Medical Memo, Depression

This newsletter is for your information only and is not a substitute for talking with your psychiatrist, medical doctor, and/or therapist.

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What Is Depression?

Depression is probably best understood as a persistent mood of pronounced sadness which is present at least most of the day on most days for at least 2 weeks and typically interferes with normal function. Sleep, energy, motivation, pleasure, hope, concentration, temper, self esteem, physical health, libido (sex drive), interest in or ability to communicate, the ability to think rationally, and the desire to live may, some or all, be affected. Depression may be so severe (called Major Depression) that it is disabling and life threatening, or moderate but lasting years (Dysthymic Disorder is now known in DSM 5 as Persistent Depressive Disorder), or present in varying ways (agitation, with anxiety, after giving birth (Post-Partum), seasonal, premenstrual, after psychosis, with melancholia, etc.) with varying effects for shorter or longer periods. Manic-Depression is now called Bipolar Disorder and is an alternation or mixture of depression and certain other elevated mood symptoms known as mania or hypomania. Depression may be caused by genes (inherited), directly or indirectly by a medical problem, by stress, trauma, loss, or grief, by substance abuse, by a medication, by life events, occur for no clear reason, or most often be due to some combination of factors. Depression may show itself somewhat differently in children, the developmentally delayed, young adults, older adults, the elderly, in men vs. women, and in different cultural or ethnic and racial groups.

Depression is the second most common psychiatric disorder, behind only Anxiety. Depression often occurs along with or may be confused with other disorders such as anxiety, substance abuse, or along with or due to other mental and general health problems. At least 10-20% of all people will have an episode of Major Depression sometime in their lives. About 1.6% of all persons have a Major Depression currently. About 3% have Dysthymic Disorder (chronic minor to moderate depression) currently while another 4-8% have a current minor to moderate depression lasting weeks to months.

Up to 15% of people with Major Depression, especially when recurrent and on top of dysthymic disorder (known as “double depression”), may eventually kill themselves. Suicide risks are higher for depressed persons who also have severe anxiety such as panic attacks, abuse substances, feel chronically very hopeless, have severe depression marked by severe loss of interests and pleasure, marked insomnia, and delusional thinking or hallucinations. Of course, other factors like increasing age, access to lethal means (especially guns), and a personal and family history of suicide, suicide attempts, and suicidal ideas, plans, and intent are also important risk factors.

75% of all depressed people never see a mental health professional. Many go to their primary care doctor where their symptoms may or may not be recognized as depression. Even so, primary care doctors treat more people for depression than psychiatrists do. This occurs because stigma keeps some from accepting or being referred to mental health caregivers, some have no or poor mental health insurance coverage, some just feel too depressed and hopeless to seek help, recognize their need, or suffer from outdated negative stereotypes or misinformation about the treatment itself. Unfortunately, half of all people with depression are never diagnosed or treated. Too many who are treated are treated only partly and most are never referred to or never seek out a mental health professional. This is especially sad when you realize the success rate for treating Major Depression is 70%; higher than or close to similarly dangerous or disabling illnesses like heart disease, cancer, diabetes, arthritis, lung disease, and hypertension. There is also strong evidence that co-existing depression increases the impairment and chances of dying from other medical illnesses such as heart disease and cancer.

When depression is being considered as a possible cause of health, emotional, or behavioral problems a visit to the primary care doctor is often a good idea before, along with, or after seeing a mental health professional. An updated medical history and physical exam, perhaps even a few tests, may help ensure not missing another health problem that may cause or complicate depression. This is especially worth considering if the therapist is not a psychiatrist since only psychiatrists are also physicians. Sometimes, in complicated or confusing situations, in depth psychological tests done by a Psychologist may be quite helpful in clarifying the diagnosis.

