Depression

6/4/2002

What is a depressive disorder?
Depressive disorders have been with man since the beginning of recorded history. In the Bible, King David, as well as Job, suffered from this affliction. Hippocrates referred to depression as melancholia, which literally means black bile. Black bile, along with blood, phlegm, and yellow bile were the four humors (fluids) that accounted for the basic medical physiology of that time. Depression has been portrayed in literature and the arts for hundreds of years, but what do we mean today when we refer to a depressive disorder? In the nineteenth century, depression was seen as an inherited weakness of temperament. In the first half of the twentieth century, Freud linked the development (pathogenesis) of depression to guilt and conflict. John Cheever, the author and a modern sufferer of depressive disorder, wrote of conflict and experiences with his parents as influencing his development of depression.

In the 1950’s and 60’s, depression was divided into two types, endogenous and neurotic. Endogenous means that the depression comes from within the body, perhaps of genetic origin, or comes out of nowhere. Neurotic or reactive depression has a clear environmental precipitating factor, such as the death of a spouse, or other significant loss, such as the loss of a job. In the 1970’s and 80’s, the focus of attention shifted from the cause of depression to its effects on the afflicted people. That is to say, whatever the cause in a particular case, what are the symptoms and impaired functions that experts can agree make up a depressive disorder? Although there is some argument even today (as in all branches of medicines), most experts agree that:

1. A depressive disorder is a syndrome (group of symptoms) that reflects a sad mood exceeding normal sadness or grief. More specifically, the sadness of depression is characterized by a greater intensity and duration and by more severe symptoms and functional disabilities than is normal.
2. Depressive disorders are characterized not only by negative thoughts, moods, and behaviors, but also by specific changes in bodily functions (e.g., eating, sleeping, and sexual activity). The functional changes are often called neurovegetative signs.
3. Certain people with depressive disorder, especially bipolar depression, seem to have an inherited vulnerability to this condition. 4. Depressive disorders are a huge public health problem.
In 1990, depression cost the United States 43 billion dollars in both direct costs, which are the treatment costs, and indirect costs, such as lost productivity and absenteeism.
In a major medical study, depression caused significant problems in the functioning of those affected more often than did arthritis, hypertension, chronic lung disease, and diabetes, and in two categories of problems, as often as coronary artery disease.
Depression can increase the risks for developing coronary artery disease, HIV, asthma, and some other medical illnesses. Furthermore, it can increase the morbidity (illness) and mortality (death) from these conditions.
5. Depression is usually first identified in a primary care setting, not in a mentalhealth practitioner’s office. Moreover, it often assumes various disguises, which causes depression to be frequently under-diagnosed.
6. In spite of clear research evidence and clinical guidelines regarding therapy, depression is often under-treated. Hopefully, this situation can change for the better.
7. For full recovery from a mood disorder, regardless of whether there is a precipitating factor or it seems to come out of the blue, treatments with medications and/or electroconvulsive therapy (ECT) and psychotherapy are necessary.
9 Symptoms – of Depression
Depression is one of the world’s oldest and most common ailments. It can have both physical and psychological symptoms. Millions of Americans are estimated to suffer from depression, a condition so widespread that it has been dubbed “the common cold of mental illness.”

Even so, depression is widely misunderstood. Myths and misconceptions have led many people to believe things about depression that simply are not true. Depression is associated with many symptoms and not everyone has the same ones. Some people have many symptoms, while others may only have a few. The symptoms below may signal that you or someone you love may be depressed:
1. Appearance – Sad face, slow movements, unkept look
2. Unhappy feelings – feeling sad, hopeless, discouraged, or listless
3. Negative thoughts – “I’m a failure,” “I’m no good,” “No one cares about me.”
4. Reduced activity – “I just sit around and mope,” “Doing anything is just too much of an effort.”
5. Reduced concentration
6. People problems – “I don’t want anybody to see me,” “I feel so lonely.”
7. Guilt and low self-esteem – “It’s all my fault,” “I should be punished.”
8. Physical problems – Sleeping problems, weight loss or gain, decreased sexual interest, or head aches
9. Suicidal thoughts or wishes – “I’d be better off dead,” “I wonder if it hurts to die.”
Seek Help if you:
Are thinking about suicide;
Are experiencing severe mood swings;
Think your depression is related to other problems that require professional help;
Think you would feel better if you talked with someone; or Don’t feel in control enough to handle things yourself.
To Find Help
Ask people you know (your physician, clergy, etc.) to recommend a good therapist;
Try local mental health centers (usually listed under mental health in the telephone directory);
Try family service, health, or human service agencies;
Try outpatient clinics at general or psychiatric hospitals;
Try university psychology departments;
Try your family physician; or
Look in the yellow pages of your phone book for counselors, marriage and family therapists, or mental health professionals.

