Depression

What is Depression?

Depression is a disorder that affects your thoughts, moods, feelings, behavior and physical health. People used to think it was “all in your head” and that if you really tried, you could “pull yourself out of it.” Doctors now know that depression is not a weakness, and you can’t treat it on your own. It’s a medical disorder with a biological or chemical basis.

Sometimes, a stressful life event triggers depression. Other times depression seems to occur spontaneously with no identifiable specific cause. Whatever the cause, depression is much more than grieving or a bout of the blues.

Depression may occur only once in a person’s life. Often, however, it occurs as repeated episodes over a lifetime, with periods free of depression in between. Or it may be a chronic condition, requiring ongoing treatment over a lifetime. The disorder affects more than 18 million Americans of all ages and races.

Medications are available that are generally safe and effective, even for the most severe depression. With proper treatment, most people with serious depression improve, often within weeks, and can return to normal daily activities.

Depression signs and symptoms

Two hallmarks of depression symptoms key to establishing a diagnosis are:

• Loss of interest in normal daily activities.You lose interest in or pleasure from activities that you used to enjoy. This is called anhedonia.
• Depressed mood. You feel sad, helpless or hopeless, and may have crying spells.

In addition, for a doctor or other health professional to diagnose depression, most of the following signs and symptoms also must be present most of the day, nearly every day for at least two weeks:

• Sleep disturbances. Sleeping too much or having problems sleeping can be a sign you’re depressed. Waking in the middle of the night or early in the morning and not being able to get back to sleep are typical.
• Impaired thinking or concentration. You may have trouble concentrating or making decisions and have problems with memory.
• Significant weight loss or gain. An increased or reduced appetite and unexplained weight gain or loss may indicate depression.
• Agitation or slowing of body movements. You may seem restless, agitated, irritable and easily annoyed. Or you may seem to do everything in slow motion and answer questions slowly in a monotonous tone of voice.
• Fatigue. You feel weariness and lack of energy nearly every day. You may feel as tired in the morning as you did when you went to bed the night before.
• Low self-esteem. You feel worthless and have excessive guilt.
• Less interest in sex. If you were sexually active before developing depression, you may notice a dramatic decrease in your level of interest in having sexual relations.
• Thoughts of death. You have a persistent negative view of yourself, your situation and the future. You may have thoughts of death, dying or suicide.

Depression can also cause a wide variety of physical complaints, such as generalized itching, blurred vision, excessive sweating, dry mouth, gastrointestinal problems (indigestion, constipation and diarrhea), headache and backache.

Children, teens and older adults may react differently to depression. In these groups, symptoms may take different forms or may be masked by other conditions.

What causes Depression?

There’s no single cause for depression. The illness often runs in families. Experts believe a genetic vulnerability combined with environmental factors, such as stress or physical illness, may trigger an imbalance in brain chemicals called neurotransmitters, resulting in depression. Imbalances in three neurotransmitters serotonin, norepinephrine and dopamine seem to be linked to depression.

Scientists don’t fully understand how imbalances in neurotransmitters cause signs and symptoms of depression. It’s not certain whether changes in neurotransmitters are a cause or a result of depression.

Factors that contribute to depression include:

• Heredity. Researchers have identified several genes that may be involved in bipolar disorder, and they’re looking for genes linked to other types of depression. But not everyone with a family history of depression develops the disorder.
• Stress. Stressful life events, particularly a loss or threatened loss of a loved one or a job, can trigger depression.
• Medications. Long-term use of certain medications, such as some drugs used to control high blood pressure, sleeping pills or, occasionally, birth control pills, may cause symptoms of depression in some people.
• Illnesses. Having a chronic illness, such as heart disease, stroke, diabetes, cancer or Alzheimer’s disease, puts you at higher risk of developing depression. Studies reveal an as-yet-unexplained link between depression and heart disease. Depression occurs in many people who’ve had heart attacks. Left untreated, depression may put you at a higher risk of death in the early years after a heart attack. Having an underactive thyroid (hypothyroidism), even mildly, also can cause depression.
• Personality. Certain personality traits, such as having low self-esteem and being overly dependent, self-critical, pessimistic and easily overwhelmed by stress, can make you more vulnerable to depression.
• Postpartum depression. It’s common for mothers to feel a mild form of distress that usually occurs a few days to weeks after giving birth. During this time you may have feelings of sadness, anger, anxiety, irritability and incompetence. A more severe form of the baby blues, called postpartum depression, also can affect new mothers.
• Alcohol, nicotine and drug abuse. Experts once thought that people with depression used alcohol, nicotine and mood-altering drugs as a way to ease depression. But using these substances may actually contribute to depression and anxiety disorders.
• Diet. Deficiencies in folate and vitamin B-12 may cause symptoms of depression. Low levels of both nutrients are linked to a poorer response to antidepressant medications.

