DEPRESSION
A diagnosis is made when an individual meets
a sufficient number of the symptom criteria for the depression spectrum
as suggested in the DSM-IV-TR or ICD-9/ICD-10. An individual is
often seen to suffer from what is termed as a “clinical depression”
without fully meeting the various criteria advanced for a specific
diagnosis on the depression spectrum. Possible causes of depression
are not taken into account in diagnosis, unless it may be due to
an existing medical condition.
It is important to understand that there is no
blood test or brain scan for depression. Therefore the term “clinical
depression” can be misleading to those who erroneously believe that
there is a medical test for this disorder. Laboratory tests can
provide medical data for diseases such as diabetes and heart disease,
but currently not for depression, bipolar disorder, schizophrenia
and other mental disorders.
Symptoms of depression
According to the DSM-IV-TR criteria for diagnosing
a major depressive disorder (cautionary statement) one of the following
two elements must be present for a period of at least two weeks:
Depressed mood, or Anhedonia.
It is sufficient to have either of these symptoms
in conjunction with five of a list of other symptoms over a two-week
period. These include:
• Feelings of overwhelming sadness and/or fear,
or the seeming inability to feel emotion (emptiness)
• A decrease in the amount of interest or pleasure in all, or almost
all, daily activities
• Changing appetite and marked weight gain or loss
• Disturbed sleep patterns, such as insomnia, loss of REM sleep,
or excessive sleep (Hypersomnia)
• Psychomotor agitation or retardation nearly every day
• Fatigue, mental or physical, also loss of energy
• Intense feelings of guilt, helplessness, hopelessness, worthlessness,
isolation/loneliness and/or anxiety
• Trouble concentrating, keeping focus or making decisions or a
generalized slowing and obtunding of cognition, including memory
• Recurrent thoughts of death (not just fear of dying), desire to
just “lay down and die” or “stop breathing”, recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific
plan for committing suicide
• Feeling and/or fear of being abandoned by those close to one.
Other symptoms often reported but not usually
taken into account in diagnosis include:
• Self-loathing
• A decrease in self-esteem
• Inattention to personal hygiene
• Sensitivity to noise
• Physical aches and pains, and the belief these may be signs of
serious illness
• Fear of ‘going mad’
• Change in perception of time
• Periods of sobbing
• Possible behavioral changes, such as aggression and/or irritability.
It is hard for people who have not experienced
clinical depression, either personally or by regular exposure to
people suffering it, to understand its emotional impact and severity,
interpreting it instead as being similar to “having the blues” or
“feeling down.” As the list of symptoms above indicates, clinical
depression is a serious, potentially lethal systemic disorder characterized
by the psychiatric industry as interlocking physical, affective,
and cognitive symptoms that have consequences for function and survival
well beyond sad or painful feelings.
Diagnosing depression in children
Depression in children is not as obvious as it
is in adults. Here are some symptoms that children might display:
• Loss of appetite
• Irritability
• Sleep problems, such as recurrent nightmares
• Learning or memory problems where none existed before
• Significant behavioral changes; such as withdrawal, social isolation,
and aggression.
An additional indicator could be the excessive
use of drugs or alcohol. Depressed adolescents are at particular
risk of further destructive behaviors, such as eating disorders
and self-harm.
Treatment of depression
Treatment of depression varies broadly and is
different for each individual. Various types and combinations of
treatments may have to be tried, but without hope in a complete
solution to the problem. There are two primary modes of treatment,
typically used in conjunction: medication, and psychotherapy such
as Cognitive
Behavioral Therapy. A third treatment, electroconvulsive therapy
(ECT), may be used when chemical treatment fails. Other alternative
treatments used for depression include exercise and the use of vitamins,
herbs, or other nutritional supplements.
The effectiveness of treatment often depends on
factors such as the amount of optimism and hope the sufferer is
able to maintain, the control s/he has over stressors, the severity
of symptoms, the amount of time the sufferer has been depressed,
the results of previous treatments, and the degree of support of
family, friends, and significant others.
Although treatment is generally effective, in
some cases the condition does not respond. Treatment-resistant depression
warrants a full assessment, which may lead to the addition of psychotherapy,
higher medication dosages, changes of medication or combination
therapy, a trial of ECT/electroshock, or even a change in the diagnosis,
with subsequent treatment changes. Although this process helps many,
some people’s symptoms continue unabated.
In emergencies, psychiatric hospitalization is
used simply to keep suicidal people safe until they cease to be
dangers to themselves. Another treatment program is partial hospitalization,
in which the patient sleeps at home but spends the day, either five
or seven days a week, in a psychiatric hospital setting in intense
treatment. This treatment usually involves group therapy, individual
therapy, psychopharmacology, and academics (in child and adolescent
programs).
