Your Health - Depression

Depression

(Major Depressive Affective Disorder; Unipolar Disorder; Unipolar Mood Disorder)

Definition

Depression is a mental illness marked by feelings of profound sadness and lack of interest in activities. Depression is not the same as a blue mood. It is a persistent low mood that interferes with the ability to function and appreciate things in life. It may cause a wide range of symptoms, both physical and emotional. It can last for weeks, months, or years. People with depression rarely recover without treatment.

Causes

The precise cause is not known. It can be difficult to determine if an illness causes depression or depression caused the illness. Possible causes may be mental, physical, or environmental and include:

Stressful life events (usually in combination with one or more of the following causes)
Chronic stress
Low self-esteem
Imbalances in brain chemicals and hormones
Lack of control over circumstances (helplessness and hopelessness)
Negative thought patterns and beliefs
Chronic pain
Heart disease and heart surgery
Genetic predisposition
Altered brain structure and function, including after a stroke
Parkinson’s disease
Postpartum depression occurs after childbirth
Seasonal affective disorder is a type of depression or a worsening of symptoms thought to be due to the decreased exposure to sunlight that occurs during winter months
Hypothyroidism
Anemia
Cancer
Substance abuse

Brain

Chemical, hormonal, and physical changes in the brain may cause depression.

Risk Factors

Risk factors include:

Sex: female
Age: elderly
Chronic physical or mental illness, including thyroid disease, headaches, chronic pain, and stroke
Previous episode of depression
Major life changes or stressful life events (eg, bereavement, trauma )
Postpartum depression
Winter season for seasonal affective disorder
Little or no social support
Low self-esteem
Lack of personal control over circumstances
Family history of depression (parent or sibling)
Feelings of helplessness
Certain medications, including medications used to treat asthma , high blood pressure , arthritis, high cholesterol , and heart problems
Smoking
Anxiety
Insomnia
Personality disorders
Hypothyroidism

Symptoms

Depression can differ from person to person. Some people have only a few symptoms, while others have many.

Symptoms can change over time and may include:

Persistent feelings of sadness, anxiety, or emptiness
Hopelessness
Feeling guilty, worthless, or helpless
Loss of interest in hobbies and activities
Loss of interest in sex
Feeling tired
Trouble concentrating, remembering, or making decisions
Trouble sleeping, waking up too early, or oversleeping
Eating more or less than usual
Weight gain or weight loss
Thoughts of death or suicide with or without suicide attempts
Restlessness or irritability
Physical symptoms that defy standard diagnosis and do not respond well to medical treatments

Diagnosis

There is no blood test or diagnostic test for depression. The doctor will ask about your symptoms and medical history, giving special attention to:

Alcohol and drug use
Thoughts of death or suicide
Family members who have or have had depression
Sleep patterns
Previous episodes of depression

The doctor may also perform specific mental health exams. This will help get detailed information about your speech, thoughts, memory, and mood. A physical exam and other tests can help rule out other causes.

Treatment

Treatment may involve the use of medicine, psychotherapy, or the use of both.

Severe depression usually requires hospital care and the use of drugs, such as olanzapine .

Antidepressant Medications

Up to 70% of depressed patients find relief from their symptoms with medicine. They can take 2-6 weeks to reach their maximum effectiveness. The medications include:

Selective Serotonin Reuptake Inhibitors (SSRIs)

Fluoxetine (eg, Prozac)
Sertraline (eg, Zoloft)
Paroxetine (eg, Paxil)
Citalopram (eg, Celexa)
Fluvoxamine (eg, Luvox)
Escitalopram (eg, Lexapro)

FDA Public Health Advisory for Antidepressants

The FDA advises that people taking antidepressants should be closely observed. For some, the medications have been linked to worsening symptoms and suicidal thoughts. These adverse effects are most common in young adults. The effects tend to occur at the beginning of treatment or when there is an increase or decrease in the dose.

