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Depression: Major Depression & Unipolar Varieties
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Special Issues - Severe Depression, Dual Depression and Dual Diagnosis

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Severe, treatment-resistant depression

In approximately 10 to 30% of people with depression, treatment with antidepressant medication and/or psychotherapy provides little or no benefit. Treatment-resistant, chronic depressive symptoms usually lead to greater levels of disability, a greater likelihood of the reappearance of major depressive episodes in the future, and a poorer prognosis (expectation) with regard to work and social performance.

Remember that depression therapies do not work instantly, but instead require several weeks to several months to take effect. You must wait for at least six to eight weeks before concluding that you (or someone you care about) are not responsive to a particular medication or type of psychotherapy. In addition, multiple antidepressants and/or different types of psychotherapy (or simply different therapists) should be tested before assuming that you have treatment-resistant depression.

The first step for people who are dealing with treatment-resistant depression is to review their diagnosis. Repeating initial diagnostic tests and conducting new ones may uncover contributing factors (such as a thyroid problem, etc.) that the original diagnosing clinician may have missed initially.

When all diagnostic work has been checked, it is appropriate to work through additional reasonable medication combinations, or to move on to non-medication treatment options. Treatment-resistant depression is often treated with lithium and/or antipsychotic medications, electroconvulsive therapy (ECT, which has the highest rate of response of any form of antidepressant treatment), or Vagus nerve stimulation (VNS). Click here to return to the treatments section of this document to re-read information on non-medical treatments for severe depression. ECT and similar forms of therapy are typically considered last attempts, and should be initiated only after all other avenues of treatment have been exhausted.

Dual Depression

"Dual" or "Double" depression is a term used to describe the condition of a person with Dysthymia who also develops a more severe and persistent Major Depressive Episode at the same time. As mentioned previously, dysthymia is a less severe type of depression that involves long-term, chronic symptoms that do not disable, but which do make it difficult to function or feel good. People diagnosed with double depression require aggressive depression treatment not only during the acute Major Depression phase, but also during the chronic low-grade Dysthymia phase that follows in order to try to prevent future occurrences of Major Depressive Episodes. Studies suggest that individuals with double depression often respond well to antidepressants for their Major Depressive Episodes, but that their low-grade dysthymic symptoms may not abate completely. In other words, if you suffer from double depression, medication may relieve your most severe depressive symptoms, but you may not experience periods of feeling completely well. SSRIs and MAOIs are the most effective medications for dual depression.

Dual diagnosis

Many depressed people try to make themselves feel better by "self-medicating", which is to say by drinking alcohol or taking drugs. Unfortunately, use of these substances only serves to compound the problem by placing the depressed patient at risk for developing substance addictions in addition to their underlying depression.

Research suggests that people with psychiatric problems are much more prone to addiction than the general population. In addition, people who abuse alcohol, drugs or other substances have an increased risk of Major Depression. Depressed people who have substance addictions are more likely to need hospitalization, more likely to attempt suicide, and less likely to succeed in treatment than are depressed people who are not addicted. As a result, dually-disordered patients (who have both depression and substance abuse diagnoses) are often treated separately from patients with depression only, in inpatient settings and group therapy sessions.

Dually-disordered patients are harder to treat than patients who experience only one disorder at a time. The basic rule followed by most dual disorder treatment programs is that patients need to become sober before real treatment of their underlying depression can occur. The first step for a dually-disordered patient is thus typically detoxification (or detox) during which the body is allowed to cleanse itself of alcohol and/or drugs. Detox should be medically monitored as complications such as infections and/or lung, kidney, or liver problems can occur. Some drugs are safer to detox from than others. Specifically, it is never safe to detox from alcohol without medical attention during the process. The amount of time necessary for detox varies, depending on the particular addictive substance, the frequency of use, and the quantity consumed.

For those people whose addiction is severe, inpatient dual diagnosis treatment may be necessary. Individuals with less severe drug or alcohol addictions may benefit from an outpatient dual diagnosis treatment program. However, outpatient dual diagnosis treatment is only successful for people who are self-motivated and willing to take active steps towards improving themselves and working towards recovery.

Within specialty inpatient or partial hospital dual disorder treatment programs, detoxified patients are offered simultaneous and intensive therapies designed to help them maintain sobriety and to address their psychiatric issues, including depression. Medications are prescribed and monitored. Relapse prevention techniques are taught, and group therapies are offered. Patients are screened for substance use on a continuing basis. Sometimes, they are also encouraged to participate in various twelve step programs such as Alcoholics Anonymous, Narcotics Anonymous, Marijuana Anonymous or Cocaine Anonymous. Patients who manage to maintain sobriety for a while may be offered more specialized psychotherapy for their depression or other psychiatric condition.

The transition from hospital or partial hospital care to outpatient care is particularly critical for dual diagnosis patients. After completing a dual diagnosis program, patients are more likely to enjoy continued success when they can be transitioned into aftercare programs and sober housing in order to prevent relapse.