Depression

Am I Depressed?: Treating depression symptoms, including bipolar, clinical, and seasonal affective disorder

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By UHN Staff • December 10, 2015

“Am I Depressed?”
Treating depression symptoms, including bipolar, clinical depression, and seasonal affective disorder

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INTRODUCTION

What is depression? While everyone feels down in the dumps some of the time, for some, these feelings are more persistent and can have a lasting impact. This is depression. It is a physical disease like any other—not simply laziness or AN unwillingness to “man up” or “get a grip.”

People who find themselves wondering, “Am I depressed?”—and who suffer from sometimes serious depression symptoms—spend a good deal of their time feeling sad, empty, or irritable. Depending on the type of depression they have, they may also suffer a host of other physical symptoms, including tiredness, difficulty sleeping or concentrating, anger, low self-esteem, thoughts of death or suicide, disruptions in appetite, feelings of guilt or worthlessness, and physical symptoms such as headache or chronic pain. This is just a small sample of what depression can feel like.

Fortunately, help is available. This University Health News report has been created not only to describe depression’s symptoms, causes, diagnosis, and risk factors but potential treatment options, from therapy to natural depression remedies.

I. DEPRESSION SYMPTOMS

Different people experience depression in different ways. Here’s a list of typical depression symptoms as well as some of the less common symptoms people might experience when depressed.

Common Symptoms of Depression

• Feeling sad, down, or blue most of the time
• Loss of interest in activities and hobbies you once enjoyed
• Difficulty concentrating, paying attention, and remembering
• Disrupted sleep (difficulty getting to sleep or staying asleep, or sleeping too much)
• Change in eating habits (overeating or losing your appetite)
• Fatigue and loss of energy
• Feelings of guilt or worthlessness
• Feelings of helplessness or hopelessness
• Increased alcohol and drug use
• Irritability
• Low self-esteem
• Neglecting your personal care (such as personal hygiene)
• Physical symptoms that don’t respond to treatment (headaches, stomachaches, and chronic pain, for example)
• Reduced sex drive
• Thoughts of death or suicide

Less Common Symptoms of Depression

• Being highly sensitive to rejection or criticism, while perking up briefly with positive events
• Eating too much (often craving foods that are rich in carbohydrates such as ice cream, chocolate, bread, cereal, and pasta)
• Feeling weighed down or heavy
• Sleeping too much

Depression test: What It Can Tell You

Are you concerned that you or someone you love may be suffering from depression? The first thing you need to do is talk with your doctor or convince your loved one to do the same. In the meantime, there are some simple self-tests that you can complete on your own to see if you are likely to be suffering from depression.

Try the self-test below (“Am I Depressed?”) to find out whether you might need to seek help.

If you answer yes to at least five items on this list, and if you’ve been experiencing these symptoms for at least two weeks, that’s a sign of depression. Whatever the results, if you’re feeling worthless, if your mood is interfering with your life, or if you feel like the world might be better off without you, it is imperative that you speak with a health care professional sooner rather than later.

II. WHAT CAUSES DEPRESSION?

Genes, negative life experiences, learned ways of experiencing and interpreting the world, lifestyle habits, and other physical illnesses all interact in complex ways to produce changes in the brain that can lead to depression.

Depression and the Brain

If you compare the brain of someone with depression to the brain of someone who is not depressed, on the outside they look pretty similar. However, when imaging scans have been used to look inside the brain, discernible differences in brain activity have been noted in the brains of people with depression, particularly those with long-term or chronic depression.

People with a history of chronic depression have been found, on average, to have a smaller hippocampus—a part of the brain that is involved in memory—and a thinner right cortex, which is involved in mood.

You might have heard that depression stems from a “chemical imbalance,” and that is partly true. In people with depression, the levels of certain brain chemicals—particularly the neurotransmitters serotonin, dopamine, and norepinephrine—are thought to be out of balance. Serotonin regulates mood, emotion, and sleep. Dopamine affects movement, attention, and feelings of pleasure. Norepinephrine regulates arousal, sleep, attention, and mood.

Neurotransmitters are chemicals inside the brain that allow brain cells (also known as neurons) to communicate with each other.

Depression Triggers

While feelings and emotions lie primarily in the brain, the rest of the body and its interaction with the outside world have profound effects on how well the brain functions. Here’s a rundown of five of the internal and external factors that can disrupt the brain enough to trigger depression:

Stress: Whether we like it or not, stress is a big and ongoing part of life. Stress, in appropriate amounts, is actually a good thing. Without it, we wouldn’t even bother to get up in the morning. It also helps us develop effective coping skills, resilience, and the capacity to bounce back after hardships. But the key is balance. Just as too little stress leaves us without motivation to do anything, too much stress for too long can wear us out and lead to illness.

Having an excess of stress hormones can disrupt your brain’s natural chemistry. Results from animal studies suggest that constant exposure to stress hormones damages brain cells, making your brain less able to regulate the stress hormone response.

Illness: When your body feels miserable, your mind often follows suit. Anyone who has ever had the flu knows how down in the dumps you can feel when you’re stuck in bed all day, unable to do anything but cough and blow your nose. Now imagine being sick not for days, but for months or even years.

It’s no surprise that depression is common among people with chronic illnesses—particularly among those with debilitating conditions like chronic pain, cancer, diabetes, or heart disease.

In some cases, illnesses such as Parkinson’s disease or multiple sclerosis (MS) or injuries to the brain caused by physical trauma or stroke can produce depression simply because the parts of the brain that regulate emotion are affected by the disease or injury.

But the link between depression and illness goes even deeper than that. It’s actually a two-way street. Not only are people with chronic illnesses more likely to be depressed, but depressed people are also more likely to suffer from chronic illnesses such as heart disease, and they also have a poorer prognosis than those without depression who have the same illness.

