In any given 1-year period,
9.5% of the population, or about 19 million American adults, suffer
from a depressive illness. The economic cost is estimated at $30.4
billion a year, but the cost in human suffering cannot be estimated.
Depressive illnesses often interfere with normal functioning and
cause pain and suffering not only to those who have a disorder,
but also to those who care about them. Serious depression can destroy
family life as well as the life of the ill person. But much
of this suffering is unnecessary.
Most people with a depressive
illness do not seek treatment, although the great majority--even
those whose depression is extremely severe--can be helped.
Thanks to years of fruitful research, the medications and psychosocial
therapies that ease the pain of depression are at hand.
Unfortunately, many people
do not recognize that depression is a treatable illness. If you
feel that you or someone you care about is one of the many undiagnosed
depressed people in this country, the information presented here
may help you take the steps that may save your own or someone else's
life.
WHAT IS A
DEPRESSIVE DISORDER?
A depressive disorder is an illness
that involves the body, mood, and thoughts. It affects the way a
person eats and sleeps, the way one feels about oneself, and the
way one thinks about things. 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. Appropriate treatment, however, can help most people who
suffer from depression.
Depressive disorders come in different
forms, just as in the case with other illnesses such as heart disease.
This pamphlet briefly describes three of the most common types of
depressive disorders. However, within these types there are variations
in the number of symptoms, 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.
A less severe type of depression,
dysthymia, involves long-term, chronic symptoms that do not
disable, but keep one from functioning well or from feeling good.
Many people with dysthymia also experience major depressive episodes
at some time in their lives.
Another type of depression is bipolar
disorder, also called manic-depressive illness. Not nearly as
prevalent as other forms of depressive disorders, bipolar disorder
is characterized by cycling mood changes: severe highs (mania)
and lows (depression). Sometimes the mood switches are dramatic
and rapid, but most often they are gradual. When in the depressed
cycle, an individual can have any or all of the symptoms of a depressive
disorder. When in the manic cycle, the individual may be overactive,
overtalkative, and have a great deal of energy. Mania often
affects thinking, judgment, and social behavior in ways that cause
serious problems and embarrassment. For example, the individual
in a manic phase may feel elated, full of grand schemes that might
range from unwise business decisions to romantic sprees. Mania,
left untreated, may worsen to a psychotic state.
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.
DEPRESSION
- Persistent sad, anxious, or "empty"
mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness,
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
MANIA
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased sexual desire
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
Some types of depression run in
families, suggesting that a biological vulnerability can be inherited.
This seems to be the case with bipolar disorder. Studies of families
in which members of each generation develop bipolar disorder found
that those with the illness have a somewhat different genetic makeup
than those who do not get ill. However, the reverse is not true:
Not everybody with the genetic makeup that causes vulnerability
to bipolar disorder will have the illness. Apparently additional
factors, possibly stresses at home, work, or school, are involved
in its onset.
In some families, major depression
also seems to occur generation after generation. However, it can
also occur in people who have no family history of depression. Whether
inherited or not, major depressive disorder is often associated
with changes in brain structures or brain function.
People who have low self-esteem,
who consistently view themselves and the world with pessimism or
who are readily overwhelmed by stress, are prone to depression.
Whether this represents a psychological predisposition or an early
form of the illness is not clear.
In recent years, researchers have
shown that physical changes in the body can be accompanied by mental
changes as well. Medical illnesses such as stroke, a heart
attack, cancer, Parkinson's disease, and hormonal disorders can
cause depressive illness, making the sick person apathetic and unwilling
to care for his or her physical needs, thus prolonging the recovery
period. Also, a serious loss, difficult relationship, financial
problem, or any stressful (unwelcome or even desired) change in
life patterns can trigger a depressive episode. Very often, a combination
of genetic, psychological, and environmental factors is involved
in the onset of a depressive disorder.
Depression in Women
Women experience depression about
twice as often as men. Many factors may contribute to depression
in women--particularly such factors as menstruation, pregnancy,
miscarriage, postpartum period, and menopause. Many women
also face additional stresses such as responsibilities both at work
and home, single parenthood, and caring for children and for aging
parents.
