Depression

Depression runs in my family; in fact, "it practically gallops," with apologies to Joseph Kesselring, author of the play "Arsenic and Old Lace," who first used the phrase.

My father had major depression at least three times in his lifetime; once in college, back when they just called it a "nervous breakdown;" and two specific times after he retired, with long periods of continuous low spirits in between crises.

His mother also was prone to depression, and was hospitalized in the 40's and given electroshock therapy. And we found out well after he died that my father's father had also suffered from depression and had committed suicide.

Luckily for me and my half-sister, we seem to have dodged the family tendency; perhaps the genes on our respective mothers' sides were dilutive. Neither of us has had a major depression although we do have our periods of the blues from time to time. However, one of her daughters is bi-polar.

Why am I writing about depression here? Is it a condition that hypochondriacs tend to fear? No, but hypochondria can be related to depression. Two-thirds of hypochondriacs also have another psychiatric illness such as depression or obsessive-compulsive disorder. http://www.medicalnewstoday.com/medicalnews.php?newsid=9983

Some people, like my father, battle depression off and on for their entire lives; others have a mild and transient bout of it during a stressful period of their lives or during menopause.

On a personal basis, I have had a tendency to worry about things all my life, particularly when it came to my health, despite the fact that I was really relatively healthy. The older I got the more obsessed I became with my health and it got to the point that I could just read about a symptom that I had and if there was a possibility of it being something fatal, I'd actually get a panic attack thinking about it.

Then two years ago I actually got something wrong with me - oral cancer, of the tongue - and the hypochondria "paid off." I had gotten so neurotic over this tiny little sore on my tongue and was so sure it was cancer that I ran to the oral surgeon within a couple of weeks and had it taken off. As it turned out, it actually was cancer, but so early that it was not likely to have spread and I didn't need further treatment after additional surgery was performed to make sure the biopsy had taken it all off. (I'll write a future article on oral cancer). In a way, it was lucky I worried so much about things or I might have waited too long to do something about it.

After this incident, however, I was even more paranoid about my health and was feeling down all the time. Two of my friends had been on Prozac, one during menopause on a temporary basis, and another on an ongoing basis. I knew none of us was in the throes of a major depression as my father had been; my friends were able to work and function, they were just down, as I was. And I finally decided to ask my doctor about going on Prozac since it worked for my friends. She was willing to prescribe it for me and I started taking it and it was the best decision I ever made.

I feel as if I have a new lease on life. It's not as if I couldn't enjoy myself before, but everything was so extreme. All I'd have to do is hear a song on the radio that was sentimental or sad or reminded me of something, and the next thing I'd know I'd be crying all the way to work and have to fix my makeup before I went in! I couldn't even go to a folk music concert without bawling over some song. I had to take kleenex with me everywhere!

Now, although I can still get sad over something worthy of sadness, I am in control of my emotions and feel much more able to cope with whatever comes along. And, I've stopped being obsessed over my health. It's a very subtle effect; I still feel totally normal and like myself, and I actually feel as if I've just changed my attitude about things. But I'd be willing to bet if I went off the drug my new attitude would change and go back to the way it was.

My father was always a proponent of "better living through chemistry" - he was taking Miltown and Librium in the 60's and 70's, and went on antidrepressants in the 80's when he had his depressive crises. I never thought about whether I needed to be on any drugs until it finally dawned on me that you don't have to be catatonically depressed to need a little help. So now I take the lowest dose of Prozac (10 mg.) and an occasional Xanax for anxiety (also the lowest dose) and I am a lot happier with my life. It may not be for everyone, but if you feel you may need some help, don't deny yourself. It is nothing to be ashamed of.

And, if you are in a much worse place, and are deeply depressed, it can be a life-threatening illness. Please don't hesitate to consult your family physician and ask for a recommendation for a psychiatrist who can prescribe medicine. A combination of therapy and medicine is usually the best solution for a severe depression.

So, without further preamble, following are the details about depression.

What is depression?

Depression is an illness that causes a person to lose interest in life, can affect their eating and sleeping habits, and affects both the mind and the body.

There are various types and levels of depression, as follows:

Major Depression: This is what my father had during his worst periods. It is disabling. A person with major depression finds it impossible to function; they can't concentrate on work or on pleasurable activities; they often just sit and stare into space. They often feel so hopeless that they think life is not worth living and can see no way out besides ending it all. This is a life-threatening type of depression and sometimes can require hospitalization (my father was hospitalized several times). This is not a mood that a person can pull themselves out of by taking up a hobby or volunteering at a soup kitchen. When a person is affected by depression, he or she cannot remember ever feeling good and therefore can't imagine they will ever feel good again.

