How do I effectively manage my depression symptoms?

Question

Hello doctor,

I have felt hopeless and empty for ten months and lost interest in everything I enjoyed, including hobbies, friends, and family. I sleep 16 to 18 hours daily or have severe insomnia with only two to three hours nightly. I have lost 22 pounds without trying, feel intensely worthless and guilty, and have frequent thoughts about ending my life, terrifying my family.

I cannot concentrate, remember things, or make simple decisions at work, affecting job performance and risking termination. These symptoms affect relationships, work, health, and daily functioning. I feel physically slowed down, and moving takes enormous effort. My doctor ruled out medical causes: TSH 2.4 mIU/L (normal), B12 475 pg/mL (normal), vitamin D 16 ng/mL (low), CBC normal.

My concerns are:

Is this major depressive disorder or persistent depressive disorder?
What causes depression?
Is low vitamin D related?
What antidepressants exist?
How long until they work?
What about side effects?
What if the first medication fails?
Should I try multiple medications or combinations?
Is psychotherapy necessary?
What about ECT or TMS for treatment-resistant depression?
What is ketamine or esketamine therapy?
Will I need medication forever?
Can depression recur after stopping medication?
Can depression be permanently cured?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understand your concern.

Experiencing depression is very painful, and I cannot even imagine how much psychological pain you have to bear. This is major depressive disorder, and if symptoms had persisted for two years, then it could have been persistent depressive disorder. Your symptoms are so severe that they rule out the dysthymic disorder.

It has been affecting your life, and now you are also experiencing suicidal thoughts. It needs emergency consultation and management. It is not about being strong or weak; it can drive you to commit to these thoughts. Therefore, an urgent psychiatric consultation is mandatory. I would highly advise you to meet a psychiatrist and initiate proper management.

SSRIs are usually first-line, along with cognitive behavioral therapy (CBT). They take four to six weeks to show effect, and you can observe their maximum effect in six to 10 weeks. You will see improvement in your sleep, appetite, concentration, motivation, energy, mood, and suicidal thoughts. Medicines are not addictive; they are usually continued for six to nine months after resolution of symptoms. There are 10 to 12 sessions of CBT.

Both CBT and IPT (interpersonal psychotherapy) are effective, but they are chosen based on the causes. If relationship issues are causing depression, then IPT is preferred; but if dysfunctional thoughts and behaviors are predominant, then CBT is the choice. It does not matter what option you choose; both are effective and should be augmented with medicines.

If one SSRI does not work, then we usually choose another drug from a different class, such as a TCA. If two drugs do not make a change, then we augment them with antipsychotics or Lithium. If there is no response, then we move to Esketamine, TMS (transcranial magnetic stimulation), and ECT (electroconvulsive therapy).

They are very effective but have their own limitations. Depression is usually a relapsing condition, which means there is a high probability that you will experience another episode. Relapse depends upon many factors, like continuation of stressors, premature stopping of medicines, no augmentation of psychotherapy, and family history of depressive disorder.

Other lifestyle modifications are also important and should be augmented, such as reducing caffeine and nicotine, taking an evening walk for 30 minutes, and learning deep breathing or progressive muscle relaxation exercises. You can monitor your symptoms with the Beck Depression Inventory (BDI), also known as the Beck Test. Low vitamin D can affect mood and should be corrected, but it is not the sole cause.

I hope this helps.

Thank you.