Depression

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. However, when the down times last for weeks or months at a time or keep you from living "normal," you may be suffering from depression.

What it is

Depression is a medical illness that involves the body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things.

Causes

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior appear to function abnormally. In addition, important neurotransmitters–chemicals that brain cells use to communicate–appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Depression is more common among women than among men. Biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women's higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the "baby blues," but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression often have had prior depressive episodes.

Some women may also be susceptible to a severe form of premenstrual syndrome (PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.

Finally, many women face the additional stresses of work and home responsibilities, caring for children and aging parents. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

Symptoms

Not all people with depression experience the same symptoms. Some might only have a few; others a lot. If you have one or more of these symptoms for more than 2 weeks or months at a time, see your doctor:

• Persistent sad, anxious or "empty" feelings
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early–morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

Co-occuring illnesses

Depression often co–exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it. Regardless, these other co–occurring illnesses need to be diagnosed and treated.

• Anxiety disorders, such as post–traumatic stress disorder (PTSD), obsessive–compulsive disorder, panic disorder, social phobia and generalized anxiety disorder, often accompany depression. People experiencing PTSD are especially prone to having co-occurring depression. PTSD is a debilitating condition that can result after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat.

People with PTSD often re-live the traumatic event in flashbacks, memories or nightmares. Other symptoms include irritability, anger outbursts, intense guilt, and avoidance of thinking or talking about the traumatic ordeal. In a National Institute of Mental Health (NIMH)-funded study, researchers found that more than 40 percent of people with PTSD also had depression at one-month and four-month intervals after the traumatic event.

• Alcohol and other substance abuse or dependence may also co–occur with depression. In fact, research has indicated that the co–existence of mood disorders and substance abuse is pervasive among the U.S. population.
• Depression also often co–exists with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson's disease. Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co–existing depression. Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co–occurring illness.

Types of depression

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once–pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic disorder, also called dysthymia, is characterized by long–term (two years or longer) but less severe symptoms that may not disable a person but can prevent sufferers from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Some forms of depressive disorder exhibit slightly different characteristics, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Hormones appear to be a key precipitator since pregnancy is characterized by huge hormonal shifts as estrogen and progesterone levels rise dramatically, along with the stress hormone cortisol. These surges, which are necessary to support the developing fetus, may overwhelm a woman's brain chemistry, potentially triggering swift, varying and irrational moods.

After giving birth, when hormone levels suddenly plummet, up to 80 percent of women might experience several days of feeling down (the typical "baby blues"), characterized by crying, anxiety, irritability and difficulty sleeping. These symptoms usually begin three to four days after delivery and continue for about 12 days. In most cases, they resolve on their own.

But some new mothers who have never suffered from depression before will have major or minor depressive symptoms-such as despondency, guilt, worry, bizarre or suicidal thoughts and an inability to cope-after giving birth. This type of mood disorder typically strikes immediately after the birth and may last for several months or even years if it remains undiagnosed or is left untreated. Women who have had severe PMS, postpartum depression and major depression before are at particularly high risk.

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (mania) to extreme lows (depression).

Treatment

Once identified, depression almost always can be treated either by therapy, medication (antidepressants), or both. Some people with milder forms of depression do well with therapy alone.

As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented. The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer you to a mental health professional.

The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she will discuss any family history of depression, and get a complete history of symptoms. For example, when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if about alcohol or drug usage and thoughts about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.

Medication

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

• SSRIs The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics-named for their chemical structure and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects.
  
• MAOIs People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke.

Regardless of the class of antidepressants, regular doses of the medication must be taken for at least three to four weeks before you are likely to experience a full therapeutic effect. You should continue taking the medication for the time specified by your doctor, even if you are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit–forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

Finding the right drug regimen for you may take time. If one medication does not work, be open to trying another. NIMH–funded research has shown that patients who did not get well after taking a first medication increased their chances of becoming symptom-free after they switched to a different medication or added another medication to their existing one.

Sometimes stimulants, anti-anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co-existing mental or physical disorder. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.

Possible side effects

Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long-term. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache-usually temporary and will subside.
• Nausea-temporary and usually short-lived.
• Insomnia and nervousness (trouble falling asleep or waking often during the night)-may occur during the first few weeks but often subside over time or if the dose is reduced.
• Agitation (feeling jittery).
• Sexual problems-both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

Tricyclic antidepressants also can cause side effects including:

• Dry mouth-it is helpful to drink plenty of water, chew gum, and clean teeth daily.
• Constipation-it is helpful to eat more bran cereals, prunes, fruits, and vegetables.
• Bladder problems-emptying the bladder may be difficult, and the urine stream may not be as strong as usual.
• Sexual problems-sexual functioning may change, and side effects are similar to those from SSRIs.
• Blurred vision-often passes soon and usually will not require a new corrective lenses prescription.
• Drowsiness during the day-usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

FDA warning

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The latest information from the FDA can be found on their Web site at www.fda.gov.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006, funded in part by the National Institute of Mental Health, suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications. So always tell your doctor or pharmacist about all medications you are taking. Pregnancy and antidepressants

If you have been diagnosed with depression, the decision whether to stay on medications during your pregnancy is a complicated one that should be discussed with your doctor. Medication taken during pregnancy does reach the fetus. In rare cases, some antidepressants have been associated with breathing and heart problems in newborns, as well as jitteriness after delivery. However, women who stop medications can be at increased risk for a relapse of their depression. Talk to your doctor about the risks and benefits to decide what is best for you and your baby.

If you stopped taking your medication during pregnancy, after delivery you may need to begin taking it again. Be aware that because your medication can be passed into your breast milk, breastfeeding may pose some risk for a nursing infant.

However, a number of research studies indicate that certain antidepressants, such as some of the SSRIs (a class of antidepressants for treating depression and anxiety disorders that includes medications like Zoloft), have been used relatively safely during breastfeeding. You should discuss with your doctor whether breastfeeding is an option. Most importantly, as a mother, you need to stay healthy so you can take care of your baby. What about St. John's wort?

The extract from St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top-selling botanical products.

To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression. Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapy

Several types of psychotherapy–or "talk therapy"–can help people with depression.

Some regimens are short–term (10 to 20 weeks) and others are longer–term, depending on the needs of the individual. Two main types of psychotherapies–cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT)-have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence. Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.

Electroconvulsive therapy

For cases in which medication and/or psychotherapy does not help alleviate a person's treatment–resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. A patient typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some patients will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.

ECT may cause some short-term side effects, including confusion, disorientation and memory loss. But these side effects typically clear soon after treatment. Research has indicated that after one year of ECT treatments, patients showed no adverse cognitive effects.

What you can do

If you have depression, you may feel exhausted, helpless and hopeless. It may be extremely difficult to take any action to help yourself. But it is important to realize that these feelings are part of the depression and do not accurately reflect actual circumstances. As you begin to recognize your depression and begin treatment, negative thinking will fade.

To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Sources: National Institute of Mental Health (www.nimh.nih.gov); National Women's Health Information Center (www.womenshealth.gov)