive assessment.
Treatment goals for depression and bipolar disorder are met in three stages—acute, continuation, and maintenance. During acute treatment, the focus is on immediately relieving symptoms and restoring the person's ability to function. Once symptoms respond to acute treatment, continuation treatment begins; the focus here is on preventing a relapse. If a person has no symptoms for four to nine months after an episode, he or she is considered recovered. At this point, maintenance treatment begins, with the goal of preventing a new episode. Maintenance treatment can last from one year to a lifetime, depending on the individual.
Depression recurs in about half of cases within two years of stopping treatment, so timing must be considered carefully when stopping medications. The longer a person remains on treatment, the smaller the likelihood of relapse. The decision to try tapering off medications for bipolar disorder is more complicated because it involves the risk of recurrent manic and depressive episodes and, especially, the risk of suicide.
The main treatment options for dealing with depression and bipolar disorder are medications, psychotherapy, electroconvulsive therapy (sometimes informally referred to as shock therapy), or any combination of these. Light therapy is often used to treat SAD. In addition, exercise, getting enough sleep, and eating a healthy diet play a role in improving mood and self-image.
These days, medications are the most common form of therapy for depression. Any given antidepressant has up to a 70 percent chance of working in a particular person. It is important to start treatment as early as possible, however, as these disorders become more difficult to treat the longer they last. Because response to any particular treatment varies from one person to another, an individual who does not improve with the initial treatment may respond to a different one.
In fact, that's the important lesson to be learned from a large, six-year multicenter study called the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D, trial which looked at the use of popular antidepressants in people with chronic depression (lasting, in some cases, 15 to 16 years). This study found that systematically trying different doses of antidepressant medications, maintaining a longer duration of therapy, trying a different drug altogether, or combining medications can lead to a remission in symptoms for many severely depressed, treatment-resistant patients.
Like antidepressant medications, psychotherapy alone also can work to relieve depression—with fewer side effects. While it requires more time than antidepressant therapy to reduce symptoms, its positive effects may last longer than medication.
Severe cases of depression are best treated with medication. In the most extreme cases, electroconvulsive therapy (ECT) may be recommended. Up to 90 percent of extremely depressed people improve with ECT when it is used as a first-line treatment. However, the therapy is usually used only after other therapies have failed. When used as a last resort, the response rate drops to 50 to 60 percent.
Combination therapy (medication plus psychotherapy) has been shown in some research studies to be more effective than either therapy alone for mild to moderate depression. This option may be beneficial if either treatment alone produces only partial results, if depression is chronic, or if the person is facing multiple challenges that are best treated by different means, such as medication for depressive symptoms and psychotherapy for job-related problems. Recent research suggests that combination therapy may prevent or delay relapses and recurrences of depression.