Health

In a perfect world, every treatment would be right on the mark, every doctor or therapist would earn his or her patient's confidence, and people would find it easy to follow each bit of helpful advice. Clearly, this isn't the reality. So what are some of the barriers to getting good treatment and sticking with it? And how can you surmount them?

Barriers to treatment of depression

If you're finding it difficult to get past some barrier to treatment, share your concerns with your doctor.

The health care system

Navigating the health care system isn't always easy. Some health insurance companies confine your choices to a narrow panel of doctors or therapists. Or there may be relatively few mental health professionals in your area. It may also be hard to advocate for yourself, especially when you're depressed. Perhaps a supportive family member can help you deal with your insurance plan or accompany you to an appointment.

Most private insurers, Medicare, and managed-care plans provide some coverage for mental health treatments. However, copayments may be higher than for other types of care. There may also be a limit on how many visits the company will cover. Calling your insurer is the best way to figure out your out-of-pocket cost.

If a psychiatrist or doctor is prescribing your medication and another person is conducting psychotherapy, it may be difficult to coordinate the different aspects of your care. Let both people know that it is important to you that they talk with each other.

It's also important that you do all you can to understand your treatment. Bringing a pad and paper to your appointment and taking notes may help you take in information that is sometimes confusing. For example, studies show that although doctors report telling patients about side effects, many patients don't remember hearing that information. Also, make sure you bring up any important and possibly time-consuming issues at the beginning of your appointment. Appointment time is often limited, so plan to make good use of the time, and make follow-up appointments when necessary.

Finding the best treatment

Choosing the right treatment is difficult. While research provides guidance, it doesn't always point individuals in a specific direction. Which treatment works best for which person is still an open question. It's common to adjust dosages and switch or add drugs depending on your response and side effects. This can be a frustrating process, but your doctor isn't treating you like a guinea pig — rather, it's a normal part of good treatment. Until researchers discover a way to predict an individual's response to treatment, this step-by-step, trial-and-error process is the state of the art. With persistence, you can reach your goal.

Sticking with treatment

Obviously, no treatment plan has a chance to work if it's not followed. Yet many, if not most, people don't take medicines exactly as prescribed, especially if they must take more than one drug at different times of the day.

An estimated 5% of patients flatly refuse to take antidepressants or mood stabilizers. Side effects make these drugs intolerable for another 10%–15% and may encourage countless others to occasionally skip pills, tinker with dosages, or stop taking a drug without their doctors' knowledge. If you're having trouble with your medication, talk to your doctor or therapist. He or she can help you sort out the problem and make adjustments if necessary.

Some people who opt for therapy find that it can be difficult to keep at it. Change isn't easy. Even when you're willing to make life changes, the resulting ripples may affect your friends, coworkers, spouse or partner, and children, some of whom may not be as supportive as you'd like. It sometimes helps to encourage those most important to you to join you in a therapy session or to attend support groups.

Still a stigma

Finally, there's stigma. Many people still erroneously see symptoms of depression and seeking treatment as a sign of weak character, lack of fortitude, or an inability to pull oneself up by the bootstraps. Because depression can be a source of shame, people with this illness may suffer silently. But by not getting treatment, they remain stuck on a destructive course that leads to more pain, a poorer quality of life, and, at worst, suicide.

This description is stark, but there's hope. Therapy and medications can help tremendously, and given the advances in our understanding of this condition, it seems likely that people with depression will soon have even greater treatment options. Public awareness about depression is growing, partly as a result of national public service campaigns, and perhaps funding for the development of new treatments will follow suit. As more and more people seek treatment, it may also be easier for families and friends of those suffering from depression to be more active in encouraging them to get help.

Managing side effects

No matter what medications you take, always tell your doctor about uncomfortable or worrisome side effects immediately. You and your doctor can often alleviate side effects with a few simple steps. Here are some suggestions for dealing with common side effects of antidepressants:

Dry mouth. Drink a lot of water, chew sugarless gum, and brush your teeth frequently.