What are the types of depression?
Depressive disorders come in different forms, just as do other illnesses, such as heart disease and diabetes. Three of the most common types of depressive disorders are discussed below. However, remember that within each of these types, there are variations in the number, severity, and persistence of symptoms.

Major Depression

Major depression is characterized by a combination of symptoms, including sad mood (see symptom list), that interfere with the ability to work, sleep, eat, and enjoy once-pleasurable activities. Disabling episodes of depression can occur once, twice, or several times in a lifetime.

Dysthymia

Dysthymia is a less severe type of depression. It involves long-term (chronic) symptoms that do not disable, but yet prevent the affected person from functioning at “full steam” or from feeling good. Sometimes, people with dysthymia also experience episodes of major depression. This combination of the two types of depression is referred to as double-depression.

Bipolar Disorder

Another type of depression is bipolar disorder, which was formerly called manic-depressive illness or manic depression. This condition shows a particular pattern of inheritance. Not nearly as common as the other types of depressive disorders, bipolar disorder involves cycles of depression and mania, or elation. Bipolar disorder is often a chronic, recurring condition. Sometimes, the mood switches are dramatic and rapid, but most often they are gradual.

When in the depressed cycle, the person can experience any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all of the symptoms listed under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when an individual is in a manic phase. A significant variant of bipolar disorder is designated as bipolar II. (The usual form of bipolar disorder is referred to as bipolar I.) Bipolar II is a syndrome in which the affected person has repeated depressive episodes punctuated by what is called hypomania (mini-highs). These euphoric states in bipolar II do not fully meet the criteria for the complete manic episodes that occur in bipolar I.

What are the symptoms of depression and mania?

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

Depression

Persistently 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.
Insomnia, early-morning awakening, or oversleeping.
Decreased appetite and/or weight loss, or overeating and weight gain.
Fatigue, decreased energy, being “slowed down.”
Thoughts of death or suicide, suicide attempts.
Restlessness, irritability.
Difficulty concentrating, remembering, making decisions.
Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.

Mania

Inappropriate elation.
Inappropriate irritability.
Severe insomnia.
Grandiose notions.
Increased talking speed and/or volume.
Disconnected and racing thoughts.
Increased sexual desire.
Markedly increased energy.
Poor judgment.
Inappropriate social behavior.

What are the causes of depression?

Some types of depression run in families, indicating that a biological vulnerability to depression can be inherited. This seems to be the case especially with bipolar disorder. Studies have been done of families in which members of each generation develop bipolar disorder. The investigators found that those with the illness have a somewhat different genetic makeup than those who do not become ill. However, the reverse is not true. That is, not everybody with the genetic makeup that causes vulnerability to bipolar disorder has the illness. Apparently, additional factors, possibly a stressful environment, are involved in its onset.

Major depression also seems to occur in generation after generation in some families, although not as strongly as in Bipolar I or II. Indeed, major depression can also occur in people who have no family history of depression.

An external event often seems to initiate an episode of depression. Thus, a serious loss, chronic illness, difficult relationship, financial problem, or any unwelcome change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder.

Nothing in the universe is as complex and fascinating as the human brain. The over 100 chemicals that circulate in the brain are known as neurochemicals or neurotransmitters. Much of our research and knowledge, however, has focused on four of these neurochemical systems: norepinephrine, serotonin, dopamine, and acetycholine. In the new millennium, after new discoveries are made, it is possible that these four neurochemicals will be viewed as the ‘black bile, yellow bile, phlegm, and blood’ of the twentieth century.

