Depression

Introduction

Sadness is a natural reaction to a disappointing event. Usually after something happens that makes us sad, we rebound. But sometimes, we don't. When sadness exists over a steady period of time and seems to occur for no apparent reason, it may be called "clinical depression." It's important to realize that this type of depression is a medical illness - not a sign of weakness. It cannot be "willed away" nor is it "all in your head." The good news is that in most cases, it can be successfully treated.

What is it?

Depression is an illness that can cause noticeable changes in your moods, your perceptions of yourself and your environment. There are several types of depression, each varying in the number, severity and length of symptoms.

In real life, depression does not always fall into neat categories. It is sometimes hard to know when depression crosses the line from being a normal reaction to a difficult life situation to being a depressive illness. Friends, relatives, and busy family doctors often miss the symptoms of a major depression, particularly in the case of an elderly person who may have other medical concerns. Depression in an adolescent or teenager may be mistaken for the normal mood swings that seem to happen at this age. This is one of the reasons why clinical depression if often not diagnosed and treated.

Normal Depressed Mood and Grief

Normal Depressed Mood and Grief is the term for conditions that are natural reactions to losses in life. This condition covers a range of depressive reactions from sadness and lethargy to the intense emotions of deep grief following the death of a loved one. These reactions are normal if the person eventually recovers. In some cases, it may take a day or two, in others, like after the death of a loved one, it may take a year. If an individual displays these symptoms without a loss, or if the depression seems to be excessive considering the nature of the loss, then the individual could be suffering from a major depression, and should seek medical help.

Adjustment Disorder with Depressed Mood

People who have this disorder find it difficult to cope with the inevitable changes of life, like moving to a new city, or changing a job. Rather than adjusting to the change, the individual becomes persistently gloomy, angry, and unable to cope.

Mild Depression, also called Dysthymia

Mild Depression, also called Dysthymia, is a condition characterized by a chronic depressed mood, poor self-esteem, and low-level symptoms of major depression. People can often have a mild depression for years. In most cases, they can function, but seem to have a bleak outlook on life that keeps them from realizing their full potential. This disorder was once called neurotic depression. It often begins in childhood or adolescence. Although mild in intensity, the chronic nature of Dysthymia can be very disabling.

Some people with Dysthymia also have episodes of major depression, with their symptoms becoming dramatically more severe for periods of time. These people are said to have double depression; that is, Dysthymia plus major depression. Individuals with double depression are at much higher risk for recurring episodes of major depression, so careful treatment and follow up are very important.

Major Depression

Major Depression is marked by episodes of deep depression that last at least two weeks and can completely disrupt normal functioning. The person can lose interest in life, be incapable of feeling pleasure, and may be unable to perform life's daily functions. However, a major depression can also manifest itself in symptoms that are not usually recognized as depression. These symptoms can include weight loss or gain; anxiety, irritability, or agitation; chronic indecisiveness; or sleep disturbances. This kind of depression can strike without any triggering loss. The feelings of hopelessness, despair and guilt can be so profound that the sufferer may contemplate or even attempt suicide. This is a very serious risk in major depression, and family members and caregivers should take any talk of suicide very seriously.

Bipolar disorders

Bipolar disorders, formerly referred to as manic depressive disorders, involve cycles of depression and elation. Usually, bipolar disorder develops without any clear cause. The elation (or manic) phase is often marked by inappropriate social behavior, racing thoughts, and poor judgment. The depressive phase can have the same features as those of a major depression. Bipolar disorders require treatments different from those used for other mood disorders.

Atypical Depression

An Atypical Depression does not follow the usual patterns of the disorder. A person with an Atypical Depression may fluctuate between deep depression and normality, and then have an episode of anxiety or irritability.

Seasonal Affective Disorder (SAD)

A person suffering from Seasonal Affective Disorder (SAD) becomes depressed in reaction to a lack of sunlight in winter. A person who suffers from SAD may start feeling blue in the late fall, and find their mood lifting with the arrival of spring. The incidence of SAD increases with distance from the equator. In the Northern Hemisphere, December, January, and February are the worst months.

