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 8.2 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
TABLE 8.2
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: Margaret Strock, "Symptoms of Depression and Mania," in Depression, National Institute of Mental Health, Bethesda, MD, 2000 [Online] http://www.nimh.nih.gov/publicat/depression.cfm [accessed March 15, 2004] | |
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 and 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. An estimated 5.4 percent of Americans 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 disability when disability is measured in years of healthy life lost. (These are called DALYs—disability adjusted life years.) Table 8.3 shows the causes of disease burden—disability from various diseases—measured in DALYs.
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,
TABLE 8.3
Disease burden in established market economies, 1990
| The leading sources of disease burden in established market economies, 1990 | ||
| (measured in DALYs*) | ||
| Total (millions) | Percent of total | |
| All causes | 98.7 | |
| 1 Ischemic heart disease | 8.9 | 9.0 |
| 2 Unipolar major depression | 6.7 | 6.8 |
| 3 Cardiovascular disease | 5.0 | 5.0 |
| 4 Alcohol use | 4.7 | 4.7 |
| 5 Road traffic accidents | 4.3 | 4.4 |
| 6 Lung & UR cancers | 3.0 | 3.0 |
| 7 Dementia & degenerative CNS | 2.9 | 2.9 |
| 8 Osteoarthritis | 2.7 | 2.7 |
| 9 Diabetes | 2.4 | 2.4 |
| 10 COPD | 2.3 | 2.3 |
| Disease burden by selected iIllness categories in established market economies, 1990 | ||
| (measured in DALYs*) | ||
| Percent of total | ||
| All cardiovascular conditions | 18.6 | |
| All mental illness including suicide | 15.4 | |
| All malignant disease (cancer) | 15.0 | |
| All respiratory conditions | 4.8 | |
| All alcohol use | 4.7 | |
| All infectious and parasitic disease | 2.8 | |
| All drug use | 1.5 | |
| Mental illness as a source of disease burden in established market economies, 1990 | ||
| (measured in DALYs*) | ||
| Total (millions) | Percent of total | |
| All causes | 98.7 | 6.8 |
| Unipolar major depression | 6.7 | 2.3 |
| Schizophrenia | 2.3 | 1.7 |
| Bipolar disorder | 1.7 | 1.5 |
| Obsessive-compulsive disorder | 1.5 | 1.5 |
| Panic disorder | 0.7 | 0.7 |
| Post-traumatic stress disorder | 0.3 | 0.3 |
| Self-inflicted injuries (suicide) | 2.2 | 2.2 |
| All mental disorders | 15.3 | 15.4 |
| *Disability Adjusted Life Years (DALYs) measure lost years of healthy life regardless of whether the years were lost to premature death or disability. | ||
| SOURCE: "The Leading Sources of Disease Burden in Established Market Economies, 1990," "Disease Burden by Selected Illness Categories in Established Market Economies, 1990," and "Mental Illness as a Source of Disease Burden in Established Market Economies, 1990," in "..the Burden of Psychiatric Conditions Has Been Heavily Underestimated": The Impact of Mental Illness on Society, National Institute of Mental Health, Bethesda, MD, 2001 [Online] http://www.nimh.nih.gov/publicat/burden.pdf [accessed March 15, 2004] | ||
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 show that depression has a biological and chemical basis. Researchers suggest that the problem may be caused by the complex neurotransmission (chemical messaging) system of the brain and that people suffering depression have either too much or too little of certain neurochemicals in the brain. Investigators believe that patients with depression who have 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 selective serotonin reuptake inhibitors (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, 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 tricyclic 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 FDA issued a warning that depression may worsen or suicidal thoughts may occur in people, particularly children, who take any of ten 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 alter 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.
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: Margaret Strock, "Side Effects," in Depression, National Institute of Mental Health, Bethesda, MD, 2000 [Online] http://www.nimh.nih.gov/publicat/depression.cfm [accessed March 15, 2004] |
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.
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 she or he 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
Depression Is Linked to Heart Disease
The finding that patients with heart disease, especially those who had suffered heart attacks or undergone cardiac bypass surgery, had higher than expected rates of depression was not surprising because the diagnosis and treatment of a potentially life-threatening illness seemed to be a reasonable cause for depression in this population. More surprising was the finding that depression is itself a risk factor for heart disease. Several studies conducted during the late 1990s concluded that people with a history of depression were four times as likely to suffer from heart disease than those who were not depressed. Canadian researchers found patients with heart problems and depression were four times as likely to die within six months as those patients with heart problems who were not depressed.
Researchers speculate that the psychological stress of depression may promote heart disease by increasing blood pressure, pulse, cholesterol, and insulin levels and decreasing blood flow to the heart. Depression also can produce elevated levels of the stress hormones cortisol and adrenaline which may damage the heart.
Bipolar Disorder
Bipolar disorder, also known as manic depression, is characterized by alternating periods of persistently elevated, expansive, or irritable mood—called mania—and periods of depression. During a manic episode, a person may feel inflated self-esteem, decreased need for sleep, unusually talkative or pressure to keep talking, and easily distracted. He or she may also have flights of ideas, racing thoughts, increased goal-directed activity such as shopping and excessive involvement in high-risk activities. (See Table 8.2 for symptoms of bipolar disorder.) Bipolar disorder strikes about 2.3 million adult Americans, about 1.2 percent of the population, and it affects males and females equally.
In the early stages of the illness, patients may experience few symptoms or even symptom-free periods between relatively mild episodes of mania and depression. As the illness progresses, however, manic and depressive episodes become more serious and more frequent. Patients are less likely to experience intermissions, manic euphoria is increasingly replaced by irritability, and depressions deepen. Some individuals suffer psychotic episodes during periods of mania or depression. Bipolar disorder is one of the most lethal illnesses. According to Frederick K. Goodwin and Kay Redfield Jamison in their Manic Depressive Illness (Oxford University Press, 1990):
Patients with depressive and manic-depressive illnesses are far more likely to commit suicide than individuals in any other psychiatric or medical risk group. The mortality rate for untreated manic-depressive patients is higher than it is for most types of heart disease and many types of cancer.
TREATMENTS FOR BIPOLAR DISORDER.
Lithium has been widely used to treat bipolar disorder since the 1960s, and it is still the medication of choice for controlling the illness. In the 1970s psychiatrists also began using anti-convulsant drugs, including valproate, carbamazepine, and clonazepam to treat patients who could not tolerate lithium or for whom the drug did not work. Chlorpromazine and haloperidol, both antipsychotics, are also helpful in some cases. Antimanic and antipsychotic agents are often combined with antidepressants to relieve depressive symptoms and promote better sleep patterns, an important factor in maintaining patients' mood stability. These medication strategies have proven highly effective in treating bipolar disorder; however, many patients still experience a residual pattern of ups and downs
Medications may become less effective over time and have to be changed. Another major concern among practitioners and patients are medication side effects, especially of lithium. Since therapeutic blood levels of the drug are very close to fatal levels, patients taking lithium must consume adequate amounts of water and salt to prevent dehydration, which would cause lithium blood levels to rise to toxic levels. People who take lithium must have their blood levels of the drug checked frequently, and they must also be aware of the signs of lithium poisoning. Long-term usage of the drug has been shown to cause kidney damage; adequate consumption of water and careful dosage monitoring are believed to reduce the risk of kidney disease.
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