How can psychiatry help with depression?

The word “depression” often causes confusion because of its varied interpretations, even within clinical settings. It’s a complex and multifaceted condition. People often use it to describe a mood state, indicating feelings of sadness, dysphoria, or emptiness—which is “normal” and an adaptive response to life’s challenges. 

Conversely, “depression” can signify a symptom within a syndrome or medical condition. Understanding the circumstances surrounding the subjective experience of feeling depressed is therefore crucial for clients and their clinicians to effectively address depressive disorders. 

Understanding clinical depression

Clinical depression goes beyond ordinary mood fluctuations. It significantly impacts daily life, relationships, functioning, and overall well-being. The National Institute of Mental Health says that the most prevalent form of clinical depression, Major Depressive Disorder (MDD), is “the leading cause of disability in the U.S. for ages 15–44.”

What are the symptoms of Major Depressive Disorder?

People with MDD present with more than two weeks of persistent sadness or anhedonia—which is when people experience less interest or satisfaction from activities they typically enjoy. Clinical depression is further characterized by someone showing at least three of the following symptoms: 

• Changes in sleep patterns—Disturbances leading to insomnia or hypersomnia
• Changes in appetite or weight—Manifesting as increased or decreased appetite, contributing to weight gain or loss
• Fatigue and loss of Energy—Persistent feelings of tiredness, even after restful sleep
• Difficulty concentrating or making decisions—Impaired cognitive functions impacting decision-making and focus
• Feelings of worthlessness or guilt—Overwhelming emotions often unrelated to personal control.
• Physical symptoms—Headaches, digestive issues, or pain without an apparent physical cause
• Thoughts of death or suicidal ideation—Severe cases may lead to thoughts of death or suicide attempts, necessitating immediate help.

How does a psychiatrist accurately diagnose Major Depressive Disorder?

Even if a client comes in with a diagnosis, I work to remain unbiased and not predetermine what they’re experiencing. I will review the information already provided, but it’s important to also have a new lens to accurately understand someone’s presentation. That includes working to see if depression symptoms are occurring because of some other condition or substance, as well as getting specific about the type of depression a client is experiencing.

Medical conditions and substance use

Accurately diagnosing depression requires a thorough medical evaluation to rule out other medical conditions that could cause depression-like symptoms. These include:

• Hypothyroidism
• Vitamin deficiencies
• Neurological disorders
• Autoimmune diseases
• Chronic fatigue syndrome
• Chronic pain conditions
• Sleep disorders

We also factor in a client’s substance use, including alcohol, drugs, and the chronic use of certain medications to rule them out as potential contributors or causes of symptoms.

Diagnosing other psychiatric conditions with similar symptoms

Other mood and psychiatric disorders can lead to apparent symptoms of depression. I make sure to understand what a client is experiencing during our session and by reviewing information from their therapist and other providers. These are some examples of disorders: 

• Adjustment disorders with depressed mood are typically mood symptoms related to identifiable psychosocial stress, such as work, marriage, finances, illness, or some other change or event that can cause distress.
• Complicated Grief happens due to experiences of loss, which can cause intense and prolonged grief that mimics some aspects of MDD.
• Personality disorders can present with dysphoria and mood fluctuations, mirroring symptoms of MDD. However, these fluctuations can happen within a day, are less episodic, and can be highly impacted by routine circumstances and relationships. 
• Bipolar disorder is characterized by experiencing at least one episode of mania (Bipolar I) or hypomania (Bipolar II) in one's lifetime. 
• Psychotic disorders can also present with mood symptoms—but are characterized with other diagnostic features to include a distorted reality or hallucinations, and may also include fixed false beliefs or delusions.  

What is a specifier for depression?

Once I’ve diagnosed someone with MDD, it’s time to add further diagnostic clarity by identifying and including specifiers—the specific features—that are part of their depression. Besides exhibiting the symptoms mentioned earlier, they may show other symptoms that should be considered.

Severity of depression symptoms

MDD can vary in severity, depending on how much symptoms impact a person’s daily functioning.

• Mild—Few symptoms beyond the required criteria are present, resulting in minor functional impairment.
• Moderate—More symptoms present or show greater impact on a client’s functional impairment. 
• Severe—The symptoms cause significant impairment in social, occupational, or other important areas of functioning.

Melancholic features

The client presents with a profound loss of pleasure in almost all activities. They typically show a lack of mood reactivity, and their mood is distinctly characterized by profound and pervasive sadness.

Anxious distress

The client also presents with significant anxiety symptoms, such as feeling tense, restless, or having a persistent worry that something bad will happen.

Atypical features

Features include mood reactivity (brightening in response to positive events), significant weight gain or increased appetite, hypersomnia, and sensitivity to rejection.

Catatonia

Catatonia can be the presence of motor immobility or excessive motor activity, odd voluntary movements, and other behavioral abnormalities. 

Psychotic features

The client presents with delusions or hallucinations. These may be mood-congruent, meaning that the content of the delusions or hallucinations are depressive, or it may be mood-incongruent and relating to different emotions. 

Peripartum onset

The timing of MDD can be of importance, such as if depression occurs during pregnancy or starts in the four weeks following childbirth, indicating postpartum depression. 

Seasonal pattern

Again, timing matters: A regular recurrence of depressive episodes at a particular time of the year, most commonly in the fall or winter, and full remission at other times may suggest that MDD is seasonally affected.

