This newsletter is for your information only and is not a substitute for talking with your psychiatrist, medical doctor, and/or therapist.
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What Is
Depression?
Depression
is
probably best understood as a persistent mood of pronounced sadness which
is present at least most of the day on most days for at least 2 weeks and
typically interferes with normal function. Sleep, energy, motivation,
pleasure, hope, concentration, temper, self esteem, physical health,
libido (sex drive), interest in or ability to communicate, the ability to
think rationally, and the desire to live may all, or some, be affected to
some degree. Depression may be so severe (called Major Depression) it is
disabling and life threatening, or moderate but lasting years (Dysthymic
Disorder), or present in varying ways (agitation, with anxiety, after
giving birth, seasonal, premenstrual, after psychosis, with melancholia,
etc.) with varying effects for shorter or longer periods. Manic-Depression
is now called Bipolar Disorder and is an alternation or mixture of
depression and certain other elevated mood symptoms known as mania or
hypomania. Depression may be caused by genes (inherited), directly or
indirectly by a medical problem, by stress, trauma, loss, or grief, by
substance abuse, by a medication, by life events, occur for no clear
reason, or most often be due to some combination of factors. Depression
may show itself somewhat differently in children, the developmentally
delayed, young adults, older adults, the elderly, in men vs. women, and in
different cultural or ethnic and racial groups.
Depression is the second most
common psychiatric disorder, behind only anxiety. Depression often occurs
along with or may be confused with other disorders such as anxiety,
substance abuse, or along with or due to other mental and general health
problems. At least 10-20% of all people will have an episode of Major
Depression sometime in their lives. About
1.6% of all persons have a Major Depression currently. About 3% have
Dysthymic Disorder (chronic minor to moderate depression) currently while
another 4-8% have a current minor to moderate depression lasting weeks to
months.
Up
to 15% of people with Major Depression, especially when recurrent and on
top of dysthymic disorder (known as “double depression”),
may eventually kill themselves. Suicide risks are higher for depressed
persons who also have severe anxiety such as panic attacks, abuse
substances, feel chronically very hopeless, have severe depression marked
by severe loss of interests and pleasure, marked insomnia, and delusional
thinking, or hallucinations. Of course, other factors like increasing age,
access to lethal means (especially guns), and a personal and family
history of suicide, suicide attempts, and suicidal ideas, plans, and
intent are also important risk factors.
75%
of all depressed people never see a mental health professional.
Many go to their primary care doctor where their symptoms may or may not
be recognized as depression. Even so, primary care doctors treat more
people for depression than psychiatrists do. This occurs because stigma
keeps some from accepting or being referred to mental health caregivers,
some have no or poor mental health insurance coverage, some just feel too
depressed and hopeless to seek help, recognize their need, or suffer from
outdated negative stereotypes or misinformation about the treatment
itself. Unfortunately, half of all
people with depression are never diagnosed or treated. Too many who
are treated are treated only partly and most are never referred to or
never seek out a mental health professional. This is especially sad when
you realize the success rate for
treating Major Depression is 70%; higher than or close to similarly
dangerous or disabling illnesses like heart disease, cancer, diabetes,
arthritis, lung disease, and hypertension. There is also strong evidence
that co-existing depression increases the impairment and chances of dying
from other medical illnesses such as heart disease and cancer.
When depression is being
considered as a possible cause of health, emotional, or behavioral
problems a visit to the primary care doctor is often a good idea before,
along with, or after seeing a mental health professional. An updated
medical history and physical exam, perhaps even a few tests, may help
ensure not missing another health problem which may cause or complicate
depression. This is especially worth considering if the therapist is not a
psychiatrist since only psychiatrists are also physicians. Sometimes, in
complicated or confusing situations, in depth psychological tests done by
a Psychologist are very helpful in clarifying the diagnosis.
Left untreated, half of all
persons with Major Depressions will recover completely in under a year.