Medication for depression
Medications that relieve the symptoms of depression,
antidepressants,
have been available for several decades. These drugs are listed
in order of historical development. Typical first-line therapy for
depression is the use of an selective serotonin reuptake inhibitor,
such as sertraline. Research has indicated that medication should
be prescribed in combination with psychotherapy for most effective
treatment.
Monoamine oxidase inhibitors (MAOIs) such as Nardil
may be used if other antidepressant medications are ineffective.
Because there are potentially fatal interactions between this class
of medication and certain foods and drugs, they are rarely prescribed
anymore. MAOI’s are used to block the enzyme monoamine oxidase which
breaks down neurotransmitters such as serotonin and norepinephrine.
MAOI’s are as effective as tricyclics, if not slightly more effective.
A new MAOI has recently been introduced. Moclobemide, known as a
reversible inhibitor of monoamine oxidase A (RIMA), follows a very
specific chemical pathway and does not require a special diet.
Tricyclic antidepressants are the oldest and include
such medications as amitriptyline and desipramine. Tricyclics block
the reuptake of certain neurotransmitters such as norepinephrine
and serotonin. They are used less commonly now because of their
side effects, which include increased heart rate, drowsiness, dry
mouth,constipation, urinary retention, blurred vision,dizziness,
confusion, and sexual dysfunction. Most importantly, they have a
high potential to be lethal in moderate overdose. However, tricyclic
antidepressants are still used because of their high potency, especially
in severe cases of clinical depression.
Selective serotonin reuptake inhibitors (SSRIs)
are a family of antidepressant considered to be the current standard
of drug treatment. It is thought that one cause of depression is
an inadequate amount of serotonin, a chemical used in the brain
to transmit signals between neurons. SSRIs are said to work by preventing
the reabsorption of serotonin by the nerve cell, thus maintaining
the levels the brain needs to function effectively, although two
researchers recently demonstrated that this is a marketing technique
rather than a scientific portrayal of how the drugs actually work.
Recent research indicates that these drugs may interact with transcription
factors known as “clock genes”, which may be important for the addictive
properties of drugs of abuse and possibly in obesity. This family
of drugs includes fluoxetine, paroxetine, escitalopram , citalopram,
and sertraline. These antidepressants typically have fewer adverse
side effects than the tricyclics or the MAOIs, although such effects
as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased
appetite, and decreased ability to function sexually may occur.
Some side effects may decrease as a person adjusts to the drug,
but other side effects may be persistent.
Norepinephrine reuptake inhibitors such as reboxetine
(Edronax) act via norepinephrine (also known as noradrenaline).
NeRIs are thought to have a positive effect on concentration and
motivation in particular. Drugs such as Bupropion can help with
smoking cessation. It is also known to inhibit the neuronal reuptake
of dopamine.
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
such as venlafaxine and duloxetine are a newer form of antidepressant
that works on both noradrenaline and serotonin. They typically have
similar side effects to the SSRIs, although there may be a withdrawal
syndrome on discontinuation that may necessitate dosage tapering.
Dietary supplements
5-HTP supplements are claimed to provide more
raw material to the body’s natural serotonin production process.
There is a reasonable indication that 5-HTP may not be effective
for those who haven't already responded well to an SSRI because
of their similar function: SSRIs allow the brain to use its serotonin
more effectively, while 5-HTP induces production of more serotonin.
S-adenosyl methionine (SAM-e) is a derivative
of the amino acid methionine that is found throughout the human
body, where it acts as a methyl donor and participates in other
biochemical reactions. It is available as a prescription antidepressant
in Europe and an over-the-counter dietary supplement in the United
States. Clinical trials have shown SAM-e to be as effective as standard
antidepressant medication, with fewer side effects; however, some
studies have reported an increased incidence of mania resulting
from SAM-e use compared to other antidepressants. Its mode of action
is unknown.
Omega-3 fatty acids (found naturally in oily fish,
flax seeds, hemp seeds, walnuts, and canola oil) have also been
found to be effective when used as a dietary supplement (although
only fish-based omega-3 fatty acids have shown antidepressant efficacy.
Dehydroepiandrosterone (DHEA), available as a
supplement in the U.S., raises serotonin levels. Chocolate improves
mood, probably by raising serotonin.
St John’s Wort [Hypericum perforatum] has traditionally
been used by ‘wise women’ and midwives for hundreds of years, to
‘chase away the devil’ of melancholia and anxiety. It is a mood-enhancing
herbal substance which acts like an antidepressant and increases
the availability of serotonin, norepinephrine and dopamine at the
neuron synapses. Also popular for treating insomnia, mood swings,
fatigue, PMS and menopause. It should not be used at the same time
as other antidepressants.
Ginkgo Biloba Effective is claimed to be a natural
antidepressant, apparently stabilizing cell membranes, inhibiting
lipid breakdown and aiding cell use of oxygen and glucose - so subsequently
a mental and vascular stimulant that improves neurotransmitter production.
It is also popular for treating mental concentration (such as for
Alzheimer’s and stroke patients).
