Defining Depression
Depression is a "whole body" illness, involving physical, mental, and emotional problems. A depressive disorder is not a temporary sad mood, and it is not a sign of personal weakness or a condition that can be willed away. People with depressive illness cannot just "pull themselves together" and hope they will become well. Without treatment, the symptoms can persist for months or even years. Table 8.3 is a list of symptoms that characterize depression. Not everyone who is depressed experiences all of the symptoms. Some people have very few symptoms; some have many. Like other mental illnesses, the severity and duration of the symptoms of depression may vary.
There are several types of depressive disorders. The most common form is dysthymic disorder (dysthymia), a less severe but chronic form of depression that by definition lasts at least two years in adults or one year in children. Dysthymic disorders commonly appear for the first time in children, teens, and young adults, and although they may not disable people as severely as other forms of depression, these disorders can ruin lives by robbing them of joy, energy, and productivity. The NIMH estimates 5.4% of American adults suffer from dysthymia, and many also suffer from major depression during the course of their lives.
Major depression (also called unipolar major depression) is a more severe and disabling form; nearly ten million Americans are affected every year. Major depression is second only to heart disease as a cause of
TABLE 8.3
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 sad, 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
Mania
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased sexual desire
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
SOURCE: "Symptoms of Depression and Mania," in Depression, National Institute of Mental Health, 2000, http://www.nimh.nih.gov/publicat/nimhdepression.pdf (accessed January 18, 2006)
disability when disability is measured in years of healthy life lost.
Causes of Depression
Combinations of genetic, psychological, and environmental factors are involved in the development of depressive disorders. Some types of depression run in families, and research studies of twins have demonstrated that genetic factors determine susceptibility to depression. Major depression seems to recur in generation after generation of some families, but it also occurs in people with no family history of depression.
Studies of the brain support the premise that depression may have a biological and chemical basis. Although there are clearly differences between the brain imaging studies, it is not yet known if these differences cause the depression or result from it. Researchers speculate that the problem may be caused by the complex neurotransmission (chemical messaging) system of the brain and that persons suffering depression have either too much or too little of certain neurochemicals in the brain. Investigators believe that depressed patients with normal levels of neurotransmitters may suffer from an inability to regulate them. Most antidepressant drugs currently used to treat the disorder attempt to correct these chemical imbalances.
A person's psychological makeup is another factor in depressive disorders. People who are easily overwhelmed by stress or who suffer from low self-esteem or a pessimistic view of life, of themselves, and of the world tend to be prone to depression. Events outside the person's control also can trigger a depressive episode. A major change in the patterns of daily living—such as a serious loss, a chronic illness, a difficult relationship, or financial problems—can trigger the onset of depression.
Treatment of Depression
Antidepressant medications that alter brain chemistry have been used to treat depressive disorders effectively. Antidepressant medications—including SSRIs such as Prozac, tricyclic antidepressants such as Elavil, and monoamine oxidase inhibitors (MAOIs)—work by influencing the function of neurotransmitters such as dopamine or norepinephrine. The SSRIs have fewer reported side effects (such as sedation, headache, weight gain or loss, and nausea) than tricyclic antidepressants.
Antidepressants do not offer immediate relief from symptoms; most take full effect in about four weeks, and some take up to eight weeks to achieve optimal therapeutic effects. Patients must be closely monitored by health professionals for side effects, dosage, and effectiveness. Table 8.4 lists the most common side effects of antidepressants. In some cases of chronic depression, medication may be needed continuously, on a long-term basis, to prevent recurrence of the disease.
In March 2004 the U.S. Food and Drug Administration (FDA) issued a warning that depression may worsen or suicidal thoughts may occur in people, particularly children and adolescents, who take any of the popular antidepressants. This is most likely to occur at the beginning of treatment or when the doses are increased or decreased. The FDA ordered manufacturers to revise labeling of Prozac (also sold generically as fluoxetine), Zoloft, Paxil, Luvox, Celexa, Lexapro, Wellbutrin, Effexor, Serzone, and Remeron to increase awareness of these side effects.
Psychotherapy also has been demonstrated as effective therapy for mild to moderate depression. Talking about problems with mental health professionals can help patients better understand their feelings. Two types of short-term therapy lasting ten to twenty weeks appear to improve symptoms of depression. Interpersonal therapy concentrates on helping patients improve personal relationships with family and friends. Cognitive behavioral therapy attempts to help patients replace negative thoughts and feelings with more positive, optimistic approaches and actions.
Some people respond well to psychotherapy, and others respond well to antidepressants. Many do best with a combination of treatment—drugs for relatively quick relief of symptoms and therapy to learn how to cope with life's problems more effectively.
TABLE 8.4
Side effects of antidepressants
Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:
- Dry mouth—it is helpful to drink sips of water; chew sugarless gum; clean teeth daily.
- Constipation—bran cereals, prunes, fruit, and vegetables should be in the diet.