Different neuropsychiatric illnesses seem to be associated with an over-abundance or a lack of some of these neurochemicals in certain parts of the brain. For example, a lack of dopamine at the base of the brain causes Parkinson disease. Alzheimer dementia seems to be related to lower acetylcholine levels in the brain. The addictive disorders are under the influence of the neurochemical dopamine. That is to say, drugs and alcohol work by releasing dopamine in the brain. The dopamine causes euphoria, which is a pleasant sensation. Repeated use of drugs or alcohol, however, desensitizes the dopamine system, which means that the system gets used to the drugs and alcohol. Therefore, a person needs more drugs or alcohol to achieve the same high feeling. Thus, the addicted person takes more and more to feel less and less high.

The different types of schizophrenia are associated with an imbalance of dopamine (too much) and serotonin (poorly regulated) in certain areas of the brain. Finally, the depressive disorders appear to be associated with altered brain serotonin and norepinephrine systems. Both of these neurochemicals are lower in depressed people. Please note that I specified, ‘associated with’ instead of, ’caused by.’ I made this distinction because we really don’t know whether low levels of neurochemicals in the brain cause depression or whether depression causes low levels of neurochemicals in the brain.

What we do know is certain medications that alter the levels of norepinephrine or serotonin can alleviate the symptoms of depression. Some medicines that affect both of these neurochemical systems appear to perform even better or faster. Other medications that treat depression primarily affect the other neurochemical systems. The most powerful treatment for depression, electroconvulsive therapy (ECT), is certainly not specific to any particular neurotransmitter system. Rather, ECT, by causing a seizure, produces a generalized brain activity that probably releases massive amounts of all of the neurochemicals.

Women are twice as likely to become depressed as men. However, scientists do not know the reason for this difference. Psychological factors also contribute to a person’s vulnerability to depression. Thus, persistent deprivation in infancy, physical or sexual abuse, clusters of certain personality traits, and inadequate ways of coping (maladaptive coping mechanisms) all can increase the frequency and severity of depressive disorders, with or without inherited vulnerability.

The effect of maternal-fetal stress on depression is currently an exciting area of research. It seems that maternal stress during pregnancy can increase the chance that the child will be prone to depression as an adult, particularly if there is a genetic vulnerability. It is thought that the mother’s circulating stress hormones can influence the development of the fetus’s brain during pregnancy. This altered fetal brain development occurs in ways that predispose the child to the risk of depression as an adult. Further research is still necessary to clarify how this happens. Again, this situation shows the complex interaction between genetic vulnerability and environmental stress, in this case, the stress of the mother on the fetus.

How is depression diagnosed?
The first step to obtaining appropriate treatment is a complete physical and psychological evaluation to determine whether the person may have a depressive illness, and if so, what type. Certain medications, as well as some medical conditions, can cause symptoms of depression. Therefore, the examining physician should rule out (exclude) these possibilities through an interview, physical examination, and laboratory tests. A thorough diagnostic evaluation includes a complete history of the patient’s symptoms: (1) When did the symptoms start? (2) How long have they lasted? (3) How severe are they? and (4) Have the symptoms occurred before, and, if so, were they treated and what treatment was received? The doctor should ask about alcohol and drug use, and whether the patient has had thoughts about death or suicide. Further, the history should include questions about whether other family members have had a depressive illness, and if treated, what treatments they received and which were effective.

A diagnostic evaluation also includes a mental status examination to determine if the patient’s speech, thought pattern, or memory has been affected, as often happens in the case of a depressive or manic-depressive illness. As of today, there is no laboratory test, blood test, or X-ray that can diagnose a mental disorder. Even the powerful CT, MRI, SPECT, and PET scans, which can help diagnose other neurological disorders, such as stroke or brain tumors, cannot detect the subtle and complex brain changes in psychiatric illness. However, these techniques are currently useful in research on mental health and perhaps in the future they will be useful for diagnosis as well.

What treatments are available for depression?
Antidepressant Medications

Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. (Remember that brain serotonin levels are low in depression.) As their name implies, the SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) are connected to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neuron to another.

