Depression

Depression affects more than emotions. It can change a person's behavior, physical health, appearance, job performance, sleep patterns -- even the ability to handle everyday decisions and pressures. Depression goes beyond the grief and sadness that a person experiences when reacting to life's losses and disappointments, such as a death in the family, a relationship gone sour, or a conflict at work. In fact, sadness is only one of the symptoms of depression; feelings of apathy, anxiety or irritability may also be present.

Who's at risk? Each year, 15% of Americans suffer from some form of depression, and the disease accounts for at least one-half of the nation's suicides. At some point in their lives, one fourth of all women and one eighth of all men will experience an episode of depression.

Depression is not a sign of weakness or a condition that can be willed away. Without treatment, symptoms can last for weeks, months or years. However, with appropriate treatment, 80-90% of those suffering from depression can be helped.

Risk factors & causes

Both recognition and diagnosis of depression rest on awareness of risk factors, as well as knowing the key signs, symptoms, and history of the illness. There are biological (i.e., a biochemical imbalance in the brain) and emotional factors that may increase the likelihood of developing a depressive disorder. Bad life experiences and certain personality patterns, such as the way one handles stress, low self-esteem, or extreme pessimism about the future, may increase the chances of becoming depressed. Research also suggests that there may be a genetic link to depressive disorders.

Types of depression

The term clinical depression means that the depression is severe enough to warrant treatment. An episode of clinical depression means that a person has been severely depressed during a single period of time. Major depression involves a combination of symptoms that can impact a person's ability to eat, sleep, work or enjoy activities that were once pleasurable. Sufferers of dysthmia, a less severe form of depression, experience symptoms that are less intense and debilitating, but on a recurrent or long-term basis. The dramatic changes to a mother's body and her environment that occur after giving birth can trigger post partum depression. Seasonal affective disorder (SAD) arises from sensitivity to seasonal changes in the amount of available daylight, which can cause a downward swing in mood. A person with bipolar disorder, commonly known as manic-depressive illness, alternates between cycles of extreme despair and elation (mania).

Symptoms

The first step toward defeating depression is to identify it. However, people who are depressed often have a hard time thinking clearly or recognizing their own symptoms, so they don't get help. Because episodes of depression vary in frequency and intensity, this also compounds the problem of identifying the disease.

While depressive episodes are often associated with a life situation or stress, they can occur for no reason at all. Some people might have only one episode in their entire life, whereas others will have several recurrences. Not every symptom may be present and the severity of symptoms varies among individuals. Another common finding is the presence of apparent physical complaints that rarely have a medical basis. Family strife and alcohol abuse can also be related to the causes and symptoms of depression.

Treatment

The most important step toward treatment of depression is asking for help. Most people suffering from depression--even the most serious forms--can be helped. Symptoms can be relieved quickly with psychological therapies, medications, or a combination of both.

A complete evaluation is essential to develop an effective treatment plan. Depression is a complex illness and there are many factors in a person's life that can affect his/her condition. For example, illnesses such as thyroid imbalance, adrenal gland insufficiency, hypertension, and even commonly used medications can bring on depression. A thorough evaluation will include: a medical/psychiatric history to outline the person's physical and emotional background; a mental status examination to uncover changes in mood, thoughts, patterns of speech, and memory that are manifestations of depression; and a physical examination to rule out any undiagnosed medical problems.

Once depression has been diagnosed, antidepressant medication may be prescribed, based on the individual's general health, weight, metabolism, and other unique physical and emotional characteristics. Physicians generally prescribe one of four major types of medications to treat depression: tricyclics, monoamine oxidase inhibitors (MAOIs), serotonin reuptake inhibitors, and lithium. Antidepressant drugs must be used carefully, at an adequate dosage level and for a long enough time to be effective.

• Tricyclics are antidepressant medications that raise the level of the neurotransmitters (chemicals that carry electrical messages to and from nerve cells in the brain). Typically prescribed for individuals with major depression.
• MAOIs block the action of a chemical substance known as monoamine oxidase in the nervous system. May be prescribed for individuals who do not respond to tricyclics and for cases of mixed anxiety and depression, depression accompanied by pain, panic disorder, post-traumatic stress disorder and bipolar depression.
• Serotonin reuptake inhibitors, a newer class of antidepressants, inhibit the uptake of serotonin. A neurotransmitter in the brain and blood, serotonin plays an important role in mental activity and mood stabilization.
• Lithium is used to treat the manic stage of bipolar disorder or for people who are suffering from recurrent depression. It works by bringing various neurotransmitters in the brain into balance.