A recent NIMH study showed that
in the case of premenstrual syndrome (PMS), women with a preexisting
vulnerability to PMS experienced relief from mood and physical symptoms
when their sex hormones were suppressed. Shortly after the
hormones were re-introduced, they again developed symptoms of PMS.
Women without a history of PMS reported no effects of the hormonal
manipulation.
Many women are also particularly
vulnerable after the birth of a baby. The hormonal and physical
changes, as well as the added responsibility of a new life, can
be factors that lead to postpartum depression in some women.
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 and her ability to
care for and enjoy the infant.
Depression in the Elderly
Some people have the mistaken idea
that it is normal for the elderly to feel depressed. On the
contrary, most older people feel satisfied with their lives.
Sometimes, though, when depression develops, it may be dismissed
as a normal part of aging. Depression in the elderly, undiagnosed
and untreated, causes needless suffering for the family and for
the individual who could otherwise live a fruitful life. When
he or she does go to the doctor, the symptoms described are usually
physical, for the older person is often reluctant to discuss feelings
of hopelessness, sadness, loss of interest in normally pleasurable
activities, or extremely prolonged grief after a loss.
Recognizing how depressive symptoms
in older people are often missed, many health care professionals
are learning to identify and treat the underlying depression. They
recognize that some symptoms may be side effects of medication the
older person is taking for a physical problem, or they may be caused
by a co-occurring illness. If a diagnosis of depression is
made, treatment with medication and/or psychotherapy will help the
depressed person return to a happier, more fulfilling life. Recent
research suggests that brief psychotherapy (talk therapies that
help a person in day-to-day relationships or in learning to solve
problems of everyday life) is effective in reducing symptoms in
short-term depression in older persons who are medically ill.
Psychotherapy is also useful in older patients who cannot or will
not take medication. Efficacy studies show that late-life
depression can be treated with psychotherapy.
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.
Depression in Children
Only in the past two decades has
depression in children been taken very seriously. The depressed
child may pretend to be sick, refuse to go to school, cling to a
parent, or worry that the parent may die. Older children may
sulk, get into trouble at school, be negative, grouchy, and feel
misunderstood. Because normal behaviors vary from one childhood
stage to another, it can be difficult to tell whether a child is
just going through a temporary "phase" or is suffering
from depression. Sometimes the parents become worried about
how the child's behavior has changed, or a teacher mentions that
"Johnny doesn't seem to be himself." In such a case,
if a visit to the child's pediatrician rules out physical symptoms,
the doctor will probably suggest that the child be evaluated, preferably
by a psychiatrist who specializes in the treatment of children.
If treatment is needed, the doctor may suggest that another therapist,
a social worker or a psychologist, provide therapy while the psychiatrist
will oversee medication if it is needed. Parents should not
be afraid to ask questions: What are the therapist's qualifications?
What kind of therapy will the child have? Will the family
as a whole participate in therapy? Will my child's therapy
include an antidepressant? If so, what might the side effects
be?
The National Institute of Mental
Health (NIMH) has identified the use of medications for depression
in children as an important area to learn more about. The
NIMH-supported Research Units on Pediatric Psychopharmacology (RUPPs)
form a network of seven research sites where clinical studies on
the effects of medications for mental disorders can be conducted
in children and adolescents. Among the medications being studied
are antidepressants which can be effective in treating children
with depression, if properly monitored by the child's physician.
The first step to getting appropriate
treatment for depression is a complete physical examination by a
family physician or internist. Certain medications as well
as some medical conditions such as a viral infection 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 should be done, usually by a psychiatrist or psychologist.
A good diagnostic evaluation will
include a complete history of symptoms, i.e., 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.
Further, a history should include questions about whether other
family members have had a depressive illness and, if treated, what
treatments they may have received and which were effective.
Last, a diagnostic evaluation should
include a mental status examination to determine if speech
or thought patterns or memory have been affected, as sometimes happens
in the case of a depressive or manic-depressive illness.
