Return to Depression and Bipolar Disorders
Why We Are Depressed and What We Can Do
About It
Dennis B. Kottler, MD
Introduction
This is the
fifth part in a series looking at major health concerns that affect our society in
epidemic proportions. The current monograph
deals with the epidemic of Depressive Disorders and
discusses currently available treatments, including self-help strategies, to combat this
major health threat. It is hoped that many
individuals with this disorder will find this monograph of major help.
What is “Normal” Mood
In
discussing disorders of mood it is helpful to consider for a moment what is
“normal.” It is certainly normal
for an individual to have a range of moods, from despondent to ecstatic. These mood states will normally correlate with the
external as well as the ”internal” environment.
Thus, if a person has a good reason to feel sadness, this is a normal mood state,
and one would be suspicious if the reaction were otherwise.
Similar reasoning pertains in the case of elation.
Sometimes the precipitant of the mood state is less than obvious and involves the
“internal” environment. For
example, a person may feel sadness because he feels he has failed himself in attaining
some very personal goal. This sadness may be
quite appropriate, assuming this person’s expectations for himself are not
excessively unrealistic.
Generally,
there should be concern when a mood state, either positive or negative, appears totally
unjustified by external and/or internal precipitants and when the mood deviation is of a
degree that it affects one’s usual social and/or occupational functioning.
Of course it
is normal to have “good days” and “bad days,” often without apparent
reason. Perhaps this just reflects some
transitory change in the “chemical soup” of our nervous system. Nonetheless, there is usually a more or less
customary baseline mood that seems to be the norm for a given individual. However, when the mood deviation is sufficient
that it begins to affect one’s life in adverse ways, and when this mood deviation
persists for more than several days, there should be concern that something beyond the
“normal” has occurred.
A second
scenario of concern occurs when a mood deviation is in fact precipitated by some
situational event, but the reaction is more extreme and of longer duration than one would
usually expect. Except in extreme situations,
such as bereavement, this situation is cause for concern as well.
Major Depressive Disorder
One common
form of depression, often quite disabling when it occurs, is the “major depressive
disorder” (see Diagnostic and Statistical Manual of Mental Disorders – 4th
ed. pg. 339). A person is considered to have
a major depressive disorder if he experiences one or more major “depressive
episodes” and the disorder cannot be explained by substance abuse, a general medical
condition, or another mental disorder.
Some of the
characteristics of a “depressive episode” are listed below. These symptoms are considered especially
significant if they have lasted two weeks or more and represent a deviation from the usual
behavioral state of the individual. According
to the Diagnostic and Statistical Manual of Mental Disorders – 4th ed.,
these characteristics include (paraphrased):
--
sadness and sometimes irritability, especially in children and adolescents, much of the
day for most days and lasting for two weeks
--
diminished interest and pleasure in almost all activities, most of the day, nearly every
day
--
weight loss or gain of greater than 5% of body weight in a month when not dieting, or
significant change in appetite
--
diminished or excessive sleep sustained over a period of more than a few days
--
agitation or slowing of movements and/or speech and other behaviors daily
--
fatigue or loss of energy most days
--
worthless feelings or excessive and/or inappropriate guilt feelings nearly every day
--
interference with ability to think or concentrate or make decisions most every day
--
repeated thoughts of death and dying, including thoughts of suicide, suicide plans, or
attempts at suicide
From the
clinical standpoint, the presence of five or more of the above characteristics, lasting
over a period of two weeks or greater, and including sad mood or loss of interest or
pleasure, are thought to be hallmarks of the “depressive episode.” This is especially so if the symptoms cause
significant distress or interfere with social and/or occupational functioning and are not
the result of bereavement.
It is
important to rule out a specific medical condition, for example, hypothyroidism, that may
be causing some of these symptoms, prior to diagnosing a “depressive episode.” It is also necessary to rule out the effects of
substance abuse, which may mimic a depressed state. For
example the use of alcohol or other central nervous system depressants can produce a
condition indistinguishable from clinical depression.
Finally, one must consider that the depressed state may, in fact, be part of
another serious mental condition, such as schizophrenia or an anxiety disorder. Such considerations might change the recommended
course of treatment.
There are
milder forms of depression other than the major depressive disorder described above. In one such form of depression, a person has many
of the above symptoms but the symptoms are generally of less severity. This condition, referred to as dysthymic
disorder, is usually chronic, lasting for years, if not most of one’s life. In contrast, in the case of major depressive disorder, the episodes of
depression are usually more discrete with periods of remission between episodes.
