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About
Depression
A depressive disorder is an illness that
involves the body, mood, and thoughts. It affects
the way a person eats and sleeps, the way one
feels about oneself, and the way one thinks about
things. A depressive disorder is not the same as a
passing blue mood. It is not a sign of personal
weakness or a condition that can be willed or
wished away. People with a depressive illness
cannot merely "pull themselves together"
and get better. Without treatment, symptoms can
last for weeks, months, or years. Appropriate
treatment, however, can help most people who
suffer from depression.
Depressive disorders come in different forms,
just as is the case with other illnesses such as
heart disease. This pamphlet briefly describes
three of the most common types of depressive
disorders. However, within these types there are
variations in the number of symptoms, their
severity, and persistence.
Major depression is manifested by
a combination of symptoms (see symptom list) that
interfere with the ability to work, study, sleep,
eat, and enjoy once pleasurable activities. Such a
disabling episode of depression may occur only
once but more commonly occurs several times in a
lifetime.
A less severe type of depression, dysthymia,
involves long-term, chronic symptoms that do not
disable, but keep one from functioning well or
from feeling good. Many people with dysthymia also
experience major depressive episodes at some time
in their lives.
Another type of depression is bipolar
disorder, also called manic-depressive
illness. Not nearly as prevalent as other forms of
depressive disorders, bipolar disorder is
characterized by cycling mood changes: severe
highs (mania) and lows (depression). Sometimes the
mood switches are dramatic and rapid, but most
often they are gradual. When in the depressed
cycle, an individual can have any or all of the
symptoms of a depressive disorder. When in the
manic cycle, the individual may be overactive,
overtalkative, and have a great deal of energy.
Mania often affects thinking, judgment, and social
behavior in ways that cause serious problems and
embarrassment. For example, the individual in a
manic phase may feel elated, full of grand schemes
that might range from unwise business decisions to
romantic sprees. Mania, left untreated, may worsen
to a psychotic state.
Not everyone who is depressed or manic
experiences every symptom. Some people experience
a few symptoms, some many. Severity of symptoms
varies with individuals and also varies over time.
Depression
- Persistent sad, anxious, or
"empty" mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness,
helplessness
- Loss of interest or pleasure in hobbies and
activities that were once enjoyed, including
sex
- Decreased energy, fatigue, being
"slowed down"
- Difficulty concentrating, remembering,
making decisions
- Insomnia, early-morning awakening, or
oversleeping
- Appetite and/or weight loss or overeating
and weight gain
- Thoughts of death or suicide; suicide
attempts
- Restlessness, irritability
- Persistent physical symptoms that do not
respond to treatment, such as headaches,
digestive disorders, and chronic pain
Mania
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased sexual desire
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
Some types of depression run in families,
suggesting that a biological vulnerability can be
inherited. This seems to be the case with bipolar
disorder. Studies of families in which members of
each generation develop bipolar disorder found
that those with the illness have a somewhat
different genetic makeup than those who do not get
ill. However, the reverse is not true: Not
everybody with the genetic makeup that causes
vulnerability to bipolar disorder will have the
illness. Apparently additional factors, possibly
stresses at home, work, or school, are involved in
its onset.
In some families, major depression also seems
to occur generation after generation. However, it
can also occur in people who have no family
history of depression. Whether inherited or not,
major depressive disorder is often associated with
changes in brain structures or brain function.
People who have low self-esteem, who
consistently view themselves and the world with
pessimism or who are readily overwhelmed by
stress, are prone to depression. Whether this
represents a psychological predisposition or an
early form of the illness is not clear.
In recent years, researchers have shown that
physical changes in the body can be accompanied by
mental changes as well. Medical illnesses such as
stroke, a heart attack, cancer, Parkinson's
disease, and hormonal disorders can cause
depressive illness, making the sick person
apathetic and unwilling to care for his or her
physical needs, thus prolonging the recovery
period. Also, a serious loss, difficult
relationship, financial problem, or any stressful
(unwelcome or even desired) change in life
patterns can trigger a depressive episode. Very
often, a combination of genetic, psychological,
and environmental factors is involved in the onset
of a depressive disorder. Later episodes of
illness typically are precipitated by only mild
stresses, or none at all.