Even so, treatment often saves enormous pain, agony, societal, work,
relationship, and other costs. Of course, the other 50% either recover
more slowly, have higher rates of chronic or relapsing patterns, have
other complications, or may die. Persons who have 2, or certainly 3,
episodes of depression in any 5 year period are very likely to have more
episodes in the future. Medication helps prevent recurrence as well as
treat the current episode. Some research indicates a first episode of
Major Depression in one’s youth, especially when severe, indicates a
higher likelihood of future recurrences and a higher chance of Bipolar
Disorder. Treatment for
depression, like all illnesses, is aided by improving basic health habits,
eating nutritiously, getting rest and exercise, and keeping connected with
both activities and other people. Spiritual and creative pursuits help
many. The core treatments for
Depression are psychotherapy and medication. 25% respond well to
psychotherapy alone, 25% to medication alone, and 50% to a combination of
both. Cognitive Therapy and Interpersonal Therapy are two forms of
psychotherapy which have repeatedly been shown to be very powerful in
treating depression. Cognitive Therapy focuses on correcting and changing the negative
and distorted thoughts that are a core finding in depression. Interpersonal
Therapy focuses on addressing dysfunctional and problematic
relationships and interactional styles that are also noted in many
depressions. There is a substantial and growing number of medication
options for depression and related or co-occuring conditions. Medicines
are becoming more and more focused in their effects and show less and less
side effects. In fact, most of the modern antidepressant side effect
possibilities are in the range of nuisance and are not dangerous; some
side effects can even be used to be helpful in some situations.
Medications are especially important ,if not essential, for Major
Depression and Bipolar Disorder. Stopping alcohol or drug use, especially
abuse, is also strongly advised. Electro-convulsive therapy, known as ECT,
is another option which is remarkably effective for severe depression.
Despite the media’s distortions, ECT is a very safe and rapidly
effective option appropriate when other options have failed or are too
slow. Hospitalization continues to have a role, especially when danger to
self or others is severe, and when other efforts fail or are unavailable.
No “alternative” herbs,
supplements, vitamins, homeopathic remedies, etc. have been shown to be
effective in Major Depression or Bipolar Disorder. Many
“complementary” treatments such as biofeedback, hypnosis, special
breathing techniques, massage, etc. have nonspecific but possibly helpful
effects on depression. Adequate sleep, a healthy diet, and regular
exercise are also helpful but also not enough alone, especially for Major
Depression or Bipolar Disorder. Research into a special type of magnetic
therapy called rTMS and Vagal Nerve Stimulators (VNS) show some promise in
some cases.
Treatment options have both
expanded greatly and become much more effective with much lower side
effect risks in the last 10 years. This improvement in the number,
quality, and convenience of treatment options gives hope.
It is a rewarding time to be doing this work.
What Is Major Depression?
Major
Depression is the most severe form of depression. Major Depression is
almost always a biologically based disorder of the brain just as asthma is
based in the lungs and diabetes is based in the pancreas. The more
"biological" signs of depression that are present the more
likely medication treatment will be advisable and helpful. These
biological signs are the criteria listed below. Other health problems may
worsen or cause depression. In
order to give the diagnosis of Major Depression at least 5 of the
following criteria (signs and symptoms) must be present for at least 2
weeks and cause substantial impairment in functioning:
a) Depressed mood most of the day, almost every day
b) Marked loss of interest or pleasure in usual
activities (anhedonia) often including libido
c) Fatigue or loss of energy nearly every day
d) Feelings of worthlessness, hopelessness, and
unreasonable feelings of guilt
e) Significant weight loss when not dieting or
weight gain (appetite changes)
f) Insomnia or excessive sleep nearly every day
g) Agitation or pronounced slowing of body
movements
h) Significant decreased ability to think,
concentrate, or make decisions
i) Recurrent thoughts of death or suicide
What
Is Dysthymic Disorder? Dysthymia
is a more moderate to mild but persistent form of depression in which less
than 5, but at least 2, of the above criteria of Major Depression are
present for at least 2 years in adults and at least 1 year in youth under
18 years old. In the past this condition was often called Depressive
Personality or Depressive Neurosis. Until the last decade psychotherapy
was thought to be the only treatment for the condition. Now we know people
with Dysthymia also often respond to antidepressants, especially the newer
ones.