Bipolar Disorder
In addition
to the unipolar, major depressive disorder and the dysthymic disorder described above,
there is the bipolar disorder, or in older terminology, “manic-depressive”
disorder. This disorder will not be a
focus of this current monograph but it needs to be mentioned, since during the depressed
state an individual can appear to have a unipolar, major depressive disorder. Sometimes only the history of a prior manic
episode can reveal the presence of the bipolar problem.
Manic episodes are characterized by periods of excessively elevated
mood, sometimes with irritability intermixed, that last by definition (DSM IV) at least
one week. During a manic episode there may be
grandiosity, increased talkativeness, decreased sleep requirement, agitation, easy
distractibility, and uncharacteristic behavior, such as excessive spending or greatly
increased, high-risk, sexual activity.
Bipolar
disorder exists as both the classic bipolar I disorder of extreme mood states (depressed
and manic), as well as the atypical form, sometimes called bipolar II, consisting of
depressed states and more muted manic states, or hypomanic states. A final form of cyclical mood disorder is the
cyclothymic disorder, sometimes thought of as more of a personality type, wherein the
individual vacillates between highs and lows but not of a severity sufficient to diagnose
a true bipolar condition.
Mood and the Seasons
There is
increasing evidence that some individuals’ mood states may be sensitive to changes in
the seasons. Thus we have the
expression, “seasonal affective disorder,” abbreviated as SAD. Individuals with this problem seem to
fall into depression more often in the fall and winter.
The prevailing theory holds that changes in the amount of daylight
during the year, particularly the shorter daytimes in the winter, trigger depression in
these people. The resulting depression
frequently follows a pattern of diminished energy, weight gain with overeating, a craving
for carbohydrates, and increased sleep. This
pattern has been compared to the hibernation seen in some animals. In some susceptible individuals the seasonal
effect can trigger a true depressive episode, in other cases it may lead to a milder form
of depressed mood.
One
treatment for this disorder involves the use of bright visible light therapy, the
so-called “light box” treatment. Sometimes,
getting up early in the morning light and taking a walk (assuming a reasonable amount of
light present outdoors) can help. However,
the “light” treatment has been alleged to trigger a reversion to a manic state
in susceptible bipolar patients.
It is
interesting to note that a symptom of major depressive disorder is frequently “early
morning awakening.” Can it be that this
symptom is a “built-in” adaptive mechanism whereby the depressed individual is
exposed to the early morning light? In
this regard, it is interesting to consider the effects of morning light on stabilizing the
internal diurnal clock and its role in treating sleep disorders (see “Why We Can’t Sleep and What We Can Do About
It” by this author, also available through “FatBrain”).
A Spectrum of Moods
One may be
getting the impression that mood disorders exist on a continuum. This may well be the case. There are probably many degrees of cyclical mood
disturbance from the classic bipolar disorder on the one hand to the much more mild
cyclothymic (personality). Similarly,
in the case of unipolar depression, there exist many degrees of depression, from the
mildly melancholic individual, to the more melancholic dysthymic condition, to the
“true” major depressive episode.
Thus it can
be hypothesized that there is a very complex system in the brain responsible for mood
regulation. Changes in the functioning of
this system are reflected in a whole range of variations, some of which are sufficiently
extreme and intrusive on function, that we consider them “mental disorders.”
Note of Caution
One
important caveat is in order. It is
advisable, when a mood disorder (unipolar or
bipolar) is suspected, that the individual (and family members if appropriate) obtain
suitable consultation from a psychiatrist especially skilled in the treatment of these
disorders. During this consultation the
psychiatrist should be able to formulate an appropriate diagnosis and explain the various
treatment options available.
Depression: Where Does It Come From?
There are a
great many theories which have evolved over the years to try to explain depressive
disorders. The
psychoanalytic movement came upon the notion that depression may involve rage turned
inward. This may be a useful explanation for
some individuals, but it often does not seem to apply.
Other
theorists have tried to relate depression to a pattern of negative thinking, which the
individual seems to have acquired. Whether
the negative thinking is secondary to the depressed mood state, or the primary disorder
itself, with the negative mood the result, is not resolved.
Nonetheless, a cognitive therapy approach, with coaching by a
therapist in re-evaluating and reformulating thought (from negative to more
“realistic”) seems to be helpful in treating depression.