- Bladder problems—emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; the doctor should be notified if there is marked difficulty or pain.
- Sexual problems—sexual functioning may change; if worrisome, it should be discussed with the doctor.
- Blurred vision—this will pass soon and will not usually necessitate new glasses.
- Dizziness—rising from the bed or chair slowly is helpful.
- Drowsiness as a daytime problem—this usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.
The newer antidepressants have different types of side effects:
- Headache—this will usually go away.
- Nausea—this is also temporary, but even when it occurs, it is transient after each dose.
- Nervousness and insomnia (trouble falling asleep or waking often during the night)—these may occur during the first few weeks; dosage reductions or time will usually resolve them.
- Agitation (feeling jittery)—if this happens for the first time after the drug is taken and is more than transient, the doctor should be notified.
- Sexual problems—the doctor should be consulted if the problem is persistent or worrisome.
SOURCE: "Side Effects of Antidepressants," in Depression, National Institute of Mental Health, 2000, http://www.nimh.nih.gov/publicat/nimhdepression.pdf (accessed January 18, 2006)
Less commonly, electrical stimulation of the brain, known as electroconvulsive therapy (ECT), is used to treat people with severe depression that has not responded to medication. Electric shocks administered to one side of the patient's head while he or she is under general anesthesia cause brain seizures that somehow relieve depression. The mechanism by which ECT works is unknown. The treatment requires multiple sessions to achieve results; patients usually receive one, sometimes two, treatments per week over the course of nine to twelve weeks. Because ECT has the potential for serious side effects—reactions to anesthesia and memory loss, for example—and because of the history of abuses of the treatment, ECT is a controversial treatment of last resort for people with the most refractory (treatment-resistant) depression.
Children Suffer from Depression Too
The most frequently diagnosed mood disorders in children and adolescents are major depressive disorder, dysthymic disorder, and bipolar disorder. Children who are depressed are not unlike their adult counterparts. They may be teary and sad, lose interest in friends and activities, and become listless, self-critical, and hypersensitive to criticism from others. They feel unloved, helpless, and hopeless about the future, and they may think about suicide. Depressed children and adolescents also may be irritable, aggressive, and indecisive. They may have problems concentrating and sleeping and often become careless about their appearance and hygiene. The Surgeon General's report distinguishes childhood depression from adult depression, noting that children display fewer psychotic symptoms, such as hallucinations and delusions, and more anxiety symptoms, such as clinging to parents or unwillingness to go to school. Depressed children also experience more somatic symptoms, such as general aches and pains, stomachaches, and headaches, than adults with depression.
Dysthymic disorder usually begins in childhood or early adolescence and is a chronic but milder depressive disorder with fewer symptoms. The child or adolescent is continuously depressed for months to years. Because the average duration of the disorder is about four years, some children become so accustomed to feeling depressed that they may not identify themselves as depressed or complain about symptoms. Nearly three-quarters of children and adolescents with dysthymic disorder experience at least one major depressive episode in the course of their lives.
Reactive depression (formerly termed adjustment disorder with depressed mood) is the most common mental health problem in children and adolescents. It is not considered a mental disorder, and many health professionals consider occasional bouts of reactive depression as entirely consistent with normal adolescent development. It is characterized by transient depressed feelings in response to some negative experience, such as a rejection from a boyfriend or girlfriend or a failing grade. Sadness or listlessness spontaneously resolves in a few hours or may last as long as two weeks. Generally distraction, in the form of a change of activity or setting, helps to improve the mood of affected individuals.
According to the NIMH, until recently, physicians and family members did not recognize depression in children and often attributed mood changes in children and adolescents to a normal process of development. During the past ten years, there has been increasing recognition that clinical depression occurs in children and adolescents. Recent epidemiological studies suggest that up to 1% of preschoolers, 2% of schoolchildren, and 8% of adolescents may have major depressive disorder. The lifetime risk of major depressive disorder and dysthymia among adolescents has been estimated at about 15%, which is comparable to the adult lifetime risk ("Depression Research at the National Institute of Mental Health," February 17, 2006, http://www.nimh.nih.gov/publicat/depresfact.cfm, and G. Saluja et al, "Prevalence of and Risk Factors for Depressive Symptoms among Young Adolescents," Archives of Pediatric and Adolescent Medicine, vol. 158, August 2004, http://intramural.nimh.nih.gov/research/pubs/giedd04.pdf).
Prepubescent girls and boys are equally likely to experience major depression and dysthymic disorder, but from ten to fourteen years of age, girls outpace boys, soon reaching the two-to-one ratio observed among adults, according to the NIMH. Depression in young people often occurs along with anxiety and behavioral problems and predicts continued and possibly more severe depression in adulthood. Depression also increases the risk for substance abuse and is a major risk factor for suicide. The incidence of suicide attempts peaks during adolescence. Mortality from suicide increases through the teens and is the third-leading cause of death among adolescents and young adults. (See Table 1.12 in Chapter 1.)
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