Depression in Women
Women experience depression about twice as
often as men.1
Many hormonal factors may contribute to the
increased rate of depression in women-particularly
such factors as menstrual cycle changes,
pregnancy, miscarriage, postpartum period,
pre-menopause, and menopause. Many women also face
additional stresses such as responsibilities both
at work and home, single parenthood, and caring
for children and for aging parents.
A recent NIMH study showed that in the case of
severe premenstrual syndrome (PMS), women with a
preexisting vulnerability to PMS experienced
relief from mood and physical symptoms when their
sex hormones were suppressed. Shortly after the
hormones were re-introduced, they again developed
symptoms of PMS. Women without a history of PMS
reported no effects of the hormonal manipulation.6,7
Many women are also particularly vulnerable
after the birth of a baby. The hormonal and
physical changes, as well as the added
responsibility of a new life, can be factors that
lead to postpartum depression in some women. While
transient "blues" are common in new
mothers, a full-blown depressive episode is not a
normal occurrence and requires active
intervention. Treatment by a sympathetic physician
and the family's emotional support for the new
mother are prime considerations in aiding her to
recover her physical and mental well-being and her
ability to care for and enjoy the infant.
Depression in Men
Although men are less likely to suffer from
depression than women, three to four million men
in the United States are affected by the illness.
Men are less likely to admit to depression, and
doctors are less likely to suspect it. The rate of
suicide in men is four times that of women, though
more women attempt it. In fact, after age 70, the
rate of men's suicide rises, reaching a peak after
age 85.
Depression can also affect the physical health
in men differently from women. A new study shows
that, although depression is associated with an
increased risk of coronary heart disease in both
men and women, only men suffer a high death rate.2
Men's depression is often masked by alcohol or
drugs, or by the socially acceptable habit of
working excessively long hours. Depression
typically shows up in men not as feeling hopeless
and helpless, but as being irritable, angry, and
discouraged; hence, depression may be difficult to
recognize as such in men. Even if a man realizes
that he is depressed, he may be less willing than
a woman to seek help. Encouragement and support
from concerned family members can make a
difference. In the workplace, employee assistance
professionals or worksite mental health programs
can be of assistance in helping men understand and
accept depression as a real illness that needs
treatment.
Depression in the Elderly
Some people have the mistaken idea that it is
normal for the elderly to feel depressed. On the
contrary, most older people feel satisfied with
their lives. Sometimes, though, when depression
develops, it may be dismissed as a normal part of
aging. Depression in the elderly, undiagnosed and
untreated, causes needless suffering for the
family and for the individual who could otherwise
live a fruitful life. When he or she does go to
the doctor, the symptoms described are usually
physical, for the older person is often reluctant
to discuss feelings of hopelessness, sadness, loss
of interest in normally pleasurable activities, or
extremely prolonged grief after a loss.
Recognizing how depressive symptoms in older
people are often missed, many health care
professionals are learning to identify and treat
the underlying depression. They recognize that
some symptoms may be side effects of medication
the older person is taking for a physical problem,
or they may be caused by a co-occurring illness.
If a diagnosis of depression is made, treatment
with medication and/or psychotherapy will help the
depressed person return to a happier, more
fulfilling life. Recent research suggests that
brief psychotherapy (talk therapies that help a
person in day-to-day relationships or in learning
to counter the distorted negative thinking that
commonly accompanies depression) is effective in
reducing symptoms in short-term depression in
older persons who are medically ill. Psychotherapy
is also useful in older patients who cannot or
will not take medication. Efficacy studies show
that late-life depression can be treated with
psychotherapy.4
Improved recognition and treatment of
depression in late life will make those years more
enjoyable and fulfilling for the depressed elderly
person, the family, and caretakers.