Presently,
there is strong support for the concept that many depressions have a biological basis in
the form of some abnormality in the amount or action of certain chemicals in the brain
called neurotransmitters. The
neurotransmitters occur throughout the brain, including the brain regions thought to be
responsible for mood regulation (limbic system and related structures). Medication treatment of depression is directed at
correcting these abnormalities, which may involve the neurotransmitters known as serotonin
and norepinephrine. Some depressions are
thought to result from serotonin and/or norepinephrine depletion in the synapses, or
junctions between neurons. Thus some
medications are known as serotonergic, they increase serotonin in the synapse, or
noradrenergic, they increase norepinephrine, also called noradrenalin, in the synapse. Some medications can have both effects. Another neurotransmitter which may be involved is
dopamine.
Medical
science is still in the beginning stages of identifying which of these abnormalities of
neurotransmitters is operating in a particular individual who is experiencing depression,
or for that matter any of the other mood disorders, described above. Thus, although we have medications which target
these different neurotransmitter abnormalities, it is still trial and error in selecting a
medication for a particular individual.
Treatment Approaches for Depressive Disorders
Treatment
approaches for depressive disorders fall into
the categories of medication management, cognitive/behavioral therapy, group therapy,
family therapy, and traditional psychotherapy, both psychodynamic as well as supportive. An approach which often seems highly effective in
treating many depressed individuals is the combination of medication treatment and
cognitive treatment. Studies have shown this
combined approach to be superior to either medication or psychotherapy (including
cognitive therapy) by itself. See
above for description of cognitive therapy.
Medication
treatment of depression has expanded enormously in the last ten years. Many more medications are now available, although
as mentioned, it is still largely trial and error to decide which medication will benefit
a particular individual. The newest
medications are the SSRI’s (selective serotonin re-uptake inhibitors) which cause
more serotonin to be available in the synapses between neurons by blocking the re-uptake
of the serotonin by the pre-synaptic neuron. Common
SSRI’s are Prozac, Zoloft, Paxil, Celexa, and Luvox.
The SSRS’s are much less problematic as far as certain troublesome side
effects, which the older tricyclic antidepressants caused.
These side effects were dry mouth, blurred vision, constipation, and
dizziness. However, these newer SSRI
medications sometimes cause gastrointestinal distress, headaches, insomnia, and the
inhibition of orgasm, in both men and women. These
side effects can be minimized by starting at a low dose and titrating the dose gradually,
by taking the medication with food (in the case of GI side effects), and by taking the
medication in the morning (in the case of insomnia).
But most importantly, not everyone has the same experience with medication. Some medications which cannot be tolerated
by some individuals because of side effects,
do quite well in other cases. Also efficacy
varies among the different medications when used for different individuals, for reasons
not understood at this point.
In addition
to the serotonin medications (SSRI’s), the older tricyclic medications, such as
Elavil, Tofranil, Norpramin, and Sinequan, are still quite useful for some patients and
their sedating effects can be helpful when a sleep disorder is part of the problem. There is also a class of medications called
monoamine oxidase inhibitors (MAOI’s) which have a role in treating some depressions,
not responsive to other medications. They are
often most useful in treating depressions with elements of
“atypia,” such as is the case with “seasonal affective
disorder.” However, there are special
dietary concerns when using these medications. There
is also a group of “newer” medications, which do not fall neatly into any of the
previous categories. These include
Serzone, Effexor, and Wellbutrin. Again, medication
treatment must be individualized to the patient . In
some refractory cases of depression, the addition of an adjunctive medication such as
lithium carbonate, Cytomel (a form of thyroid), or a stimulant medication such as Ritalin
or dextroamphetamine has been found helpful.
Medication
is often effective in 60% to 70% of patients. Sometimes
the medication needs to be given chronically, although it can often be stopped on a trail
basis after 6 months to 1 year and it can be restarted if necessary.
In all
cases, it is important to bear in mind that medications must be carefully monitored by a
physician, well versed in the use of antidepressants.
Self-help Techniques
Self-Education
It is
imperative that the person with a depressive
disorder feels some sense of empowerment and control over his illness. Depression often leads one to feel helpless
and powerless. Thus treatment,
including self-help treatment, should give the person some sense of empowerment and
control over his illness.
One way to
attain a sense of control is to become familiar with the subject matter. For some individuals a survey of the
available literature in the bookstore, or these days, spending a few hours on the
internet, makes a big difference. In the case
of the internet, it is important to verify information by checking various different
sources.
By careful
study of depression, the illness is demystified. The
individual feels more on top of the problem through the knowledge acquired. If he does ultimately consult a professional he
feels on a “firmer footing.” Sometimes this individual is in the position of
sharing helpful knowledge with the physician, who may discover deficits (tiny ones it is
hoped) in his knowledge of the field. Another
benefit of this time spent researching the problem is the structuring of time in a
productive manner. The individual feels he is
doing something useful again, and this works to combat the feeling of helplessness that
often accompanies depression. In fact the
planning of productive, as well as leisure activities, is a very important aspect of the
self-treatment of depression. This is
discussed further below.