Left untreated, half of all persons with Major Depressions will recover completely in under a year. Even so, treatment often saves enormous pain, agony, societal, work, relationship, and other costs. Of course, the other 50% either recover more slowly, have higher rates of chronic or relapsing patterns, have other complications, or may die. Persons who have 2, or certainly 3, episodes of depression in any 5 year period are very likely to have more episodes in the future. Medication helps prevent recurrence as well as treat the current episode. Some research indicates a first episode of Major Depression in one’s youth, especially when severe, indicates a higher likelihood of future recurrences and a higher chance of Bipolar Disorder. Treatment for depression, like all illnesses, is aided by improving basic health habits, eating nutritiously, getting rest and exercise, and keeping connected with both activities and other people. Spiritual and creative pursuits and outlets help many. The core treatments for Depression are psychotherapy and medication. 25% respond well to psychotherapy alone, 25% to medication alone, and 50% do best with a combination of both. Cognitive Therapy, Interpersonal Therapy, and Psychodynamic Therapy are three forms of psychotherapy which have repeatedly been shown to be very powerful in treating depression. Cognitive Therapy focuses on correcting and changing the negative and distorted thoughts that are a core finding in depression. Interpersonal Therapy focuses on addressing dysfunctional and problematic relationships and interactional styles that are noted in many depressions. There is a substantial and growing number of medication options for depression and related or co-occuring conditions. Medicines are becoming more and more focused in their effects and show less and less side effects. In fact, most of the modern antidepressant side effect possibilities are in the range of nuisance and are not dangerous; some side effects can even be used to be helpful in some situations. Medications are especially important, if not essential, for Major Depression and Bipolar Disorder. Stopping alcohol or drug use, especially abuse, is also strongly advised. Electro-convulsive therapy, known as ECT, is another option that is remarkably effective for severe depression. Despite the media’s distortions, ECT is a very safe and rapidly effective option appropriate when other options have failed or are too slow. Hospitalization continues to have a role, especially when danger to self or others is severe, and when other efforts fail or are unavailable.

No “alternative” herbs, supplements, vitamins, homeopathic remedies, etc. have been shown to be effective in Major Depression or Bipolar Disorder. Many “complementary and integrative” treatments such as biofeedback, hypnosis, special breathing techniques, massage, etc. have nonspecific but possibly helpful effects on depression and other conditions. Adequate sleep, a healthy diet, fish oil, and regular exercise are often necessary but not sufficient alone, especially for Major Depression or Bipolar Disorder. Research into a special type of magnetic therapy called rTMS and Vagal Nerve Stimulators (VNS) show some promise in some cases.

Treatment options have both expanded and become more effective with less side effect risks in the last 10 years. This improvement in the number, quality, and convenience of treatment options gives hope. It is a rewarding time to be doing this work.

What Is Major Depression?
Major Depression is the most severe form of depression. Major Depression is almost always a biologically based disorder of the brain just as asthma is based in the lungs and diabetes is based in the pancreas. The more "biological" signs of depression that are present the more likely medication treatment will be advised and helpful. These biological signs are the criteria listed below. Other health problems may worsen or cause depression. In order to give the diagnosis of Major Depression at least 5 of the following criteria (signs and symptoms) must be present for at least 2 weeks including either depressed mood or loss of interest and pleasure (anhedonia) and cause substantial impairment in functioning:
a) Depressed mood most of the day, almost every day
b) Marked loss of interest or pleasure in usual activities (anhedonia) often including libido
c) Fatigue or loss of energy nearly every day
d) Feelings of worthlessness, hopelessness, and unreasonable feelings of guilt
e) Significant weight loss when not dieting or weight gain (appetite changes)
f) Insomnia or excessive sleep nearly every day
g) Agitation or pronounced slowing of body movements
h) Significant decreased ability to think, concentrate, or make decisions
i) Recurrent thoughts of death or suicide

What Is Persistent Depressive Disorder (Dysthymic Disorder)?
Dysthymia is a more moderate to mild but persistent form of depression in which less than 5, but at least 2, of the above criteria of Major Depression are present for at least 2 years in adults and at least 1 year in youth under 18 years old. In the past this condition was often called Depressive Personality or Depressive Neurosis. Until the last decade psychotherapy was thought to be the only treatment for the condition. Now we know people with Dysthymia also often respond to antidepressants, especially the newer ones.

What is Other Specified or Unspecified Depressive Disorder ?
This includes all the varying kinds of depression that are not severe enough to fit Major and not long lasting enough to fit Dysthymic Disorder. Treatment advice and need for treatment depends on the unique situation.

