Drug treatment for depression

There are situations when a depressive episode reaches such a level of severity that the cognitive failure of these patients, often observed in moderate to severe depression, makes it impossible to carry out psychotherapeutic work. But, in the case when the occurrence of depression psychotherapy can be successfully used .
Among various methods, cognitive behavioral psychotherapy (CBT) has a quick and noticeable effect. There are a number of techniques for treating depression. Modern psychotherapy has many approaches in its arsenal: Gestalt, psychoanalysis, client-centered psychotherapy, CBT, etc. All of them are effective in the treatment of certain mental disorders, including depressive ones. We can talk about their comparative effectiveness for a long time, but one thing is clear - each person needs his own approach.

We will review the concept of treating depression according to cognitive behavioral therapy (CBT).

Cognitive behavioral psychotherapy for depression

According to the concept of cognitive behavioral psychotherapy, during depression we operate with thoughts that do not help us get out of a depressed state, but on the contrary, further aggravate our anxiety and depression. It is because of these thoughts that we find ourselves in situations that seem to us more difficult and irreversible than they actually are.

For example, a depressed person may generalize about unpleasant episodes that happen to him during the day. He interprets moments of conflict with others with the expression “no one ever takes me into account.” Breaking up a relationship is perceived as “nobody loves me.” Failures at work are seen in the light of “I’m not capable of anything, I’m a complete nonentity.”

Indeed, difficult moments occur in our lives when it seems that all circumstances are opposing us and do not provide any opportunity to get out of the problem. However, with depression we exaggerate the scale of this negativity several times over. The cognitive-behavioral approach to psychotherapy allows you to look at yourself and your life from the outside. Together with a specialist, the client finds those negative stimuli and patterns of behavior that lead him into a depressive state.

According to the CBT model, our emotions are in direct interaction with our thoughts. Negative thoughts trigger a pathological depressogenic mechanism that plunges a person into a feeling of hopelessness and anxiety. Here some will say that this is a wrong position, because events happen to all people that lead to negative thoughts. But not all people are the same. Everyone interprets what happened in their own way, through their own prism of vision, which depends on their upbringing, social environment, worldview, etc. Therefore, some events do not leave any trace on a person’s mental balance, while others disable him.

For example, if you met a friend and he didn’t say hello to you, what consequences might this have on your mood? One person will think that he is guilty of something, so his friend does not want to talk to him. Another will feel sad that others ignore him. And the third person will jokingly ask this same friend afterwards why he didn’t say hello to him. As you can see, the perception of the same action can be different, which affects our emotional state.

Treatment of depression in Moscow

Treatment for depression is determined by whether it is endogenous (genetically determined - drug treatment is used) or psychogenic (a reaction to stress - psychotherapy or combination treatment is used).

Psychotherapy and combined treatment (psychotherapy + medications)

Duration of the initial appointment - 1.5 hours:

Making an accurate diagnosis:

• determining the treatment plan;
• choice of medications (if necessary);
• beginning of psychotherapy.

Repeated appointment - 1 hour:

• psychotherapeutic session;
• assessment of state change;
• changing your medication regimen (if necessary).

Drug treatment

It is of decisive importance in endogenous depression.

Initial appointment (1.5 hours) includes:

• Making an accurate diagnosis;
• determining the treatment plan;
• choice of medications (if necessary).

Repeated appointment – ​​30 min:

assessment of state change;

• changing your medication regimen (if necessary).

Causes and symptoms

There are endogenous and psychogenic depression.

Endogenous depression is associated with genes that are inherited. If you have a relative who has depression, you are more likely to have it. Moreover, you could receive such genes from distant ancestors.

Reactive depression (depressive neurosis) - develops immediately after stress, the patient is fixated on it, because of this, the mood is reduced.

The choice of treatment method for depressive disorder is determined depending on its type: with psychogenic depression, psychotherapy is very important, and with endogenous depression, the use of antidepressants comes first.

Classification of depression The choice of treatment method for depressive disorder is determined depending on its type: with psychogenic depression, psychotherapy is very important, and with endogenous depression, the use of antidepressants comes first.

In addition to dividing depression into endogenous and reactive, there are specific types of depression.

Bipolar disorder (“manic-depressive psychosis”) - episodes of disorders are replaced by episodes of mania (increased mood, performance).

Dysthymia is a variant of the disorder, expressed to a lesser extent (primarily by irritability).

