Anita H. Clayton, M.D.
Chair, Department of Psychiatry & Neurobehavioral Sciences
University of Virginia School of Medicine
For many of us, depression treatment isn’t straightforward, as we encounter medical, practical, cultural, and other issues. This shouldn’t be seen as reason for despair, but – with flexibility, creativity, compassion, and an open mind – an opportunity to create the right treatment plan for each individual.
In a previous post, Dr. Clayton explained how to work with your provider to get the treatment that will work for you. Here, she guides us through some particular issues.
You’re dealing with more than depression
When a person has co-morbid conditions, the best approach is to address them together. Sometimes treatment is not having the desired results because there is something else going on, so we screen for other conditions such as substance abuse, anxiety, or sleep disorders, and unidentified or poorly managed medical problems (e.g. obstructive sleep apnea). These other factors affect both the efficacy of treatment and the order of which treatment to implement first, so it’s important for providers to know. Your clinician is not there to judge you, but to help you find the treatment that will help you to get well. For example, if you also have a substance use condition, then let’s not give you a medication that is more likely to give you cravings. With this information, we can develop an algorithm for treatment, one that gets you on the path to wellness.
You have experienced trauma
Trauma is a big issue that is often left unaddressed. Both men and women are understandably reluctant to talk about these experiences. Primary care providers should be able to refer their patients to therapy with an appropriate provider, even if that provider is online or accessed by telephone. (Visit the SAMHSA website for more about trauma.)
You can’t afford your prescription
We know that people have different kinds of insurance and that medications can be expensive. We want people to get the treatment they need and will work for them, so we know the Medicaid formulary, and we encourage use of coupons and discount programs for patients with commercial insurance. Many antidepressants are available as generics, making them more affordable than brand names. Pharmaceutical companies also have assistance programs for people who meet low-income guidelines or who have high co-pays or deductibles. And primary care providers may have samples from pharmaceutical companies as well. There are usually ways of getting the medicine you need, just ask your provider, your pharmacist, your insurer, and prescription assistance programs.
You can’t tolerate the medication
We can be flexible in creating your personalized treatment plan. That might mean keeping treatment as simple as possible – one pill taken once a day, for example – so that you have a good chance of sticking to your treatment regimen. Or it might mean spacing doses at different times of the day to improve tolerability. Work with your provider to find the treatment that has the best chance of success for you, so that it relieves the symptoms of depression AND does not cause side effects that reduce your quality of life.
As we move forward in your treatment, if you’re not improving on the first or second medication or you’re experiencing intolerable adverse effects, we can order genetic testing to narrow down to the medicines that you are most likely to tolerate, so you can take them as prescribed. These tests may give us insights about how you metabolize (i.e., break down) the medication so we can consider whether to reduce or increase the dosage or to try a different medication altogether. These tests might also identify potential drug interactions that are affecting your progress. Many insurance plans now cover this testing for patients diagnosed with major depressive disorder (after trial requirements are satisfied). The companies that provide these tests may offer discounts to reduce out-of-pocket costs.
You have religious or other restrictions
People don’t always realize that there are a variety of interventions available, so if you have a preference, let your provider know. Your provider won’t respect your preferences unless they know what your preferences are, and they’re not going to know unless you tell them. I’ve had patients who had religious restrictions and we worked together to find a treatment plan that would be effective. I’ve had patients who have trouble sticking to a schedule, so we worked together to find the right treatment approach for them. But I couldn’t do those things – and help position them for success – if they hadn’t shared those issues with me.
You are of child-bearing age
I could spend hours talking about women and depression, particularly issues involved in pregnancy and after childbirth. A recent focus has been on the “fourth trimester,” the year after birth during which women are at higher risk for depression. There is a movement to help identify women who may be experiencing depression after giving birth and into the child’s first year, and the goal is to have obstetricians, gynecologists, pediatricians, and primary care providers ready, willing, and able to recognize when a woman meets the criteria for depression and needs treatment. We especially have to make diagnosis and treatment readily available to low-income women, who suffer a disproportionate impact relative to other women due to less screening after birth, economic instability, limited supports and disparities in seeking help based on income and race.
Editor’s Note: Watch for upcoming posts on shared decision making and how tailored treatments improve treatment process and results.
What do you think?
How do you think clinicians can work with people living with depression and their families to address areas of special concern? What has been your experience with being creative or flexible with a depression treatment plan?
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Read the other posts in the series to date
- Depression Treatment: It’s About You
- What You Know Affects Treatment
- Response, Remission, Recovery: What Are Your Depression Treatment Goals?
- How to Get the Best, Most Appropriate, Tailored-for-You Depression Treatment
Tips for working with primary care providers when a loved one has depression
Maternal Mental Health: A National Health Care Crisis and Why Psychiatric Care for Pregnant Women Often Falls Short by Nancy Byatt, D.O., M.S., M.B.A., F.A.P.M.
Why Doctors Can’t Treat Their Patients: Barriers to Mental Health Care for Obstetricians, Pediatricians, and Psychiatrists by Tiffany A. Moore Simas, MD, MPH, MEd, FACOG, John Straus, MD, FAAP
More posts on Maternal Mental Health on Care for Your Mind
Understanding the Impact of Trauma, Chapter 3 in TIP 57: Trauma-Informed Care in Behavioral Health Services, SAMHSA
Partnership for Prescription Access (if you cannot afford medications, check this site)
Anita H. Clayton, M.D., is the David C. Wilson Professor of Psychiatry, Chair of Psychiatry & Neurobehavioral Sciences, and Professor of Clinical Obstetrics & Gynecology at the University of Virginia, Charlottesville, VA. Dr. Clayton has focused her research on major depressive disorder, mood disorders associated with reproductive-life events in women, sexual dysfunction related to illness and medications, and treatment of primary sexual disorders. She has published over 175 peer-reviewed papers, and developed and validated several measurement tools including the Changes in Sexual Functioning Questionnaire (CSFQ), the Sexual Interest and Desire Inventory (SIDI), and the Decreased Sexual Desire Screener (DSDS). She co-edited Women’s Mental Health: A Comprehensive Textbook, and is the author of Satisfaction: Women, Sex, and the Quest for Intimacy for the general public. She has served as President of the International Society for the Study of Women’s Sexual Health (ISSWSH), as Vice-Chair for Women’s Sexual Health for the 3rd and 4th International Consultation on Sexual Medicine in 2009 and 2015, and on the Board of Directors and Scientific Program Committee of the American Society of Clinical Psychopharmacology and ISSWSH.
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