Constipation. Eat whole grains, bran cereal, prunes, and hearty servings of fruits and vegetables. Drink plenty of water.

Trouble urinating. If you have difficulty starting urination, your doctor may be able to adjust your medication to relieve this problem.

Dizziness. Sudden changes in position can lead to a sharp drop in blood pressure that causes dizziness. To counter this effect, rise slowly from a chair or when getting out of bed. Also, drink plenty of fluids.

Daytime drowsiness. This problem usually occurs at the beginning of treatment and may not last long. In some cases, it may help to take medication at bedtime, but ask your doctor about this first. If you feel drowsy, don't drive or use heavy equipment.

Trouble sleeping. Sleep often improves after a few weeks, but sometimes a mild sleep aid or a switch to another medication is necessary.

Nausea. Often, nausea disappears within a few weeks. It may help to take the drug shortly after a substantial meal.

Agitation. You might feel uncomfortably nervous or restless after you start taking a drug. Jittery feelings may pass within a few weeks. But in relatively rare cases, agitation will persist; sometimes it's an early symptom of worsening depression or mania.

Headache. Headaches may come and go. Some persist, but they usually disappear within a few weeks.

Sexual difficulties. Sometimes sexual problems are transient or not related to the drug. Talk with your doctor about sexual problems that don't pass soon. Also, see "Sexuality and SSRIs."

If side effects continue to bother you, your doctor may change your dosage, shift the time of day that you take the medication, or split the dosage into smaller amounts to be taken over the course of the day. Or he or she may recommend combining the drug with another one, switching to a different drug, or replacing drugs with therapy or other forms of treatment.

Call your doctor right away if you feel more depressed instead of less or if you feel worse for any reason.

The problem of recurrence

When depression isn't treated, there's a high likelihood that it will recur. Roughly half of those who have a single untreated episode of major depression will go on to have another. The second untreated episode boosts the odds of a third. Once that occurs, the chances of having a fourth episode are 90%. Over a lifetime, people with untreated major depression will have an average of five to seven episodes, and episodes often accelerate, becoming more frequent and more severe.

Bipolar disorder, dysthymia, and all other mood disorders are also more likely to persist or recur if they go untreated. As with depression, episodes occur more frequently and become more intense over time. This suggests that it's best to treat major depression, bipolar disorder, and dysthymia as early as possible.

Aggressive treatment pays off

Recurrences also occur more frequently if treatment has not wholly eradicated depressive symptoms. Therefore, treatment should aim for maximum relief.

It's best to gradually increase the dose of an antidepressant until no further improvement is seen. Preliminary research also supports continuing with the full, therapeutic dose even after you start to feel better, rather than risk taking a lower dose that may be only partially effective. Yet inadequate dosages are a common problem. Primary care doctors who are less experienced with psychopharmacology are often reluctant to increase doses, and people who are uneasy about taking medication may be reluctant to try a higher dose.

Here are some other strategies worth considering in search of a lasting, full recovery:

• switching to a different antidepressant if the first one is not adequately effective
• combining two antidepressants that have different mechanisms of action
• adding a second drug (not primarily an antidepressant) that may augment the effect of the antidepressant you're taking
• combining medications and therapy.

Keeping up with medication

To prevent a relapse, it's important to continue taking your medication even after you feel better. A study from the Journal of the American Medical Association divided into two groups 150 people with dysthymia or double depression who had responded to treatment with sertraline (Zoloft). Some of these people continued to take the drug, while the rest took a placebo. After 18 months, only 6% of the group taking sertraline had relapsed, compared with 23% of the placebo group.

Most psychiatrists will recommend that you stay on your medication for about a year after a first episode of depression. If you have had several episodes, your doctor will probably recommend maintenance treatment indefinitely.

Source: from Harvard Health Publications, Copyright © 2008 Harvard University. All rights reserved. Harvard Medical School does not endorse products.
Used with permission of StayWell.
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