Somatized (massed, larved) depression - pain predominates (in the head, heart, ventricle) and fluctuations in blood pressure, constipation in the absence of physical illness. Characterized by dry mouth and dilated pupils.

Postpartum depression in women who have recently given birth. Often it is caused by the difficulty of getting used to new responsibilities, stress, unpreparedness for the role of a mother, and changes in hormonal levels.

Psychotherapy course for depression

In order to effectively deal with negative thoughts, you must learn to recognize them. After all, you need to see your enemy in the face! Awareness of your experiences and ways to cope with them is a skill that a specialist teaches during a course of psychotherapy . For example, start mindfully keeping an observation journal and writing down all the depressogenic thoughts that arise, giving them a definition and rating on a scale of one to ten.

You can start keeping a table where you will record all the events that have happened. It is important to understand that you need to record in your diary only those cases that really affected your emotional balance. You can divide the paper into four columns, where you can write down times and situations, as well as the emotions and thoughts that these situations create. Thanks to this, you can learn to become aware of these thoughts and sensations, and also learn to control them.

What to do after you have identified the essence of the negative thought? You must learn to deal with them. The first step is to distract your thoughts. The more active we are throughout the day and the more joy our activity brings us, the less time we have to think. However, this is a very simple and short-term method. The second step is to realize why this thought makes you sad and how it happens. Here you should already work out this fact with a psychotherapist. Perhaps the source of these thoughts are unfinished childhood conflicts or complexes. Or there is a trigger in the person’s environment that is the source of negative thoughts.

Is it possible to fight on your own?

In the case of endogenous depression, it is almost impossible to independently choose an antidepressant that is right for you. Therefore, be sure to consult a psychotherapist.

In the case of reactive depression, psychotherapy allows you to get rid of it faster. At the same time, many people can cope with stress on their own sooner or later.

• Find out about the treatment of depressive disorders on our website. Note the symptoms you have.
• Contact a specialist - a psychotherapist. It will help make a diagnosis, determine the type of disorder and how to deal with it
• Talk to your loved ones - they will support you and help you find a specialist

Fighting depression with psychotherapy methods

As we already mentioned, during depression, activity decreases. A person stops doing those things that previously pleased him. No interest in work, any activities or hobbies. One of the first goals in the difficult fight against depression will be planning your activity. Think about what you spend the most time on? Which activities bring you pleasure, and which ones take energy and give you nothing in return? To do this, you should understand the following points:

Assess the amount of work you do throughout the day

You will need to figure out—perhaps with the help of a therapist—what you do during the day, how you allocate your time, where you spend most of your time, and whether it is enjoyable. Maybe there is some hobby that gives you pleasure, but due to the large number of things to do, you cannot get to it?

Create a daily routine based on the above

To start fighting depression, you need to understand that daytime activity should be increased. Therefore, you need to devote more time to those activities that bring joy and a sense of satisfaction. You can make room for them by eliminating or reducing time for activities that drain energy. For example, you can cut down on social media activity and go for a walk. Drink a cup of coffee or take a bath. The classes may not be extraordinary, because it doesn’t matter what you do, what matters is how you feel about the class.

Do you remember a hobby that used to be fulfilling, but which you have long since forgotten? Guitar playing, sports? Try to renew them, even if through force. But afterwards you will feel a sense of achievement, which will bring you additional joy.

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Psychogenic depression

Psychogenic depressions are reactive (associated with stress) and neurotic (associated with personality traits). Psychological factors play a large role in their development.

Neurotic depression

Neurotic depression most often occurs as a result of being in a situation of prolonged stress. The reasons may be troubles at work, in the family, leaving home, adaptation to new conditions. Please note that this type of depression is often characteristic of insecure and indecisive people. The condition is manifested by decreased mood and loss of interest in life, lethargy, weakness, weakness, headaches, etc.

Reactive depression

Reactive depression is the result of acute mental trauma (loss or death of a loved one, severe stress and anxiety at work or in the family). Characteristic for emotional and sensitive people. There is a clear connection with a traumatic situation, complaints of helplessness, a pessimistic assessment of life, irritability, lethargy and severe weakness appear. The main treatment method for this group of depression is psychotherapy. Antidepressants are used if necessary.