What kind of treatment options are available for someone with depression? 

In medicine, t​he first tenant is “Do No Harm.” My approach to treatment starts with the least invasive, evidence-based, effective treatment option. 

Therapy should be part of managing depression. Common modalities for MDD include Cognitive Behavioral Therapy and interpersonal psychotherapy. 

When clients need more support than therapy, the next least invasive treatment or option is usually to add an SSRI. Selective Serotonin Reuptake Inhibitors are approved by the FDA and are the most commonly prescribed class of antidepressants in treating MDD.   

If SSRIs are ineffective, intolerable, or the client does not want to use it as part of their treatment plan—usually due to concerns about side effects—I’ll have a discussion with them. I walk them through the risks, benefits, and potential side effects of alternative options, and allow the client autonomy to play a significant role in their treatment planning.

Managing with medication

Many options exist for treating MDD with medication, and it’s important to factor in what a client wants and what works for them. Here is an idea of what we might use for treating MDD. 

• Selective Serotonin Reuptake Inhibitors (SSRIs) are a common treatment for MDD due to its tolerability and efficacy. It increases the availability of serotonin, which is a neurotransmitter that aids in regulating mood and emotions. Examples of SSRIs include Citalopram, Escitalopram, Fluoxetine, and Sertraline. 
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are another widely used treatment because it shares tolerability and efficacy. SNRIs increase the levels of serotonin and norepinephrine, providing another option for managing symptoms. Examples of SNRIs include Venlafaxine, Desvenlafaxine, and Duloxetine. 
• Serotonin modulators—sometimes referred to as SMS or serotonin modulator and stimulator—affect functions of serotonin receptors as well as inhibit the reuptake of serotonin. SMS examples include Vortioxetine and Trazodone.
• Atypical antidepressants, with unique effects on receptors and neurotransmitters, are alternatives for clients who are intolerant to SSRIs and SNRIs. They can be prescribed alone or combined with other antidepressants to target specific symptoms, like Bupropion for focus or Mirtazapine for sleep and appetite.
• Less commonly used are Tricyclic Antidepressants—including Amitriptyline, Nortriptyline, and Doxepin—and Monoamine Oxidase Inhibitors (MAOIs). These medications have been around longer, but are used less due to concerns about side effects and safety. 

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Monitoring the effects of treatment for depression

During treatment, I meet with clients to observe that the path we’ve taken is working for them and to make changes if necessary. 

There are several different reasons why we may need to change course. Over time, medications or the dosage can become less effective. Clients may experience side effects later on, such as changes in weight or sex drive. Clients might also have trouble with compliance—meaning they have difficulty taking medications correctly or at all. 

If it’s time to change course, we discuss dose adjustment, augmentation to add another medication, or changing the medication/treatment altogether to try a different path. Once again, the client's comfort level and preferences should be taken into account after discussing risks, benefits, and potential side effects of alternative options.  

Treatment goals for depression

When I’m monitoring the effects of treatment and medication, I’m looking for safety, tolerability, and effectiveness.

I prioritize safety, because medication can sometimes have unintended effects. These are usually uncommon but can be concerning, such as suicidal ideation, severe allergic reactions, or other effects. 

Next, clients must be able to tolerate the medication. If they can’t tolerate it, they may struggle with compliance due to unpleasant side effects, such as weight gain, nausea, abdominal pain, headaches, sexual side effects, drowsiness, among others. 

Then we need to check that treatment is effective—that symptoms are presenting less and that there’s improved functioning in a client’s daily life. 

The goal for treatment is to reach a response of greater than 50% improvement and ultimately remission. We measure this by using objective rating scales to monitor symptoms, such as the PHQ9, the Hamilton rating scale for depression, or the Montgomery-Asberg depression rating scale. Each scale has defined parameters for remission that we aim to achieve with each client. 

Adjusting treatment when medication isn’t working

There are some clients who have treatment-resistant depression, which means that after trying two or more different medications, we aren’t seeing any signs of effectiveness. 

For these clients, we might consider additional treatment options, which include: 

• Pharmacological second-line options for treating depression, such as mood stabilizers or second-generation/atypical antipsychotics
• Ketamine-assisted psychotherapy  
• Electroconvulsive therapy (ECT)
• Transcranial Magnetic Stimulation (TMS) 
• Deep brain stimulation

The Food and Drug Administration has also issued guidance on the use of psychedelic drugs in clinical trials. This includes Psilocybin, a hallucinogen and drug derived from mushrooms, for treating mental health disorders in controlled environments accompanied by psychotherapy. There is promising research offering potential treatment options for depression, PTSD, substance use disorders, and other conditions. 

Collaborating with therapists

If a client experiencing MDD isn’t already in therapy, I strongly recommend it as part of their treatment. Therapists see clients more often and have more time with them in sessions, so they have a more intimate understanding of a client’s psychological make-up and socioeconomic factors that impact their mental health. 

A therapist provides more frequent support and can also work with a client to incorporate other parts of treatment for MDD, such as any lifestyle changes that could benefit their mental health and improve daily functioning. 

At UpLift, therapists and psychiatric providers can share notes about clients and work together as a care team. We welcome collaboration and encourage therapists to refer clients for a psychiatric consultation when additional evaluation and treatment may be beneficial.