Treatment choice will depend on
the outcome of the evaluation. There are a variety of antidepressant
medications and psychotherapies that can be used to treat depressive
disorders. Some people with milder forms may do well with psychotherapy
alone. People with moderate to severe depression often benefit from
antidepressants. Most do best with combined treatment: medication
to gain relatively quick symptom relief and psychotherapy to learn
more effective ways to deal with life's problems, including depression.
Depending on the patient's diagnosis and severity of symptoms, the
therapist may prescribe medication and/or one of the several forms
of psychotherapy that have proven effective for depression.
Electroconvulsive therapy (ECT)
is useful, particularly for individuals whose depression is severe
or life threatening or 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 that deliver
electrical impulses 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.
Medications
There are several types of antidepressant
medications used to treat depressive disorders. These include newer
medications--chiefly the selective serotonin reuptake inhibitors
(SSRIs)--the tricyclics, and the monoamine oxidase inhibitors (MAOIs).
The SSRIs--and other newer medications that affect neurotransmitters
such as dopamine or norepinephrine--generally have fewer side effects
than tricyclics. Sometimes your doctor will try a variety
of antidepressants before finding the medication or combination
of medications most effective for you. Sometimes the dosage must
be increased to be effective. Antidepressant medications must
be taken regularly for as many as 8 weeks before the full therapeutic
effect occurs.
Patients often are tempted to stop
medication too soon. They may feel better and think they no longer
need the medication. Or they may think the medication isn't
helping at all. It is important to keep taking medication
until it has a chance to work, though side effects may appear before
antidepressant activity does. Once the individual is feeling
better, it is important to continue the medication for 4 to 9 months
to prevent a recurrence of the depression. Some medications
must be stopped gradually to give the body time to adjust. For individuals
with bipolar disorder or chronic major depression, medication may
have to be maintained indefinitely.
Antidepressant drugs are not habit-forming.
However, as is the case with any type of medication prescribed for
more than a few days, antidepressants have to be carefully monitored
to see if the correct dosage is being given. The doctor will
check the dosage and its effectiveness regularly.
For the small number of people for
whom MAO inhibitors are the best treatment, it is necessary to avoid
certain foods that contain high levels of tyramine, such as many
cheeses, wines, and pickles, as well as medications such as decongestants.
The interaction of tyramine with MAOIs can bring on a hypertensive
crisis, a sharp increase in blood pressure that can lead to a stroke.
The doctor should furnish a complete list of prohibited foods that
the patient should carry at all times. Other forms of antidepressants
require no food restrictions.
Medications of any kind--prescribed,
over-the counter, or borrowed--should never be mixed without
consulting the doctor. Other health professionals who may prescribe
a drug--such as a dentist or other medical specialist--should be
told that the patient is taking antidepressants. Some drugs,
although safe when taken alone can, if taken with others, cause
severe and dangerous side effects. Some drugs, like alcohol
or street drugs, may reduce the effectiveness of antidepressants
and should be avoided. This includes wine, beer, and hard liquor.
Some people who have not had a problem with alcohol use may be permitted
by their doctor to use a modest amount of alcohol while taking one
of the newer antidepressants.
Antianxiety drugs or sedatives are
not antidepressants. They are sometimes prescribed along
with antidepressants; however, they are not effective when taken
alone for a depressive disorder. Stimulants, such as amphetamines,
are not first-line antidepressants and share the habit-forming risks
of antianxiety medications and sleeping pills.
Questions about any antidepressant
prescribed, or problems that may be related to the medication, should
be discussed with the doctor.
Lithium has for many years been
the treatment of choice for bipolar disorder, as it can be effective
in smoothing out the mood swings common to this disorder.
Its use must be carefully monitored, as the range between an effective
dose and a toxic one is small. If a person has pre-existing
thyroid, kidney, or heart disorders or epilepsy, lithium may not
be recommended. Fortunately, other medications have been found
to be of benefit in controlling mood swings. Among these are
two mood-stabilizing anticonvulsants, carbamazepine (Tegretol®)
and valproate (Depakote®). Both of these medications
have gained wide acceptance in clinical practice, and valproate
has been approved by the Food and Drug Administration for first-line
treatment of acute mania. Other anticonvulsants that are being
used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®).
