Depressive Disorders

A depressive disorder is not a passing blue mood but rather persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities. A complex mind/body illness, depression can be treated with drugs and/or therapy.

Definition

A depressive disorder is an illness that involves the body, mood, and thoughts. It interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her.

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. Depression is a common but serious illness, and most people who experience it need treatment to get better. 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. Three of the most common types of depressive disorders are described here. However, within these types there are variations in the number of symptoms as well as 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.

Dysthymic disorder, also called dysthymia, involves long-term (two years or longer) less severe symptoms that do not disable, but keep one from functioning normally or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Some forms of depressive disorder exhibit slightly different characteristics than those described above, 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.

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 prevalent as major depression or dysthymia, and characterized by cycling mood changes: severe highs (mania) and lows (depression).

Symptoms

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.

• Persistent sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or 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, or 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

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 it 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 in Women

Women experience depression about twice as often as men. Biological, life cycle, hormonal, and other factors unique to women may be linked to their higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. Some women may be susceptible to a severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women affected by PMDD typically experience depression, anxiety, irritability, and mood swings the week before menstruation, in such a way that interferes with their normal functioning. Women with debilitating PMDD do not necessarily have unusual hormone changes, but they do have different responses to these changes. They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more sensitive to menstruation-related hormone changes. 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.

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 have had prior depressive episodes. 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 as well as her ability to care for and enjoy the infant.

Many women also face additional stresses of work and home responsibilities, single parenthood and caring for children and aging parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

Depression in Men

Researchers estimate that at least 6 million men in the United States suffer from a depressive disorder every year. Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.

Depression can also affect the physical health in men differently from women. One 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.

Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm's way.

More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. In light of the research indicating that suicide is often associated with depression, the alarming suicide rate among men may reflect the fact that many men with depression do not obtain adequate diagnosis and treatment that may be life saving.

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 work-site 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, older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, a co-existing cardiovascular illness or stroke.

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both. Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults. Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.

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.

Treatments

Depression, even the most severe cases, is a highly treatable disorder. 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.

Appropriate treatment for depression starts with a physical examination by a physician. Certain medications, as well as some medical conditions such as viral infections or a thyroid disorder, 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 that includes a mental status exam should be done either by the physician or by referral to a mental health professional.

He or she should discuss any family history of depression including their treatment, and get a complete history of symptoms, such as 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.

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

Medications

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine.

The newest and most popular 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. However, medications affect everyone differently so "no one-size-fits-all" approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice.

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. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances.

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they 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.

In addition, if one medication does not work, the doctor may switch to another medication and patients should be open to trying another. NIMH-funded research has shown that patients who did not improve 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.

Medications of any kind—prescribed, over-the-counter or borrowed—should never be mixed without consulting the doctor. All health professionals who are working with the patient should be told of all the medications that are being taken. Some drugs, though safe when taken alone, can cause severe and dangerous side effects if taken with others. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided.

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. Based on the FDA's thorough review of published and unpublished controlled clinical trials of antidepressants of nearly 4,400 children and adolescents, the FDA was prompted, 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. A "black box" warning is the most serious type of warning on prescription drug labeling.

Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

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 and clean teeth daily.
• Constipation—eat bran cereals, prunes, fruit and vegetables.
• Bladder problems—emptying the bladder may be troublesome, 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, discuss 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 most common side effects associated with SSRIs and SNRIs include:

• Headache—this usually goes 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, there has been much interest 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 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.

Because of the widespread interest in St. John's Wort, the National Institutes of Health (NIH) conducted a three-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 eight-week trial. One third of patients received 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 St. John's Wort, but has no active ingredients). The trial found that St. John's wort was no more effective than the placebo in treating major depression.

A late 2008 German study reviewed and analyzed previous studies on St. John's Wort in the treatment of mild or minor depression. Their results indicated that the herbal remedy was effective and study participants experienced fewer side effects. Yet the researchers issued some caveats regarding their findings. First, the St. John's Wort that is available on the market varies widely so their results are only applicable to the preptions tested. Secondly, they cautioned against using the remedy without medical advice because St. John's Wort can affect the effectiveness of other drugs.

In February 2000, the Food and Drug Administration had issued a Public Health Advisory, stating that St. John's Wort appears to interfere with certain drugs prescribed to treat conditions such as AIDS, 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.

Psychotherapies

Many forms of psychotherapy, including some short-term (10- to 20-week) and other regimens 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 (ECT) is useful, particularly for individuals whose depression is severe or life threatening, or for those who cannot take antidepressant medication. 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.

How to Help Yourself If You Are Depressed

Depressive disorders can make a person 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 reflect 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 or a ball game, or participating in religious, social or other activities may also 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 divorce—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 this negative thinking will disappear as your depression responds to treatment.
• Let your family and friends help you.

How Family and Friends Can Help the Depressed Person

If you know someone who is depressed, it affects you too. The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with her to see the doctor. Encourage him to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

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 dispge 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. Keep trying if he declines, but don't push her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure. Remind your friend or relative that with time and treatment, the depression will lift.

References

• Medscape Women's Health Depression
• National Health and Nutrition Examination Survey
• Archives of Internal Medicine
• Psychopharmacology Bulletin
• Journal of the American Medical Association
• National Institute of Mental Health
• U.S. Department of Health and Human Services
• Biological Psychiatry
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