Depression in Children
Only in the past two decades has depression in
children been taken very seriously. The depressed
child may pretend to be sick, refuse to go to
school, cling to a parent, or worry that the
parent may die. Older children may sulk, get into
trouble at school, be negative, grouchy, and feel
misunderstood. Because normal behaviors vary from
one childhood stage to another, it can be
difficult to tell whether a child is just going
through a temporary "phase" or is
suffering from depression. Sometimes the parents
become worried about how the child's behavior has
changed, or a teacher mentions that "your
child doesn't seem to be himself." In such a
case, if a visit to the child's pediatrician rules
out physical symptoms, the doctor will probably
suggest that the child be evaluated, preferably by
a psychiatrist who specializes in the treatment of
children. If treatment is needed, the doctor may
suggest that another therapist, usually a social
worker or a psychologist, provide therapy while
the psychiatrist will oversee medication if it is
needed. Parents should not be afraid to ask
questions: What are the therapist's
qualifications? What kind of therapy will the
child have? Will the family as a whole participate
in therapy? Will my child's therapy include an
antidepressant? If so, what might the side effects
be?
The National Institute of Mental Health (NIMH)
has identified the use of medications for
depression in children as an important area for
research. The NIMH-supported Research Units on
Pediatric Psychopharmacology (RUPPs) form a
network of seven research sites where clinical
studies on the effects of medications for mental
disorders can be conducted in children and
adolescents. Among the medications being studied
are antidepressants, some of which have been found
to be effective in treating children with
depression, if properly monitored by the child's
physician.8
The first step to getting appropriate treatment
for depression is a physical examination by a
physician. Certain medications as well as some
medical conditions such as a viral infection can
cause the same symptoms as depression, and the
physician should rule out these possibilities
through examination, interview, and lab tests. If
a physical cause for the depression is ruled out,
a psychological evaluation should be done, by the
physician or by referral to a psychiatrist or
psychologist.
A good diagnostic evaluation will include a
complete history of symptoms, i.e., when they
started, how long they have lasted, how severe
they are, whether the patient had them before and,
if so, whether the symptoms were treated and what
treatment was given. The doctor should ask about
alcohol and drug use, and if the patient has
thoughts about death or suicide. Further, a
history should include questions about whether
other family members have had a depressive illness
and, if treated, what treatments they may have
received and which were effective.
Last, a diagnostic evaluation should include a
mental status examination to determine if speech
or thought patterns or memory have been affected,
as sometimes happens in the case of a depressive
or manic-depressive illness.
Treatment choice will depend on the outcome of
the evaluation. There are a variety of
antidepressant medications and psychotherapies
that can be used to treat depressive disorders.
Some people with milder forms may do well with
psychotherapy alone. People with moderate to
severe depression most often benefit from
antidepressants. Most do best with combined
treatment: medication to gain relatively quick
symptom relief and psychotherapy to learn more
effective ways to deal with life's problems,
including depression. Depending on the patient's
diagnosis and severity of symptoms, the therapist
may prescribe medication and/or one of the several
forms of psychotherapy that have proven effective
for depression.
Electroconvulsive therapy (ECT) is useful,
particularly for individuals whose depression is
severe or life threatening or who cannot take
antidepressant medication.3
ECT often is effective in cases where
antidepressant medications do not provide
sufficient relief of symptoms. In recent years,
ECT has been much improved. A muscle relaxant is
given before treatment, which is done under brief
anesthesia. Electrodes are placed at precise
locations on the head to deliver electrical
impulses. The stimulation causes a brief (about 30
seconds) seizure within the brain. The person
receiving ECT does not consciously experience the
electrical stimulus. For full therapeutic benefit,
at least several sessions of ECT, typically given
at the rate of three per week, are required.
Medications
There are several types of antidepressant
medications used to treat depressive disorders.
These include newer medications-chiefly the
selective serotonin reuptake inhibitors (SSRIs)-the
tricyclics, and the monoamine oxidase inhibitors (MAOIs).
