Depression

Like anxiety, depressed feelings strike almost everyone at some time. And like anxiety, depression is an appropriate response to some situations. But depression that is overwhelming and persistent is a serious illness. An estimated 15 percent of people with severe depression commit suicide and many more make a suicide attempt. Depression is the most common emotional disorder in women, about one­fourth of all women suffer from depression at some time in their lives.

Since we all tend to use the term depression to describe the “blues”, people often think a serious depression is simply more of the same, a problem that will pass in time. But serious depression is more than the ordinary feelings of grief, disappointment, or burnout that are normal, short­lived responses to real disappointment or loss. People suffering from depression are suffering from an illness, just like a physical illness such as appendicitis or diabetes. And just like a physical illness, serious depression doesn't respond to common sense, you cannot just snap out of it, and it doesn't improve when things get better. Most important, despite some commonly held views, it is not a sign of a weak character, or lack of will power. Certainly it's not a disorder that implies failure in your life: Ludwig van Beethoven, Winston Churchill, Charles Dickens, Abraham Lincoln, and Virginia Woolf, among many other famous historical figures, all suffered from depression at one time or another.

Causes of Depression

There are many theories about the cause of depression. Recent research suggests that some people are biologically inclined to react with depression when they experience a stress overload. Another suspected culprit is an imbalance of certain chemical messengers in the brain, particularly a substance called serotonin. Other theories suggest that depression is a result of anger turned inward towards oneself, an ingrained sense of helplessness, or patterns of negative thinking.

Depression can also be caused by illnesses (such as thyroid or adrenal gland problems, infections, and multiple sclerosis), by drug or alcohol abuse, and by prescription medications. For example, among the drugs that can cause depression are some of those prescribed for high blood pressure, heart disease, pain relief, stomach and intestinal problems, and Parkinson's disease. Anticonvulsants, sedatives, sleeping pills, oral contraceptives, antibiotics, and cancer chemotherapy drugs can also be at fault.

Diagnosing Depression

Depression is not always easily diagnosed and many women go from doctor to doctor with vague complaints of fatigue, difficulty sleeping, irritability, poor concentration, or stomach and intestinal distress until someone finally realizes they are seriously depressed. (This is often referred to by physicians as “masked depression.”) You should suspect depression if you find that in addition to all of your symptoms, you are simply not able to enjoy yourself.

PRIME SUSPECTS IN DEPRESSION: THE CHEMICAL MESSENGERS OF THE BRAIN

To pass messages among themselves, nerve cells in the brain release bursts of chemicals that briefly stimulate receptors on a neighboring cell, then quickly disappear. These chemicals, called neurotransmitters, are manufactured within the cell and stored in tiny bubbles (vesicles) at the end of the cell's tentacle-like axons. They travel to the receiving cell across a tiny gap called the synapse. To eliminate one burst of a neurotransmitter and prepare for the next, the chemical is either destroyed by the receiving cell or taken back by the sending cell in a process called “reuptake.” Serotonin, a neurotransmitter that plays a central role in the brain, appears to be in short supply among the depressed; and a number of antidepressant drugs are thought to work by preventing serotonin's destruction or reuptake. The celebrated drug Prozac, for instance, is classified as a “serotonin uptake inhibitor.”

There is no specific diagnostic test for every type of depression but a thorough medical examination and interview with a psychiatrist, psychologist or neurologist can help make a diagnosis. Since specific medical conditions can cause depression, if indicated, your doctor will do diagnostic tests to make sure that a physical illness is not the underlying cause. Depression disorders fall into three categories:

Major depression, also called unipolar or clinical depression, is a syndrome with specific symptoms that affect your body, emotions and thoughts. Criteria for a diagnosis of depression include:

• Depressed mood most of the day, nearly every day
• Loss of interest in pleasurable activities
• Significant weight loss or gain
• Disturbed sleep
• Constant fidgeting or a slowdown in movement
• Fatigue, loss of energy
• Feelings of guilt, worthlessness, hopelessness
• Difficulty thinking or concentrating
• Indecisiveness
• Recurrent thoughts of suicide

If you have at least five of these symptoms and they interfere with your daily life, the condition is called major depression. If you have fewer than five or if the symptoms are mild and do not interfere with daily life, the condition is called mild depression.

Bipolar depression, which used to be called manic depression, causes not only the “lows” of major depression, but also a mood swing to a wild euphoric state. These “highs,” or manic episodes, can be extremely disruptive.

Most people with bipolar depression go for many months between episodes of depression or mania. Women are more likely than men to have more frequent episodes, called rapid cycling.