Recent research suggests that whole body inflammation may help explain this two-way association. Elevated blood levels of C Reactive Protein (C-RP), a marker for whole body inflammation, have been found to correlate with the number of depressive episodes suffered by adolescents and young adults. High levels of C-RP have also been linked with several other illnesses, including heart disease and cancer. Many diseases associated with chronic body inflammation have also been linked with depression.

Diseases That Can Complicate or Mimic Depression

A number of illnesses have symptoms that can mimic, cause, be a consequence of, or complicate depression. That’s why it’s important to diagnose the underlying condition and to be alert for symptoms of depression. Medical conditions that can cause depression include:

• Addison’s disease
• AIDS
• Brain tumors
• Cancer
• Coronary artery disease
• Cushing’s disease
• Diabetes
• Encephalitis
• Fibromyalgia
• Head trauma
• Heart disease
• Hypercalcemia (high levels of calcium in the blood)
• Hyperparathyroidism (overactive parathyroid glands)
• Hyperthyroidism (overactive thyroid glands)
• Hypothyroidism (underactive thyroid glands)
• Infection with Toxoplasma gondii (found in cat feces)
• Influenza (flu)
• Kidney or liver failure
• Mononucleosis
• Multiple sclerosis
• Parkinson’s disease
• Seizures
• Sleep apnea
• Stroke
• Systemic lupus erythematosus
• Tuberculosis
• Viral hepatitis
• Viral pneumonia
• Vitamin deficiencies (folate, B12, D)

A number of psychological conditions also can stem from, or contribute to, depression. These include:

• Alcoholism and other substance abuse disorders:
  • Anxiety disorders, including post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), social phobia, and generalized anxiety disorder.
  • Eating disorders, including anorexia nervosa and bulimia nervosa.
  • Personality disorders, including borderline personality disorder.
• Lifestyle: Several studies have linked poor diet with an increased risk of depression. But it’s not all about your diet. Research has linked overworking with a twofold increase in the likelihood of depression, and depression and lack of physical activity are known to also be closely linked. On the plus side, exercise has been shown to help alleviate depression.
• Sleep: Sleep is another lifestyle factor that is known to have an effect on depression risk. While depression can disrupt sleep, not getting the right amount of sleep also can trigger depression. Studies have shown that both too little and too much sleep are linked with depression. In general, about 7 to 8 hours of sleep per night is considered healthy for most adults, although there are individual differences.
• 

  Click image to expand view. Is your depression a result of sleeplessness? If so, you may be suffering from sleep apnea. One hallmark of sleep apnea is snoring

  The relationship between lifestyle and depression is a chicken-and-egg situation. That is, poor lifestyle habits can lead to depression, and depressed people frequently slip into poor lifestyle habits. When you can barely drag yourself out of bed, it can be unimaginably difficult to exercise or cook yourself a healthy meal.

• Drugs: Certain depression medications affect brain levels of serotonin and other brain chemicals. Other drugs are very sedating. They slow down thinking, making people feel sleepy, withdrawn, and unmotivated. All this can contribute to feeling depressed. It’s not only prescription drugs that have been linked with depression. Use of illicit drugs also has been shown to increase susceptibility to the disease. The association between illicit drug use and depression may also be a chicken-and-egg conundrum because depressed people may be tempted to self-medicate with illicit drugs.
• Hormones: Hormones are chemical messengers that regulate various functions throughout the body. Hormones are produced by the glands of the endocrine system. Their release in the body is governed by a very sensitive feedback system controlled by the hypothalamus and pituitary gland in the brain. When hormones are produced in excess or in too limited supply, certain body functions won’t work as well as they should. Depression is one of the potential side effects of a hormonal imbalance.

III. DEPRESSION TYPES

Depression is a complex condition, and it comes in many forms. In order to help tease apart the different ways depression can manifest and help clinicians choose the right treatments, the condition is classified into several different types. The two main ones are known as major depressive disorder (also called clinical depression or major depression) and persistent depressive disorder, but there are several other subtypes as well.

Major Depressive Disorder

Major depressive disorder, or major depression, is the most common type of depression. People who have major depression aren’t just sad for a few days. Their low mood lasts for at least two weeks, and usually much longer, and is significant enough to interfere with their thoughts, behavior, and physical health.

Usually, there are other symptoms in addition to low mood, including:

• Appetite changes with weight loss or weight gain
• Sleeping too little or too much
• Trouble with concentration and/or memory
• Unexplained aches and pains
• Fatigue/lack of energy
• Loss of interest in activities that once were pleasurable
• Agitation, restlessness, or irritability
• Feelings of isolation or loneliness
• Feelings of worthlessness, self-hate, or guilt
• Recurring thoughts of death or suicide

Persistent Depressive Disorder

Persistent depressive disorder is a relatively new classification of the condition. A person is diagnosed with this type of depression when they have at least two of the symptoms listed above in addition to a depressed mood that lasts for two years or more.

Individuals who suffer from persistent depressive disorder typically describe their mood as “low” or “down in the dumps.” Many people with this disorder suffer from it for so long that they don’t know what it feels like not to be depressed and may not even realize they have depression, thinking their symptoms are just part of life.

The condition often begins in adolescence or even childhood, which contributes to the perception among sufferers that the symptoms are “normal.” Because of this, many people with persistent depressive disorder may not report their symptoms to their doctor.

Psychotic Depression

In people who have this condition, depression is accompanied by strange hallucinations or delusions. Delusions are beliefs, often bizarre, that have no basis in reality. For example, a woman with psychotic depression might be convinced that her children have been possessed by demons, that aliens are controlling her behavior, or that she is being followed by government agents. She may hear voices that confirm these beliefs. People who have psychotic depression often recognize that their thoughts are distorted and may try to hide those thoughts from other people.

• Bipolar disorder (manic depressive illness): For people with bipolar disorder, life is often a rollercoaster ride. Their moods may shift radically from week to week between manic and depressed phases.
• Manic episodes: During the high points, people with bipolar disorder may be almost euphorically happy and full of energy and activity, sleep little or not at all for days on end, engage in reckless behavior, have intense flashes of irritability, and have grandiose beliefs about themselves. They may also have racing, disorganized thoughts and speak almost too quickly to be understood. This is known as a manic episode. As with psychotic depression, sometimes people in a manic stage of bipolar disorder hallucinate or have delusions. A somewhat less intense form of mania is known as hypomania.