Approaches to the treatment of depression in clinical practice

Magazine “Medical Council.
Neurology/Rheumatology" No. 1, 2018 B.A.
Volel , Doctor of Medical Sciences, Professor,
O.Yu.
Sorokin ,
First Moscow State Medical University named after.
THEM. Sechenov Ministry of Health of Russia (Sechenov University) Depression is one of the most common diseases. According to various researchers, the incidence of this affective pathology in the population averages from 3 to 10% [1-3]. Among patients with depression, females predominate (the gender ratio is on average 2:1). Depressive disorders cause a deterioration in the quality of life of patients, the occurrence and worsening of the course of concomitant chronic diseases, and an increased risk of suicide and disability. Thus, depression accounts for 6.2% of all DALYs [4], and, according to WHO, by 2021 depression will already occupy second place among diseases leading to disability. It should be noted that, according to the results of epidemiological studies, a fairly large number of patients with depressive disorders remain outside the attention of psychiatrists, turning to general somatic doctors [2, 5, 6].

On average, the prevalence of depression and depressive spectrum disorders in patients in general somatic hospitals ranges from 20 to 45% [7, 8], with the highest incidence among people hospitalized in neurological, cardiological, gastroenterological and endocrinological departments. The highest prevalence rates of depressive states are in hypertension, coronary heart disease [9, 10], parkinsonism [11-13], and consequences of acute cerebrovascular accident [14-16].

It must be emphasized that in clinical practice, internists may encounter a number of difficulties: difficulties in diagnosis (over- and underdiagnosis of depression), lack of experience in the use of psychopharmacotherapy, insufficient information about compatibility with other drugs and possible side effects. At the same time, it is also difficult to recognize mild depressive states, which, according to many doctors, are “normal” reactions to external troubles, as well as atypical forms of depression (masked, somatized).

For optimal treatment of depression in a general somatic hospital or outpatient setting, it is necessary to assess the presence and severity of psycho-emotional distress (using the most common validated scales: Hospital Anxiety and Depression Scale (HADS), Hamilton Scale (HAM-D), Beck Scale (BDI) , Montgomery-Asberg scale (MADRS)) with the involvement of psychiatrists as necessary (in the presence of ideas of self-blame, suicidal thoughts, severe insomnia and/or weight loss, psychotic symptoms) with the subsequent prescription of a balanced drug from the group of antidepressants with a minimum number of side effects and better tolerated, and also combined with the somatotropic therapy taken by the patient.

In addition to the widely used diagnostic criteria of ICD-10, which place the main emphasis on the severity of depressive disorder (mild, moderate and severe), the use of psychopathological classification is also relevant (division of depression according to the leading pathological affect: melancholy, anxious, apathetic, etc.; nature of origin : reactive, endogenous; separation of atypical forms of depression into a separate group, etc.). Recognizing the clinical characteristics of affective disorders is fundamentally important and determines further patient management tactics and approaches to therapy.

Both in psychiatric and general somatic practice, depressive states of various clinical structures can occur: milder neurotic and more severe endogenous/endogenomorphic.

Depression of a neurotic level is characterized by a predominance in the clinical picture of astheno-neurotic manifestations and somatized symptoms against the background of a moderately reduced affective background. The occurrence of neurotic depression is often associated with exposure to chronic psychotraumatic situations, such as long-term intra-family troubles (cases of mental/physical violence; alcoholism/drug addiction), conflicts with employees, superiors, unfavorable living conditions, low income, etc. In some cases, In the initial stages of depression, patients are more concerned about vegetative and somatized manifestations (unpleasant sensations in the heart, increased or decreased blood pressure, functional disorders of the gastrointestinal tract, etc.), neurasthenic symptoms (physical and mental fatigue, impaired cognitive functions, hyperesthesia, irritability ), and not directly reduced mood [20-24]. Such clinical manifestations make patients with neurotic depression similar to patients suffering from masked (somatized) depression [25]. Often, the complaints expressed about the somatovegetative and neurasthenic manifestations that burden patients are of a functional nature; pronounced somatic pathology cannot be detected during examination (including clinical laboratory, instrumental, etc.). However, patients, forming a hypochondriacal fixation on their own condition, repeatedly turn to doctors in general somatic hospitals and sometimes regard their disease as rare and difficult to treat due to the long-term insufficient effectiveness of the prescribed somatotropic therapy.

