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Why We Are Depressed and What We Can Do About It
Dennis B. Kottler, MD
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 persons 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 ones 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 ones 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 or more
-- 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 ones life. In contrast, in the case of major depressive disorder, the episodes of depression are usually more discrete with periods of remission between episodes.
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 Cant 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 SSRIs (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 SSRIs are Prozac, Zoloft, Paxil, Celexa, and Luvox. The SSRSs 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 (SSRIs), 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 (MAOIs) 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.
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 ones 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 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. Dont 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.
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
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