• Depressive episodes: During “pure” episodes of depression, the symptoms of bipolar disorder are hard to distinguish from the symptoms of major depression. The person will often feel sad, tired, and withdrawn, and will have trouble concentrating, sleeping, and eating. He or she may experience thoughts of worthlessness, guilt, death, or suicide. Although mania is a defining feature of bipolar disorder, most individuals with bipolar disorder experience depression far more frequently and for much longer periods of time than they experience mania. For that reason, people with bipolar disorder are often initially misdiagnosed as having depression.
• Mixed episodes: Although manic and depressive episodes usually alternate with each other, doctors now recognize that in some people, bipolar disorder appears as a mixture of the two states: mania and depression. During these mixed episodes, a person can experience the elements of mania (such as high energy, physical restlessness, and impulsivity) at the same time as the symptoms of depression (such as intense sadness, guilt, or suicidal urges). Not only are mixed states more common than was once thought, they may be particularly dangerous because the person’s energy level is high enough for them to act on their negative thoughts, such as thoughts of self-harm.

Seasonal Affective Disorder (SAD)

Depression that occurs exclusively with the change of seasons is called seasonal affective disorder, or SAD. Researchers believe that the lack of sunlight in the winter disrupts the body’s natural internal clock (circadian rhythm), which determines when you sleep and when you are awake. For some people, lower vitamin D levels that are more likely to occur in the northern winters may contribute to the risk for depressive symptoms. Usually SAD sets in during the winter months and improves by spring, but some people experience mood swings during the summer months, too. Summer-onset SAD may be due to malaise brought on by rising heat and humidity. Whereas people with winter-onset SAD experience a drop in energy, those with summer-onset SAD tend to be more irritable and anxious. The symptoms of depression are generally mild in people with SAD, but they return year after year.

Substance-Induced Depression

Use of certain medications and illicit drugs can lead to depression. When this happens, a person is said to have substance-induced depression. This type of depression is considered separate from other types because both the cause and treatment are typically different. In this case, the offending drug, if prescribed, is discontinued or the dose is reduced. If the drug causing the depression is being abused, the person will likely require some form of addiction treatment in order to recover completely. The key to proper treatment is to identify the underlying problem and correct it.

Melancholic, Atypical, and Anxious Depression

Some researchers distinguish among people with three different types of depression symptoms and categorize them as having melancholic, atypical, or anxious depression. It is not clear whether these are truly different forms of major depressive disorder with different causes and treatments, or whether they are simply different ways that depression manifests itself among the millions of people who suffer from it.

Melancholic depression: Depressed people with the following symptoms are said to have melancholic depression:

• Drop in appetite and weight
• Poor sleep
• Strong feelings of guilt
• Little or no response to pleasurable events when they are depressed

Atypical depression: People with this type of depression tend to:

• Gain weight and crave carbohydrates (such as cereal, bread, pasta, and sweets)
• Oversleep
• Experience heavy sensations in their limbs (leaden paralysis)
• Become less depressed, though only transiently, when exposed to pleasurable events (mood reactivity)
• Have enhanced reactions to criticism or rejection (rejection sensitivity)

Depression with anxious distress: Anxious distress in major depression tends to be accompanied by:

• Feeling keyed up and restless
• Difficulty concentrating due to worry
• Feeling that something very bad may happen
• Worrying about losing control

IV. HOW DEPRESSION AFFECTS DIFFERENT PEOPLE

Depression unquestionably affects people’s lives in many different ways. Different cultures, genders, and ages experience depression in unique ways.

Signs of Depression in Women

There is a real gender gap when it comes to depression. Women face double the risk of the condition compared to men, in part due to hormonal differences and in part because of the way they deal emotionally with stress. Depression often coexists with other health and mental conditions that have a higher prevalence in women, such as eating and anxiety disorders and multiple sclerosis.

Signs of depression in women are often different in women than are depression signs in men, but this may be in part related to men having symptoms that are not usually considered in the diagnosis of depression, such as outbursts of anger. Women are more likely to experience anxiety and physical symptoms. They also tend to overeat and gain more weight. There is a close relationship between obesity and depression, particularly in women, and doctors may need to screen for depression more often in obese women.

Depression in Men

Although women face double the risk, depression afflicts millions of men worldwide, and recent research suggests that men may actually suffer from depression nearly as often as women but just show it in different ways. While women tend to turn their emotions inward and feel worthless and guilty, men tend to reflect their emotions outward, sometimes becoming angry or aggressive or turning to alcohol or illicit drugs.

Because men are traditionally perceived as the stronger, more stoic gender, they are more likely to gloss over depression symptoms such as a lack of interest in life, fatigue, and low self-esteem. They might fear that revealing their condition will make them look weak or overly emotional to their family, friends, and colleagues.

Depression in the Elderly

Age brings wisdom, but it doesn’t always bring contentment. Growing older can introduce many new stresses into a person’s life, such as getting accustomed to retirement, moving to a new home, or dealing with the idea that adult children have less time for them than they would like.

There may be financial concerns after retirement, especially if investments have lost value and medical bills are piling up. There may be physical limitations from diseases that are more common with advancing age, such as arthritis, Parkinson’s disease, or heart disease. There can be grief and sadness that comes with the loss of friends, family members, or a spouse.

Finally, neurological and other health changes that occur with age can make people more vulnerable to depression and vice versa. Cognitive decline or dementia and depression are intimately intertwined in older people. The symptoms of each can be difficult to tease apart, and one condition frequently worsens the other.

Depression in Children

Children—especially young children—may have great difficulty articulating that they are upset. If depression is all they know, they may not even realize that they have a problem that can be helped. Their symptoms often do not follow the typical pattern of adult depression. For example, a child might seem bored or angry rather than sad. Depressed kids also tend to complain of physical ailments, such as stomachaches or headaches, because they aren’t able to express their emotions accurately.

