Article from: MyTreatment.com
What is Depression?
Depression is a treatable medical illness that causes a person to have a very low mood for an extended period of time. It interferes with one's ability to function in the home, work and social environment. Depression lasts longer and is more severe than a person's normal response to disappointment or failure. It is important to realize that depression is an illness and not a character flaw. In 15% of untreated cases depression can become so debilitating it leads to suicide. About 10% of the population in North America experience depression at any given time.
How do I know it is depression? (you do not like signs and symptoms)
People experiencing major depressive disorder report feeling five or more of the following symptoms, with depressed mood or no interest in normal activities being one of their symptoms.
Depressed mood
No interest in normal activities
Feeling hopeless, guilty, worthless, or helpless
Decreased sexual desire or pleasure
Decreased energy, feeling tired
Difficulty concentrating, remembering, or making decisions
Restless or irritable
Sleeping too much or unable to sleep
Increased or decreased appetite with weight loss or gain
Psychomotor retardation (slowed down), agitation
Chronic pain or increase in somatic complaints not caused by illness or injury
Suicidal thoughts, feelings or attempts
Causes
What causes depression?
Research into the causes of depression is ongoing. There are several factors that can increase the risk of a person developing depression. These are both genetic and environmental in nature. However, it is important to realize that many people with risk factors never do develop this illness.
Risk factors include:
Family history
Social factors
Developmental factors
There are several neurotransmitters found in the brain that are important for maintaining a normal mood. When these chemicals get out of balance or become depleted depression can result. Three neurotransmitters that are often focused on are:
Norepinephrine
Serotonin
And dopamine
Sometimes, although not always, a stressful event might cause a person who is inclined to depression to develop an episode. As time goes on, with frequent episodes of illness, depression may be caused by relatively mild stressors or with no stressor present.
Depression Treatment
Treatment Goals
Why do we talk about treatment goals? Wouldn't everybody's goal be to get completely better? This is a very important question. Our first goal in all cases is to bring depression into remission. In other words we want to return people to their previous level of functioning before depression occurred. Unfortunately many people choose to settle for only partial improvement. Many people with depression prefer to settle for partial remission rather than increase the dose of their medication to achieve full remission. However, people who choose only partial remission have a higher likelihood of experiencing a relapse. They also have shorter depression free periods than people who choose full remission.
Our second goal is to prevent relapse. This is best done by:
Achieving full remission;
And by keeping the patient on medication for a long enough period of time to prevent relapse.
Many people choose to go off treatment soon after their symptoms have gone away. People who do this too soon often experience relapse. People who remain on medication treatment for a period of six months to one year after achieving remission have a much better prognosis. They have fewer relapses and longer periods of time between relapses.
It is recommended that people who have had two or more relapses of Major Depressive Disorder remain on medication treatment to prevent further relapses and to prevent relapses from becoming too severe, if they do occur.
A variety of treatments including medications and short-term psychotherapies have proven effective for depression.
Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.
The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.
The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression, and get a complete history of symptoms, e.g., when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs, and whether the patient is thinking about death or suicide.
Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.
Medication
Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.
The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics–named for their chemical structure–and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects. However, medications affect everyone differently–no one–size–fits–all approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice.
People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances.
For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit–forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.
In addition, if one medication does not work, patients should be open to trying another. NIMH–funded research has shown that patients who did not get well after taking a first medication increased their chances of becoming symptom–free after they switched to a different medication or added another medication to their existing one.
Sometimes stimulants, anti–anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co–existing mental or physical disorder. However, neither anti–anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.
What are the side effects of antidepressants?
Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long–term. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.
The most common side effects associated with SSRIs and SNRIs include:
Headache–usually temporary and will subside.
Nausea–temporary and usually short–lived.
Insomnia and nervousness (trouble falling asleep or waking often during the night)–may occur during the first few weeks but often subside over time or if the dose is reduced.
Agitation (feeling jittery).
Sexual problems–both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.
Tricyclic antidepressants also can cause side effects including:
Dry mouth-it is helpful to drink plenty of water, chew gum, and clean teeth daily.
Constipation-it is helpful to eat more bran cereals, prunes, fruits, and vegetables.
Bladder problems–emptying the bladder may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected. The doctor should be notified if it is painful to urinate.
Sexual problems–sexual functioning may change, and side effects are similar to those from SSRIs.
Blurred vision–often passes soon and usually will not require a new corrective lenses prescription.
Drowsiness during the day–usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.
FDA Warning on antidepressants
Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.
This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.
The warning emphasizes that children, adolescents and young adults taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations.
Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.
What about St. John's wort?
The extract from St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top–selling botanical products.
To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight–week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one–third to a commonly prescribed SSRI, and one–third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.29 Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.
Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.
Psychotherapy
Several types of psychotherapy–or "talk therapy"–can help people with depression.
Some regimens are short–term (10 to 20 weeks) and other regimens are longer–term, depending on the needs of the individual. Two main types of psychotherapies–cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT)-have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.
For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence.25 Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.21
Electroconvulsive Therapy
For cases in which medication and/or psychotherapy does not help alleviate a person's treatment–resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.
Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. A patient typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some patients will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.
ECT may cause some short-term side effects, including confusion, disorientation and memory loss. But these side effects typically clear soon after treatment. Research has indicated that after one year of ECT treatments, patients showed no adverse cognitive effects.30
What efforts are underway to improve treatment?
Researchers are looking for ways to better understand, diagnose and treat depression among all groups of people. New potential treatments are being tested that give hope to those who live with depression that is particularly difficult to treat, and researchers are studying the risk factors for depression and how it affects the brain. NIMH continues to fund cutting–edge research into this debilitating disorder.
An overall assessment of the nation's largest real-world study of treatment-resistant depression suggests that a patient with persistent depression can get well after trying several treatment strategies, but his or her odds of beating the depression diminish as additional treatment strategies are needed. The conclusions from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, funded by NIMH, were published in the American Journal of Psychiatry on November 1, 2006.
A combination of psychotherapy and antidepressant medication appears to be the most effective treatment for adolescents with major depressive disorder—more than medication alone or psychotherapy alone, according to results from a major clinical trial funded by the National Institutes of Health’s National Institute of Mental Health (NIMH). The study was published in the October 2007 issue of the Archives of General Psychiatry.
