Matt Ruble, M.D., Diagnosis and Treatment

Dr. Matt Ruble on Diagnosis and TreatmentMatt Ruble, M.D., is Associate Training Director of Psychiatry at Cambridge Health Alliance, Harvard Medical School.

How long does it typically take for someone with depression to get diagnosed?

The length of time—from onset of symptoms until diagnosis and treatment—varies greatly, from six months to ten years. Many factors affect the timing of the initial diagnosis.

For example, denial, self-blame, and/or shame often delay initiation of treatment. Many sufferers feel that depression is a character trait rather than a serious but treatable disease much like diabetes and cardiovascular disease. Men have their own issues. Some refuse to admit they have depression and thus postpone treatment. Living in an underserved area for mental health services can also interfere with treatment.

Another factor is the type of depression from which the individual suffers. Several studies have suggested that people afflicted with “atypical” depression might have the ability to “grin and bear it” and thus delay diagnosis as compared with those who suffer from more debilitating types of depression.

And, if a major depression actually turns out to be bipolar disorder, diagnosis may take as long as ten years.

How do you diagnose or evaluate someone with a depressive disorder?

  • Physical Exam Everyone who suffers from depression should first have a physical exam and laboratory tests. It is important that the physical exam rule out some common illnesses and conditions that may contribute to depressed mood, such as thyroid disorder, anemia, vitamin deficiencies, and diabetes.
  • Depressive Symptoms What symptoms is the individual experiencing? For example, does he or she have feelings of guilt, low self-esteem, and/or hopelessness, changes in appetite or sleep patterns, thoughts of suicide? What about past mental health issues and co-occurring mental health disorders, such as substance abuse, anxiety, mania? The clinician will need a complete record—past and present—in order to make a comprehensive treatment plan.
  • Life Situation Next, the clinician will want to review the individual’s current life situation—including stressors, such as losses, incidents of violence, neglect, and abuse, as well as major supports and sources of strength in the individual’s life.
  • Family History It is essential to take a family history of mental illness and suicide, since depressive disorders are often hereditary. For example, more than two-thirds of people with bipolar disorder have at least one close relative either with bipolar depression or major depression.

What is the most effective treatment for depression and how effective is it?

Experts today consider the combination of talk therapy and medication to be the gold standard of treatment.

There are several types of talk therapy, including Cognitive Behavioral Therapy or CBT (focuses on thoughts, beliefs, and assumptions), Psychotherapy (interpersonal therapy), Psychodynamic Therapy (modified form of Psychoanalysis), Group Therapy, and Family Therapy.

Many medication options exist. Nearly one-third of individuals with major depression will achieve remission after trying antidepressant medication. For others, multiple trials of medications may be necessary before the correct medication is found. After trying multiple medications, two-thirds of patients improve.

Exercise, a balanced diet, meditation, support groups, and other options prove beneficial for depression.

What do families need to know about medications?

Some antidepressants have rare but serious side effects. Other side effects are just annoying. As a result, family members need to monitor the impact of medications.

Contact the clinician who prescribed the medication before stopping medication. Only the clinician can tell the difference between a potentially dangerous side effect and a nuisance side effect that will pass the longer the person takes the medicine.

Family members can also help make sure that the depressed person is taking his or her medication every day. On average, an antidepressant may not start to work until four to six weeks has elapsed. Even when the depression has begun to lessen, the individual needs to continue until the clinician says to stop the medication.

Sometimes an antidepressant triggers bouts of mania in people who have been diagnosed with depression but who actually have a bipolar disorder that has, until now, escaped detection.

How do families initiate diagnosis and treatment?

If you suspect someone in your family is depressed, work with that person to fill out the Depression Test and the Mental Health Family Tree.

Seek professional help. If the depressed person has a doctor or mental health clinician, get his or her permission to call for an appointment. Try to attend the appointment or call the doctor ahead of time to report the symptoms.

Always ask if the depressed family member is hopeless or suicidal. If so, get help immediately.

Sometimes a clinician will only prescribe an antidepressant medication. However, the best outcome is usually medication in combination with talk therapy. So ask the clinician for a referral to a talk therapist.

Often the clinician will perform the medical part of the evaluation only. He or she may then provide a referral to a psychopharmacologist, a psychiatrist who specializes in antidepressant medication. The psychopharmacologist may then continue the evaluation by filling in the mental health pieces, prescribing the appropriate medication, and making recommendations for a talk therapist.

What are the guidelines in helping someone seek treatment?

Depression is a treatable illness, but it can be challenging to diagnose and treat. Be aware of its signs and symptoms. Always err on being intrusive. Help the depressed family member fill out an evaluation form. Attend his or her first diagnostic appointment.

If someone in your family does not get better after several months, you may want to get a second opinion. It may also be helpful to research your geographic area to see what other treatment options are available. Are you located near a large city? Is there a clinic, hospital, medical school, or university nearby? If so, what is its expertise in the area of mental health?

See the Adult Depression Wellness Guide for more information on all these questions.