Some children’s expression of depression can be so different from that of adults that experts have proposed a new subtype of depression that more closely fits that seen in children. This is known as disruptive mood regulation disorder and is characterized by a mood that is persistently angry or irritable combined with regular outbursts of temper. This condition is believed to appear for the first time among children aged six to 18. Some experts suspect that many children diagnosed with bipolar disorder may be more accurately described as having disruptive mood regulation disorder, at least until they get older and the true source of their troubles becomes clearer.

V. DIAGNOSING DEPRESSION

Once you approach your doctor about the possibility that you might be depressed, he or she will likely ask you several questions about how you have been feeling over the past weeks, months, and years. He or she might will likely perform a physical exam and might use screening tests or order some laboratory tests to help confirm your diagnosis and ensure there isn’t another underlying medical condition that could be driving or worsening your symptoms.

Screening Questionnaires

Guidelines from the American Psychiatric Association recommend that people with major depressive disorder complete a rating scale—either administered by their doctor or self-reported—to assess the type, frequency, and severity of their symptoms. Using a rating scale to evaluate symptoms can help the mental health professional tailor the treatment plan specifically to you.

Laboratory Tests

The following blood tests can help detect medical conditions that can cause depression symptoms:

• Levels of hormones, such as thyroid hormone
• Infection, such as Lyme disease or HIV
• Levels of medications or illicit drugs
• Blood sugar (glucose) levels
• Liver and kidney function tests
• Complete blood count (CBC)
• Levels of vitamins and minerals such as B12, folate, calcium, and vitamin D
• Test for inflammatory problems, such as erythrocyte sedimentation rate (ESR)

Less commonly, people with depression symptoms may be given brain scans, cardiovascular testing, neuropsychological testing, or a sleep study to rule out diseases that mimic or contribute to depression.

VI. DEPRESSION TREATMENTS: THERAPY

There are many options for treating depression, from antidepressants to psychotherapy (talk therapy) and even pioneering brain and nerve stimulation treatments. Yet there isn’t a single “one-size-fits-all” treatment. To find the treatment that will work best for your type and severity of depression, you’ll need to work closely with your doctor.

We take a look at therapy options in this chapter, followed by medications and natural depression remedies in Chapter VII.

Specialists Who Treat Depression

Your family doctor is the first person you should approach about your symptoms of depression and, in many cases, will be able to provide some, if not all of your treatment. Many people with depression, however, require the help of a professional who specializes in mental illness. Such professionals include:

Psychiatrist: These physicians (MDs) specialize in the prevention, treatment, and diagnosis of mental disorders. Psychiatrists are able to prescribe medications for depression. They also may treat patients with talk therapy or refer patients to psychologists, social workers, or other mental health professionals for talk therapy. They must be licensed to practice in the state in which they work. Psychiatrists also may be certified by the American Board of Psychiatry and Neurology.

Psychologist: These specialists typically hold a doctorate degree (PhD, PsyD, or EdD) or master’s degree in psychology. Psychologists can diagnose depression using various tests, and they can treat the condition with talk therapy. In most states, they cannot prescribe drugs but often refer patients who need depression medication to psychiatrists, primary care doctors, or nurse practitioners. Psychologists must be licensed by their state and certified by the American Board of Professional Psychology.

Psychiatric nurse: Psychiatric nurses are specialized nurses who treat people with depression and other mental health issues. They hold a degree in nursing, are licensed as registered nurses (RN), and have additional training in psychiatry. In some states, psychiatric nurses can prescribe medications, but usually only under a doctor’s supervision.

Social worker: Social workers hold a master’s degree in social work and are trained in psychotherapy. Most states require them to be licensed or certified. Clinical social workers often work for hospitals or social services agencies. They help ensure that patients get access to the care they need. Like psychologists, social workers work closely with a psychiatrist, primary care doctor or nurse practitioner if patients need depression medication along with talk therapy to treat their depression.

Therapist: “Therapist” is a broad and non-specific term for professionals who provide support to families, groups, or individuals. Therapists may have some form of certification and licensure. Many but not all therapists are social workers, psychologists, or psychiatrists. However, there are therapists (such as certain mental health or addiction counselors) who do not have a master’s, doctorate, or MD degree but have completed shorter, specialized training programs. If you choose to see a therapist, it’s a good idea to ask about their training and experience in treating depression.

Choosing the Right Mental Health Professional

Here are some tips for finding the psychiatrist, psychologist, or other mental health professional who best fits your needs:

Referrals: Ask your primary care physician for a referral. The American Psychological Association or American Psychiatric Association both offer online listings of psychologists and psychiatrists in your area.

Local hospitals: Many hospitals and health centers have departments of psychiatry or divisions of mental health that can offer information on local resources. Increasingly, hospitals have their own specialized depression treatment and research centers.

Health insurance: Contact your insurance company for information about local providers with expertise in depression.

Area of expertise: Ask about the mental health professional’s areas of expertise (including types of mental health problems treated and kinds of treatment offered), professional degrees held, and number of years in practice.

Personality and style: When you meet with the mental health professional for the first time, make sure you are comfortable with his or her personality and style.

Treatment recommendation: After you have your first session, ask what treatment or range of treatments your clinician recommends and how long treatment will take. It’s also a good idea to ask how long it will take to start feeling better once treatment has begun.

Types of Depression Therapy

Another important component of treatment for depression is to talk with a trained professional about the issues that may be causing or worsening your symptoms. It might sound simple, but talking can lift a lot of the emotional weight that you feel. Psychotherapy is available in one-on-one sessions, as part of a group, or in conjunction with your spouse or family.