Post-Partum Depression

It is estimated that one in ten women have a major depressive episode within four to sixteen weeks after childbirth. Some mothers experience Post-Partum Depression in reaction to the hormonal changes of giving birth, and the challenges of taking care of an infant. In most cases, this depression passes as hormone levels settle down and the new mother adjusts to her new baby. However, about 10 to 15 percent become clinically depressed. In rare cases, the depression becomes so severe that the mother must be hospitalized for her own safety and the safety of her child. Symptoms include appetite changes, sleep disturbances, heightened anxiety and feelings of helplessness and hopelessness.

What causes it?

Depression is thought to be due to a combination of mental and physical factors; although it may also occur (or reoccur) at any time for no obvious reason. Some individuals appear to be genetically predisposed to depression and may, therefore, have a family history of it. Other factors involved in the development of clinical depression can be related to:

• extreme stress
• trauma
• physical illness
• environmental conditions

Clinical depression also can occur if some of the chemicals in your brain are not functioning effectively. A decrease in the amount of the following chemicals in your brain can affect your mood:

• dopamine
• norepinephrine
• serotonin

Who has it?

The true prevalence of depression in the United States is unknown. According to the National Institute of Mental Health, in 2003, 35 million Americans (more than 16% of the population) suffer from depression severe enough to warrant treatment at some time in their lives. In addition, one out of every four adults experiences depression at some point in life with about 7% of Americans living with depression in a given year. Depression is two to three times as frequent in women as in men; although anyone, including children, can develop depression. According to the World Health Organization in their 2002 report, depression (including complications of depression) was the fourth leading cause of premature death and disability worldwide in 2000 and will be the second greatest cause of this by the year 2020.

While there is help for depression, nearly two-thirds of depressed people do not seek or receive appropriate treatment.

Authorities estimate that depression costs the nation $43 billion a year for medications, professional care, and time lost from school and work. Of that figure, the direct cost of medication and treatment is estimated at $12 billion. However, these figures do not reflect the toll that depressive illness takes on the lives of family members and loved ones. There is also an economic cost for the premature deaths of individuals whose depression impacts on their health, as well as for deaths by suicide. Each year, tens of thousands of depressed people attempt suicide and, sadly, about 16,000 succeed.

What are the risk factors?

Risk factors for depression include the following:

• Family history of depression (3 times greater risk)
• Age (highest incidence between 20-40 years old)
• Postpartum (greater risk 6 months following delivery for women)
• Marital status (associated more with married and divorced individuals. Single individuals that have never been married have the least risk).
• Major stresses at home or work
• Medications such as some drugs used for high blood pressure, sleeping pills, heartburn, or birth control pills
• The loss of a loved one
• Reaching your senior years
• Having an overall negative attitude
• An inability to handle stress
• Medical conditions such as heart disease, stroke, diabetes, cancer or Alzheimer's disease, Parkinsons disease, Multiple sclerosis, certain infections, and thyroid disorders.
• Eating disorders
• Abuse of drugs or alcohol

What are the symptoms?

Depression is frequently overlooked, because it can present itself in a range of signs and symptoms that are not necessarily obvious, particularly because there may be no clear cause, or triggering event. The condition often manifests itself in physical symptoms like headaches, back pain, and chronic fatigue. There are also non-physical symptoms of depression that are sometimes harder to identify or separate from everyday behavior and can last weeks, months or even years if not treated, these symptoms include:

• A persistent feeling of worthlessness or sadness
• A numb or empty feeling or the absence of any feelings at all
• An inability to experience pleasure in hobbies and activities that were once enjoyed
• Irritability
• Restlessness
• Insomnia, early-morning awakening, or oversleeping
• Abrupt changes in eating habits; decreased appetite and/or weight loss or overeating and weight gain
• Difficulty concentrating
• Decreased ability to perform normal daily tasks
• Recurrent thoughts of death or suicide

Depression can also be associated with other disorders, such as alcoholism, anorexia, anxiety, and obsessive-compulsive disorders. This can make it hard to correctly diagnose a patient with depression.