Diagnosing Depression

To diagnose depression, your doctor may perform a physical examination, including tests to rule out conditions that can cause symptoms that mimic depression.

If your doctor sees signs of severe depression or suspects the possibility of suicide, he or she may refer you to a medical doctor who specializes in mental illness (psychiatrist) or even recommend immediate hospitalization.

Your doctor or psychiatrist diagnoses depression based on the hallmark signs and symptoms of the disease, plus the presence of other signs and symptoms that typically accompany depression.

How is Depression treated?

The development of newer antidepressant medications and mood-stabilizing drugs has improved the treatment of depression. Medications can relieve symptoms of depression and have become the first line of treatment for most types of the disorder.

Treatment may also include psychotherapy, which may help you cope with ongoing problems that may trigger or contribute to depression. A combination of medications and a brief course of psychotherapy usually is effective if you have mild to moderate depression. If you’re severely depressed, initial treatment usually is with medications or electroconvulsive therapy. Once you improve, psychotherapy can be more effective.

Doctors usually treat depression in two stages. Acute treatment with medications helps relieve symptoms until you feel well. Once your symptoms ease, maintenance treatment typically continues for six to 12 months to prevent a relapse. It’s important to keep taking your medication even though you feel fine and are back to your usual activities. Episodes of depression recur in the majority of people who have one episode, but continuing treatment for at least six months greatly reduces your risk of a rapid relapse. If you’ve had two or more previous episodes of depression, your doctor may suggest long-term treatment with antidepressants.

What medications are used to treat Depression?

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often consider selective serotonin reuptake inhibitors, such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro), as the first-line treatment for depression because they have fewer serious side effects. They seem to work by increasing the availability of the neurotransmitter serotonin in your brain. Drugs similar to SSRIs include serotonin and norepinephrine reuptake inhibitors (SNRIs), such as nefazodone (Serzone), trazodone (Desyrel) and venlafaxine (Effexor), and dopamine reuptake inhibitors, such as bupropion (Wellbutrin, Zyban).
• Tricyclic and tetracyclic antidepressants. These medications also affect neurotransmitters, but by a different mechanism than SSRIs. They may be used for any type of depression, be it mild or severe. Among tricyclic antidepressants are amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), trimipramine (Surmontil) and a combination of perphenazine and amitriptyline (Triavil, Etrafon). Tetracyclics include maprotiline and mirtazapine (Remeron).
• Monoamine oxidase inhibitors (MAOIs). These drugs, which include phenelzine (Nardil) and tranylcypromine (Parnate), prevent the breakdown of neurotransmitters. The drugs have potentially serious side effects if combined with certain other medications or food products. Doctors rarely use them unless other options have failed. Your doctor may prescribe them if you have chronic depression and eat or sleep excessively.
• Stimulants. If you’re severely depressed, your doctor may initially prescribe a stimulant such as methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine, Dextrostat) or modafinil (Provigil) in addition to an antidepressant because most antidepressants are slow to work. After one to four weeks, your doctor may then switch you to just an antidepressant.
• Lithium and mood-stabilizing medications. Doctors prescribe lithium (Eskalith, Lithobid), valproic acid (Depakene), divalproex (Depakote) and carbamazepine (Epitol, Tegretol, Carbatrol) to treat bipolar depression. Medications called atypical antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) were initially developed for treatment of psychotic disorders. Doctors sometimes also use them to treat bipolar disorder.

According to the American Diabetes Association, certain antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure. A study published in the February 2004 issue of Diabetes Care recommends that doctors screen and monitor people who take Risperdal, Seroquel and Zyprexa.

Most antidepressants have a similar level of effectiveness. However, a medication that works for someone else might not work for you. Doctors choose antidepressants based on your family history and the match between your symptoms and the medication’s side effects. For example, if you have insomnia, a sedating antidepressant may help you. But if you’re lethargic, then a more energizing antidepressant may be more helpful.

Most antidepressants are slow to work. You may see a response in two weeks, but many people don’t see a full benefit for six to eight weeks. If your response to medication hasn’t resulted in satisfactory progress after six to eight weeks, your doctor may suggest either adding another antidepressant or replacing the first medication with another drug from a different chemical family.

One person’s body may break down drugs faster or slower than another person’s body. Scientists are developing techniques to measure this. If you’ve taken several medications and your condition hasn’t improved or you’ve experienced side effects, tell your doctor. He or she may order blood tests for you to determine how rapidly your body breaks down your current medications.