Cognitive behavioral therapy (CBT): People with depression are often plagued by negative thoughts. The idea behind CBT is that your thoughts can have a big impact on your mood. This treatment aims to identify and then change your negative perceptions to give you a more positive outlook. CBT starts with identifying the negative thoughts you have about yourself (“I’m a failure”), your environment (“Everyone hates me”), and your future (“I have nothing to look forward to”). Working closely with your therapist, you start to understand how certain negative beliefs have no basis in reality. Then, you reframe those false beliefs and replace them with more positive ones.

Acceptance and commitment therapy (ACT): The primary goal of ACT therapy is to help individuals accept what is out of their personal control and to commit to actions that can improve and enrich their lives. Taking a somewhat different perspective about thoughts and feelings than CBT, ACT adopts the view that trying to change them can be counterproductive. A therapist using an ACT approach often uses mindfulness techniques, which teach recognition and acceptance of thoughts and feelings without judgment and without any attempt to change them. In doing so, negative thoughts and feelings can have less of an influence on one’s actions and wellbeing. Another component of ACT is to learn to focus on values and activities that bring meaning to one’s life.

Concreteness training (CNT): This intriguing new form of psychotherapy, which uses many of the principles of CBT, is known as concreteness training, or CNT. The therapy involves teaching depressed people, who have a tendency toward negative abstract thinking and overgeneralization of negative thoughts, to think more concretely. For instance, the therapy involves teaching people to be more specific when thinking about individual problems, with the goal of keeping their problems in perspective and working on concrete solutions, rather than just worrying about them.

Interpersonal therapy (IPT): Interpersonal therapy focuses on identifying the relationship issues that are driving your depression symptoms, particularly unresolved grief, relationship conflicts, transitions to a new role (such as from wife to wife and mother), and difficulty with interpersonal relationships. Then it helps you improve your communication and conflict resolution skills so that you are better equipped to handle issues that arise with your friends and family members.

Psychodynamic therapy: Psychodynamic therapy is often a longer-term approach to treating depression. This treatment seeks to identify the roots of your depression by focusing on the behaviors and relationships that are making you unhappy and then developing new insights about how they affect you. You may go back as far as your early childhood, recalling events that you might have consciously forgotten but that are unconsciously driving your dark mood. By using techniques such as self-reflection and self-examination, your therapist can bring the painful memories and feelings that are haunting you to light and then try to work through them so you can learn how to live a healthier, happier life.

Dialectical behavior therapy (DBT): DBT was primarily developed for people who struggle with a particularly severe form of personality disorder called borderline personality disorder, which includes profound feelings of emptiness, unstable interpersonal relationships, self-destructive behaviors, and suicidal tendencies. DBT emphasizes acceptance and change, and was influenced by psychological research and practice as well as by Buddhism.

Brain and nerve stimulation therapies: No one is exactly sure why, but it appears that stimulating the whole brain, certain parts of the brain, or specific major nerves can sometimes produce relief from depression, even when other therapies fail. Different brain and nerve stimulation therapies vary with respect to the area being stimulated, the source of the stimulation, and the invasiveness of the procedure, but in all cases the goal is to get brain cells firing, new connections forming, or communication networks re-balanced.

Electroconvulsive therapy (ECT): ECT is a safe and highly effective medical therapy used to treat severe depression that has not responded enough to medication and psychotherapy. ECT uses an electrical shock to trigger seizures in the brain, but the current is well controlled and delivered while the patient is under anesthesia, making it painless. It’s designed to cause the brain to release the neurotransmitters that improve mood.

Deep brain stimulation: A more invasive technique, called deep brain stimulation (DBS), involves implanting a device in the chest. The device sends electrical signals directly into specific brain regions via wires connected to electrodes implanted deep in the brain. These signals stimulate areas in the brain that affect mood and depression.

Transcranial magnetic stimulation: This noninvasive therapy uses an electromagnetic coil placed on the forehead to send pulses to a part of the brain that helps regulate mood. Unlike more invasive brain stimulation techniques, TMS can be delivered right in a doctor’s office using specialized equipment.

A more recent version of TMS is called “deep TMS” because it involves stimulation of deeper regions of the brain than TMS. Deep TMS may prove to be more effective for some individuals than regular TMS, but further information is needed about this innovative form of treatment.

Transcranial direct current stimulation: An even newer brain stimulation technique is called transcranial direct current stimulation (tDCS). Also non-invasive, this technique involves using electrodes placed on the scalp to run a weak electrical current into the front portion of the brain, which is the area responsible for intellectual functioning.

Magnetic seizure therapy (MST): Already available in a handful of medical centers worldwide, MST provokes seizures in the brain in a manner similar to ECT. The difference is that instead of using electrical currents to stimulate generalized seizures, MST employs magnetic pulses to induce seizures in only one small portion of the brain. The biggest benefit of this more focused treatment is that it is less likely to produce the memory problems commonly seen with ECT.

Nerve stimulation therapies: Electrical and magnetic stimulation as a means of relieving depression is not just limited to the brain. Other forms of stimulation target major nerve pathways.

In vagus nerve stimulation (VNS), a pacemaker-like device called a pulse generator (about the size of a silver dollar) is implanted in the chest by a surgeon (usually a neurosurgeon or thoracic surgeon). The pulse generator sends signals to the vagus nerve in the neck for about 30 seconds once every five minutes. These signals are thought to improve mood, although doctors still don’t know exactly how.

A new and experimental electrical stimulation therapy that is showing promise for treating depression is called trigeminal nerve stimulation (TNS). This therapy was originally designed for patients with treatment-resistant epilepsy. TNS uses a stimulator about the size of a large cell phone, which is connected by wires to electrodes attached to the forehead. The electrodes send an electrical current to the trigeminal nerve in the face. Stimulating this nerve sends signals deep into the brain in a noninvasive way.

Complementary and Alternative Therapies

Some people prefer to try alternative therapies for depression. Although some of these treatments have shown effectiveness against depression symptoms, they may not be enough to fully treat all aspects of the condition, particularly if you have more severe depression.

