Depression

Source: Adapted from Know Your Options: The Definitive Guide to Choosing The Best Medical Treatments; Lookin

What is depression?

For generations, depression was stigmatized as a personal weakness. Even friends would exhort the sufferer to “snap out of it.” Then, in the 1980s, scientists started using cutting-edge imaging techniques to take a closer look at what happens in the brain when a person feels depressed. They found that the condition has a lot more to do with brain chemistry and genetics than it does with willpower.

When you’re fine with the world and not feeling depressed, plentiful stores of chemical messengers called neurotransmitters zip effortlessly around your brain. They literally leap critical gaps between the brain’s millions of nerve cells, called neurons, and keep communication flowing. When you’re depressed, this easy interchange breaks down. The key mood neurotransmitters—chemicals such as serotonin, norepinephrine, and dopamine—become unbalanced. Then neurons have problems conducting impulses back and forth.

Depression can take many forms. Its causes are complex. Underlying brain chemistry is all-important in some people. In others, a single upsetting event can trigger a downward spiral. In most people, a complex interaction of internal chemical imbalances and external factors is involved. Most of the time, depression is formally diagnosed after at least two consecutive weeks of sadness, sleeplessness, poor appetite and concentration, or loss of interest in normally pleasurable activities. More severe forms of clinical depression can be acutely distressing and debilitating. Their symptoms can last for months or years.

Who is at risk for depression?

You’re at higher risk for depression if you:

• Are a woman;
• Have been depressed before;
• Lack an adequate social support system;
• Have ongoing stresses in your life, such as illness in the family or financial burdens;
• Have an illness associated with depression, such as Alzheimer’s disease, arthritis, cancer, diabetes, heart disease, Parkinson’s disease, stroke, or a thyroid disorder;
• Take medications that may cause depression—for example, beta-blockers, sleep medications, narcotics, benzodiazepines, corticosteroids, sedating antihistamines, and tranquilizers.

Treatment for depression

No two cases of depression are alike. You may need to combine several therapeutic approaches to find the mix that’s best for you. Medications, psychotherapy—or both—are the first step for most people with milder depression. The newer antidepressants (SSRIs particularly) adjust chemical imbalances and have transformed many lives. When an SSRI works, you’ll likely feel a bit better within a week, although its full effect will take several weeks. If it doesn’t work, your doctor may switch you to another SSRI or different antidepressant. These drugs aren’t addictive. You can safely take them for a long time.

Psychotherapy often works as well as medication for mild to moderate symptoms of some types of depression. However, your best chance to feel better, and even banish the depression altogether, is to pursue drugs and therapy simultaneously. If you start with psychotherapy and don’t feel any relief after six weeks or feel only somewhat better by the 12-week mark, adding antidepressants is a smart move. In fact, antidepressants are a good first step, even for severe, debilitating depression. After that, ECT (electroconvulsive therapy) may be your next logical option.

Along with these medical approaches, you’ll need to develop smart lifestyle strategies. Focus on communicating openly with your doctor, exercising regularly, and maintaining a healthy diet. Most people eventually find a balanced approach that makes them feel much better and helps them deal with their depression. Concentrate on finding the combination that works best for you. If your depression doesn’t lift completely during the first intensive phase of treatment, the risk for relapse is high. Enlist those who care for you to help you get on the road to recovery as quickly as possible.

Medications for depression

When selecting an antidepressant, your doctor will consider many factors, ranging from your other medical conditions and medications to the nature of your depression—mild or severe, brief or long-term, with or without psychotic features. This decision is often far more complex than it seems. And the more severe or complicated your depression, the more likely that your family physician will refer you to the care of an expert; probably a psychiatrist who is well versed in the actions, benefits, and drawbacks of the dozens of antidepressants available today.

Many patients with mild depression are now started on selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Luvox, Paxil, and Zoloft. SSRIs are relatively safe to use if you have another illness, even a psychiatric one like obsessive-compulsive disorder, panic disorder, social phobia, or bulimia. In fact, these conditions often improve with the addition of SSRIs. Easy to manage and taken only once a day, SSRIs are less likely than older drugs to cause annoying reactions that might tempt you to stop taking them. Their side effects (mild nausea, headache, diarrhea) also tend to fade once your body adjusts. For some, the worst drawback is loss of interest in sex.