The SSRIs-and other newer medications that affect
neurotransmitters such as dopamine or
norepinephrine-generally have fewer side effects
than tricyclics. Sometimes the doctor will try a
variety of antidepressants before finding the most
effective medication or combination of
medications. Sometimes the dosage must be
increased to be effective. Although some
improvements may be seen in the first few weeks,
antidepressant medications must be taken regularly
for 3 to 4 weeks (in some cases, as many as 8
weeks) before the full therapeutic effect occurs.
Patients often are tempted to stop medication
too soon. They may feel better and think they no
longer need the medication. Or they may think the
medication isn't helping at all. It is important
to keep taking medication until it has a chance to
work, though side effects (see section on Side
Effects on page 13) may appear before
antidepressant activity does. Once the individual
is feeling better, it is important to continue the
medication for at least 4 to 9 months to prevent a
recurrence of the depression. Some medications
must be stopped gradually to give the body time to
adjust. Never stop taking an
antidepressant without consulting the doctor for
instructions on how to safely discontinue the
medication. For individuals with bipolar
disorder or chronic major depression, medication
may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming.
However, as is the case with any type of
medication prescribed for more than a few days,
antidepressants have to be carefully monitored to
see if the correct dosage is being given. The
doctor will check the dosage and its effectiveness
regularly.
For the small number of people for whom MAO
inhibitors are the best treatment, it is necessary
to avoid certain foods that contain high levels of
tyramine, such as many cheeses, wines, and
pickles, as well as medications such as
decongestants. The interaction of tyramine with
MAOIs can bring on a hypertensive crisis, a sharp
increase in blood pressure that can lead to a
stroke. The doctor should furnish a complete list
of prohibited foods that the patient should carry
at all times. Other forms of antidepressants
require no food restrictions.
Medications of any kind -
prescribed, over-the counter, or borrowed - should
never be mixed without consulting the doctor.
Other health professionals who may prescribe a
drug-such as a dentist or other medical
specialist-should be told of the medications the
patient is taking. Some drugs, although safe when
taken alone can, if taken with others, cause
severe and dangerous side effects. Some drugs,
like alcohol or street drugs, may reduce the
effectiveness of antidepressants and should be
avoided. This includes wine, beer, and hard
liquor. Some people who have not had a problem
with alcohol use may be permitted by their doctor
to use a modest amount of alcohol while taking one
of the newer antidepressants.
Antianxiety drugs or sedatives are not
antidepressants. They are sometimes prescribed
along with antidepressants; however, they are not
effective when taken alone for a depressive
disorder. Stimulants, such as amphetamines, are
not effective antidepressants, but they are used
occasionally under close supervision in medically
ill depressed patients.
Questions about any antidepressant
prescribed, or problems that may be related to the
medication, should be discussed with the doctor.
Lithium has for many years been the treatment
of choice for bipolar disorder, as it can be
effective in smoothing out the mood swings common
to this disorder. Its use must be carefully
monitored, as the range between an effective dose
and a toxic one is small. If a person has
preexisting thyroid, kidney, or heart disorders or
epilepsy, lithium may not be recommended.
Fortunately, other medications have been found to
be of benefit in controlling mood swings. Among
these are two mood-stabilizing anticonvulsants,
carbamazepine (Tegretol®)
and valproate (Depakote®).
Both of these medications have gained wide
acceptance in clinical practice, and valproate has
been approved by the Food and Drug Administration
for first-line treatment of acute mania. Other
anticonvulsants that are being used now include
lamotrigine (Lamictal®)
and gabapentin (Neurontin®):
their role in the treatment hierarchy of bipolar
disorder remains under study.
Most people who have bipolar disorder take more
than one medication including, along with lithium
and/or an anticonvulsant, a medication for
accompanying agitation, anxiety, depression, or
insomnia. Finding the best possible combination of
these medications is of utmost importance to the
patient and requires close monitoring by the
physician.
Side Effects
Antidepressants may cause mild and, usually,
temporary side effects (sometimes referred to as
adverse effects) in some people. Typically these
are annoying, but not serious. However, any
unusual reactions or side effects or those that
interfere with functioning should be reported to
the doctor immediately. The most common side
effects of tricyclic antidepressants, and ways to
deal with them, are:
- Dry mouth it is helpful to drink
sips of water; chew sugarless gum; clean teeth
daily.