It’s important to check with your doctor before taking any therapy—even a natural remedy—to make sure you are receiving the best and safest treatment possible. It’s also important to be sure that natural or alternative remedies you are taking or would like to take do not interact with any drugs you are taking for depression or another medical condition. Both your doctor and your pharmacist can help you determine that.

VII. DEPRESSION TREATMENTS: MEDICATION AND NATURAL REMEDIES

For anyone struggling with depression, there may be medications and natural approaches that can help. In this chapter, we’ll discuss commonly prescribed antidepressants and meds as well as natural strategies that can ease symptoms.

Medications most often used to treat depression are thought to improve mood by adjusting levels of the brain chemicals (neurotransmitters) that contribute to feelings of depression. Antidepressants are usually the first drugs prescribed for depression. Because different types of antidepressant drugs have similar effectiveness, the one your doctor prescribes will largely depend on the side effects and how well you tolerate the drug.

Selective serotonin reuptake inhibitors (SSRIs): Among the newer antidepressant classes, SSRIs are widely considered to be the first choice for patients who receive antidepressants. They include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), escitalopram (Lexapro), and paroxetine (Paxil). Potential side effects include increased risk of sunburn, rash, drowsiness, kidney or liver impairment, and low blood sugar and low blood sodium levels.

Serotonin and norepinephrine reuptake inhibitors (SNRIs): Another relatively new class of antidepressant that may be just as effective as the SSRIs. Examples include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). Most common side effects: excessive sweating, dry mouth, nausea, and dizziness. SNRIs also may cause tiredness, difficulty urinating, constipation, or sexual problems such as reduced desire, difficulty reaching orgasm, or erectile dysfunction. (For more on serotonin, see sidebar below.)

Reuptake inhibitors and receptor blockers: Two drugs in this class are FDA-approved to treat depression: trazodone (Desyrel) and nefazodone (Serzone). Nefazodone is rarely prescribed today because of its association with rare but serious liver problems. Dizziness, nervousness, nausea, drowsiness, and headaches are among the potential side effects, as are diarrhea, vomiting, dry mouth, and reduced sexual desire.

Tricyclic antidepressants (TCAs): Among the oldest antidepressants, this class includes imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline (Elavil), and clomipramine (Anafranil). Side effects can range from dry mouth to increased sweating, increased appetite to urinary retention, and blurred vision to drowsiness.

Monoamine oxidase inhibitors (MAOIs): Also an older class of drugs and generally reserved for very treatment-resistant depression because of their multiple interactions with food and other drugs, MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan), and selegiline (Emsam, which comes in a skin patch formulation). Most common side effects include insomnia,headaches, dizziness, drowsiness, dry mouth, or nausea.

Other drugs sometimes prescribed in people with depression include anti-anxiety medications (also known as anxiolytics) such as lorazepam (Ativan) or clonazepam (Klonopin) to treat accompanying anxiety; atypical antipsychotics such as aripiprazole (Abilify), quetiapine (Seroquel), or olanzapine (Zyprexa), to boost the effects of antidepressants; and mood stabilizers such as lithium and anticonvulsants to manage bipolar disorder.

Maintenance drug therapy: Depression treatment guidelines from the American Psychiatric Association recommend that doctors use maintenance drug therapy to prevent depression from returning. This is especially important for people whose depression tends to recur, and particularly for those who have had three or more episodes of depression or have a chronic illness. This means that your doctor may recommend staying on your medication even after you are feeling better.

In some cases, you may try lowering your dose, especially if you’re experiencing troublesome side effects, but only with the help of careful follow-up from your doctor. You should never stop taking medication prescribed for depression on your own. Your symptoms could recur or you might experience uncomfortable effects associated with rapid withdrawal of the medication.

Other antidepressants: Newer antidepressants that work a little differently from those listed above include:

• Bupropion (Wellbutrin), which has as more common side effects anxiety, hyperventilation or shortness of breath, dry mouth, irritability, shaking, restlessness or sleeplessness, or irregular heartbeats;
• Mirtazapine (Remeron), which can produce as more common side effects dizziness, drowsiness, back pain, increased appetite, weight gain, and constipation and as less common side effects back pain, abdominal pain, low blood pressure, vomiting, trembling or shaking, thirstiness, and n increased need to urinate.
• Vilazodone (Viibryd), which may result in diarrhea, dizziness, dry mouth, nauseous feelings, and sleeplessness.
• Vortioxetine (Brintellix), which can cause such side effects as constipation or dry mouth (more common) or excessive gas, itchy skin, or unusual dreams (less common).

Natural Therapies for Beating Depression

Diet: What you eat can have a big impact on your mood. Foods like fish, nuts, and seeds, which are high in omega-3 fatty acids, may help ward off depression. That might be why people who eat a Mediterranean diet (in which olive oil, nuts, and fish are staples) are less likely to develop depression than people who eat other kinds of foods. Processed and sugary foods are high in simple carbs and trans fats, which may boost energy transiently, but ultimately can drain your energy and make you feel even more down in the dumps.

Omega-3 fatty acid supplements: The essential polyunsaturated fatty acids found in fish like salmon, tuna, and halibut, as well as in flaxseed and other plants, are crucial to healthy brain function. A number of studies have found that people with diets that are high in fish are less likely to be depressed, but results of studies on the effectiveness of omega-3 fatty acid supplements for treating depression have been mixed.

B and D vitamins: There is some evidence linking deficient levels of certain B vitamins and vitamin D with depression. B vitamins are important for the production of brain chemicals that help regulate mood, and vitamin D is important for proper communication between the nervous system and the rest of the body. At least in older people, researchers have found that higher intake of some B vitamins may help prevent depression. Recently, vitamin D supplementation among women with known vitamin D deficiency has been shown to be an effective treatment for depression, but it is less clear whether vitamin D is helpful for alleviating mood problems when vitamin D deficiency is not present.