Symptoms of Bipolar Disorder

In bipolar depression, also called manic-depressive disorder, sufferers experience alternating bouts of depression and mania. When depressed, individuals experience the symptoms associated with major depression. But, when they are in a manic phase of the cycle, the NIMH lists some of the typical symptoms as:

1. Increased energy
2. Decreased need for sleep
3. Increased risk-taking
4. Unrealistic beliefs in their own abilities
5. Increased talking and physical, social and sexual activity
6. Feelings of mood elevation or irritability
7. Aggressive response to frustration.

In their manic phase, these individuals can wreak havoc with their own lives, and those of their loved ones. Because they tend to overlook the painful or harmful consequences of their behavior, they may incur huge debts, behave badly, make poor decisions, and even break the law and land in jail. In extreme cases, patients with bipolar disorders can become psychotic, experiencing delusions and hallucinations. This can be in both their manic and depressive phases. When the patient is suffering from a clinical depression, he or she may have exaggerated feelings of helplessness, hopelessness, or guilt.

Bipolar disorders often begin in adolescence. The mood swings of bipolar disorders -- episodes of impulsivity, irritability and loss of control, alternating with periods of excessive sleeping and withdrawal, can be mistaken for normal, volatile adolescent behavior. For this reason, this treatable disorder may not be recognized.

Depression in the elderly

Depression is also frequently missed in elderly people, because it is often misdiagnosed as senility, or assumed to be a reflection of the usual problems of aged people. In elderly people, depression is often expressed by physical complaints. It is important for clinicians to probe further, because depression in the aged that is masked behind physical symptoms can often be treated.

Depression in Adolescents

There appears to be a rising incidence of depressive illness in teenagers, but their symptoms are often ascribed to the normal mood swings of an adolescent, and they do not get the help they need. Mental health professionals are concerned about this, because some adolescents become so despairing that they conclude that their only option is to end their lives. Over the past 30 years, suicide among adolescents has increased 300 percent.

The key to recognizing a depressive disorder in an adolescent is noting whether the change in behavior lasts for weeks or longer. Teenagers who may be suffering from a depressive illness include those who appear to have four or more symptoms of depression over a period of time. Other hints are deterioration in schoolwork, withdrawal from social life, and a loss of interest in activities that used to be enjoyable. Depressive illness in teenagers can be treated, so it is important to seek medical advice if a teenager's behavior causes concern.

Diagnosis of Depression

To help increase awareness of depression, the National Institute of Mental Health lists a range of symptoms, which include:

• Persistent feelings that can be low, anxious, or numb and empty
• Decreased energy, and fatigue, and a sense of slowing down from one's usual pace of activity
• Loss of interest or pleasure in usual activities, including sex
• Sleep disturbances like insomnia, early-morning waking, or oversleeping
• Appetite and weight changes, which include either losing or gaining weight
• Feelings of hopelessness, pessimism and despair
• Feelings of inappropriate or excessive guilt, worthlessness, helplessness
• Thoughts of death or suicide, possibly even attempted suicide
• Difficulty in concentrating, remembering, and making decisions
• Chronic aches or persistent bodily symptoms that are not caused by physical disease.

The NIMH recommends that anyone who experiences five or more of the above symptoms for more than two weeks, or whose usual functioning has become impaired by such symptoms, may have a depressive illness that should be treated.

Some mental health experts suggest changes in a person's personality or activities may be another important sign of clinical depression. A woman who usually takes great pleasure in visits from her grandchildren may express displeasure at their arrival. Or, a man who enjoys music and attends concerts whenever possible appears to lose interest in this activity. Moreover, the changes persist, and without treatment, may continue for months or years.

It is important for individuals and their families to learn how to recognize a developing clinical depression and report this to a doctor, because early intervention can either prevent depression from occurring, or at least lessen the severity of the depressive episode.

How is it treated?