Criteria for a diagnosis of the manic phase of bipolar depression include:

• Less need for sleep
• Talkativeness
• Distractibility
• Flight of ideas
• Increase in goal­directed activities—either socially, at work, in school or sexually—or restlessness and agitation
• Inflated self­esteem
• Excessive involvement in pleasurable activities that have high potential for negative consequences, such as buying sprees, sexual indiscretions, or foolish business investments

If you have these symptoms in a milder form insufficient to disrupt your daily life, the condition is called hypomania.

Postpartum Depression. Many new mothers suffer from some degree of “baby blues,” after childbirth. They find themselves crying or laughing easily and often. They feel anxious and have trouble concentrating. Typically, this situation lasts a few weeks.

For some new mothers, however, the blues become a serious postpartum depression that can, without treatment, last more than a year. Anxiety, fatigue, phobias, an inability to enjoy life, sleep disturbance, lack of appetite, and guilt are common. If you suffer from postpartum depression, you may be overly anxious about the care and health of your baby or doubt your ability to be a good mother. If you are a first­time mother, you are more likely to have mild baby blues rather than serious postpartum depression.

Postpartum depression may be caused by a number of physical, psychological and social factors that accompany childbirth. Two important contributors may be postpartum hormone levels and the inevitable sleep deprivation that comes with a new baby. Your expectations, family situation, and the baby's personality and condition may all also contribute.

Related Disorders

Depression and Premenstrual Syndrome (PMS). PMS is not depression, although if you have PMS you may have some of the same symptoms (see chapter 3, “PMS: Sorting Fact from Fiction.”) PMS is considered a recurring mood disorder, caused by hormonal changes related to menstruation. Researchers are investigating the relationship of PMS to depression.

Seasonal Affective Disorder (SAD) is a cyclical mood disturbance that affects mostly women. It is often related to a lack of light, and usually occurs in the fall and winter. Most people with SAD become depressed when the days are short and get better as the days lengthen in the spring. (Paradoxically, a few feel better in the winter, worse in the spring, and summer.) Researchers are investigating a link between SAD and the hormonal changes that accompany menstruation.

Treating Depression

A combination of psychotherapy and medication is usually helpful in treating major and bipolar depression. Psychological approaches, including cognitive (learning), behavioral, and interpersonal therapies, can help you understand patterns of negative thinking and can help you develop a more positive outlook.

Treatment for postpartum depression may include counseling, cognitive therapy, and medication. Most doctors suggest that new mothers also seek out social support systems such as new mothers groups. Some women find relaxation training to be helpful. About two­thirds of women with postpartum depression recover in one year.

Seasonal Affective Disorder (SAD) is treated with both antidepressants and exposure to bright sun or special treatment lights.

Drugs used in treating depression can take several weeks to become effective. They require close medical follow­up to monitor potential side effects.

There are three common types of antidepressant medication. Drugs in one category may work very well for a particular individual, while another type has little effect. There is no way to predict which type is best for a specific patient, so don't be surprised if your doctor has to try several different prescriptions before finding the medication that works best for you.

The newest type of antidepressant, called serotonin uptake inhibitors, includes the widely publicized drug fluoxetine (Prozac). Other drugs in this category are paroxetine (Paxil), sertraline (Zoloft), and the new drug venlafaxine (Effexor), which affects several of the brain's chemical messengers. These drugs claim to have fewer side effects than some of the others.

A second major type, called tricyclic antidepressants, is thought to work by increasing the availability of another brain chemical called norepinephrine. Included in this category are amitriptyline (Elavil, Endep), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), desipramine (Norpramin, Pertofrane), and amoxapine (Asendin).

A third category, known as mao inhibitors, is often tried when other antidepressants fail. Included in this group are phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). mao inhibitors cause dangerous interactions with a number of foods and need to be taken with care.

Falling outside these three categories are medications such as buproprion (Wellbutrin), trazodone (Desyrel), and maprotiline (Ludiomil). Lithium (Lithonate) is prescribed for treatment of the manic phase of bipolar depression, and is now also being used for recurrent depressive episodes.

For a small group of people, psychotherapy and drug therapy are not effective. Electroconvulsive therapy (ECT), also known as shock therapy, can be helpful to these people. New methods of ECT are painless and pose little risk of harm. The most common side effect is a limited, temporary loss of memory.

Outook

Depression usually has a beginning and end, but many people who have major depression once will have it again. Major depressions generally last six months to two years; the average duration is nine months.

Bipolar depression tends to be a lifelong condition, requiring close medical supervision. If you learn to manage this condition effectively, as most people do, you can lead a fully­functioning life.

Next: Chronic Fatigue Syndrome