In addition to medications, depression treatment may include:

Psychotherapy
There are several types of psychotherapy. Each type involves a short-term, goal-oriented approach aimed at helping you deal with a specific issue. Prolonged psychotherapy is seldom necessary to treat depression. If an underlying factor contributing to your depression is an inability to get along with others or difficulty finding your place in life, then prolonged psychotherapy could help you.

The success of therapy depends on finding a doctor, psychiatrist or psychologist you’re comfortable with. Both medications and psychotherapy can take four to eight weeks to have an effect. Specialized and supervised group therapy, such as bereavement groups, stress management classes, marital counseling and family therapy, also may help.

Electroconvulsive therapy
Despite the images that many people conjure up, electroconvulsive therapy is generally safe and effective. In fact, it’s the gold standard for treatment of severe depression.

In this therapy, you receive a light general anesthesia and a muscle relaxant. An electrical current is passed through your brain for one to three seconds. The stimulus causes a controlled seizure, which typically lasts for 20 to 90 seconds. You wake up in five to 10 minutes and should rest for about half an hour. Most people require six to 10 treatments.

Experts aren’t sure how this therapy relieves symptoms of depression. The seizure may affect levels of neurotransmitters in your brain. The most common side effect is confusion that lasts a few minutes to several hours. A few people have some memory loss for several weeks. This therapy is usually used for people who don’t respond to medications and for those at high risk of suicide. It may be the only treatment available for severely depressed older adults who can’t take medications because of heart disease.

Light therapy
This therapy may help if you have seasonal affective disorder. This disorder involves periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Scientists believe fewer hours of sunlight may increase levels of melatonin, a brain hormone thought to induce sleep and depress mood. Treatment in the morning with a specialized type of bright light, which suppresses production of melatonin, may help if you have this disorder.

Alternative Medicine
Herbal and dietary supplements sold in stores have become increasingly popular. People take them to help prevent or treat a number of health conditions. Some of these alternative therapies are being studied to determine their effectiveness in helping depression. Within the next few years, researchers may know more about these products, how effective they are and if they can cause other health problems or interfere with medications.

In the meantime, talk with your doctor before taking any herbal or dietary supplement. The downfall of herbal and dietary products is that they aren’t regulated. The Food and Drug Administration doesn’t test them for safety, purity or effectiveness. You can’t always be sure of what you’re getting and if it’s safe.

Some popular supplements marketed or taken for treatment of depression include:

• St. John’s wort. St. John’s wort is an herbal preparation from the Hypericum perforatum plant. It has long been used in folk medicine, and today it’s widely prescribed in Europe to treat anxiety, depression and sleep disorders. In the United States, it’s sold in health food stores and pharmacies in the form of tablets or tea.European studies suggest that St. John’s wort may work as well as antidepressants in mild depression and with fewer side effects. Adverse reactions include dry mouth, dizziness, digestive problems, fatigue, confusion and sensitivity to sunlight. In most cases, signs and symptoms are mild. Of concern is that St. John’s wort can interfere with the effectiveness of prescription medications, including antidepressants, drugs to treat human immunodeficiency virus (HIV) infections and AIDS, and drugs to prevent organ rejection in people who’ve had transplants. There’s also a risk of serotonin syndrome if St. John’s wort is used with an SSRI or another serotonin-active antidepressant.
• SAM-e. Pronounced “sammy,” short for S-adenosyl-methionine, this chemical substance is available in Europe as a prescription drug to treat depression. In the United States it’s sold as an over-the-counter dietary supplement.SAM-e is a chemical substance found in all human cells and plays a role in many body functions. It’s thought to increase levels of serotonin and dopamine, but this is unproved. The pills are expensive, especially considering their effectiveness is unproved. Too much of this product could be harmful, boosting serotonin to dangerously high levels.
• 5-HTP. One of the raw materials that your body needs to make serotonin is a chemical called 5-HTP, which is short for 5-hydroxytryptophan. 5-HTP is prescribed in Europe to treat depression and other conditions, including obesity and insomnia. In the United States it’s available as an over-the-counter supplement.In theory, if you boost your body’s level of 5-HTP, you should also elevate your levels of serotonin. But there’s not enough evidence to determine if 5-HTP is effective and safe. Larger studies than have been conducted to date are needed.
• Omega-3 fatty acid. Omega-3 fatty acids are found in fish oil and certain plants. They’re being studied as a possible mood stabilizer for people with bipolar depression and other psychiatric disorders. Some studies have suggested that people with depression have decreased amounts of an active ingredient found in omega-3 fatty acids.Fish oil capsules containing omega-3 fatty acids are sold in stores. The capsules are high in fat and calories and may produce gastrointestinal problems. Another way to get more omega-3 fatty acids is simply to eat more fish.