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"Depression." by Dr Deryck Pattron | Article ID: #D002

INTRODUCTION

In any given year about 18.8 million American adults, suffer from a depressive illness. The economic cost for this disorder is US $40 billion per year, but the cost in human suffering cannot be estimated. Depressive illnesses often interfere with normal functioning and cause pain and suffering not only to those who have a disorder, but also to those who care about them. Serious depression can destroy family life as well as the life of the ill person. But much of this suffering is unnecessary. Most people with a depressive illness do not seek treatment because they do not recognize that depression is a treatable illness.

WHAT IS DEPRESSION?

Depressive is a mental illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. Depression is not the same as a passing blue mood nor is a sign of personal weakness.

TYPES OF DEPRESSION

Depressive manifest itself in different forms, but there are three common types of depression. However, within these types there are variations in the number of symptoms, their severity and persistence.

1. Major depression is manifested by a combination of symptoms that interfere with the ability to work, study, sleep, eat and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.
2. Dysthymia is a less severe type of depression. It involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia may also experience major depressive episodes at some time in their lives.
3. Bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression).

SYMPTOMS OF DEPRESSION AND MANIA

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

DEPRESSION

• Persistent sadness, anxious, or "empty" mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Thoughts of death or suicide; suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

CAUSES OF DEPRESSION

Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of depression.

• Hereditary
• Environmental e.g. possibly stresses at home, work, or school
• Drug use and abuse
• Poor nutrition
• Psychological predisposition associated with one or more of the above combinations.

DEPRESSION IN WOMEN

• Women experience depression about twice as often as men.
• Many hormonal factors may contribute to the increased rate of depression in women, particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause and menopause.
• Many women also face additional stresses such as responsibilities both at work and home, single parenthood and caring for children and for aging parents.

DEPRESSION IN MEN

• Men are less likely to suffer from depression than women.
• 3 to 4 million men in the United States are affected by the illness.
• Men are less likely to admit to depression, and doctors are less likely to suspect it.
• The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.
• Depression can also affect the physical health in men differently from women.
• Although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.
• Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours.
• Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men.
• Even if a man realizes that he is depressed, he may be less willing than a woman to seek help.

DEPRESSION IN THE ELDERLY

• Some people have the misconception that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives.
• Sometimes, though, when depression develops, it may be dismissed as a normal part of aging.
• Depression in the elderly, undiagnosed and untreated causes needless suffering for the family and for the individual who could otherwise live a fruitful life.
• Loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss.

DEPRESSION IN CHILDREN

• The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die.
• Older children may sulk, get into trouble at school, be negative, grouchy, and feel misunderstood.
• Because normal behaviours vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary "phase" or is suffering from depression.
• In such a case, if a visit to the child's pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed. Parents should not be afraid to ask questions: What are the therapist's qualifications? What kind of therapy will the child have? Will the family as a whole participate in therapy? Will my child's therapy include an antidepressant? If so, what might the side effects be?

DIAGNOSTIC EVALUATION AND TREATMENT

• The first step to getting appropriate treatment for depression is a physical examination by a physician.
• Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview and lab tests.
• If a physical cause for the depression is ruled out, a psychological evaluation should be done, by the physician or by referral to a psychiatrist or psychologist.
• A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given.
• The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.
• A diagnostic evaluation should include a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.
• Treatment choice will depend on the outcome of the evaluation.
• There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders.
• Some people with milder forms may do well with psychotherapy alone.
• People with moderate to severe depression most often benefit from antidepressants.
• Most do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems, including depression.
• Depending on the patient's diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have proven effective for depression.
• Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication.
• There are several types of antidepressant medications used to treat depressive disorders. These include newer medications, namely the selective serotonin reuptake inhibitors (SSRIs), the tricyclics, and the monoamine oxidase inhibitors (MAOIs).
• The SSRIs and other newer medications that affect neurotransmitters such as dopamine or norepinephrine generally have fewer side effects than tricyclics.
• Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications.
• Sometimes the dosage must be increased to be effective.
• Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.

PSYCHOTHERAPIES

Many forms of psychotherapy therapies exist which may be used to help depressed people resolve conflicting feelings. Some of these psychodynamic therapies are given below:

• "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with "homework" assignments between sessions.
• "Behavioral" therapies help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioural patterns that contribute to or result from their depression.
• Interpersonal therapies focus on the patient's disturbed personal relationships that both cause and exacerbate the depression.

HOW TO HELP YOURSELF IF YOU ARE DEPRESSED

• Set realistic goals in light of the depression and assume a reasonable amount of responsibility.
• Break large tasks into small ones, set some priorities and do what you can as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Mild exercise, going to a movie, a ballgame, or participating in religious, social, or other activities may help.
• Expect your mood to improve gradually, not immediately. Feeling better takes time.
• It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition change jobs, get married or divorced discuss it with others who know you well and have a more objective view of your situation.
• People rarely "snap out of" a depression. But they can feel a little better day-by-day.
• Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression responds to treatment.
• Let your family and friends help you.

HOW FAMILY AND FRIENDS CAN HELP DEPRESSED PERSONS?

• The most important thing anyone can do for the depressed person is to help him /her get an appropriate diagnosis and treatment.
• Encouraging the individual to stay with treatment until symptoms begin to abate or to seek different treatment if no improvement occurs.
• Offer emotional support. This involves understanding, patience, affection, and encouragement.
• Do not ignore remarks about suicide. Report them to the depressed person's therapist.
• Encourage participation in some activity that once gave pleasure e.g. hobbies, sports, religious or cultural activities, walks, outings, etc.
• Keep reassuring the depressed person that, with time and help, he/she will feel better.

WHERE TO GET HELP

• Family doctors
• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Family service and social agencies
• Private clinics and facilities
• Employee assistance programmes

FURTHER INFORMATION

Blehar MD, Oren DA. Gender differences in depression. Medscape Women's Health, 1997;2:3. Revised from: Women's increased vulnerability to mood disorders: Integrating psychobiology and epidemiology. Depression, 1995;3:3-12.

Ferketick AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to heart disease among women and men in the NHANES I study. National Health and Nutrition Examination Survey. Archives of Internal Medicine, 2000; 160(9): 1261-8.

Frank E, Karp JF, Rush AJ (1993). Efficacy of treatments for major depression. Psychopharmacology Bulletin, 1993; 29:457-75.

Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278:1186-90.

Robins LN, Regier DA (Eds). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study, 1990; New York: The Free Press.

Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 1998; 44(9):839-50.

Schmidt PJ, Neiman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. Journal of the American Medical Association, 1998; 338:209-16.

Vitiello B, Jensen P. Medication development and testing in children and adolescents. Archives of General Psychiatry, 1997; 54:871-6.

ABOUT THE AUTHOR

Dr Deryck Pattron is a Public Health Scientist attached to the Ministry of Health in Trinidad.

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