What Should I Look for in Outpatient Treatment Programs for Severe Depression?

Summary: The things to look for in outpatient treatment programs for severe depression include clinicians with experience treating people with severe depression and extensive knowledge of the differences between treating mild-to-moderate depression and severe depression.

Key Points:

• Evidence-based treatment for severe depression can help you manage symptoms, reduce the impact of depression on daily activity, and improve your overall health and wellbeing.
• If you have severe depression, your symptoms may completely prevent you from fully engaging in the basic activities of daily life.
• Symptoms may cause you to self-isolate, which can exacerbate depression and increase risk of serious negative consequences, including suicidality.
• To get the best support possible, you should find a treatment center that specializes in severe, treatment resistant mental health disorders, including treatment-resistant depression.

Depression: Definition and Symptoms

The difference is in the frequency, duration, and intensity of your symptoms, combined with the level of disruption they cause in your daily life.

To clarify, we’ll start with a basic definition of depression – officially called major depressive disorder (MDD) – and the primary symptoms associated with MDD. When you understand more about the disorder, you can develop a better idea of what to look for in outpatient treatment programs for severe depression.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) – the go-to reference for mental health professionals – offers this definition of major depressive disorder:

“…an overwhelming feeling of sadness, isolation, and despair that last two weeks or longer at a time.”

Now let’s take a look at the symptoms of depression.

The Primary Signs and Symptoms of Depression

• Daily feelings of sadness
• Declining interest and participation in favorite activities and hobbies
• Daily/persistent crying
• Recurring sense of hopelessness
• Chronic irritability/anger
• Chronic sense of guilt/worthlessness
• Fatigue
• Withdrawal from family, friends, and social activities
• Extreme restlessness and boredom
• Problems with memory, concentration, learning, and decision-making
• Changes in sleep: too much or too little
• Rapid loss of gain of weight
• Declining personal hygiene
• Headaches, stomachaches, minor physical maladies that don’t respond to typical over-the-counter treatment
• Suicidality: thinking about, talking about, planning, and/or attempting suicide

First, if you engage in suicidal ideation, please take it seriously. If you’re at risk of harm, call the 988 National Crisis Line immediately: do not wait. A trained counselor will help you with whatever is happening right now, and connect you with resources close to you for additional support.

Next, please understand that to meet the criteria for major depressive disorder (MDD), you must experience at least five of the symptoms above nearly every day for at least two consecutive weeks, and include the presence of both depressed mood/sadness and loss of interest in favorite activities.

Depression: What’s the Difference Between Mild, Moderate, and Severe?

To be clear, these aren’t three different diagnoses, but rather three categories of the same disorder placed on a continuum from least to most frequent, intense, and disruptive. Here’s how to think about the differences:

Mild Depression:

People with mild depression experience persistent emotional distress that interferes with daily life but doesn’t completely prevent participation in most activities. If you have mild depression, basic things can feel difficult, and you may begin to withdraw from friends and family and decline invitation for social activities or other voluntary events.

Moderate Depression:

People with moderate depression experience emotional distress that’s more frequent and more intense and may interfere more significantly with daily activities without making them feel impossible. However, if you have moderate depression, meeting daily responsibilities may feel exhausting, interest in favorite/social activities decreases further, and you may begin to neglect daily essentials like eating and attending to personal hygiene.

Severe Depression:

People with severe depression experience intense, frequent, and persistent emotional distress that cam completely prevent participation in most essential daily activities. If you have severe depression, you may be unable to meet your own basic needs, such as eating and personal hygiene, and unable to attend school or show up to/perform at work. Sadness and hopelessness may be profound, and emotions like anger may appear more frequently. If you have severe depression, the likelihood that you’ll think about, talk about, or attempt suicide increases significantly, and you may begin to experience depression-related psychosis.

These distinctions reveal the need for different approaches to treatment, and sometimes completely different treatment modalities, particularly when severe depression does not respond to treatment, which is known as treatment-resistant depression.

With this information in mind, we’ll spend the rest of this article discussing what you should look for in outpatient treatment programs for severe depression.

Outpatient Treatment Programs for Severe Depression: Based on Your Symptoms and Needs

The first thing to look for in outpatient treatment programs for severe depression is whether the treatment center offers a full psychiatric evaluation to confirm the accuracy of your depression diagnosis and confirm the accuracy/appropriateness of the severe specifier.

An accurate diagnosis based on a full in-person assessment is essential because inappropriate treatment based on an inaccurate diagnosis can delay treatment progress, and in some cases, exacerbate your depressive symptoms.

To understand what we mean by that, let’s look at the standard treatment for depression, whether mild, moderate, or severe.