Although the warning is for all antidepressants, of most concern are the SSRI class such as:

Prozac ( fluoxetine ), Zoloft ( sertraline ), Paxil ( paroxetine ), Luvox ( fluvoxamine ), Celexa ( citalopram ), Lexapro( escitalopram )

For more information, please visit: http://www.fda.gov/cder/drug/antidepressants/

Tricyclic Antidepressants

Imipramine (eg, Tofranil)
Doxepin (eg, Adapin, Sinequan)
Clomipramine (eg, Anafranil)
Nortriptyline (eg, Pamelor)
Amitriptyline (eg, Elavil)

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine (eg, Nardil)
Tranylcypromine (eg, Parnate)

Other Antidepressants

Venlafaxine (eg, Effexor)
Nefazodone (eg, Serzone)
Mirtazapine (eg, Remeron)
Bupropion (eg, Wellbutrin)
Duloxetine (eg, Cymbalta)

Psychotherapy

Short-term (10-20 weeks) cognitive-behavior therapy (CBT) can help some people. Psychotherapy is designed to help you:

Cope with difficulties in relationships
Change negative thinking and behavior patterns
Resolve difficult feelings

Electroconvulsive Therapy (ECT)

ECT is the use of an electric stimulus to produce a generalized seizure. It may be used in people with severe or life-threatening depression. ECT is also used for people who cannot take or do not respond to medicine. It is considered a safe and effective procedure.

Exercise

A regular exercise program has been shown to relieve some of the symptoms. It should play a large role in the overall management of depression.

Phototherapy

Phototherapy is done by sitting under special lights. It usually lasts about 30 minutes every morning.

Dietary Supplements and Herbal Therapy

St. John's wort is an herb that is available without prescription. It is widely used in Europe for the treatment of mild to moderate depression. Studies have shown that the herb is as effective as standard antidepressants and has fewer side effects.

There is also recent evidence that DHEA, a dietary supplement, may help some people. DHEA is an ingredient in fish oil . Some experts disagree with these findings. Always discuss the use of dietary and herbal supplements with your doctor.

Dietary Changes

Research suggests that diets high in tryptophan, certain B vitamins, and fish oil may be helpful. They have shown promise in both relieving and preventing depression.

If you want to take supplements or change your diet, be sure to talk to your doctor first.

Vagal Nerve Stimulation (VNS)

VNS is used as therapy for depression when multiple trials of medicine do not work. A pacemaker-like device stimulates the vagus nerve in the neck.

Vagus Nerve

Stimulation of the vagus nerve (yellow) at the neck is a depression therapy option.

If you are diagnosed with depression, follow your doctor's instructions .

Transcranial Magnetic Stimulation (TMS)

TMS is still under investigation, but seems to have some issues in treatment-resistant depression. An electromagnetic coil is held against your forehead. The change in electrical field stimulates nerves, improving symptoms of depression.

Prevention

Strategies to reduce your chance of becoming depressed include:

Being aware of your personal risk
Having a psychiatric evaluation and psychotherapy if needed
Developing social supports
Learning stress management techniques
Exercising regularly
Not abusing alcohol or drugs
Getting adequate sleep, rest, and recreation
Eating a Mediterranean diet. This includes plant foods, olive oil, and fish and chicken.

RESOURCES:

Depression and Bipolar Support Alliance
http://www.ndmda.org/

International Foundation for Research and Education on Depression
http://www.ifred.org/

The National Mental Health Association
http://www.nmha.org/

CANADIAN RESOURCES:

Canadian Mental Health Association
http://www.ontario.cmha.ca/

Canadian Psychiatric Association
http://www.cpa-apc.org/

References:

Antidepressant use in children, adolescents, and adults. US Food and Drug Administration website. Available at: http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/UCM096273 . Published May 22, 2009. Accessed July 15, 2009.

Depression. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/health/topics/depression/index.shtml . Accessed July 21, 2008.

Factsheet: depression. The National Mental Health Association website. Available at: http://www.mentalhealthamerica.net/go/depression . Accessed July 21, 2008.

Groves DA, Brown VJ. Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects. Neurosci Biobehav Rev . 2005;29:493-500.

Medical Letter, Inc. Treatment Guidelines from the Medical Letter. Medical Letter . 2003;1:11.

¹12/16/2008 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Linde K, Berner M, Kriston L. St. John's wort for major depression. Cochrane Database Syst Rev . 2008;CD000448.

²10/9/2009 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A, et al. Association of the Mediterranean dietary pattern with the incidence of depression. Arch Gen Psychiatry. 2009;66:1090.

Last reviewed November 2009 by Rosalyn Carson-DeWitt, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.