Once a treatment of choice, heterocyclic antidepressants (originally called tricyclics) still have a special place in the panoply of drug options for depression, with names such as Elavil, Tofranil, and Pamelor. On the plus side, they’re proven entities. Psychiatrists know what to expect when prescribing them, and they can offer significant relief from depression. On the downside, side effects (drowsiness, dry mouth, blurry vision, and weight gain) have now relegated these drugs to second-choice status. However, if insomnia accompanies depression, doctors may take advantage of the drowsiness side effect and prescribe a small dose of a heterocyclic at bedtime.

Each of five newer antidepressants has a unique mechanism of action and isn’t classified in any of the preceding groups. Exactly how buproprion (Wellbutrin) works is not known, but it seems to affect serotonin and a second neurotransmitter called dopamine. (A side effect causes smokers to lose interest in cigarettes, so it’s also marketed under the name Zyban.) Venlafaxine (Effexor), nefazodone (Serzone), trazodone (Desyrel), and mirtazapine (Remeron) also have this dual neurotransmitter action, changing brain levels of both serotonin and norepinephrine. If serotonin is affected more than norepinephrine, as with Serzone and Desyrel, the effect is sedation. If the reverse, as with Effexor or Remeron, you may feel stimulated or unable to sleep. Let a clinician familiar with these medications select what’s best for your depression.

Lastly, over past decades, countless people have found relief of depression with monoamine oxidase inhibitors (MAO inhibitors), such as Nardil, Marplan, and Parnate. These drugs are prescribed primarily by psychiatrists with extensive experience and knowledge about how they work, who will benefit from them, and what side effects might result. MAOs can cause serious interactions if combined with certain antidepressants, vasoconstrictors, and decongestants. Also, they can produce problems when taken along with tyramine-rich foods, such as dark chocolate, aged cheeses, and certain red wines.

If an antidepressant isn’t making you feel better, your doctor may add a mood stabilizer like lithium or a thyroid hormone to your regimen. In many cases, one of these can make all the difference.

Lifestyle Changes

Swim, bike, walk. Get regular exercise. You’ll feel better in part because you took charge. You may also have a surge of “feel-good” (and pain-relieving) substances called endorphins. Countless studies reinforce the emotional lift of exercise. Stress and anxiety drop. Blood gets flowing. Blood pressure falls. Negative emotions—helplessness, anxiety, hostility—diminish. Even a simple 15-minute walk can enhance your mood. A small Johns Hopkins study found that adults who were fitter and relatively lean were more likely to feel happier, but the benefits won’t last unless you keep at it.

Exercise also improves sleep, another key factor in improving mood. The right amount of sleep is critical. Seven to eight hours a night is ideal. Avoid napping, and get up at the same time every morning. Aim for a healthy diet, too. Poor eating can increase fatigue and feelings of unease.

You might also explore your spiritual side, whether religion or other beliefs, for answers to meaning in life. Meditation and yoga are risk-free ways to get a valuable perspective on your daily troubles.

Stay connected socially in any way you can. Adopt a pet. Take a class. Or join a club related to something you’re interested in (maybe bridge, chess, gardening, or walking). If you find yourself turning to alcohol or drugs, ask your doctor about a support group that can help you reduce your intake: Both alcohol and drugs can trigger and intensify depression.

Related Procedures for Depression

Psychotherapy may be the place to start, especially if you’re only mildly depressed. This type of verbal (and nonverbal) exchange can sometimes work on depression as effectively as drugs. Side effects are less of an issue, and you don’t have to worry about interactions with other medicines (this can be particularly important for older people who are taking lots of pills). There are drawbacks, however. Psychotherapy alone is not effective for severe depression; this give-and-take process can take longer than drugs to work (results in six to eight weeks or more versus four to six weeks with medication) and it can be expensive.

A skilled therapist will often mix and match therapeutic approaches for depression based on what you’re going through. Psychodynamic therapy, for example, looks to past experiences to shed light on why you’re feeling what you’re feeling now. Interpersonal therapy, or crisis intervention, works especially well when an immediate problem—a child leaving home, a spouse dying—is causing you to feel low.