When response to other treatments has failed, electroconvulsive therapy (ECT) has proven effective for some severe cases of depression. In the past, ECT was not as safe, low risk or painless as it is today. Typically, a series of several treatments is given over a week or two. Maintenance with antidepressant drugs or psychotherapy is commonly employed following ECT to avoid relapse.

Bipolar Disorder (manic-depressive illness)

Bipolar disorders are recurrent conditions characterized by a history of at least one manic episode. 95% of persons with bipolar disorder also have recurrent episodes of major depression.

Symptoms

Bipolar disorders are not often recognized by the patient, relatives, friends, or even physicians. An early sign of a bipolar depressive illness is a persistent, intense elevation in mood far beyond what is considered usual for the individual. Other symptoms include corresponding increases in energy, wakefulness, a sense of power and influence, decisiveness, and euphoria that could eclipse good judgment. In its early stages, bipolar disorder may masquerade as a problem other than mental illness. It may first appear as alcohol or drug abuse, or poor school or work performance. Unlike clinical depression, which can occur at any age, bipolar depression usually strikes before the age of 35.

A person experiencing the manic cycle of bipolar illness may feel so good that when family or friends recognize the mood swings, the individual will often deny that anything is wrong. Sometimes the feeling may exceed pleasantness so severely that a manic episode may be accompanied by hallucinations and distorted thinking, resembling symptoms of schizophrenia.

Bipolar disorder is a cyclical disease of highs and lows. During the mania stage, some individuals may go on spending sprees, travel long distances, become promiscuous, or disturb public peace and end up at the police station. In the remission phase of this disease, the person may fall into a state indistinguishable from major depression. These wide mood swings can be so severe that the effect on the individual's life can be devastating.

Treatment

Though not as common as other forms of depressive illness, nearly one in 100 people will suffer from bipolar disorder at some point in their lives. The current accepted theory of bipolar disorder revolves around a biochemical imbalance. In individuals with bipolar illness, the chemical norepinephrine is in excess in the mania stage, while sufferers of major depression lack a sufficient amount of this crucial substance. Why the imbalance occurs in some people is unknown, but proper medication is essential for recovery. Psychotherapy may also be useful to the treatment of bipolar disorder.

The most common medication prescribed for bipolar disorder is lithium carbonate, which successfully reduces the number and intensity of manic episodes for 70% of individuals who take this medication. During remission, lithium reduces or prevents relapses of both mania and depression in patients. Individuals who have a family history of depressive illness and have periods of relatively normal moods between their manic and depressive phases typically respond well to lithium treatment.

Alternative drugs are available to victims of bipolar depression. Recent findings show that drugs like carbamazepine and valproate have been successful in treating people who do not respond effectively to lithium.

As with many prescribed medications, lithium treatment requires very careful medical supervision and can have side effects involving the thyroid, kidneys, fluid and chemical balance, and neurological symptoms. Follow-up medical visits are necessary, and treatment may have to be life-long.

Depression & physical illness

Primary care physicians presented with patients who have a major depressive disorder fail to diagnose clinical depression in half of these cases. There may be a tendency among primary care physicians to believe it's reasonable for a patient with a severe physical illness to experience depression and, therefore, do not identify and treat it as an independent illness. Also, some patients do not report mood or emotional symptoms to their physicians, believing that their physical ailment is affecting their mental outlook.

Studies have shown that clinical depression can accompany a variety of medical disorders, such as diabetes, cancer, heart attacks, and stroke. For example, major depression occurs in approximately 25% of patients with cancer, and should be independently diagnosed and treated. Considerable evidence suggests that for patients with cancer, a depressive disorder can lead to greater distress; decreased physical, social, and occupational functioning; and decreased ability to follow medical advice. When depression and physical illness coexist, treating the depression can dramatically improve the speed of recovery from the physical illness.

We can help

Help for depression begins with excellent diagnosis and treatment. At Dominion Hospital, our mental health professionals have extensive experience in the treatment of depressive disorders in children, adolescents, adults and older adults. Through careful evaluation of medical and psychological history, our experts can determine the most effective treatment approach and identify the appropriate treatment resources, both at Dominion and in the community.

Dominion offers a complete spectrum of care with varying levels of treatment intensity to meet individual needs. Dominion Hospital also hosts a free weekly support group for sufferers of depression and their families that is led by a licensed mental health professional specializing in this area.

To learn more about how we can help, call Dominion Hospital's FirstStep, a free, 24-hour information, assessment and referral service, at 703/538-2872.