Most people who have bipolar disorder
take more than one medication including, along with lithium and/or
an anticonvulsant, a medication for accompanying agitation, anxiety,
or insomnia. Finding the best possible combination of these
medications is of utmost importance to the patient and requires
close monitoring by the physician.
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 lots of water; chew sugarless gum; clean teeth daily.
- Constipation--bran cereals,
prunes, fruit, and vegetables should be in the diet.
- 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
any pain.
- Sexual problems--sexual
functioning may change; if worrisome, it should be discussed with
the doctor.
- Blurred vision--this will
pass soon and will not 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 newer antidepressants have different
types of side effects:
- Headache--this will usually
go away.
- Nausea--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, much interest
has risen 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 recently
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.
Today in Germany, Hypericum is used in the treatment of depression more
than any other antidepressant. However, the scientific studies
that have been conducted on its use have been short-term and have
used several different doses.
Because of the widespread interest
in St. John's wort, the National Institutes of Health (NIH) is conducting
a 3-year study,
sponsored by three NIH components--the National Institute of Mental
Health, the National Institute for Complementary and Alternative
Medicine, and the Office of Dietary Supplements. The study
is designed to include 336 patients with major depression, randomly
assigned to an 8-week trial with one-third of patients receiving
a uniform dose of St. John's wort, another third receiving a selective
serotonin reuptake inhibitor (SSRI) commonly prescribed for depression,
and the final third receiving a placebo (a pill that looks exactly
like the SSRI and the St. John's wort, but has no active ingredients).
The study participants who respond positively will be followed for
an additional 18 weeks. After the 3-year study has been completed,
results will be analyzed and published.
Many forms of psychotherapy, including
some short-term (10-20 weeks) therapies, can help depressed individuals.
"Talking" therapies help patients gain insight into and
resolve their problems through verbal "give-and-take"
with the therapist. "Behavioral" therapies help patients
learn how to obtain more satisfaction and rewards through their
own actions and how to unlearn the behavioral patterns that contribute
to or result from their depression.
Two of the short-term psychotherapies
that research has shown helpful for some forms of depression are
interpersonal and cognitive/behavioral therapies. Interpersonal
therapists focus on the patient's disturbed personal relationships
that both cause and exacerbate (or increase) the depression. Cognitive-behavioral
therapists help patients change the negative styles of thinking
and behaving often associated with depression.
Psychodynamic therapies, which are
sometimes used to treat depressed persons, focus on resolving the
patient's internal conflicts. These therapies are often reserved
until the depressive symptoms are significantly improved. In general,
severe depressive illnesses, particularly those that are recurrent,
will require medication (or ECT under special conditions) along
with, or preceding, psychotherapy for the best outcome.
Depressive disorders make one 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 accurately reflect the situation. Negative
thinking fades as treatment begins to take effect. In the meantime:
- Set realistic goals 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,
a ballgame, or participating in religious, social, or other activities
may 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
divorced--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 will disappear as your depression responds to treatment.
- Let your family and friends help
you.
How Family and Friends
Can Help the Depressed Person
The most important thing anyone
can do for the depressed person is to help him or her get an appropriate
diagnosis and treatment. This may involve encouraging the individual
to stay with treatment until symptoms begin to abate (several weeks),
or to seek different treatment if no improvement occurs. On occasion,
it may require making an appointment and accompanying the depressed
person to the doctor. It may also mean monitoring whether the depressed
person is taking medication. The depressed person should be
encouraged to obey the doctor's orders about the use of alcoholic
products while on medication. 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 disparage 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.
Be gently insistent if your invitation is refused. Encourage participation
in some activities that once gave pleasure, such as hobbies, sports,
religious or cultural activities, but do not push the depressed
person to undertake too much too soon. The depressed person needs
diversion and company, but too many demands can increase feelings
of failure.
Do not accuse the depressed person
of faking illness or of laziness, or expect him or her "to
snap out of it." Eventually, with treatment, most depressed
people do get better. Keep that in mind, and keep reassuring the
depressed person that, with time and help, he or she will feel better.
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