How is depression best treated?
This is the single most important question in psychiatry because depression is the most common psychological cause for compromised functioning and emotional anguish. The answer I present is based upon my treatment of more than 2000 depressed patients in my private practice over the past 15 years.
Depression is often misdiagnosed
90% of the treatment of depression is done by non-psychiatric physicians, mostly by primary care. Often patients feel less stigma with their primary care physician (PCP) than seeking psychiatric treatment. Treatment consists of using selective serotonin re-uptake inhibitors, e.g. Prozac or drugs that increase the concentration of other neurotransmitters that include dopamine and noradrenalin. If the initial treatment fails, antidepressant drugs are often prescribed sequentially and/or in combination.
Unfortunately only about 40% of these depressions are MDD. Therefore about 60% of treatments by primary care physicians are ineffective.
Not only does your PCP frequently misdiagnose depression, but on average most psychiatrists also fail to correctly diagnosis these, so-called, “treatment-resistant “or “atypical” depressions.
This 60% of all MDDs are not unipolar depressions but mood disorders that are part of Bipolar (BP) Spectrum Disorders. Here mood regulation in general is more globally unstable. These patients, on average, report experiencing depressed mood about 70% of the time and feeling extra good (high) or “wired” the remaining 30% of the time. To further complicate diagnosis, patients can experience these moods at the same time (mixed state) or in rapid cycling.
About one-third of these BP spectrum depressions are what we see in ”conventional” BP when in the depressed phase. Conventional bipolar means that the patient has a past history of mania.
The remaining two thirds of all “atypical” depressions (nearly one-half of all MDDs) is BPII. This means that more depressions are bipolar in nature than are unipolar, e.g. treatable with a Prozac -type antidepressants.
Therefore understanding the diagnosis of Bipolar type 2 is the key to understanding depression in general, MDD, mood disorders and Bipolarity.
Major Depressive Disorder and Bipolar type II, clinically present as very similar depressive episodes. However, knowing the proper diagnosis is absolutely crucial: antidepressants fully treat unipolar depression and accompanying anxiety. The same antidepressants will not only fail to treat bipolar depression, but may even result in precipitating antidepressant induced mania, so-called, BPIII.
Proper diagnosis allows effective treatment
This is about as simple as I can explain why one depressed person gets better on an antidepressant, while another depressed patient does not. It is not really about which antidepressant but whether the patient has MDD or BPII. About half of major depressed patients have unipolar type of depression, while the other half have the bipolar form.
As to treating BPII patients, a mood stabilizer is critical. Either lithium of depakote can be effective. The drug companies hate lithium because it is an unpatentable naturally occurring salt that is by far the most used mood stabilizer throughout the world including the countries with the best health: Sweden, Denmark, Norway and Canada.
Once on a mood stabilizer, in the blood test measured therapeutic range, I usually give a half dose of a Prozac type drug and that is it!
Although diagnosis and treatment can become very complex, one simple elegant proof of my theories is that at least once or twice every month, I see a new patient who is on an antidepressant that has either failed to treat or worsened their depression. Once lithium is begun, within a few days to a week the patient is nearly all better.
Two final thoughts on the treatment of BPII. Most patients are involved in substance abuse (self-medicating). This must fully stop for treatment to succeed. Lastly, nearly all patients with BPII have AD(H)D. With a mood stabilizer, treatment with stimulants is typically very successful without precipitating mania.
What about the use psychotherapy in the treatment of Bipolar MDD?
Although I regard psychotherapy as one of the most powerful modalities to transform human nature, I personally have never seen psychotherapy alone successfully treat BP depression. It is possible that bipolar patients may experience a mood shift during psychotherapy which may appear as successful treatment, but invariably unstable mood regulation will again precipitate a major mood episode. I am such a believer in the transformative potential of psychotherapy that nearly one-half of my practice consists of patients being treated with regular weekly psychotherapy. However, every one of these patients were initially stabilized with medication during a bipolar mood episode. For these patients, medication makes psychotherapy possible.