Siberian Ginseng [Eleutherococcus senticosus],
although not a true panax ginseng, is a mood enhancement supplement
against stress. It is also popular for treating depression, insomnia,
moodiness, fatigue, poor memory, lack of focus, mental tension and
endurance.
Zinc at 25mg per day has had an antidepressant
effect in one experiment.
Vitamin B-12: Symptoms of a vitamin B-12 deficiency
can include depression and other psychiatric disorders.
The amino acids phenylalanine and tyrosine have
also a favorable effect on easy forms of depression. They are supposed
to enhance the neurotransmitters dopamine and noradrenalin.
Psychotherapy
In psychotherapy, or counseling, one receives
assistance in understanding and resolving habits or problems that
may be contributing to or the cause of the depression. This may
be done individually or with a group and is conducted by mental
health professionals such as psychiatrists, psychologists, clinical
social workers, or psychiatric nurses.
Effective psychotherapy may result in different
habitual thinking and action which leads to a lower relapse rate
than antidepressant drugs alone. Medication, however, may yield
quicker results and be strongly indicated in a crisis. Medication
and psychotherapy are generally complementary, and both may be used
at the same time.
It is important to ask about potential therapists’
training and approach; a very close bond often forms between practitioner
and client, and it is important that the client feel understood
by the clinician. Moreover, some approaches such as cognitive behavioral
therapy have been convincingly demonstrated to be much more effective
in treating depression.
Counselors can help a person make changes in thinking
patterns, deal with relationship problems, detect and deal with
relapses, and understand the factors that contribute to depression.
There are many counseling approaches, but all
are aimed at improving one’s personal and interpersonal functioning.
Cognitive
Behavioral Therapy has been demonstrated in carefully controlled
studies to be among the foremost of the recent wave of methods which
achieve more rapid and lasting results than traditional “talk therapy”
analysis. Cognitive therapy, often combined with behavioral therapy,
focuses on how people think about themselves and their relationships.
It helps depressed people learn to replace negative depressive thoughts
with realistic ones, as well as develop more effective coping behaviors
and skills.
Therapy can be used to help a person develop or
improve interpersonal skills in order to allow him or her to communicate
more effectively and reduce stress. Interpersonal psychotherapy
focuses on the social and interpersonal triggers that cause their
depression. Narrative therapy gives attention to each person’s “dominant
story” by means of therapeutic conversations, which also may involve
exploring unhelpful ideas and how they came to prominence. Possible
social and cultural influences may be explored if the client deems
it helpful. Behavioral therapy is based on the assumption that behaviors
are learned. This type of therapy attempts to teach people more
healthful types of behaviors. Supportive therapy encourages people
to discuss their problems and provides them with emotional support.
The focus is on sharing information, ideas, and strategies for coping
with daily life. Family therapy helps people live together more
harmoniously and undo patterns of destructive behavior.
Electroconvulsive therapy
Also known as electroshock or electroshock therapy,
this therapy uses short bursts of a controlled current of electricity
(typically fixed at 0.9 ampere) into the brain to induce a brief,
artificial seizure while the patient is under general anesthesia.
ECT has acquired a fearsome reputation, in part
from its use as a tool of repression in the former USSR and its
barbaric fictional depiction in films such as One Flew Over
the Cuckoo’s Nest and Requiem for a Dream, but remains
a common treatment where other means of treatment have failed or
where the use of drugs is unacceptable. Also, in contrast to direct
electroshock of years ago, most countries now allow ECT to be administered
only under anesthesia.
In a typical regimen of treatment, a patient receives
three treatments per week over three or four weeks. Repeat sessions
may be needed. Short-term memory loss, disorientation, and headache
are very common side effects. In some cases, permanent memory loss
has occurred, but detailed neuropsychological testing in clinical
studies has not been able to prove permanent effects on memory.
ECT offers the benefit of a very fast response; however, this response
has been shown not to last unless maintenance electroshock or maintenance
medication is used. Whereas antidepressants usually take around
a month to take effect, the results of ECT have been shown to be
much faster. For this reason, it is the treatment of choice in emergencies
(e.g., in catatonic depression in which the patient has ceased oral
intake of fluid or nutrients).
Exercise
It is widely believed that physical activity and
exercise help depressed patients and promote quicker and better
relief from depression. They are also thought to help antidepressants
and psychotherapy work better and faster. It can be difficult to
find the motivation to exercise if the depression is severe, but
sufferers should be encouraged to take part in some form of regularly
scheduled physical activity. A workout need not be strenuous; many
find walking, for example, to be of great help. Exercise produces
higher levels of chemicals in the brain, notably dopamine, serotonin,
and norepinephrine. In general this leads to improvements in mood,
which is effective in countering depression.
Note that before beginning an exercise regime,
it is wise to consult a doctor. He or she can establish whether
a person has any health problems that could contraindicate some
types of exercise.
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