The SSRIs work by keeping the serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. This, in turn, helps arouse (activate) cells that have been deactivated by depression, and relieves the depressed person’s symptoms.

In the United States, SSRIs have been used successfully for a decade to treat depression. They have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), which are discussed below. SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs. Also, SSRIs do not cause orthostatic hypotension and heart rhythm disturbances, like the TCAs do. Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and fluvoxamine (Luvox).

SSRIs are generally well tolerated and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart rhythm disturbances. This condition is very rare and has been reported only in very ill psychiatric patients taking multiple psychiatric medications.

All patients are unique biochemically. Therefore, the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean that another medication in this group will not be beneficial. However, if someone in the patient’s family has had a positive response to a particular drug, that drug would be the preferable one to try first.

Dual Action Antidepressants:
The biochemical reality is that all classes of medications that treat depression (MAOIs, SSRIs, TCAs, and atypical antidepressants) have some effect on both norepinephrine and serotonin, as well as on other neurotransmitters. However, the various medications affect the different neurotransmitters in varying degrees.

Some of the newer antidepressant drugs, however, appear to have particularly robust effects on both the norepinephrine and serotonin systems. These drugs seem to be very promising, especially for the more severe and chronic cases of depression. (Psychiatrists, rather than family practitioners, see such cases most frequently.) Venlafaxine (Effexor) is one of these dual action compounds. It is a serotonin reuptake inhibitor that, at lower doses, shares many of the safety and low side effect characteristics of the SSRIs. At higher doses, this drug appears to block the reuptake of norepinephrine. Thus, venlafaxine can be considered an SNRI, a serotonin and norepinephrine reuptake inhibitor.

Another newer antidepressant, mirtazapine (Remeron), is a tetracyclic compound (four-ring chemical structure). It works at somewhat different biochemical sites and in different ways than the other drugs. It affects serotonin, but at a post-synaptic site (after the connection between nerve cells.) It also increases histamine levels, which can cause drowsiness. For this reason, mirtazapine is given at bedtime and is often prescribed for people who have trouble falling asleep. Like venlafaxine, it also works by increasing levels in the norepinephrine system. Other than causing sedation, this medication has side effects that are similar to those of the SSRIs, but to a lesser degree in many cases.

Atypical antidepressants are so named because they work in a variety of ways. Thus, atypical antidepressants are not TCAs or SSRIs, but they act like them. More specifically, they increase the level of certain neurochemicals in the brain synapses (where nerves communicate with each other). Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), venlafaxine (Effexor), and bupropion (Wellbutrin). The United States Food and Drug Administration (FDA) has also approved bupropion for use in weaning from addiction to cigarettes. This drug is also being studied for treating attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). These problems affect many children and adults and restrict their ability to focus or concentrate on one thing at a time.

Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote) carbamazepine (Epitol, Tegretol), neurontin (Gabapentin), and lamictal (Lamotrigine) are mood stabilizers and anticonvulsants. They have been used to treat bipolar depression. Certain antipsychotic medications, such as ziprasidone (Geodon), risperidone (Risperdal), and quetiapine (Seroquel), have sometimes also been used to treat bipolar depression, usually in combination with other antidepressants and/or the mood stabilizers.

Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants. Examples of MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). MAOIs elevate the levels of neurochemicals in the brain synapses by inhibiting monoamine oxidase. Monoamine oxidase is the main enzyme that breaks down neurochemicals, such as norepinephrine. When monoamine oxidase is inhibited, the norepinephrine is not broken down and, therefore, the amount of norepinephrine in the brain is increased.

MAOIs also impair the ability to break down tyramine, a substance found in aged cheese, wines, most nuts, chocolate, and some other foods. Tyramine, like norepinephrine, can elevate blood pressure. Therefore, the consumption of tyramine-containing foods by a patient taking an MAOI drug can cause elevated blood levels of tyramine and dangerously high blood pressure. In addition, MAOIs can interact with over-the-counter cold and cough medications to cause dangerously high blood pressures. The reason for this is that these cold and cough medications often contain drugs that likewise can increase blood pressure. Because of these potentially serious drug and food interactions, MAOIs are usually only prescribed after other treatment options have failed.