Severe depression is a complex illness that should be treated by professionals who are familiar with all of its manifestations. A complete clinical evaluation will include a physical examination, a medical and psychiatric history, and a mental status examination.

The first step in the treatment of depression is a physical examination. This is done to rule out disorders like thyroid disease, anemia or a recent viral infection, which can produce symptoms similar to those found in a depressive illness. In an estimated 20 to 25 % of major depressive episodes, the cause is an underlying factor such as a particular medication or a medical condition.

A neurological examination should also be done to rule out the possibility that the depressive symptoms are being caused by a neurological disorder.

An important part of the evaluation should be a detailed case history, which can give the family practitioner or mental health specialist valuable clues about the person's condition. Usually, the doctor will ask about the reasons for the visit and carefully discuss all of the person's symptoms. This will permit the doctor to evaluate whether specific events in the person's life could be contributing to their depression or whether the depression appears to have occurred for no obvious reason. The doctor will probably also inquire whether other family members have suffered from depression. A vital element of this examination is to assess the severity of the depression, particularly whether there is any danger that the patient will attempt suicide. In cases such as this, the individual may be hospitalized until the danger passes.

The treatment of depression is tailored to the individual, with the severity and cause of the depressive episode taken into account. Antidepressant medications are frequently prescribed, but it is usually helpful for depressed individuals to receive some form of psychotherapy as well.

The two most common types of antidepressants used are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). With these medications, it may take up to eight weeks before an improvement in depressive symptoms is seen. Since it can take several weeks for the symptoms of depression to improve after treatment has begun, it is helpful for friends and family to encourage the depressed person to continue taking his or her medication. In some cases, different types of antidepressants will need to be tried to find the right match. Antidepressants may cause significant side effects, so drugs and dosages must be monitored closely by a doctor. SSRIs are associated with fewer side effects than TCAs or monoamine oxidase inhibitors (MAOIs). Treatment is usually evaluated six weeks after starting an antidepressant medication. It is then generally re-evaluated after 12 weeks. If the person improves somewhat on a particular medication, treatment can appropriately be continued with dosage adjustments. If there is no improvement, however, treatment should be augmented or changed.

Usually, by the twelfth week of treatment, the most suitable medication for the person has been established. If the individual clearly appears to be benefiting from the medication, it should be continued for four to nine months. After this time, maintenance therapy may be considered.

Studies are ongoing to establish the optimal length of time that antidepressant medications should be taken. Most mental health professionals now recommend that persons who suffer from recurring episodes of major depression and those with bipolar, or manic-depressive disorders stay on maintenance therapy.

Treating Adolescent Depression

An estimated 2-10% of children and adolescents in the U.S. have depression. In light of this, it is important to try and find the best therapy for this younger population with the fewest side effects. However, in recent years, several antidepressant medications have been in the news due to reports of increased suicide risk among adolescent users. Because of these reports, beginning in 2004, the U.S. Food and Drug Administration (FDA) now requires manufacturers to add a black-box warning to the labeling of antidepressant medications to inform healthcare providers and the public of the increased risk of suicidal tendencies in adolescents who use antidepressants. This warning was extended by the FDA in May 2007 to include young adults aged 18-24 years who are just starting antidepressant therapy (usually the first 1-2 months of antidepressant therapy). A medication guide has also been developed to be distributed at the pharmacy with each new or refilled prescription for antidepressants. This doesn't mean that antidepressants shouldn't be used to treat younger depressed persons; however, more caution needs to be exercised to determine if the benefits of the antidepressant truly outweigh the potential risks.

Treatment Options

First-line treatment options for depression in adolescents include Cognitive Behavioral Therapy (CBT), interpersonal psychotherapy, antidepressants, psychosocial intervention, or a combination of the above. Non-drug options should be generally considered before starting a medication for depression.

The only antidepressant medication officially approved by the FDA for children 8 years of age or older is fluoxetine (brand name: Prozac). This generally should be the first medication considered. Other antidepressant options that are available but with less evidence to support their use in children and adolescents include sertraline (brand name: Zoloft) and paroxetine (brand name: Paxil).

