What's Up Doc? Concerns about psychiatry referral for depression

Q: I have been seeing a therapist for a few months and they recently referred me to a psychiatrist. I am apprehensive about the referral because I am not sure that I want to start taking antidepressants. What are some things I should consider in making this decision?

A: One of the biggest misconceptions of psychiatry is that in seeing a psychiatrist you are committing yourself to take medications such as antidepressants; this is not the case. A psychiatrist will talk with you to understand what your needs are, and will work with you to determine the best way to address them. Below is a broad overview of depression and what different treatment options may be considered.

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In the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) there are several different possible depressive disorders identified, including:

• Major depressive disorder (also called unipolar depression to differentiate it from depression associated with bipolar disease)

• Persistent depressive disorder (dysthymia)

• Disruptive mood dysregulation disorder

• Premenstrual dysphoric disorder

• Substance/medication induced depressive disorder

• Depressive disorder due to another medical condition

• Other specified depressive disorder (e.g. minor depression)

• Unspecified depressive disorder

Since major depression is one of the most common disorders in the U.S., affecting more than 15 percent of Americans at some point in their lives (women more often than men), that is what I will focus on below in order to illustrate some key concepts.

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The diagnosis of major depression is made by having five of the following nine symptoms (specifically including at least one of the first two, and not associated with substance abuse or caused by another medical disorder) causing substantial distress or impairment essentially daily for at least two weeks:

• Depressed mood most of the day, especially in the morning

• Diminished interest or pleasure in almost all daily activities

• Significant change in appetite or weight (loss or gain)

• Poor sleep (too much or too little)

• Psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness or guilt

• Impaired concentration or indecisiveness

• Recurring thoughts of death or suicide

Since certain other medical conditions, for example hypothyroidism (abnormally low levels of thyroid hormone), side effects from medications (for example steroids), vitamin/electrolyte imbalances (such as high calcium states, vitamin B12 deficiency, others), having a chronic disease (for example diabetes, multiple sclerosis, kidney disease, heart disease, lupus, fibromyalgia, others) and many others may mimic/cause depression-like symptoms, certain blood and/or urine tests may be indicated to evaluate for these. When major depression is associated with another condition (so it is a coexisting entity), as opposed to being mimicked by it, it will usually be treated as part of the patient’s overall care plan.

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The treatment of depression has come a long way, and there are now many therapeutic options including psychotherapy/counseling techniques (sometimes called "talk therapy," examples of which include cognitive-behavioral therapy, interpersonal psychotherapy, behavioral activation, problem solving therapy, psychodynamic therapy, and others), many different medications (for example serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors, atypical antidepressants, serotonin modulators, tricyclic antidepressants, monoamine oxidase inhibitors, others) and several other treatment modalities as well. Some studies have shown that many patients have their best response to a therapy that combines medications and psychotherapy/counseling.

The specific treatment that is best for an individual patient must be individualized (as is the case for all medical conditions) based on their response to treatments, possible side-effects that may arise, and other factors. It is common that a given care plan will be tried for six to 12 weeks before a medication/medication dosage, psychotherapy approach or other changes are made in order to give the patient adequate time to achieve their best possible response to the therapy they are on. As with any chronic condition, if a patient stops responding to their treatment plan at some point, their care plan should be reevaluated.

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In order to be able to follow a patient more closely for improvements (or worsening) of their condition, a quantitative rating scale may be utilized. A common one is the Hamilton Rating Scale for Depression, which looks at the patient’s self-reported symptoms on things like their mood, feelings of guilt, thoughts of suicide, sleeping issues, engagement in work and other activities, psychomotor functioning, and other symptoms (including psychiatric symptoms like agitation, anxiety, and insight/understanding of their condition, as well as multiple symptoms relating to their physical body).

A positive response to treatment is demonstrated by improvement in symptoms, and the patient’s depression is considered to be in remission when their symptoms resolve to a level of severity similar to that of the general population (since we ALL have symptoms as noted above at times, a complete absence of symptoms is not typically expected), for example a score on the Hamilton Rating scale of 7 or less.

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Over a third of major depression patients have a good response to their initial treatment plan, with another 50 percent improving after their treatments are further adjusted (sometimes two or three refinements are needed). Over half of major depression patients have their symptoms remit over a year or so, and three-quarters by two years. However, as with many medical conditions, symptoms may subsequently recur (this occurs in over two-thirds of patients).

More than 50 percent of people with major depression are not diagnosed, and hence are not getting the care and treatment that may help them. If you are worried that you or a loved one may be depressed, a health care provider should be consulted. Once the specifics of the patient’s situation and condition are known, their best course of treatment can begin so they can start down the road to recovery.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com

This article originally appeared on MetroWest Daily News: Seeing a psychiatrist doesn't necessarily mean you need medications