Depression

Depression is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way they feel about themselves, and the way they think about things. Depression 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.

In any given one-year period, almost 10 percent of the population suffers from depression. The economic cost of the disorder is high, but the cost in human suffering cannot be estimated. Depression often interferes with normal functioning and can cause pain and suffering, not only to those who have it, but also to those who care about them. Serious cases can destroy family life, as well as the life of the person with this illness. But much of this suffering is unnecessary.

Depression can strike anyone, regardless of age, ethnic background, socioeconomic status, or gender. Researchers estimate that in the United States at least 6 million men suffer from the illness every year. This is about 7 percent of the population. Nearly twice as many women (more than 12 million women) suffer from depression each year.

Depression is also not just a condition of the young or old. For example, of the 35 million Americans age 65 and older, about 2 million suffer from full-blown depression. Another 5 million suffer from less severe forms.

Types of Depression

Many people may think of depression as a symptom. However, depression is actually a type of illness. Similar to other illnesses, such as heart disease, depression can come in several forms (or types). The three most common depression types are:

• Major depression
• Bipolar disorder (also known as manic depression)
• Dysthymia.

Within these different types are variations in the number of symptoms, their severity, and how long they last.

Major Depression

Major depression is identified by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy activities that were once pleasurable. Such a disabling episode of depression may occur only once, but more commonly occurs several times in a lifetime. This type of depression is also known as:

• Clinical depression
• Unipolar depression
• Major depressive disorder.

A subtype of major depression is atypical depression. Atypical depression signs and symptoms are similar to those of major depression. Yet, unlike a person with major depression, someone who has atypical depression will also have one or more of the following:

• Significant anxiety
• Oversleeping
• Panic attacks
• Overeating or significant weight gain
• Increased sensitivity to rejection.

Atypical depression is the most common subtype of major depression. This type of depression is common in women.

Bipolar Disorder

Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as common 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 depression. 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 and full of grand schemes that might range from unwise business decisions to romantic sprees. If left untreated, mania may worsen to a psychotic state.

Dysthymia

Dysthymia is a less severe type of depression that involves long-term, chronic symptoms that do not disable a person, but do keep him or her from functioning well or feeling good. Many people with dysthymia also experience major depression at some time in their lives.

Other Depression Types

There are several other types of depression, including:

• Postpartum depression -- A condition that occurs in some women following childbirth. Postpartum depression is when "baby blues" last longer than two weeks, or are more severe than simple mood swings or mild depression.

• Premenstrual dysphoric disorder (PMDD) -- A condition in which depression symptoms occur one week prior to menstruation and disappear after the menstrual period ends.

• Seasonal affective disorder (SAD) -- A pattern of depression that occurs during fall and winter and disappears during spring and summer. It is thought that SAD is due to lack of sunlight. It is more common in northern latitudes.

• Adjustment disorder with depressed mood -- A type of depression that follows a significant life stress. It usually lasts less than six months and improves when the stress is removed or the person develops coping skills. For this condition, the symptoms of depression are not severe enough to meet the criteria for major depression.

• Cyclothymic disorder -- A condition that resembles bipolar disorder, but with mood swings that are less severe than those seen with bipolar disorder. The mood swings are not severe enough to meet the criteria for bipolar disorder, nor are the signs of depression severe enough to meet the criteria for major depression.

Risk Factors

While depression research scientists are still searching for the exact cause or causes of depression, they do know a number of factors that increase a person's chances of developing depression. These are known as depression risk factors. Some risk factors for depression include:

• Family history
• Medications
• Substance abuse
• Medical illnesses
• Hormonal factors
• Stress.

Family History

Some types of depression run in families, which suggests that a biological vulnerability to depression can be inherited. This seems to be the case with bipolar disorder (also known as manic-depression). Studies of families in which members of each generation developed 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. In other words, not everybody with the genetic makeup that causes a vulnerability to bipolar disorder will have the illness. It seems that additional factors -- possibly stresses at home, work, or school -- are involved in the onset of bipolar disorder.

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 depression is often associated with changes in brain structures or brain function.

Among the people who are prone to depression are those with low self-esteem, those who consistently view themselves and the world with pessimism, and those who are readily overwhelmed by stress. Whether this represents a psychological predisposition or an early form of the illness is not clear.