Behavioural therapy attempts to change destructive patterns of acting or thinking by honing social skills, self-control, and problem-solving strategies. It works best when the problem can be clearly defined and “good behaviour” rewarded. It’s often blended with cognitive therapy, which boosts confidence and counters your fear of failure by showing you how competent you can be. In group therapy, you’re given a chance to share your feelings (and solutions) with others.

If your depression is severe and psychotherapy combined with medications hasn’t improved how you feel, your doctor may recommend electroconvulsive therapy (ECT), which shocks the nervous system and resets the brain’s chemistry. It may be an option if you’re losing touch with reality (psychosis), or threatening suicide.

Experts aren’t sure exactly why ECT works for depression. Electrodes are placed on the head and an electric current causes a brief convulsion. General anesthesia prevents pain from muscle contractions. Most patients are treated every other day for five to seven sessions. Headache and memory loss sometimes occur, but are almost always temporary. Despite its Hollywood image as being barbaric, ECT is quite safe: One study showed that treatments relieved symptoms in 80% of patients with severe depression.

Questions for Your Doctor

• Will I have to take this medicine for the rest of my life?
• Am I going to gain weight while I’m on this anti-depressant?
• How likely is it that my depression will get worse?
• Will this happen to my kids?

Living with Depression

If you’re living with Depression, here are some helpful tips to help you take control:

• Steel yourself for a search. The odds that the first antidepressant you take will lift your depression are only 65%. So don‘t be surprised if you have to try a few before settling on one (or a combo). The good news: Increasingly sophisticated antidepressants are becoming available.
• Investigate what‘s worked for family members. If a certain antidepressant relieves symptoms for a parent or other close relative, mention this to your doctor. The same drug may work best for you, too.
• Tell your doctor about any herbs you take. Many herbs and supplements interact with prescription antidepressants, blunting their action or causing serious reactions.
• Stick with it. The longer you stay in treatment—medications or therapy—the less likely you are to have another depressive episode.
• Ignore drug company ads. Try as they might to convince you otherwise, there‘s no good evidence that one SSRI antidepressant (Paxil, Prozac, or Zoloft) is superior to another.
• Write a list of questions for a prospective therapist. What kind of experience do you have in treating depression? How will you treat me? What will this approach do to help me? Are there any risks?
• Take suicidal feelings seriously. This is an emergency. Talk with someone. Call your doctor. Go to the hospital. Sign a contract promising not to hurt yourself. Have guns removed from your home, and don‘t drive.

Prevention of depression

• Eat right. Eat a well-balanced diet with lots of vegetables, fruits, and other complex carbohydrates—whole-wheat bread, cereal, pasta, and rice. Complex carbohydrates boost the brain’s serotonin levels. Get enough protein in the form of dairy products, tofu, lean meats, and fish. Protein is essential for producing neurotransmitters.
• Fish for dinner. Researchers in Finland found that people who ate fish less than once a week had a 31 percent higher chance of mild to severe depression than those who ate fish more often. They think the beneficial component is the omega-3 polyunsaturated fatty acids in fish.
• Embrace exercise. Aerobic exercise can boost your mood by stimulating the release of endorphins, chemicals that produce a natural “high” and reduce stress. Some studies have shown that regular aerobic exercise works as well as antidepressants to relieve mild depression. It may even help prevent depression in the first place. Work out 45 minutes to an hour five times a week or as near as you can manage. Good bets: brisk walking, swimming, running, dancing, and cycling. You’ll get the maximum mood-enhancing benefit if you exercise hard enough to feel out of breath.
• Vitamin B12. One study found that older women with vitamin B12 deficiency were at higher risk for severe depression. To get enough B12, consume plenty of milk, eggs, fish, and meat. If your diet is restricted or you are over age 70, consider taking a supplement of 5 mcg a day.
• Stay in focus. Yoga, tai chi, or meditation can help you relax, focus your thoughts, regulate breathing, and improve flexibility. Try 30 to 60 minutes a day to lift your mood.
• Sleep tight. Get enough sleep. Avoid naps and try to go to sleep at the same time every night and wake up at the same time every morning.
• Reach out. Interacting with other people helps keep depression at bay. Stay active socially by doing volunteer work or joining a group.
• Adopt a pet. Caring for a dog, cat, or bird gives you another focus and provides companionship.