Dysthymia: This is probably what I have a tendency to have. Unlike major depression, dysthymia involves long-term, chronic symptoms that do not disable a person but prevent them from ever feeling really good or truly happy. Some people who suffer from this syndrome also have major depression at some time in their lives.

Bi-polar Disorder: People with bi-polar disorder have also been known as "manic-depressive." This disorder is a type of depression wherein the patient has cyclic episodes; at some periods they will experience "mania" (where they are extremely energized and excited, can go without sleep, and feel invincible), while during other periods they may have all the symptoms of a major depression. Manic episodes can lead to a psychotic break where the patient loses touch with reality. This has happened to my half-sister's daughter, my niece, who suffers from bi-polar disorder. Thankfully, she has found medications that are stabilizing her.

My father had a manic period later on in his life; looking back, I often wonder whether his moodiness during the time I was growing up were mild symptoms of bi-polar disorder.

What are the symptoms?

Depression:

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness and pessimism
• Feelings of guilt, worthlessness or helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed (including sex)
• Decreased energy, fatigue; feeling "slowed down."
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Loss of 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

Mania:

• Abnormal or excessive elation
• Unusual irritability
• Decreased need for sleep
• Grandiose notions
• Increased talking (often skipping from one thought to another)
• Racing thoughts
• Increased sexual desire
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

Some people who are depressed have thoughts of hurting themselves, or actually do hurt themselves, to try to take away the pain of the depression by distracting themselves from it with physican pain. It can also be to punish oneself, or to divert anger. In fact, depression is sometimes decribed as "anger turned inward."

Recently there has been media attention on teens who cut themselves, which may be a manifestation of depression or obsessive-compulsive disorder. More information can be found here:
http://www.kidshealth.org/teen/your_mind/mental_health/cutting.html

What causes depression?

Major depression is caused by a chemical imbalance in the brain or changes in brain structure. However, there may be a number of reasons why the brain chemicals get out of balance.

Some types of depression may be inherited; there is a particular tendency for bi-polar disorder to run in families, and a genetic component has been identified. However, not everyone with the genes that predispose them to get bi-polar disorder actually develop it, so other co-factors may be involved, such as stress or illness.

Certain illnesses such as Parkinson's Disease, Alzheimer's Disease, strokes, heart attacks, cancers, and more - can be factors in developing depression. In fact, anyone who exhibits signs of depression without having any previous tendencies to the illness should be carefully checked for other illnesses that may be the actual cause.

People who are overwhelmed by stress, have low self-esteem or have pessimistic viewpoints tend to develop major depression. However, it is hard to know whether their issues are symptoms of incipient major depression or the cause of it.

Hormones can play a part in depression. In particular, disorders of the thyroid can be a factor. People who are hyper-thyroid (too much thyroid hormone) may seem manic, with irritability, anxiety, and nervousness; while those with an underative thyroid (hypo-thyroid) may seem depressed, lethargic, and apathetic. It is very important that anyone with manic or depressive symptoms have tests of their thyroid function. Please see this link for more information. http://www.tsh.org/disorders/related/depression.html

Women, with all the hormonal fluctuations they are prone to, are more likely to develop depression than men. Their multiple responsibilities for the household, children and job may contribute to their stress and trigger depression as well.

Men are less apt to be depressed, but when they are they are less likely to admit it, less likely to seek help, and doctors are less likely to identify it. Men are four times more likely to successfully commit suicide than women, although more women attempt it.

Depression can play a role in coronary heart disease, and men who are depressed have a higher death rate from heart disease than women.

People with undiagnosed depression may "self-medicate" with alcohol or drugs to make themselves feel better. This is particularly likely with men. Men may also work obsessively long hours or exhibit their depression as anger and irritability.

Depression is often under-diagnosed in elderly people. It is not normal for the elderly to feel depressed, and if they are, family members or caretakers should make sure the elderly person is checked for diseases, overmedication with prescription drugs, or other factors, and if there is no other cause of their condition, then they should be treated appropriately for depression.

Children can also be clinically depressed, and new research is being done to further understand the best ways to treat them.

How is it diagnosed?

The first step is for the patient to consult his or her family physician and get a full check-up. As mentioned above, there are a number of diseases and conditions that can cause or mimic depression, and certain viral infections or medications can also cause the same symptoms. The physician should rule out these possibilities through examination, interview, and lab tests. In cases where a neurological cause such as Alzheimer's is suspected, a visit to a neurologist would be in order. If a physical cause for the depression is ruled out, a psychological evaluation should be done, preferably by referral to a psychiatrist or psychologist.

How is it treated?

There are two major components of treatment: psychotherapy and medication. If nothing else works, electro-convulsive therapy (ECT, formerly known as electro-shock therapy) or other less common therapies may be tried.