The distinctive features of depression of the neurotic level are, on the one hand, a milder severity of psychopathological manifestations, as well as a fundamentally different structure of affect: patients do not exhibit ideas of low value, melancholy affect, suicidal ideation, a clear circadian rhythm (or it is inverted), or significant loss in weight.

Neurotic-level depression in most cases does not require hospitalization in a psychiatric hospital; treatment of these depressive states can be carried out by internists (with or without the involvement of psychiatrists).

Among the most common affective disorders found in the general somatic network and associated with the presence of somatic/neurological pathology, we should note nosogenic/somatogenic, endogenous/endogenomorphic depression, as well as cyclothymia provoked by a physical illness. Depression can either precede a somatic disease (acting either as a factor provoking somatic pathology, or a concomitant, amplifying disease), or be provoked by actual organic pathology.

Nosogenic depression occurs as a reaction to the disease, associated with the patient’s fear of becoming a burden to relatives, losing social and labor status, as well as the need for hospitalization. The leading role in the occurrence of nosogenies, in addition to the presence of somatic disease, is played by a personal factor/constitutional predisposition, which in some cases predetermines vulnerability to the effects of somatic harm. In the case of nosogenic depression, the patient, against the background of a moderately reduced affective background, reveals pronounced hypochondriacal fears of repeated attacks of the disease (angiosis, asthmatic, etc.), fear of death, disability, and another hospitalization. In the structure of this kind of affective states, especially those developing against the background of severe organic pathology, there are reactions of demoralization with a feeling of hopelessness, helplessness, inferiority, thoughts about the loss of physical health, social status, and professional unsuitability [26]. In some cases, patients note the emergence of a “revaluation of values” against the background of a physical illness, completely changing their idea of ​​lifestyle and creating gentle conditions for functioning (with ideas about registering as a disability, abandoning previous social and professional activities, and adhering to a specially designed regime). An increase or decrease in the severity of emotional distress is associated, respectively, with an increase and decrease in the symptoms of somatic illness that burden patients.

Somatogenic depression, unlike nosogenies, occurs in response to physiological and biochemical processes in the body and is most often observed in the unfavorable course of neurological, cardiovascular diseases, as well as in the presence of malignant neoplasms with numerous metastases (including during radiation therapy). and chemotherapy). Thus, the cause of the most serious somatogenic depression is often the consequences of a stroke (with disruption of the physiological processes of neurotransmitter metabolism in the affected area of ​​the brain and the involvement of cytokines) [16]. In these cases, patients become irritable, whiny, and often indifferent to their surroundings. They present numerous complaints about asthenic manifestations that bother them (weakness, lethargy, loss of strength), impaired cognitive functions, drowsiness during the daytime, combined with insomnia. It should be noted that, contributing to the aggravation of cognitive impairment, disability, depression that arose after a previously suffered stroke, often occurs with ideas of low value, futility, which significantly increases the suicidal risk in this group of patients (up to 7-14% of suicide attempts in patients are detected with post-stroke major depressive disorder [27]). It is extremely important to assess the presence and severity of depression in the post-stroke period, also taking into account the fact that affective symptoms (apathy, fatigue, sleep and appetite disorders) can often be hidden under the guise of neurological pathology itself.

Periodic exacerbations of somatic pathology may be accompanied by a more significant aggravation of depressive symptoms, which leads to the formation of endogenous/endogenomorphic depression with phenomena of vital melancholy localized in the retrosternal projection, a feeling of unworthiness, hopelessness, ideas of self-blame, persistent sleep and appetite disturbances, circadian rhythm worsening in the morning watch. In patients with endogenous/endogenomorphic depression, due to the presence of vital manifestations and ideas of self-deprecation, timely identification of depressive disorder with an assessment of suicidal risk is necessary.

Somatoreactive cyclothymia is a separate type of combination of affective and somatic pathology (most often oncological) [28, 29]. The disease initially occurs as endogenomorphic depression in the form of a reaction to the diagnosis of somatic/neurological pathology. Subsequently, there is a change in depression and hypomania, both without pronounced external provocation, and in connection with a deterioration or improvement of well-being, respectively. A distinctive feature of somatoreactive cyclothymia is the persistence of persistent anxiety of hypochondriacal content throughout the entire disease (expressed in the form of neurosis of anticipation before the next visit to the doctor or examination, as well as in the form of compliance with health procedures).