Tricyclic antidepressants (TCAs) were developed in the 1950’s and 60’s to treat depression. They are called tricyclic antidepressants because their chemical structures consist of three chemical rings. TCAs work mainly by increasing the level of norepinephrine in the brain synapses, although they also may affect serotonin levels. Doctors often use TCAs to treat moderate to severe depression. Examples of tricyclic antidepressants are amitriptyline (Elavil), protriptyline (Vivactil), desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), trimipramine (Surmontil), and perphenazine (Triavil).
Tetracyclic antidepressants are similar in action to tricyclics, but their structure has four chemical rings. Examples of tetracyclics include maprotiline (Ludiomil) and mirtazapine (Remeron), a drug that was discussed above under dual action antidepressants.
TCAs are safe and generally well tolerated when properly prescribed and administered. However, if taken in over-dose, TCAs can cause life-threatening heart rhythm disturbances. Some TCAs can also have anti-cholinergic side effects, which are due to the blocking of the activity of the nerves that are responsible for control of the heart rate, gut motion, and saliva production. Thus, some TCAs can produce dry mouth, constipation, and dizziness upon standing. The dizziness results from low blood pressure that occurs upon standing (orthostatic hypotension). Anti-cholinergic side effects can also aggravate narrow angle glaucoma, urinary obstruction due to benign prostate hypertrophy, and cause delirium in the elderly. TCAs should also be avoided in patients with seizure disorders and a history of strokes.

Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) are used primarily for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, anti-psychotics, or even thyroid hormone. They are sometimes used alone, but rarely. The reason they are usually used with other medications for depression is that unlike the other medications, they induce a rush and a high in both depressed and non-depressed people. Therefore, the stimulants are highly addictive drugs. Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) are used primarily for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, anti-psychotics, or even thyroid hormone. They are sometimes used alone, but rarely. The reason they are usually used with other medications for depression is that unlike the other medications, they induce a rush and a high in both depressed and non-depressed people. Therefore, the stimulants are highly addictive drugs.

Electroconvulsive therapy (ECT)
In the ECT procedure, an electric current is passed through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or are not responding to antidepressants, have severe depression, or are at a high risk for suicide. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. This procedure probably works, as previously mentioned, by a massive neurochemical release in the brain due to the controlled seizure. Highly effective, ECT relieves depression within 1 to 2 weeks after beginning treatments. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications.

In recent years, the technique of ECT has been much improved. The treatment is given in the hospital under anesthesia so that people receiving ECT do not feel pain. Most patients undergo 6 to 10 treatments. An electrical current is passed through the brain to cause a controlled seizure, which typically lasts for 20 to 90 seconds. The patient is awake in 5 to 10 minutes. The most common side effect is short-term memory loss, which resolves quickly. After the initial course of treatment, ECT can be safely done as an outpatient procedure.

Psychotherapies
Many forms of psychotherapy are effectively used to help depressed individuals, including some short-term (10 to 20 weeks) therapies. Talking therapies help patients gain insight into their problems and resolve them through verbal give-and-take with the therapist. Behavioral therapists help patients learn how to obtain more satisfaction and rewards through their own actions. These therapists also help patients to unlearn the behavioral patterns that contribute to their depression.

Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient’s disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with depression.

Psychodynamic therapies are sometimes used to treat depression. They focus on resolving the patient’s internal psychological conflicts that are typically thought to be rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a life-long history and pattern of inadequate ways of coping (maladaptive coping mechanisms) in negative or self-injurious behavior.

What is the general approach to treating depression
In general, the severe depressive illnesses, particularly those that are recurrent, will require antidepressant medications along with psychotherapy for the best outcome. If a person suffers one major depressive episode, he or she has a 50% chance of a second episode. If the individual suffers two major depressive episodes, the chance of a third episode is 75 to 80%. If the person suffers three episodes, the likelihood of a fourth episode is 90 to 95%. Therefore, after a first depressive episode, it might make sense for the patient to gradually come off medication. However, after a second and certainly after a third episode, most clinicians will have a patient remain on a maintenance dosage of the medication for an extended period of years, if not permanently.

Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for the patient. Sometimes, the dosage must be increased to be effective. Also, new types of antidepressants are being developed all the time, and one of these may be the best for a particular patient.

If the depressed person is taking more than one drug for depression or drugs for any other medical problem, all of the patient’s doctors should be made aware of the other prescriptions. Many of these medications are cleared from the body (metabolized) in the liver. This means that the multiple drugs can interact competitively with the liver’s biochemical clearing systems. Therefore, the actual blood levels of the drugs may be higher or lower than would be expected from the dosage. This information is especially important if the patient is taking anti-coagulants (blood thinners), anticonvulsants (seizure medications), or heart medications, such as digitalis. Although multiple medications do not necessarily pose a problem, all of the patient’s doctors need to be in close contact to adjust dosages accordingly.

Patients often are tempted to stop their medication too soon. It is important to keep taking medication until the doctor says to stop, even if the patient feels better beforehand. Some medications must be stopped gradually to give the body time to adjust. For individuals with bipolar disorder or chronic major depression, medication may have to become a part of everyday life in order to avoid disabling symptoms.

Antidepressant drugs are not habit-forming, so there need not be concern about that. However, as is the case with any type of medication prescribed for more than a few days, antidepressants must be carefully monitored to ensure that the patient is getting the correct dosage. The doctor will want to check the dosage and its effectiveness regularly.

If the patient is taking MAOIs, certain aged, fermented, or pickled foods must be avoided. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. Remember that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.

People should never mix medications of any kind (prescribed, over-the counter, or borrowed) without consulting their doctor. The dentist or any other medical specialist who prescribes a drug should be informed that the patient is taking antidepressants. Some drugs that are harmless when taken alone can cause severe and dangerous side effects when taken with other drugs. Some drugs, such as alcohol (including wine, beer, and hard liquor), reduce the effectiveness of antidepressants and should be avoided.
Antianxiety drugs such as Valium, Xanax, and Ativan are not antidepressants but they are occasionally prescribed alone or with antidepressants for a brief period of anxiety. However, they should not be taken alone for depressive disorder. Furthermore, the antianxiety drugs should be phased out as soon as the antidepressant and antianxiety effects of the antidepressant medications begin to work, which is usually in 4 to 6 weeks.

Finally, the doctor should be consulted concerning any questions about a drug or problem that the patient believes is drug related.

What about self-help? Depressive disorders make those afflicted feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual situation. It should be remembered that negative thinking fades as treatment begins to take effect. In the meantime, the following are helpful guidelines and advice for the depressed individual:
Do not set difficult goals for yourself or take on a great deal of responsibility.
Break large tasks into small ones, set some priorities, and do what you can when you can.
Do not expect too much from yourself too soon, as this will only increase feelings of failure.
Try to be with other people, which is usually better than being alone.
Participate in activities that may make you feel better.
You might try exercising mildly, going to a movie or a ball game, or participating in religious or social activities.
Don’t rush or overdo it.Don’t get upset if your mood is not greatly improved right away. Feeling better takes time.
Do not make major life decisions, such as changing jobs or getting married or divorced without consulting others who know you well. These people often can have a more objective view of your situation. In any case, it is advisable to postpone important decisions until your depression has lifted.
Do not expect to ‘snap out’ of your depression. People rarely do. Help yourself as much as you can, and do not blame yourself for not being up to par.
Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.

can someone help a person who is depressed?
Family and friends can help! Since depression can make the affected person feel exhausted and helpless, he or she will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effect. Although unintentional, friends and loved ones may unknowingly say and do things that may be hurtful to the depressed person. It may help to share the information in this article with those you most care about so they can better understand and help you.

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This help may involve encouraging the individual to stay with treatment until symptoms begin to go away (usually several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication. Always report a worsening depression to the patient’s physician or therapist.

The second most important way to help is to offer emotional support. This support involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always report them to the depressed person’s therapist.

Invite the depressed person for walks, outings, and to the movies and other activities. Be gently insistent if your invitation is refused. Encourage participation in activities that once gave pleasure, such as hobbies, sports, or religious or cultural activities. However, do not push the depressed person to undertake too much too soon. The depressed person needs company and diversion, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness. Do not expect him or her “to snap out of it.” Eventually, with treatment, most depressed people do get better. Keep that in mind. Moreover, keep reassuring the depressed person that, with time and help, he or she will feel better.