Standard First Line Treatments: Mild, Moderate, Or Severe Depression

• Psychotherapy and counseling:
  • Cognitive behavioral therapy(CBT)
  • Dialectical behavior therapy(DBT)
  • Mindfulness-based cognitive behavioral therapy(MBCBT)
  • Acceptance & commitment therapy (ACT)
  • Solution-focused brief therapy (SFBT)
  • Strengths-based therapy
• Medication:
  • Antidepressants
  • Mood stabilizers

If you have severe depression and have tried treatment before without success, the outpatient treatment program for severe depression you choose should identify that during your intake assessment, and tailor your treatment accordingly. In practice, this means:

1. If you’ve tried a full course of antidepressant medication + psychotherapy without satisfactory progress, then an experienced clinician will likely consider – and recommend – different options.
2. For instance, they may change your medication and/or change your mode of therapy.
3. If an antidepressant + CBT didn’t yield results, they may suggest DBT + a different antidepressant.
4. When a second attempt at psychotherapy does not yield satisfactory progress, you may have treatment-resistant depression, which means you’re eligible for several new/emerging treatments.

We’ll discuss those new and emerging treatments for severe/treatment-resistant depression in a moment.

First, we’ll finish the basic list of things to look fr in outpatient treatment programs for severe depression.

In addition to the components we list above, a high-quality treatment program for severe depression should include a variety of supportive, adjunct, and alternative modalities in order to offer you a complete, holistic, and integrated approach to treatment, which can improve outcomes.

Complementary and Supportive Treatments for Depression

• Education:
  • Life skills
  • Work skills
  • Science of depression and treatment
  • Nutrition for health and mood
  • Relationships dynamics/family dynamics
  • Communication skills workshops
• Lifestyle changes:
  • Healthy eating
  • Sleep hygiene
  • Exercise and activity
  • Stress management
• Complementary/expressive Therapies:
• Music, writing, visual arts
• Meditation, breathwork, yoga
• Mindfulness

When you look for outpatient treatment programs for severe depression, they should include all the standard first-line treatments in the first bullet list above, and some variation of most, if not all, or the treatments in the second bullet list.

Now we’ll discuss those new and emerging treatments for severe/treatment-resistant depression we mention briefly above.

New, Innovative, Emerging Treatments for Severe Depression

To recap, the first thing to look for, which we mentioned in the introductory summary, is a treatment center with clinical staff experienced in supporting patients with severe, chronic, or treatment-resistant depression. If a center has the ability to support patients with severe depression or serious mental illness, they’ll likely make that a prominent feature of their website and marketing materials.

The second thing to look for is whether they offer a full psychiatric evaluation as part of their intake process. You can check on this by getting on the phone and/or emailing the center itself: admissions phone staff at a high-quality treatment center should be able to answer that question in the affirmative, right away.

The third thing we encourage you to look for is a full complement of standard, first-line evidence-based treatments for depression. A treatment center for severe depression should have all the available treatment means at its disposal, and understand how to manage and support you at any level of need or symptom severity.

 

Fourth, we encourage you to find a treatment center that offers a range of complementary and supportive treatment modalities in addition to – not in place of – standard, evidence-based treatment for depression.

Finally, we encourage you to look for outpatient programs for severe depression that can offer new, innovative, and emerging treatments for severe, treatment-resistant depression. Those modalities – some FDA-approved, some used off-label – include, but aren’t limited to, treatments such as:

IV Ketamine/ketamine:

Peer-reviewed research shows ketamine can relieve symptoms of severe, treatment-resistant depression quickly, with treatment benefit lasting a month or longer.

Spravato®:

Studies that led to FDA approval for this medication showed that, in combination with standard medication, outcomes improve, with symptom reduction appearing within an hour (minimum) and about 48 hours (common) and lasting for over three weeks.

Transcranial magnetic stimulation (TMS):

TMS is non-invasive brain stimulation technique approved by the FDA for treatment-resistant depression and other severe, treatment-resistant mental health disorders. TMS is attractive to patients because (a) its effective when other treatments aren’t, (b) it’s non-invasive, and (c) there are almost no side effects, including an absence of sexual side effects.

Those new treatment approaches show effective symptom reduction for patients with severe depression who don’t – or haven’t yet – made satisfactory treatment progress. If you have severe depression, we encourage you to look for outpatient treatment programs that include the core modalities associated with effective treatment – i.e. antidepressant medication, CBT, DBT – and also offer a wide range of complementary and/or new and innovative treatments for depression.

Summing It Up: Finding Your Outpatient Program for Severe Depression

We’ve mentioned all the things we think you should look for in outpatient programs for severe depression: experienced clinicians, thorough diagnostic systems, evidence-based modalities, complementary modalities, and new and emerging treatments.

We’ll close by listing several benefits of outpatient treatment for severe depression:

• Choose your schedule: once a week, twice a week, or more, depending on your needs and other practical considerations.
• Live at home: you get to apply what you learn every day, in your real life.
• Learn to manage your symptoms and live a full, productive life
• If typical outpatient treatment doesn’t yield satisfactory results, you can try an intensive outpatient program (IOP), which involves 2-3 hours of treatment, five days a week, while still living at home.

If you have severe depression, we encourage you to seek high-quality, evidence based treatment as soon as possible: the sooner you get the treatment you need, the better the outcome.