Mood and Depression Disorder

Depression is more than just “feeling blue” for a period of time. Everyone has days when they feel sad, but depression is a serious medical illness caused by changes in brain chemistry. It affects the way you think, feel and act and can cause difficulty in functioning at work and at home. It is not something that you can “snap out of”.

What is Depression?

Although depression is a serious condition it is also a common one. It affects roughly one in five women and one in ten men at some stage of their lives. It also doesn’t discriminate; depression is found across age groups, educational levels and social backgrounds. Once an episode of depression has occurred there is an increased chance that it can reoccur.

Fortunately depression is very treatable with medication, psychotherapies and other methods and there are many effective strategies for living with depression. It is best to treat depression as soon as possible when symptoms are less severe.

There are several forms of depressive disorders:

Major depression: This is the most common form of depression. It is debilitating and interferes with a person’s quality of life. Symptoms must last for more than two weeks. Once a person has had a major depressive episode once, it is likely to reoccur. An estimated 80-90 percent of people respond well to treatment for depression.

Persistent depressive disorder: This is a low mood that lasts as long as two years or more. There may be episodes within this low mood of major depression and then times with less severe symptoms. People can function adequately but not at their best. This type of depression responds well to talk therapy.

Some forms of depression develop as a result of circumstances or are slightly different to the forms above. They are:

Postpartum depression: This occurs in new mothers who feel extreme sadness and even suicidal thoughts after the birth of their babies. It can happen anywhere from weeks to months after childbirth, but usually within a year.

Seasonal Affective Disorder (SAD): 4-6 percent of people in the USA are estimated to have SAD. This is a condition where the symptoms of depression occur during winter, most likely because of the lack of sunlight. Symptoms are usually mild, but they can be severe in some cases. SAD usually lifts in spring. Light therapy may help.

Psychotic depression: This is when a person has depression as well as some sort of psychosis, such as delusions or hallucinations. In effect they lose touch with reality.

Bipolar disorder has periods of major depression that alternate with extreme highs or mania.

Situational depression is depression that is triggered by a stressful life event or trauma. It is three times more common than major depression and generally clears up after the traumatic event has come to an end. If it persists after the event it may become major depression.

Causes

Scientists agree that depression is a brain disorder, caused by changes in brain chemistry, however research indicates that there many other factors that may contribute, these include; genetic vulnerability, faulty mood regulation, some medical conditions or medications and triggers such as stress, or difficult life circumstances.

When it comes to chemical imbalances, it is not a simple equation of one chemical level being too low or high. There are many chemicals and millions of chemical reactions that are responsible for mood and how you see and experience life. This complexity is why different people respond differently to different medications.

Scientists are doing ongoing research into depression and have identified genes that make people more vulnerable to depression, but they don’t have a complete understanding of the illness.

Brain-imaging technologies such as magnetic resonance imaging (MRI) have shown that areas of the brains in people with depression look different from people who don’t have depression. The areas that look different are involved in mood, sleep, thinking, appetite and behaviour.

Signs & Symptoms

Depression symptoms can vary from mild to severe. People with depression do not all have the same symptoms. Signs and symptoms include:

Long-term feeling of sadness or a depressed mood
Feelings of anxiety and “emptiness”
Loss of interest or pleasure in hobbies or activities that were once pleasurable
Feeling irritable or restless
Weight loss or gain, not related to dieting or loss of appetite
Insomnia or sleeping too much
Thoughts of suicide or attempts to commit suicide
Tiredness or loss of energy
Difficulty concentrating, thinking or making decisions
Feelings of worthlessness or guilt
Feelings of hopelessness or pessimism
Unexplained aches or pains, headaches or digestive problems that don’t ease with treatment.

Some medical conditions, for example, thyroid problems can mimic symptoms of depression, so it is important to have a thorough medical assessment to rule out other causes. Of course, many of these symptoms may happen to anyone at a particular time, but clusters of these symptoms indicate depression. For a diagnosis of depression the symptoms should have occurred for two weeks or longer.

Who Is At Risk?

Depression is one of the most common mental disorders. It can affect anyone; however several factors can play a role. Biochemistry, which manifests as differences in levels of certain chemicals in the brain, plays a role. A genetic predisposition can be responsible. Depression can run in families, but it is not always the case. Personality may play a role, such asbeing naturally pessimistic or being prone to stress. Adverse environmental factors such as exposure to violence, neglect, abuse or poverty can make some people more vulnerable to depression.

A depressive episode can happen at any time, but it generally first appears during late adolescence to mid-20s.

Diagnosis

The earlier depression is diagnosed and treatment begins, the more effective it is. Many people with depression do not seek help, which can lead to a greater chance of another episode of depression.