S-adenosylmethionine (SAMe): pronounced “sammy,” this natural substance is found in all of the body’s cells. It helps produce serotonin and dopamine, and it participates in myriad other natural physiological reactions in the body. (For more on dopamine, see sidebar below.) Taking SAMe in supplement form is thought to increase the levels of certain brain chemicals and to improve mood.
St. John’s wort: This flower extract is one of the most popular, and best studied, alternative remedies for depression. Although a large review of studies conducted by the National Center for Complementary and Alternative Medicine (NCCAM) showed that the herb wasn’t any better for treating major depression than a placebo, it may be more effective for mild-to-moderate depression. But be careful, as this herb has side effects and can interact with many different types of drugs.
Roseroot: This is another herb that has been shown to help alleviate symptoms of depression. Used for over 3,000 years in European folk medicine, a new study suggests roseroot might be nearly as effective as an antidepressant but without the troublesome side effects.
Curcumin and saffron Want to relieve your depression symptoms using safe, natural antidepressants? Want an herbal alternative that can improve your depression symptoms without side effects like weight gain and sexual dysfunction sometimes associated with antidepressant medications? Two herbal extracts known for their brilliant, yellow-orange hues—curcumin and have been found in randomized, controlled studies to be safe and effective treatments for depression. Taking either of these natural antidepressants will relieve your depression symptoms as much as Prozac, the research shows.
Exercise: Research reveals that what’s good for the body is also good for the mind. When you go for a run or a swim, your brain releases brain chemicals such as norepinephrine and endorphins—both of which can boost mood.
Massage: If you have ever had a massage, you know how relaxed the therapy can make you feel. A review of studies found that massage therapy had “potentially significant effects” on the symptoms of depression, possibly through its ability to reduce stress and induce a state of relaxation.
Acupuncture: This traditional Chinese medicine practice of stimulating various pressure points throughout the body with very fine needles has been used to treat conditions ranging from osteoarthritis to low back pain. Although one review of studies did not find enough evidence to recommend the use of acupuncture for depression, another study found that acupuncture significantly improved depression in pregnant women.
Relaxation techniques: Guided imagery, in which you use a recording or the help of an instructor to focus on a particular image (such as a lemon) in great detail, can be a good way to teach your body how to relax. Meditation, in which you sit quietly for 10 to 15 minutes and repeat a word or “mantra,” is another effective relaxation technique. Yoga also can help relax the body and mind. Recently, mindfulness meditation, a form of meditation adapted from Buddhist practice in which you learn to be in the moment and accepting of your immediate thoughts, feelings, and sensations in a non-judgmental manner, has been shown to be particularly effective for mental health issues.
Light therapy: In people with seasonal affective disorder (SAD), short, dark winter days trigger depression. It is thought these symptoms are caused by alterations in the body’s circadian rhythm and production of melatonin (a hormone that regulates sleep and mood). Light therapy can help regulate circadian rhythms and melatonin production to boost mood, not only in people with SAD but also in those with depression who want to try an alternative to medication and therapy.

New and Experimental Treatments for Depression

Researchers are constantly working to fine-tune and add to the currently available therapies for depression. Here are a few of the exciting new developments you might expect to see in the near future:

Agomelatine (Valdoxan): Agomelatine works on two types of brain cell receptors: a type of serotonin receptor called 5HT2C and a receptor for the sleep-regulating hormone melatonin. Research suggests it might be particularly beneficial for the treatment of anxiety related to depression.

Triple reuptake inhibitors: Researchers are working on a number of antidepressants that block the reuptake of three neurotransmitters: serotonin, norepinephrine, and dopamine. They hope that by making more of all three of these chemicals available in the brain, triple reuptake inhibitors will have a more significant impact on depression than the antidepressants that are currently available (which generally work on only one or two neurotransmitters).

Stress hormone blocking agents: Certain hormones released during the “fight-or-flight” stress response (such as cortisol) may have a role in depression, particularly in forms of depression that develop from chronic stress. Medications such as mifepristone (Mifeprex), which block cortisol production, are currently being investigated for the treatment of depression.

Neurogenesis stimulators: There are a number of experimental therapies undergoing study for the treatment of depression each of which, in their own different way, stimulate neurogenesis, or the growth of new nerve cells and connections within the brain. They include glutamate blocking drugs such as ketamine and similar drugs, which are being actively researched for use in depression.

Brain-derived neurotrophic factor stimulators: It is now believed that many antidepressants boost the levels or activity of chemicals in the brain that promote nerve health and growth, such as brain-derived neurotrophic factor (BDNF). Some researchers believe that antidepressants may reduce the risk of brain atrophy (shrinkage) in patients with chronic depression because they can promote BDNF. Although BDNF cannot be given as pills, the observation that antidepressants may have an effect on BDNF has opened new avenues for treatments that replicate this action on the brain.

VIII. LIVING WITH DEPRESSION

Depression can quickly turn into a self-perpetuating cycle. You feel awful, so you refuse to do anything you once thought was fun; you may not even venture out to see your friends. Your inactivity and isolation in turn feed your depression. The key to overcoming depression and moving into the light is to break that cycle.

Finding Support

Getting help for your depression starts with a visit to your doctor or a mental health professional for diagnosis and treatment. Once treatment is under way, seek out the type of support that works for you, whether it is:

• Talking to a friend or family member
• Meeting with a therapist or counselor for personal, marriage, family, or group therapy
• Joining a support group of people with depression
• Visiting an online support group
• Talking to a trusted member of your church, synagogue, mosque, or other religious organization
• Joining a community group Helping a Friend or Loved One with Depression
• Despite your best intentions, helping someone with depression isn’t always easy. Your friend or loved one might not realize he or she is depressed or may not be willing to accept your help.
• Realize that you cannot “cure” that person, no matter how hard you try. All you can do is help someone recognize that there is a problem, let him or her know you care, and suggest professional help.

When you first approach your friend or loved one about depression, bring with you a few recommendations for available local services, such as the names and phone numbers of therapists or support groups. Gently keep track of whether your loved one seeks treatment and takes medication as prescribed. Offer your encouragement along the way. Be on the lookout for signs of suicidal tendencies. If you see any warning signs, call a mental health professional or 911 right away.