Medications

There are a number of medicines whose side effects include depression. Some of these types of medicines include:

• High blood pressure medications, including beta blockers
• Corticosteroids
• Benzodiazepines
• Antiarrhythmics
• Digoxin (Digitek^®, Lanoxicaps^®, Lanoxin^®)
• H2 blockers, including cimetidine(Tagamet^®), famotidine(Pepcid^®), nizatidine (Axid^®), and ranitidine (Zantac^®).

Substance Abuse

Depression is common in people who also have substance abuse. This includes alcohol abuse, cocaine abuse, and stimulant withdrawal.

Medical Conditions

There are a number of medical conditions that increase the risk of developing depression. These conditions can include:

• Certain metabolic conditions, like:

• Hypothyroidism or hyperthyroidism
• Cushing's syndrome
• Diabetes

• Neurologic conditions, such as:

• Multiple sclerosis (MS)
• A brain tumor
• Parkinson's disease
• Epilepsy
• Dementia
• Huntington's disease
• A recent stroke

• Nutritional problems, including vitamin B₁₂ deficiency

• Certain cancers, such as pancreatic cancer

• A recent heart attack or heart surgery.

Hormonal Factors

Hormonal factors can increase a person's chances of developing depression. This includes hormonal changes that occur during menstrual cycle changes, pregnancy, miscarriage, the postpartum period, perimenopause, and menopause.

Stress

In susceptible people, stress seems to play a role in having a depressive episode. This can include stress at work and home, single parenthood, and caring for children or aging parents. Other stresses that may trigger a depressive episode include a serious loss, a difficult relationship, a financial problem, or any stressful change in life patterns (whether unwelcome or desired).

Symptoms of Depression

Depression is identified by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once-pleasurable activities.The two key symptoms of depression that are most often present when diagnosing the condition include:

• A depressed mood. This may be present as a persistent sad, anxious, or "empty" mood. In children, it may be expressed as an irritable mood.

• Loss of interest or pleasure in hobbies and activities that were once enjoyed. This may include lack of interest in eating, social interactions, exercise, or sex.

Along with these two key symptoms, a person with depression can have a number of other symptoms in a variety of combinations. The specific combination of symptoms will vary depending on the individual.

These other possible depression symptoms are as follows:

• Feelings of hopelessness and pessimism
• Feelings of guilt, worthlessness, and helplessness
• Decreased energy, fatigue, and being "slowed down"
• Difficulty concentrating, remembering, and 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 and irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, backaches, chronic pain, and digestive complaints (for example, indigestion, constipation, or diarrhea).

Diagnosing Depression

There is no one specific test that can be used for diagnosing depression. Therefore, in order to make a diagnosis, the healthcare provider will begin by asking a number of questions. This is known as taking the patient's medical history. Some of these questions may be related to:

• Current symptoms, including:

• Any thoughts of suicide
• Feeling of hopelessness
• Preoccupation with issues related to death

• Other medical conditions, including a recent history of stroke or heart attack
• Current medications
• Recent events in one's life
• A history of drug or alcohol abuse
• A family history of any medical conditions.

After asking these and other questions, the healthcare provider will perform a physical exam, looking for signs of conditions known to cause depression. There are no specific lab tests that can help in making a depression diagnosis.

Is the Diagnosis Depression or Another Medical Condition?

Before diagnosing depression, the healthcare provider will also consider other conditions that share a number of symptoms with depression. Some of these conditions include:

• Lyme disease
• Chronic fatigue syndrome(CFS)
• Fibromyalgia
• Rheumatoid arthritis
• Uncomplicated bereavement (mourning a loss or death).

Depression Treatment

With advances in medicine, clinical depressions (also known as major depression or just depression) is now quite treatable. More than 80 percent of those who seek help show improvement. As with many illnesses, early treatment for depression is more effective and helps prevent the likelihood of serious recurrences. Depression must be treated by a physician or qualified mental health professional.

The most commonly used treatments for depression are:

• Depression medications (antidepressants)
• Psychotherapy
• A combination of the two.

There are a variety of antidepressant medications and psychotherapies for depression treatment. Some people with milder forms of depression may do well with psychotherapy alone. People with moderate to severe depression most often benefit from medication. Most people do best with a combination treatment plan, including:

• Medication to gain relatively quick relief of symptoms
• Psychotherapy to learn more effective ways of dealing with life's problems, including depression.