Can Health Problems Cause Depression?
Yes! Certain medications, infections, hormone imbalances, immune system disorders, neurologic conditions, a few vitamin deficiencies, and some cancers can cause either depression or something that looks a lot like depression. Although these are uncommon causes of depression, this is a good reason to see your family physician, internist, or pediatrician as part of seeking help when depression is suspected.

What is Unipolar Depression?
Unipolar depression means the person only experiences depression and not the mania or hypomania that automatically changes the diagnosis to Bipolar Disorder (formerly called Manic Depression).

What Causes Depression?
Typically, there is an inherited tendency toward depression, which is brought on by stressful life events, losses, or may occur for no clear reason.

What Is Melancholic Depression?
Melancholia is an older term, which refers to most people’s notion of severe depression. This type of major depression is marked by weight loss, extremely low energy or agitation, marked feelings of worthlessness, extreme even irrational guilt, severe loss of pleasure in virtually all areas of life, very early morning awakening, consistent severely depressed mood, and increased risk for suicide. Medication treatment is thought to be particularly important for this condition.

What Is Atypical Depression?
Generally, this refers to the non-melancholic depression patterns such as increased eating, increased sleeping, and personality problems such as "rejection sensitivity". In the past, MAOI’S (Monoamine Oxidase Inhibitor medications) were found to be more helpful than the Tricyclic antidepressants for this subtype of depression. Now, we usually use the SRI’s (fluoxetine = Prozac, citalopram = Celexa or Lexapro, sertraline = Zoloft, etc.) or NRI (bupropion) or others first.

What Is Psychotic Depression?
This is a very severe form of Major Depression identified by the additional presence of hallucinations and delusions. Sometimes the depression (or mania) may co-exist with signs of schizophrenia and is then referred to as Schizoaffective Disorder. This condition often requires both antidepressant and antipsychotic medications.

What Is Postpartum Depression?
Postpartum means after childbirth. The dramatic drops and rebalancing of hormones and/or major life changes that come with childbirth can throw some women into a potentially severe depression. Time and treatment help. Treatment is especially key when the depression is severe as there can be severe risk to the baby as well as to the mother. Repeat episodes of depression with or without future pregnancies are not uncommon. Women with a personal history or family history of depression or bipolar disorder are at higher risk. A milder form, known as post partum "blues" is less severe but can be a warning sign and can also impact the early parent-child relationship.

What Is Co-morbidity?
Co-morbid means than one or more other conditions occur at the same time. The conditions may be related or not. For example, anxiety often occurs along with (is co-morbid with) depression. This is also common for substance abuse, ADHD, personality disorders, eating disorders, Alzheimer’s, heart disease, etc. When other disorders occur along with depression this often makes the depression (or both) more difficult to treat or chronic. Both or all conditions often benefit from simultaneous or sequential (one after the other addressing the underlying condition first) treatment.

If I had a Major Depression, will my child have it someday??
Probably not, but the chances are somewhere between 15% and 25% your child will someday have an episode of Major or other depression. This compares to the risk for the general population, which is about 2%.

If I had a Major Depression, will I have another one?
Probably not but your risk is higher, too. If you have had 3, and maybe 2, episodes of Major Depression in 5 years your risk of recurrence is so high we often advise staying on a maintenance dose of antidepressant to lessen the chance of more episodes and/or lessen their severity. If you know you have a tendency to depression it is helpful to make lifestyle adjustments just like you should if you have a tendency to diabetes, seizures, high blood pressure, heart disease, or asthma, etc. Learn to recognize warning signs, risk factors for you, and especially at difficult times lessen your stress with rest, exercise, good nutrition, supportive people and activities, spirituality, and treatment services when appropriate.

What is S.A.D. ?
Seasonal Affective Disorder is a form of depression marked by depression occurring most often in the winter when the shorter colder days lead to less exposure to sunlight. Therefore treatment may include getting more sunlight and even light therapy. Persons with SAD also have a higher risk for Bipolar disorder with manic or hypomanic episodes occurring more commonly in the spring and summer.

(07/14)