Understanding Depression
(This article is adapted from the National Institute
of Mental Health – NIMH.)
Topics:
- What Is Depression?
- What are the different forms of depression?
- What are the signs and symptoms of depression?
- What illnesses often co-exist with depression?
- What causes depression?
- How do women experience depression?
- How do men experience depression?
- How do older adults experience depression?
- How do children and adolescents experience depression?
- How is depression detected and treated?
- How can I help a friend or relative who is depressed?
- How can I help myself if I am depressed?
- Where can I go for help?
- What if I -- or someone -- I know is in crisis?
Everyone occasionally feels blue or sad, but these
feelings are usually fleeting and pass within a couple of days. When a person
has a depressive disorder, 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. Depression is a common but serious illness, and many who experience
it need treatment to get better.
Many people with a depressive illness never seek
treatment. But the vast majority, even those with the most severe depression,
can get better with treatment. Intensive research into the illness has resulted
in the development of medications, psychotherapies, and other methods to treat
people with this disabling disorder.
What are the different forms 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 one 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 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.
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 (e.g., mania) to extreme lows (e.g.,
depression).
What are the signs and symptoms of depression?
People with depressive illnesses do not all
experience the same symptoms. The severity, frequency and duration of symptoms
will vary depending on the individual and his or her particular illness.
Symptoms include:
·
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
What illnesses often co-exist with depression?
Depression often co–exists with other psychological
issues. These psychological issues may precede the depression, cause it, and/or
be a consequence of it. It is likely that the mechanics behind the intersection
of depression and other illnesses differ for every person and situation.
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.
There is no single known cause of depression. Rather,
it likely results from a combination of psychological, environmental and
biochemical factors.
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.
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.
How do women experience depression?
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.
Finally, many women face the additional stresses of
work and home responsibilities, 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.
How do men experience depression?
Men often experience depression differently than
women and may have different ways of coping with the symptoms. Men are more
likely to acknowledge having fatigue, irritability, loss of interest in
once–pleasurable activities, and sleep disturbances, whereas women are more
likely to admit to feelings of sadness, worthlessness and/or excessive guilt.
Men are more likely than women to turn to alcohol or
drugs when they are depressed, or become frustrated, discouraged, irritable,
angry and sometimes abusive. Some men throw themselves into their work to avoid
talking about their depression with family or friends, or engage in reckless,
risky behavior. And even though more women attempt suicide, many more men die
by suicide in the United States.
How do older adults experience depression?
Depression is not a normal part of aging, and studies
show that most seniors feel satisfied with their lives, despite increased
physical ailments. 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 some 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.
Although many people assume that the highest rates of
suicide are among the young, older white males age 85 and older actually have
the highest suicide rate. Many have a depressive illness that their doctors may
not detect, despite the fact that these suicide victims often visit their
doctors within one month of their deaths.
The majority of older adults with depression improve
when they receive treatment. Psychotherapy can be very effective, especially
for older adults with minor depression, and it is particularly useful for those
who are unable or unwilling to take antidepressant medication.
How do children and adolescents experience
depression?
Scientists and doctors have begun to take seriously
the risk of depression in children. Research has shown that childhood
depression often persists, recurs and continues into adulthood, especially if
it goes untreated. The presence of childhood depression also tends to be a
predictor of more severe illnesses in adulthood.
A child with depression may pretend to be sick,
refuse to go to school, cling to a parent, or worry that a parent may die.
Older children may sulk, get into trouble at school, be negative and irritable,
and feel misunderstood. Because these signs may be viewed as normal mood swings
typical of children as they move through developmental stages, it may be
difficult to accurately diagnose a young person with depression.
Before puberty, boys and girls are equally likely to
develop depressive disorders. By age 15, however, girls are twice as likely as
boys to have experienced a major depressive episode.