Antidepressants as a Depression Treatment

Several types of antidepressant medications are used as treatment for depression. Some specific classes of medications used to treat the condition include:

• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Norepinephrine and dopamine reuptake inhibitors (NDRIs)
• Tricyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs).

There are also several different medications available within each of the classes of drugs mentioned. SSRIs and other newer medications that affect neurotransmitters (SNRIs and NDRIs) generally have fewer side effects than tricyclics or MAOIs.

Sometimes, the healthcare provider must try a variety of antidepressants before finding the most effective medication or combination of medications to treat a person's depression. In some cases, the dosage must be increased for the antidepressant to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for three to four weeks (or, in some cases, for as long as eight weeks) before the full therapeutic effect occurs.

Psychotherapy as a Depression Treatment

Many forms of psychotherapy, including some short-term therapies (10 to 20 weeks), can help people with depression. "Talk" therapies help people gain insight into, and resolve, their problems through verbal exchange with the therapist. This talk therapy is sometimes combined with "homework" assignments between sessions. Behavioral therapists help people learn how to obtain more satisfaction through their own actions and how to unlearn the behavioral patterns that contribute to, or result from, their depression.

Other Treatments for Depression

In addition to medications and therapy, a few other depressiontreatments are available. These include:

• Electroconvulsive therapy (ECT)
• Alternative treatments.

ECT

When medication, psychosocial treatment, and the combination of these treatments prove ineffective (or work too slowly to relieve severe symptoms), electroconvulsive therapy (ECT) may be considered.

Electroconvulsive therapy is particularly useful for individuals whose depression is severe or life-threatening, or who cannot take antidepressant medication. ECT is often effective when antidepressant drugs do not provide sufficient relief of depression symptoms.

In recent years, this type of depression treatment has improved greatly. The person receives a muscle relaxant prior to ECT, and the treatment is performed while the person is under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief seizure within the brain, lasting about 30 seconds. The person receiving ECT does not consciously experience the electrical stimulus.

For the full therapeutic benefit to be seen, the person must receive at least several sessions of ECT -- typically given at the rate of three per week.

Alternative Treatments

Over the past few years, there has been quite a bit of interest in using herbs to treat 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.

In two large studies of people with major depression, St. John's wort was not shown to be effective at treating major depression of moderate severity. It is currently being studied in people with mild depression to see if it has any effects.

Some other possible alternative treatments for depression include:

• Acupuncture

• Omega-3 fatty acids
• Vitamin B6
• SAM-e (S-adenosyl-L-methionine)
• 5-HTP (5-hydroxytryptophan)
• Valerian.

How Long Does Depression Treatment Last?

Your healthcare provider generally separates depression treatment into two stages. The first stage treats the symptoms until a person feels well. The second stage is used to prevent symptoms from returning. The first stage of depression treatment most often involves medication. This stage may last up to 12 weeks. Once symptoms have improved, the medications may be continued for up to nine months. In depression research studies, continuing medicines has been shown to decrease the chances that the depression will return.

For some people, treatment for depression may be needed only once during their lifetime. However, for a lot of people, depression is a lifelong disease requiring ongoing treatment. It is impossible for your healthcare provider to know whether treatment will be short-term or long-term in your situation. Fortunately, in either situation, effective depression treatment is now available.

Depression Research

Doctors and scientists worldwide are conducting depression research studies. These studies are designed to answer important questions and to find out whether new approaches to depression treatment are safe and effective. Such research has already led to many advances, and researchers continue to search for more effective methods of dealing with depression.

Recent Research Findings

The following are some findings from recently completed research studies on depression:

• Brain imaging studies are revealing that in people with depression, the neural circuits responsible for moods, thinking, sleep, appetite, and behavior fail to function properly and that the regulation of critical neurotransmitters is impaired.

• Genetics research, including studies of twins, indicates that genes play a role in depression. Vulnerability to depression appears to result from the influence of multiple genes acting along with environmental factors.

• Other depression research has shown that stressful life events, particularly in the form of loss such as the death of a close family member, may trigger major depression in susceptible individuals.

• Studies of brain chemistry, how antidepressant work, and the distorted thinking and relationship problems linked to depression continue to help researchers develop new and better treatments.
• Studies of abused women have shown that abuse may lead to depression by fostering low self-esteem, a sense of helplessness, self-blame, and social isolation. There may be biological and environmental risk factors of depression resulting from growing up in a dysfunctional family.