- Constipation bran cereals, prunes,
fruit, and vegetables should be in the diet.
- Bladder problems emptying the
bladder may be trouble-some, and the urine
stream may not be as strong as usual; the
doctor should be notified if there is marked
difficulty or pain.
- Sexual problems sexual functioning
may change; if worrisome, it should be
discussed with the doctor.
- Blurred vision this will pass soon
and will not usually necessitate new glasses.
- Dizziness rising from the bed or
chair slowly is helpful.
- Drowsiness as a daytime problem
this usually passes soon. A person feeling
drowsy or sedated should not drive or operate
heavy equipment. The more sedating
antidepressants are generally taken at bedtime
to help sleep and minimize daytime drowsiness.
The newer antidepressants have different types
of side effects:
- Headache this will usually go
away.
- Nausea this is also temporary, but
even when it occurs, it is transient after
each dose.
- Nervousness and insomnia (trouble falling
asleep or waking often during the night)
these may occur during the first few weeks;
dosage reductions or time will usually resolve
them.
- Agitation (feeling jittery) if
this happens for the first time after the drug
is taken and is more than transient, the
doctor should be notified.
- Sexual problems the doctor should
be consulted if the problem is persistent or
worrisome.
Herbal Therapy
In the past few years, much interest has risen
in the use of herbs in the treatment of both
depression and anxiety. St.
John's wort (Hypericum perforatum), an
herb used extensively in the treatment of mild to
moderate depression in Europe, has recently
aroused interest in the United States. St. John's
wort, an attractive bushy, low-growing plant
covered with yellow flowers in summer, has been
used for centuries in many folk and herbal
remedies. Today in Germany, Hypericum is used in
the treatment of depression more than any other
antidepressant. However, the scientific studies
that have been conducted on its use have been
short-term and have used several different doses.
Because of the widespread interest in St.
John's wort, the National Institutes of Health (NIH)
conducted a 3-year study, sponsored by three NIH
components-the National Institute of Mental
Health, the National Center for Complementary and
Alternative Medicine, and the Office of Dietary
Supplements. The study was designed to include 336
patients with major depression of moderate
severity, randomly assigned to an 8-week trial
with one-third of patients receiving a uniform
dose of St. John's wort, another third sertraline,
a selective serotonin reuptake inhibitor (SSRI)
commonly prescribed for depression, and the final
third a placebo (a pill that looks exactly like
the SSRI and the St. John's wort, but has no
active ingredients). The study participants who
responded positively were followed for an
additional 18 weeks. At the end of the first phase
of the study, participants were measured on two
scales, one for depression and one for overall
functioning. There was no significant difference
in rate of response for depression, but the scale
for overall functioning was better for the
antidepressant than for either St. John's wort or
placebo. While this study did not support the use
of St. John's wort in the treatment of major
depression, ongoing NIH-supported research is
examining a possible role for St. John's wort in
the treatment of milder forms of depression.
The Food and Drug Administration issued a Public
Health Advisory on February 10, 2000. It
stated that St. John's wort appears to affect an
important metabolic pathway that is used by many
drugs prescribed to treat conditions such as AIDS,
heart disease, depression, seizures, certain
cancers, and rejection of transplants. Therefore,
health care providers should alert their patients
about these potential drug interactions.
Some other herbal supplements frequently used
that have not been evaluated in large-scale
clinical trials are ephedra, gingko biloba,
echinacea, and ginseng. Any herbal supplement
should be taken only after consultation with the
doctor or other health care provider.
Many forms of psychotherapy, including some
short-term (10-20 week) therapies, can help
depressed individuals. "Talking"
therapies help patients gain insight into and
resolve their problems through verbal exchange
with the therapist, sometimes combined with
"homework" assignments between sessions.
"Behavioral" therapists help patients
learn how to obtain more satisfaction and rewards
through their own actions and how to unlearn the
behavioral patterns that contribute to or result
from their depression.
