Beat Depression and End Insomnia

Depression is a life-threatening disorder that seems to be triggered by stress, hormones, genetic glitches, medical conditions, medication, and maybe even the kitchen sink. Its onset is predicted by insomnia, insomnia usually accompanies it, and insomnia is usually the last symptom to disappear. Maybe that’s why, as Ruth Benca, M.D., Ph.D., and director of the sleep program at the University of Wisconsin-Madison, says, “All the things that are good sleep therapy are good depression therapy, too.” Here are the strategies that can help you beat both.

Check with your primary-care physician. Depression can be the side effect of a laundry list of illnesses — cancer, for one; sleep apnea, for another — and medications. So if you’re feeling down for any length of time, your first step is your primary-care physician.

See a psychiatrist. Depression can kill, and the medications frequently used to rebalance your brain chemicals can be tricky. So once your primary-care physician has ruled out medical conditions and medication as a cause of depression, even if you’re comfortable with your primary physician’s care, you might want to ask for a referral to a psychiatrist.

Your primary-care physician may be able to deal with depression as a temporary side effect or the everyday blues, but it’s a psychiatrist who is trained in the ins and outs of major depression and its treatment, and it’s a psychiatrist who is most able to suggest the treatment option that, tailored to your particular situation and combination of issues, is most likely to succeed.

Think about the Big 3. The three approaches doctors usually suggest for major depression are antidepressant medication and either cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT), says James P. Krainson, M.D., a sleep medicine specialist at Miami’s South Florida Sleep Diagnostic Center.

“Most depression responds to medication,” he adds. Since it’s likely to be caused by a biochemical imbalance in your brain, a chemical can frequently help. Fortunately, however, depression responds well to all three treatments.

In a review of studies conducted at Vanderbilt University, researchers found that medication had a rapid and robust effect, plus it prevented the return of symptoms for as long as it was taken.

In the review, both CBT and IPT seemed to be just as effective as medication. In particular, IPT might help the individual work out personal issues, while CBT seemed to have an enduring effect that reduced the risk of future depressive episodes — a big concern among doctors.

Combined treatment with both medication and therapy seemed the best choice, the researchers concluded, since combination therapy seemed to boost the effectiveness of each.

Try again. “Studies have shown that about half of those who start on a treatment of medication and/or therapy get some relief,” says researcher George Niederehe, Ph.D., the National Institute of Mental Health’s project officer for STAR *D, a nationwide series of studies that included more than 4,000 men and women diagnosed with major depressive disorder. But doctors weren’t sure how to help the other half once the initial therapy had failed. Common sense told them to try another medication and see what happened, which is what many doctors did. Still, they wanted some clear direction about what helped and what didn’t — or if there was another way to approach treatment altogether.

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Enter the STAR *D study. Conducted in the real world among people with demanding jobs and relationships, the study has shown how to help the other half — the group science seemed to have left behind.

There were two key studies in STAR *D. “One study looked at how well people did if their original treatment was supplemented with a second one. The other looked at how well people did if their original medication was switched with another,” says Dr. Niederehe.

In the first study, in which an original antidepressant medication that hadn’t achieved complete remission of symptoms was supplemented with a second antidepressant, 1 in 3 patients achieved a remission of symptoms.

In the second study, in which patients were switched from the original antidepressant to another, 1 in 4 patients achieved a remission.

“In both cases the finding was that the move to a second treatment benefited a substantial number of patients,” says Dr. Niederehe, who further explains that when thinking about treatment for depression, there are a couple of things revealed by STAR *D to keep in mind.

One is that even though the 10 medications used in STAR *D work via different mechanisms, they all worked in the same numbers of people. In other words, no one antidepressant was more effective than any other. The other is that if you begin to take a particular medication and show even a partial benefit, you should stick with that particular medication for a full 12 weeks because you may well achieve remission in that time.

On the other hand, if you show no benefit at all after eight weeks on one medication, you should talk with your doctor about switching.

The bottom line, says Dr. Niederehe, is this: “If you fail at the first treatment, don’t give up. It may just be that you haven’t found the right approach. Another treatment is likely to help. And by giving treatment another try, you have a good chance of complete remission.”

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