What
is Depression NOS?
The NOS stands for Not Otherwise
Specified and includes all the varying kinds of depression that are not
severe enough to fit Major and not long lasting enough to fit Dysthymic
Disorder. Treatment advice and need for treatment depends on the unique
situation.
Can
Health Problems Cause Depression?
Yes! Certain medications,
infections, hormone imbalances, immune system disorders, neurologic
conditions, a couple of vitamin deficiencies, and some cancers can cause
either depression or something that looks a lot like depression. Although
these are uncommon causes of depression, this a good reason to see your
family physician, internist, or pediatrician as part of seeking help when
depression is suspected.
What
is Unipolar Depression? Unipolar
depression means the person only experiences depression and not the mania
or hypomania that automatically changes the diagnosis to Bipolar Disorder
(formerly called Manic Depression).
What
Causes Depression? Typically,
there is an inherited tendency toward depression, which is brought on by
stressful life events, losses, or may occur for no clear reason.
What
Is Melancholic Depression?
Melancholia is an older term,
which refers to most people’s notion of severe depression. This type of
major depression is marked by weight loss, extremely low energy or
agitation, marked feelings of worthlessness, extreme even irrational
guilt, severe loss of pleasure in virtually all areas of life, very early
morning awakening, consistent severely depressed mood, and increased risk
for suicide. Medication treatment is thought to be particularly important
for this condition.
What
Is Atypical Depression? Generally,
this refers to the non-melancholic depression patterns such as increased
eating, increased sleeping, and personality problems such as
"rejection sensitivity". In the past, MAOI’S (Monoamine
Oxidase Inhibitor medications) were found to be more helpful than the
Tricyclic antidepressants for this subtype of depression. Now, we usually
use the SRI’s (Prozac, Paxil, Zoloft, etc.) first.
What
Is Psychotic Depression?
This is another very severe form
of Major Depression identified by the additional presence of
hallucinations and delusions. Sometimes the depression (or mania) may
co-exist with signs of schizophrenia and is then referred to as
Schizoaffective Disorder. This condition often requires both
antidepressant and antipsychotic medications.
What
Is Post Partum Depression? Post
Partum means after delivery. The dramatic drops and rebalancing of
hormones that comes with childbirth can throw some women into a
potentially severe depression. Time and treatment help. Treatment is
especially key when the depression is severe as there can be risk to the
baby as well as to the mother. Repeat episodes of depression with or
without future pregnancies are not uncommon. Women with a personal history
or family history of depression are at higher risk. A milder form, known
as post partum "blues" is less dangerous but can be a warning
sign and can also impact the early parenting relationship.
What
Is Co-morbidity?
Co-morbid means than one or more
other conditions occur at the same time. The conditions may be related or
not. For example, anxiety often occurs along with (is co-morbid with)
depression. This is also common for substance abuse, ADHD, personality
disorders, eating disorders, Alzheimer’s, heart disease, etc. When other
disorders occur along with depression this often makes the depression (or
both) more difficult to treat or chronic. Both or all conditions often
benefit from simultaneous or sequential (one after the other, addressing
the underlying condition first) treatment.
If
I had a Major Depression, will my child have it someday?
Probably
not, but the chances are somewhere between 15% and 25% your child will
someday have an episode of Major or other depression. This compares to the
risk for the general population, which is about 2%.
If
I had a Major Depression, will I have another one?
Probably
not but your risk is higher, too. If you have had 3, and maybe 2, episodes
of major depression in 5 years your risk of recurrence is so high we often
advise staying on a maintenance dose of antidepressant to lessen the
chance of more episodes and lessen their severity.
If you know you have a tendency to depression it is helpful to make
lifestyle adjustments just like you should if you had a tendency to
diabetes, seizures, high blood pressure, heart disease, or asthma, etc.
Learn to recognize warning signs, risk factors for you, and especially at
difficult times lessen your stress with rest, exercise, good nutrition,
supportive people and activities, spirituality, and treatment services
when appropriate.