Don’t shy away from asking someone directly about depression. Even trained professionals sometimes don’t recognize the signs and symptoms in themselves. Feedback from a concerned friend or family member is often a helpful “wake-up call,” whether or not that friend or family member decides to act on it right away.

Similarly, don’t hesitate to ask whether a close friend or family member has had any thoughts of self-harm or not wanting to live. Asking about suicide does not make it more likely. On the contrary, it allows a loved one to share the burden and get the help he or she needs. Suicidal thoughts are often part of being depressed. They do not necessarily require hospitalization, but they do need to be taken seriously, and they always require urgent evaluation.

Preventing Episodes of Depression

You can lessen the blow of depression by recognizing when you have symptoms and getting professional help. Follow the treatment plan your doctor prescribes. Contact your doctor right away if you are having bothersome or worrisome side effects from your medication.

Keep in mind that some side effects get better on their own within the first few days or weeks of starting a medication, while others require a change in dose or medication. Don’t change any part of your treatment without first talking to your doctor. Stopping a drug suddenly can actually make side effects temporarily worse.

Take the Long View

Keep your long-term goals in mind. It usually takes two to three weeks before you begin to feel better, and it can take as long as six to 12 weeks to know whether a medication will be fully effective for you. Stopping and starting medications prematurely will not give your body enough time to respond to the recommended treatment, and it won’t allow your doctor to determine whether the medication is right for you. If you’re really not coping, ask your doctor to prescribe something, such as an anti-anxiety drug, which you can take for a couple of weeks until your antidepressant takes its full effect.

Be Kind to Yourself

Take it easy on yourself. It’s easy to blame yourself for the way you feel, or to think that you deserve to feel the way that you do. Many people, especially men, feel they should be able to “pull themselves together” and get on with life. You might have even had some people tell you this. Such feelings or comments stem from a fundamental misunderstanding of depression. Just as you can’t “decide” one day not to have diabetes, you can’t wake up one morning and choose not to be depressed.

What you can choose to do is get the help you need to feel better. Never forget that no matter how bad things are, there is always something positive to hold onto. Focus on the positive and cultivate gratefulness, which has been shown to go hand-in-hand with good mental health.

Take Care of Yourself

Incorporate the following healthy lifestyle choices, many of which have been shown to have a big impact on depression:

Exercise for 30 to 60 minutes a day: When you work out, your body releases endorphins—chemicals that make you feel better. Research has found that exercising for 30 minutes a day can be just as effective at relieving the symptoms of major depression as drug therapy. Exercising will also keep your body in shape, boosting your self-esteem. Try soothing forms of exercise, such as yoga, which recently has been linked with improvements in the symptoms of several psychiatric disorders, including depression, attention deficit/hyperactivity disorder (ADHD), and schizophrenia. It may also help alleviate sleep problems, which too frequently accompany depression.

Maintain a healthy diet: Research shows that a healthy diet can help ward off depression, while eating junk food can contribute to it.

Sleep well: Depression and poor sleep are closely linked. Understandably, people who are depressed can have trouble getting to sleep or staying asleep because of the persistent worries that plague them. When you don’t sleep well, you feel worse during the day. You have less energy to go out with friends or to exercise. The link between poor sleep and depression appears to be biological too. Some people with depression sleep too much and never seem to feel rested. Too much or too little sleep exacerbates the depression you’re already experiencing.

Control stress: Stress is a big player in depression. Control it before it controls you. Great stress-busting techniques include yoga, meditation, progressive relaxation, and guided imagery. Whenever you feel that your stress is getting out of control, take a step back. Take a vacation from work, leave your kids with a babysitter, get help taking care of an ailing spouse—whatever you need to do to regroup. Consider whether certain obligations can be tabled temporarily.

Put yourself in a position to experience pleasure: Even when you doubt that you will be able to get pleasure from life because of your depression, allow yourself to do the things you used to enjoy before your depression took root.

Release your emotions: When you’re feeling stressed out or sad, let it out. Bottled-up grief and anger can ferment until it finally explodes. Talk about your feelings to family members, friends, or a therapist. Or, write your thoughts in a journal.

Don’t get discouraged: Instead of punishing yourself for failing to recover from your depression quickly, reward yourself for all the improvements you have made. Always remember and focus on the good times, which exist even for those in the most dire of circumstances.

Relapse Prevention

One of the most important, yet most neglected, aspects of depression treatment is preventing depression from returning. “Relapse” refers to the return of depression after a period of weeks or months of doing well. “Recurrence” is a relapse that occurs late, after many months or years of stable mood and functioning.

You need to go into treatment with the expectation that you may have periods of improvement and periods in which your symptoms get worse. It is essential that you discuss relapse prevention with the doctor or mental health professional who is treating your depression.

Most important, don’t stop taking medication the minute you feel better. It can be tempting, especially if you are plagued by uncomfortable side effects, but it can trigger both discontinuation reactions from the drug as well as the return of your depression. If you want to stop therapy, talk to your doctor. Some people need to stay on medication for life while others can cope without medication, or with a lower dose, if they maintain healthy lifestyle habits and a good support network.

Identify warning signs: For most patients, identifying the warning signs that their depression is returning (such as becoming more isolated or not responding to emails and phone calls) can help nip a relapse in the bud. For many people, identifying triggers of past depression (such as a loss, move, disappointment, or work stress can also help them develop a treatment plan with their health care provider that reduces the likelihood of a full-blown relapse in the future.

Healthy Steps

Here are a few other healthy steps you can take to improve your health and quality of life:

• Work to build and maintain social support
• Tackle recurrent sources of frustration in your career or home life
• Develop new hobbies

If you’re going to treat your depression successfully and keep it under control for many years, your treatment must be part of an overall healthy lifestyle. There is no guarantee that depression won’t come back. Even when you are doing everything right, depression can relapse. But by doing all the right things, you are more likely to bring your depression under control so you can get back to your life.