Two of the short-term psychotherapies that
research has shown helpful for some forms of
depression are interpersonal and
cognitive/behavioral therapies. Interpersonal
therapists focus on the patient's disturbed
personal relationships that both cause and
exacerbate (or increase) the depression.
Cognitive/behavioral therapists help patients
change the negative styles of thinking and
behaving often associated with depression.
Psychodynamic therapies, which are sometimes
used to treat depressed persons, focus on
resolving the patient's conflicted feelings. These
therapies are often reserved until the depressive
symptoms are significantly improved. In general,
severe depressive illnesses, particularly those
that are recurrent, will require medication (or
ECT under special conditions) along with, or
preceding, psychotherapy for the best outcome.
Depressive disorders make one feel exhausted,
worthless, helpless, and hopeless. Such negative
thoughts and feelings make some people feel like
giving up. It is important to realize that these
negative views are part of the depression and
typically do not accurately reflect the actual
circumstances. Negative thinking fades as
treatment begins to take effect. In the meantime:
- Set realistic goals in light of the
depression and assume a reasonable amount of
responsibility.
- Break large tasks into small ones, set some
priorities, and do what you can as you can.
- Try to be with other people and to confide
in someone; it is usually better than being
alone and secretive.
- Participate in activities that may make you
feel better.
- Mild exercise, going to a movie, a ballgame,
or participating in religious, social, or
other activities may help.
- Expect your mood to improve gradually, not
immediately. Feeling better takes time.
- It is advisable to postpone important
decisions until the depression has lifted.
Before deciding to make a significant
transition-change jobs, get married or
divorced-discuss it with others who know you
well and have a more objective view of your
situation.
- People rarely "snap out of" a
depression. But they can feel a little better
day-by-day.
- Remember, positive thinking will
replace the negative thinking that is part of
the depression and will disappear as your
depression responds to treatment.
- Let your family and friends help you.
How Family and Friends Can Help the
Depressed Person
The most important thing anyone can do for the
depressed person is to help him or her get an
appropriate diagnosis and treatment. This may
involve encouraging the individual to stay with
treatment until symptoms begin to abate (several
weeks), or to seek different treatment if no
improvement occurs. On occasion, it may require
making an appointment and accompanying the
depressed person to the doctor. It may also mean
monitoring whether the depressed person is taking
medication. The depressed person should be
encouraged to obey the doctor's orders about the
use of alcoholic products while on medication. The
second most important thing is to offer emotional
support. This involves understanding, patience,
affection, and encouragement. Engage the depressed
person in conversation and listen carefully. Do
not disparage feelings expressed, but point out
realities and offer hope. Do not ignore remarks
about suicide. Report them to the depressed
person's therapist. Invite the depressed person
for walks, outings, to the movies, and other
activities. Be gently insistent if your invitation
is refused. Encourage participation in some
activities that once gave pleasure, such as
hobbies, sports, religious or cultural activities,
but do not push the depressed person to undertake
too much too soon. The depressed person needs
diversion and company, but too many demands can
increase feelings of failure.
Do not accuse the depressed person of faking
illness or of laziness, or expect him or her
"to snap out of it." Eventually, with
treatment, most people do get better. Keep that in
mind, and keep reassuring the depressed person
that, with time and help, he or she will feel
better.
If unsure where to go for help, check the
Yellow Pages under "mental health,"
"health," "social services,"
"suicide prevention," "crisis
intervention services," "hotlines,"
"hospitals," or "physicians"
for phone numbers and addresses. In times of
crisis, the emergency room doctor at a hospital
may be able to provide temporary help for an
emotional problem, and will be able to tell you
where and how to get further help.
Listed below are the types of people and places
that will make a referral to, or provide,
diagnostic and treatment services.
- Family doctors
- Mental health specialists, such as
psychiatrists, psychologists, social workers,
or mental health counselors
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and
outpatient clinics
- University- or medical school-affiliated
programs
- State hospital outpatient clinics
- Family service, social agencies, or clergy
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
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