There are various types of psychotherapy, from Freudian analysis to cognitive therapy. Overall it is therapy where the patient and his/her psychiatrist or psychologist work in partnership to talk through the patient's thoughts and issues. Here is a helpful link about psychotherapy: http://helping.apa.org/articles/article.php?id=52

Cognitive-Behavioral Therapy is a particularly useful type of therapy for people with depression. My father found it helpful. Instead of focusing on the past and what made the person depressed, it focuses on specific tools and methods to defeat the depression and change the thought patterns. Here is a link to more information about this useful therapy: http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/ContentDisplay.cfm&ContentID=7952

Therapy in conjunction with medication is the best way to treat major depression. There are a myriad of medications out there now, and if one doesn't work, another one, or a combination of several, should.

There are several major classes of antidepressants, which all work somewhat differently.

Older types include the tricyclic antidepressants such as Elavil, or the MAOIs (Monoamine Oxidase Inhibitors) such as Nardil and Parnate. My father was on Parnate for a fairly long while and it worked quite well for him. One of the disadvantages of MAOIs is that there are dietary restrictions for those who take this type of drug, as the drug interacts with foods such as aged cheese, red wine, sausage, and certain other substances to cause a dangerous rise in blood pressure.

The more recently developed drugs include the SSRIs, or Selective Serotonin Re-uptake Inhibitors. Prozac and Celexa are popular brands of this type of drug. Effexor is a drug which is part of another similar class of drug called Selective Serotonin-Norepinephrine Reuptake Inhibitors. All of these medications work to modulate Serotonin and other brain chemicals which control mood.

Lithium has been used for many years for bi-polar disorder and is also useful for other types of mood disorder. Not everyone can take it as it has to be carefully monitored and can cause complications if the patient has thyroid or other specific problems. Other drugs that are useful either alone or in combination with lithium include anti-convulsives such as Depakote or Neurontin. Many people with bi-polar disorder also take anti-anxiety medications.

For more information about all the different types of drugs used for depression and related disorders, please see this link. http://web4health.info/en/answers/depr-treat-links.htm

Almost all medications for depression take some time to be effective, often several weeks, so the person must be patient and wait for the results. In addition, some medications may be harmful if stopped abruptly, so the patient should never go off medication without telling the doctor. Often patients feel better after taking the medication and decide they don't need it anymore. This is dangerous, as often after medication is stopped, the person can sink back into depression. Just as they can't ever imagine feeling better while they're depressed, depressed people often forget how bad they once felt once the medication has taken effect. My father made this mistake after he'd been on Parnate and went off it once he was feeling well, and his depression returned.

All of these medications can have side effects, including dry mouth, insomnia, drowsiness, dizziness and headaches. If you are taking drugs that give you undesirable effects, be sure to tell your doctor so he or she can modify the dosage or change medications until something is found that is tolerable. Overdoses can be dangerous so always take the medication as it is prescribed.

Some people have tried herbal remedies such as St. John's Wort for depression. It seems to work for mild depression, and has been used extensively in Germany for treatment of depression. My husband became depressed after being in New York on 9/11/2001 and has found St. John's Wort to be helpful and continues to take it on a regular basis. It is very important NOT to take St. John's Wort if you are already taking some other type of prescription medication for depression, as they both work similarly and can cause a dangerous interaction. In addition, St. John's Wort can interfere with other medications for other illnesses so always tell your doctor if you are taking an herbal remedy.

As mentioned, for people with intractable depression, or for those who are unable to take medications, there is electro-convulsive therapy, or ECT. This is no longer the scary thing it was back in the mid-20th century. ECT is the next generation of this type of treatment and is much safer and less traumatic for the patient than in the past. A muscle relaxant is given before treatment. The patient is anesthetized for the process and just a small shock is administered to the brain in a more focused way than in the old days, using electrodes at specific locations on the head, which cause a short seizure. The patient wakes up and doesn't remember the experience. Treatments are usually given three times a week for a period of time in order to be effective. Some transient memory loss can occur but usually patients get their memories back. My father was treated with ECT several times when nothing else would work and it successfully pulled him back from his blackest hours. For more information, please see this link: http://familydoctor.org/058.xml

Will you get it?

Possibly. In any given 1-year period, 9.5 percent of the population, or about 20.9 million American adults, suffer from a depressive illness.

If you think you or someone you know is depressed, please do not hesitate. Go for help. No one should have to suffer from depression, with all of the remedies available today. And no one should be embarrassed or ashamed to admit they are depressed. It's no different than being a diabetic - there is a chemical imbalance and it must be treated.

Much of the above information was taken from the National Institutes of Mental Health website, http://www.nimh.nih.gov/publicat/depression.cfm#intro. Additional useful information can be found on Medline Plus: http://www.nlm.nih.gov/medlineplus/depression.html#fromthenationalinstitutesofhealth