However, it should be noted that somatoreactive cyclothymia, as well as bipolar affective disorder, which can also occur in patients in general somatic hospitals, have fundamentally different therapeutic approaches using primarily normothymic drugs [30]. In all the cases described above, affective pathology, combined with a somatic/neurological disease, contributes to a decrease in quality of life, an increase in the risk of re-hospitalization, worsening the prognosis and increasing the mortality rate.

Treatment for depression varies depending on the severity of the mood disorder. Thus, treatment of depression at a neurotic level can be carried out both on an outpatient basis and in a general somatic hospital setting. For the treatment of neurotic depression, monotherapy with an antidepressant is most acceptable. At the same time, when prescribing an antidepressant in accordance with the leading astheno-neurotic and somatovegetative complaints, it is necessary to make a choice in favor of a drug that has a more balanced and also promotes procognitive effect. Treatment of more severe forms of depression (somatogenic, endogenomorphic, endogenous), especially those accompanied by the risk of worsening somatic pathology and suicidal thoughts, should be carried out in a specialized psychiatric hospital under the supervision of psychiatrists with the selection of combination therapy taking into account the characteristics of the course of the chronic disease and possible side effects and combinations with somatotropic therapy.

Both in the case of neurotic depression and taking into account the presence of somatic/neurological pathology, the prescription of antidepressants with optimal tolerability is justified. These primarily include drugs from the group of selective serotonin reuptake inhibitors (SSRIs), in particular sertraline (Zoloft) [32-37], as well as dual-action antidepressants - venlafaxine [38] and drugs from the group of noradrenergic and specific serotonergic antidepressants - mirtazapine [39].

SSRIs, unlike a number of other antidepressants, do not cause cardiac conduction disturbances or blood pressure fluctuations. Moreover, it has been found that SSRIs prevent the accumulation of serotonin in platelets, thus helping to reduce their aggregation, which, with long-term use, leads to a reduction in the risk of cardiovascular accidents [43]. Balanced drugs of this group, especially sertraline (Zoloft), have anti-anxiety and anti-asthenic effects, and also help improve cognitive functions.

A fairly large number of studies have been accumulated that have proven the high efficiency, safety and good tolerability of SSRIs [32-37, 45-49], in particular sertraline (Zoloft), in the treatment of depression in chronic somatic diseases, such as cardiovascular pathology [32 , 34, 48], nervous diseases [36, 38, 44, 49], chronic kidney disease [35], diabetes mellitus [33], blood diseases [37]. The above studies demonstrated fewer side effects for drugs from the SSRI group, their better compatibility with somatotropic therapy, and a reduced risk of recurrence of depressive states with long-term use.

It should be noted that, in addition to drug treatment, it is also necessary to use psychotherapeutic methods (person-oriented, behavioral, rational-emotional-behavioral psychotherapy) for the purpose of rehabilitation, inclusion in everyday, social life, professional activities, prevention of repeated depressive episodes, and in case of neurotic depression to resolve chronic stressful situations, helping the patient overcome everyday difficulties.

Thus, in almost a third of patients with chronic diseases observed by doctors in the general somatic network, the presence of depression of varying degrees of severity is detected.
External factors in the form of long-term everyday stress may play a role in their occurrence; depressive states develop in response to the news of the presence of severe somatic pathology. On the other hand, affective disorders can be caused by the consequences of past illnesses, and also have an endogenous nature. It is necessary to timely identify and determine the severity of depressive disorders in order to decide on further tactics and prescribe differentiated psychopharmaco- and psychotherapy. Literature
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Is depression forever?

Due to the long course of the disease, there are fears that depression is forever. Actually this is not true.

You can get rid of mild depression on your own - survive the traumatic event, live through the emotions and recover. Without therapy, a condition that appears due to the use of certain medications also goes away. After they are cancelled, everything returns to normal.

If left untreated, depression can progress.

Moderate and severe conditions should be monitored by a doctor. The behavior of a sick person often increases symptoms, leads to the progression of pathology and deterioration of the condition. This is due both to the functioning of the brain and to the patterns that have developed throughout life.

With the right therapy, depression can be treated or stopped at any stage and for any duration. If the condition is caused by hormonal imbalances or a deficiency of biologically active substances, the symptoms will disappear after correction of the imbalance. In the case of psychogenic (caused by unpleasant events) and endogenous (arising from a malfunction of the psyche) diseases, specific treatment is required.