Share
Knowledge and Gain Support
Some
depressed individuals benefit from attending support
groups and discussion groups about their problem, both in “real life” and on the
internet. Some individuals enjoy
sharing their new found knowledge of their ailment with others as well as receiving
knowledge about the disorder. The
socialization of the group, even the internet chat group (assuming it is a high quality
group), can benefit the depressed individual enormously.
Discuss the
Problem With Good Friends and Family
This step
may seem obvious but it is often one of the more problematic areas. The individual with depression may have a
difficult time admitting he is depressed. This
is often more a problem with males, who may still cling to the traditional male role of
having to appear “strong.” Individuals
of either gender may feel they are placing an undue burden on their friends and family by
discussing their illness. This is indeed an
issue for discussion, if in fact, such guilt has
only made the depressed person feel worse. The
concern and caring received from those in one’s close circle can be very comforting
in recovering from depression. In fact,
the perception that “no one cares” is often a strong element in the depression
in the first place.
Sometimes
friends and family members can be quite helpful, especially if they have experienced
depression themselves and dealt with it successfully.
They can often be a source of helpful suggestions.
Push
Yourself Out of Bed, Off the Couch, Out of the House
This is good
advice for anyone and certainly for the depressed individual. When depressed, every effort often seems an
impossible task. There is tremendous
resistance to doing anything, in many cases.
Hence, the need for that PUSH.
Once in motion, things get easier and the individual often finds the
activity to have been rewarding, certainly better than staying at home.
Structure
Time/Make Commitments
When
depressed and totally demotivated, make an effort to conform to some routine. If one is not actively working or in school,
assign a personal “schedule.” The schedule might include such items as: get up at 8:00 am, eat a good breakfast (even if
appetite is poor), read the morning paper, write a letter or, these days, send out a few
e-mails, take a walk around the neighborhood, call up the neighbor and invite her to come
over later, etc. Of course the schedule will
be highly individualized.
Make
commitments and keep them. Enroll in a class
or make a date with a friend. Take up a hobby
and work on it several times a week. Take
up writing if that is something that had been enjoyable at one time. Write about anything, even if it is about
depression itself. More than one
well-known author has written very creatively on this subject and I bet the effort was
therapeutic as well.
Exercise
Exercise
seems to help almost anything. If
mornings are difficult, sign up for a morning exercise class, it can be low impact
aerobics, yoga, or stretching, for example. The
physical activity seems to have a specific beneficial effect on the depression, whether it
be mediated through endorphins or by the feeling of accomplishing something, or both. As mentioned above, a walk outdoors is also very
beneficial, especially in the morning when there is early morning light, and you can feel
yourself wake up with the world. And if
possible, take that walk with a companion.
Help
Yourself by Seeking out Special Guidance
When all of
the above is still not enough to chase away the depression, by all means, seek out
professional help. Speak to a family doctor,
a clergy-person, or call a psychiatrist or other mental health professional directly. When meeting with the mental health
professional, interview him (or her). See
if that individual seems to possess the knowledge and caring to be helpful. Possibly meet with more than one person till
it “feels” right.
Sometimes
inviting a family member or close friend to the meeting (after arranging this with the
professional) can be very helpful. That
individual may be able to provide insights about yourself, that in the depressed state,
you have forgotten. The friend or family
member may become a part of the treatment strategy.
Be
open-minded to different treatments. Ask
the professional to explain in detail anything that is confusing. Ask the professional to explain his
treatment philosophy and his approach to depression, in particular. Ask for suggestions about additional resources
that may be available to help yourself emerge from the depression. Ask for recommendations about reading materials. Don’t be embarrassed to ask the professional
about his (her) credentials, years of experience in practice, and success rate in treating
individuals with depression
See. You have already taken charge. In fact, by reading this monograph and
getting to this point, even if you have skimmed it, you have already taken an active step. So continue to be active and follow the path of
mental and physical activity back to your old self.
Conclusion
It is my
hope that this monograph has provided a better understanding of the nature of depression. It
is likely that there will be many new medications, with fewer side effects than the
current medications, to help psychiatrists treat individuals with depressive disorders. In addition, there will probably be many new
techniques for treating depression by means we cannot imagine. In the meanwhile, it is important to
benefit from all that is known about treating depression.
There is no point in suffering needlessly.
Dennis B.
Kottler, MD
Please e-mail the author with your
feedback to: doc@psychiatrix.com