The first step to getting the right treatment is to see a doctor or mental health practitioner. Before you see a doctor it may be helpful to educate yourself on the disorder and how it is diagnosed. Your healthcare provider or doctor will generally take you through a physical examination and then a series of questions which act as a screening tool to identify depression. As certain other illnesses can cause depression, your doctor should rule out these possibilities with tests before taking you through the screening. The doctor should also discuss any history of depression or mental disorders in your family and a history of your symptoms.

Try to be as open and honest as you can with your doctor. You want to get the most accurate diagnosis possible and it will help your doctor to do this.

There are a number of illnesses that can accompany depression such as anxiety, obsessive compulsive disorder, post-traumatic stress disorder or social phobias. Substance abuse, such as abuse of alcohol or drugs can also co-exist with depression. People who have other serious medical illnesses such as HIV/AIDS, diabetes or cancer may also suffer from depression due to dealing with an illness. They may also need to be treated for depression to help them with their illness.

Treatments

There are a number of effective ways to treat depression and these will be fitted to the patient’s needs. Treatments include psychotherapy, medications and lifestyle changes, including improvements in sleeping and eating habits, exercise and stress reduction. Depression is very treatable and the majority of people respond well to treatment.

Medication

Because brain chemicals, called neurotransmitters, are thought to contribute to depression, antidepressants are used to modify brain chemistry. The main neurotransmitters that are regulated are serotonin, norepinephrine and dopamine.

These medications are not sedatives, tranquilizers or stimulants. They are not habit forming.

The medications may produce some improvement in the first week or two if use, however it usually takes about two to three months for the full benefit to be felt. If there is no improvement after several weeks, let your doctor know and they can alter the dose or the medication. Doctors usually recommend that medication should be continued after symptoms have improved. A period of six months or more is recommended.

Popular newer antidepressants

Some of the newest and most popular antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the most commonly prescribed SSRIs for depression. Most are available in generic versions. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs tend to have fewer side effects than older antidepressants, but they sometimes produce headaches, nausea, jitters or insomnia when people first start to take them. These symptoms tend to fade with time. Some people also experience sexual problems with SSRIs or SNRIs, which may be helped by adjusting the dosage or switching to another medication.

One popular antidepressant that works on dopamine is bupropion (Wellbutrin). Bupropion tends to have similar side effects as SSRIs and SNRIs, but it is less likely to cause sexual side effects. However, it can increase a person's risk for seizures.

Tricyclics

Tricyclics are older antidepressants. Tricyclics are powerful, but they are not used as much today because their potential side effects are more serious. They may affect the heart in people with heart conditions. They sometimes cause dizziness, especially in older adults. They also may cause drowsiness, dry mouth, and weight gain. These side effects can usually be corrected by changing the dosage or switching to another medication. However, tricyclics may be especially dangerous if taken in overdose. Tricyclics include imipramine and nortriptyline.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. They can be especially effective in cases of "atypical" depression, such as when a person experiences increased appetite and the need for more sleep rather than decreased appetite and sleep. They also may help with anxious feelings or panic and other specific symptoms.

However, people who take MAOIs must avoid certain foods and beverages (including cheese and red wine) that contain a substance called tyramine. Certain medications, including some types of birth control pills, prescription pain relievers, cold and allergy medications, and herbal supplements, also should be avoided while taking an MAOI. These substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help reduce these risks. If you are taking an MAOI, your doctor should give you a complete list of foods, medicines, and substances to avoid.

MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions. MAOIs should not be taken with SSRIs. How should I take medication?

All antidepressants must be taken for at least 4 to 6 weeks before they have a full effect. You should continue to take the medication, even if you are feeling better, to prevent the depression from returning. Medication should be stopped only under a doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, suddenly ending an antidepressant can cause withdrawal symptoms or lead to a relapse of the depression. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, you should consider trying another. NIMH-funded research has shown that people who did not get well after taking a first medication increased their chances of beating the depression after they switched to a different medication or added another medication to their existing one. Sometimes stimulants, anti-anxiety medications or other medications are used together with an antidepressant, especially if a person has a co-existing illness. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision. Report any unusual side effects to a doctor immediately.

FDA warning on antidepressants

SSRI’s are generally safe, however they may have an adverse effect on some people, particularly teenagers and young adults. A study done in 2004 by the US Food and Drug Administration (FDA), conducted a comprehensive review of clinical trials and came to the finding that 4 percent of those taking antidepressants had thoughts of or attempted suicide, compared to 2 percent of those receiving placebos.

This information has led to a “black box” warning on all antidepressants to highlight the increased risk of suicidal thinking, especially in children. Patients of all ages taking antidepressants should be strictly monitored. Your healthcare provider will decide if the potential effects outweigh the risks before prescribing medication.

What about St. John's Wort?