If antidepressant medication is used in a child or adolescent, he or she should be monitored closely due to the potential increased risk for suicidality (thoughts or attempts of suicide). All pediatric patients being treated with antidepressants for any indication should be observed closely for clinical worsening of their depression, suicidality, and unusual changes in behavior, especially during the initial few months of therapy, or any time the antidepressant dose is changed. Monitoring should include at least weekly face-to-face contact with the child or adolescent or their family members or caregivers during the first 4 weeks of treatment, then every other week visits for the next 4 weeks, then at 12 weeks, and as clinically indicated beyond 12 weeks. Additional contact by telephone may be appropriate between face-to-face visits.

References

1. Paxil [package insert]. Research Triangle Park, NC: GlaxoSmithKline; July 2006, updated August 2007.
2. Dopheide JA. Recognizing and treating depression in children and adolescents. Am J Health-Syt Pharm. 2006;63(3):233-43.
3. Prozac [package insert]. Indianapolis, IN: Eli Lily Company; December 2006, updated March 2008.
4. Zoloft [package insert]. New York, NY: Pfizer Laboratories; September 2003, updated March 2008.
5. Kando JC, Wells BG, and Hayes PE. Depressive Disorders. Pharmacotherapy: a physiologic approach. 6th ed. Dipiro JT, Talbert RL, Yee GC, et al, eds. New York: McGraw-Hill, 2005: 1235-55.
6. U.S. Food and Drug Administration. FDA Issues Public Health Advisory on Cautions for Use of Antidepressants in Adults and Children. URL: http://www.fda.gov/bbs/topics/answers/2004/ANS01283.html. Accessed April 2007.
7. U.S. Food and Drug Administration. New Warnings Proposed for Antidepressants. URL: http://www.fda.gov/consumer/updates/antidepressants050307.html. Accessed March 26, 2008.
8. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006; 63:332-9.

Treatment Overview of Depression

Helping Yourself

Periods of depression can typically last from six months to a year or even longer. While you may feel better between these episodes, you might still experience symptoms or have difficulty performing normal daily tasks. The odds of having another period of depression increase with each episode you experience. When left untreated, depression can cause other problems including:

• Stomach upset
• Headaches
• Difficulty sleeping
• Chronic pain
• Problems relating to people
• Loss of productivity

That's why getting treatment is important. Treating depression can improve the quality of your life and may prevent the condition from worsening, becoming long-term and/or requiring hospitalization. Up to 75 percent of people who suffer from depression experience significant improvement with treatment and up to 50 percent experience a complete recovery. While getting treatment for your depression, some things that you can do to help include:

• Set realistic goals in light of the depression
• Try to be with other people and to confide in someone
• Participate in activities that make you feel better
• Mild exercise, going to a movie, a ballgame, or other activities
• Expect your mood to improve gradually, not immediately
• Let your family and friends help you

What is on the horizon?

Because the newer antidepressants are effective and widely used, most current research focuses on compounds that work like the drugs that are already on the market.

Other drug research involves products that affect dopamine or serotonin and dopamine together. Researchers are also studying a different type of drug called an alpha-1 adrenergic blocker. Drugs developed from these studies may improve mood, energy and alertness. Among the non-drug therapies being studied is one that uses the magnetic stimulation of the brain as an alternative to conventional shock treatment. Investigators are also studying the benefits of light therapy to treat seasonal depression, which can be a problem during winter months.

Because of the high public interest in herbal remedies for minor depression, the National Institute of Mental Health has launched a study to determine the safety and effectiveness of St. John's Wort, a common herbal supplement, and citalopram, a prescription antidepressant, compared to placebo. This study started in Februrary 2003 and is still ongoing. Once finished, researchers will assess the changes in a patient's symptoms, functioning, and quality of life.