Where can one seek help for depression?
A complete physical and psychological diagnostic evaluation by professionals will help the depressed person decide the type of treatment that might be best for him or her. However, if the situation is urgent because a suicide seems possible, taking the patient to the emergency room is the appropriate course of action. If the patient makes a suicide gesture or attempt, a 911 call is warranted. The patient might not realize how much help he or she needs. In fact, he or she might feel undeserving of help because of the negativity and helplessness that is a part of depressive illness.
Listed below are the types of people and places that will make a referral or provide diagnostic and treatment services. Check the Yellow Pages under “mental health,” “health,” “social services,” “suicide prevention,” “hospitals,” or “physicians” for phone numbers and addresses.
Family doctors.
Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors.
Health maintenance organizations.
Community mental health centers.
Hospital psychiatry departments and outpatient clinics.
University or medical school-affiliated programs.
State hospital outpatient clinics.
Family service/social agencies.
Private clinics and facilities.
Employee assistance programs.
Local medical and/or psychiatric societies

What’s in the future for depression?
The future is very bright for the treatment of depression. We are close to having genetic markers for bipolar disorder. Soon after, we hope to also have them for major depression. That way, we can know of a child’s vulnerability to depression from birth and try to create preventive strategies. For example, we can teach parents early warning signs so that they can get treatment for their children, if necessary, to ward off future problems.
The new world of pharmacogenetics holds the promise of actually keeping the genes responsible for depression turned off so as to avoid the illnesses completely. Also, by studying genes, we are learning more about the matching of patients with treatment.
This kind of information will be able to tell us which patients do well on which types of drugs and psychotherapy regimens.

We are learning more about the interactions of the neurochemicals in the brain. Moreover, new categories of neurochemicals, such as neuropeptides and substance P, are being studied. As a result, we will soon be able to develop new drugs that should be more effective with fewer side effects. Finally, we are learning startling things about how maternal stress early in pregnancy can profoundly affect the developing fetus. For example, we now know that maternal stress can greatly increase the risk for the fetus to develop depression as an adult. While sadness will always be part of the human condition, hopefully we will be able to lessen or eradicate the more severe mood disorders from the world to the benefit of all of us.

For further information about Depression, please visit the following sites:

Suicide Awareness Voices of Education (SAVE)
http://www.save.org/

APA: Women and Depression (American Psychological Association)
http://www.apa.org/ppo/issues/pwomenanddepress.html

For additional information, you can write or call the following organizations:

D/ART/Public Inquiries; National Institute of Mental Health
Room 15C-05
5600 Fishers Lane
Rockville, MD 20857

National Foundation for Depressive Illness
20 Charles Street
New York, NY 10014

National Depressive and Manic Depressive Association
730 N. Franklin
Suite 501
Chicago, IL 60601
(800) 826-3632
(312) 642-0049
(312) 642-7243–fax
http://www.ndmda.org/

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
(800) 969-NMHA (6642)
http://www.nmha.org/

National Alliance for the Mentally Ill
2101 Wilson Boulevard
Suite 302
Arlington, VA 22201
HelpLine: 1-800-950-NAMI [6264]
http://www.nami.org/

National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021 USA
Infoline: 1-800-829-8289
http://www.mhsource.com/narsad/

Substance Abuse and Mental Health Services Administration (SAMHSA)
5600 Fishers Lane
Rockville, MD 20857
http://www.samhsa.gov/

Surgeon General’s Report on Mental Illness
To receive a copy of this report, write or call:
Mental Health
Pueblo, Co 81009
1-800-789-2647
http://www.surgeongeneral.gov/library/mentalhealth/home.html

The National Institute of Mental Health (NIMH) for the Depression Awareness, Recognition, and Treatment (DART) program furnished a portion of the foregoing information.

Medical Author: Peter J. Panzarino, Jr., M.D., F.A.P.A.

Medical Editor: Leslie J. Schoenfield, M.D., Ph.D.