Depression in adolescence comes at a time of great
personal change–when boys and girls are forming an identity distinct from their
parents, grappling with gender issues and emerging sexuality, and making
decisions for the first time in their lives. Depression in adolescence
frequently co–occurs with other disorders such as anxiety, disruptive behavior,
eating disorders or substance abuse. It can also lead to increased risk for
suicide.
How is depression detected and treated?
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.
Certain medications, and some medical conditions such
as viruses or a thyroid disorder, can cause the same symptoms as depression. If
you believe that this may be the case for you, then it is important for you to
visit a doctor who will attempt to rule out these possibilities by conducting a
physical examination, interview and lab tests.
If the doctor can eliminate a medical condition as a
cause, the next step would be to visit a mental health professional to conduct
a psychological evaluation.
The mental health professional will conduct a
complete diagnostic evaluation. He or she should discuss any family history of
depression, and get a complete history of symptoms, e.g., 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 the
patient is using alcohol or drugs, and whether the patient is thinking about
death or suicide.
Once diagnosed, a person with depression can be
treated with a number of methods. The most common treatments are psychotherapy
and medication.
Psychotherapy
Several types of psychotherapy–or "talk
therapy"–can help people with depression.
Some regimens are short–term (10 to 20 weeks) 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.
Medication
[NOTE: The author of the website believes that in the
majority of cases psychotherapy is the treatment of choice for depression.]
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.
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. However,
medications affect everyone differently–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,
patients should 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.
What are the side effects of antidepressants?
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. Older men with enlarged prostate conditions may be more
affected. The doctor should be notified if it is painful to urinate.
·
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 on Antidepressants
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. A "black box" warning is the
most serious type of warning on prescription drug labeling.
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 from normal social situations.
The warning adds that families and caregivers should also be told of the need
for close monitoring and report any changes to the physician. The latest
information from the FDA can be found on their Web site at www.fda.gov.
How can I help a friend or relative who is
depressed?
If you know someone who is depressed, it affects you
too. The first and most important thing you can do to help a friend or relative
who has depression 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 him or her to see the doctor. Encourage him or her to stay
in treatment, or to seek different treatment if no improvement occurs after six
to eight weeks.
To
help a friend or relative:
·
Offer
emotional support, understanding, patience and encouragement.
·
Engage
your friend or relative in conversation, and listen carefully
·
Never
disparage feelings your friend or relative expresses, but point out realities
and offer hope.
·
Never
ignore comments about suicide, and report them to your friend's or relative's
therapist or doctor.
·
Invite
your friend or relative out for walks, outings and other activities. Keep
trying if he or she declines, but don't push him or 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.
How can I help myself if I am depressed?
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. Participate in religious, social or other
activities.
§
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.
If you are unsure where to go for help, consider some
of the following Mental Health Resources:
·
Mental
health specialists, such as psychiatrists, psychologists, marriage and family
therapists, social workers, or mental health counselors
·
Health
maintenance organizations
·
Community
mental health centers
·
Hospital
psychiatry departments and outpatient clinics
·
Mental
health programs at universities or medical schools
·
State
hospital outpatient clinics
·
Family
services, social agencies or clergy
·
Peer
support groups
·
Private
clinics and facilities
·
Employee
assistance programs
·
Local
medical and/or psychiatric societies
·
You
can also check the phone book under "mental health,"
"health," "social services," "hotlines," or
"physicians" for phone numbers and addresses. An emergency room
doctor also can provide temporary help and can tell you where and how to get
further help.
What if I -- or someone I know -- is in crisis?
If you are thinking about harming yourself, or know
someone who is, tell someone who can help immediately.
·
Call
your psychotherapist.
·
Call
your doctor.
·
Call
911 or go to a hospital emergency room to get immediate help or ask a friend or
family member to help you do these things.
·
Call the
toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at
1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a
trained counselor.
·
Make
sure you or the suicidal person is not left alone.
If
you live in Santa Cruz and vicinity, you are welcome to call:
·
Alan
Strachan, Ph.D. at (831) 685-3100.