A current research question is how best to maintain the benefits of electroconvulsive therapy (ECT) over time. Although ECT can be very effective for relieving acute depression, there is a high rate of relapse when the ECT treatments are discontinued. One study has compared maintenance medication therapy to maintenance ECT. This study found high relapse rates with both medication and ECT and neither was superior to the other. However, the medication regimen used included nortriptyline and lithium, which may have more side effects and may be less effective than SSRIs (another widely used antidepressant drug class). Because of this, a study comparing SSRIs to ECT or one that includes both medication plus ECT to avoid relapses may be warranted in the future.

Research continues in the quest to more clearly identify the causes of depression. Studies that are underway are examining genetic and environmental factors that may have a role in depression. A possible relationship between the substances released from the body when inflammation occurs and the onset of depression in healthy men has just recently been discovered. A study showed that men with depression had higher levels of inflammatory substances in their blood circulation than men without depression.

Another study showed that the drug, ketamine (a drug more commonly used for anesthesia during surgery), demonstrated rapid antidepressant effects. These effects were seen within hours as opposed to weeks or months for current therapy. Ketamine probably would not be the drug of choice for depression because it is used as an anesthetic and has been abused recently as a "party drug." Therefore, research has shifted to other drugs.

A study done in 2006 used Namenda (memantine), a medication currently approved to treat Alzheimer's disease, for persons with major depression. The trial was ended early because no effect was noticed; but low doses of the drug were used. Therefore, higher doses of memantine should be evaluated for major depression. Once the causes of depression are better identified, new treatments and techniques for prevention can be developed.

References

Depression. MayoClinic.com. Available at: http://www.mayoclinic.com/health/depression/DN99999. Accessed May 2005, June 2006, March 2007, and March 2008.

Depression. National Institute of Mental Health. Available at: http://www.nimh.nih.gov/publicat/depression.cfm. Accessed May 2005, June 2006, March 2007, and March 2008.

Glassman R, Farnan L, Gharib S, et al. Depression: A guide to diagnosis and treatment. Brigham and Women?s Hospital. http://www.brighamandwomens.org/patient/Depression.pdf Available at: Accessed May 2005, June 2006, March 2007, and March 2008.

JAMA Patient Pages: Depression. JAMA 2003; 289:3198.

Kando JC, Wells BG, Hayes PE. Depressive Disorders. In : DiPiro JT, Talbert RL, Yee GC and others, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005: 1235-53.

Depression. World Health Organization. Available at: http://www.who.int/mental_health/management/depression/definition/en/Accessed June 9, 2006, March 2007, and March 2008.

Lewis C. The Lowdown on Depression. U.S. Food and Drug Administration. Available at: http://www.fda.gov/fdac/features/2003/103_dep.html. Accessed May 2005, June 2006, March 2007, and March 2008.

American Psychiatric Association. Practice guideline for major depressive disorder in adults. American Journal of Psychiatry. 1993; 150(4 supplement):1-25

Duman R, Heninger G, Nestler E. A molecular and cellular theory of depression. Archives of General Psychiatry. 1997; 54: 597-606

Facts and Comparisons. CliniSphere 2.0. April 1998.

Hirschfeld R. et al. The National Depressive and Manic-Depressive Association consensus statement on the under treatment of depression. Journal of the American Medical Association. 1997; 277(4):333-340

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Sturm R, Wells K. How can care for depression become more cost-effective? Journal of the American Medical Association. 1995; 273(1):51-58

Weissman M, Warner V, Wickramaratne P, Moreau D, Olfson M. Offspring of depressed parents. 10 years later. Archives of General Psychiatry. 1997; 54(10):932-40

Kellner C, Knapp R, Perides G, et. al. Continuation Electroconvulsive Therapy vs Pharmacotherapy for Relapse Prevention in Major Depression. Archives of General Psychiatry. 2006; 63:1337-1344.

Berman RM, Cappiello A, Anand A, et. al. Antidepressant effects of ketamine in depressed patients. Biological psychiatry. 2000; 47:351-354.

Zarate C, Singh J, Quiroz J, et. al. A Double-Blind, Placebo-Controlled Study of Memantine in the Treatment of Major Depression. American Journal of Psychiatry. 2006; 163:153-155.

Depression Health Condition Last Updated: March 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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