St John’s Wort is a herbal remedy that has been used to hundreds of years. In Europe it is often used to treat mild depression. However, some studies indicate that it may be no more effective than a placebo. It should be taken with caution as it may interfere with certain medications taken for other conditions, such as heart disease. Talk to your doctor before taking any herbal supplement.

Psychotherapy

Psychotherapy or “talk therapy”, helps people with depression to learn ways to deal with the illness. It may be used alone for mild depression, but is usually used in conjunction with medication.There are many types of psychotherapy, but two main types, cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) are particularly effective in treating depression. CBT helps a person to notice distorted thinking and helps them to then modify their behaviours and thinking. IPT helps people to work through relationship issues that contribute to the depression.

Psychotherapy is useful for both the person suffering from depression and their families or loved ones. Group therapy may also be used.

Self-help

There are some things you can do to help ease the symptoms of depression. Amongst them are; regular exercise, getting enough good quality sleep, preferably sleeping at the same time each night. Eating a healthy diet and avoiding alcohol can also help.

Electroconvulsive therapy (ECT) and other brain stimulation therapies:

In cases of severe major depression or bipolar disorder where patients have not responded to medication and/or psychotherapy, ECT may be useful.

ECT used to be known as “shock therapy” and had a bad reputation in the past, but it has improved greatly in recent years and can provide relief where other therapies have failed.

ECT involves a short electrical stimulation to the brain. The patient is put under anaesthesia before the procedure and sleeps through it. The treatment only takes a few minutes and the patient will wake up from the anaesthesia about an hour later. The ECT may have some side effects such as confusion or memory loss, but the side-effects are usually short-lived. Research has shown that one year after ECT, most patients had no adverse effects.

A patient generally receives ECT two to three times a week for a total of six to 12 treatments. Some people may require a maintenance course of ECT for a few months.

There are some newer types of brain stimulation therapies to treat severe depression. These include vagus nerve stimulation (VNS) and repetitive transcranial magnetic stimulation (rTMS). There is current research that they may be of use in treating depression.

Living With

How do women experience depression?

Women, between the ages of 25 and 40 are three of four times more likely to experience depression than men. Women have greater fluctuations in hormones that are associated with depression than men. Hormones directly affect the brain chemicals that control emotions and mood. Women are also at risk of developing postpartum depression after the birth of a child due to the hormonal changes pregnancy and the stresses of caring for a newborn.

During menopause hormone levels also fluctuate and there is a greater risk for developing depression during this time.

Many women get premenstrual syndrome (PMS) and experience symptoms such as breast tenderness, bloating, headaches, anxiety and irritability or a feeling of sadness. These symptoms are usually short-lived. However, for a small number of women PMS may become a severe form of premenstrual syndrome (PMS) called premenstrual dysphoric disorder (PMDD). This type of depression usually needs treatment.

It seems as if the cyclical changes in estrogen, progesterone and other hormones have the ability to disrupt neurotransmitters, such as serotonin, that control mood. Scientists are studying the correlation between hormones and depression.

How do men experience depression?

Men experience depression in a different way to women. Men suffer from the common symptoms of depression such as despondent moods, tiredness, sleep disturbances, problems concentrating, and loss of interest in hobbies, family and work, but they are more likely to also be irritable, aggressive, hostile and agitated. They are also more likely to abuse substances such as alcohol and drugs. More women are likely to attempt suicide, but more men die by suicide

How do older adults experience depression?

Depression can happen at any age and is common in older adults, although it is not a normal part of aging. Often older adults, who are depressed may not recognise the symptoms or may not try to get help for fear of appearing weak.

Depression may appear different in older adults. Many claim to not feel “sad”, instead they experience low levels of motivation, a lack of energy and/or physical problems, such as headaches.

Some symptoms of depression, such as confusion, may look like other illnesses such as Alzheimer’s disease. Sometimes chronic illnesses may cause depressive symptoms, or medications used to treat illnesses can contribute to depressive symptoms. Grief over the loss of a loved one may be difficult to distinguish from depression. Grief is normal, but if it is complicated and lasts for an extremely long time, it may need treatment.

Though it is commonly thought that younger people are prone to suicide, males age 85 or over have the highest suicide rate in the United States.

Like other age groups with depression, older adults with depression improve with treatment.

How do children and teens experience depression?

Roughly five percent of children and teens in the global population suffer from depression.

If a child has attention or learning disorders, anxiety is under stress or has experienced loss is at greater risk for depression. Children who have depression often continue to suffer from the illness in adulthood.

The behaviour of depressed children and teenagers may be different to that of adults. Often the symptoms can mimic some common childhood behaviours, so they may be missed.

Common symptoms of children with depression include frequent sadness often with tearfulness, a lack of interest in the activities they once enjoyed; the child may isolate themselves from friends or display extreme boredom or lack of energy. They may be very sensitive to rejection or failure and often have low self-esteem or guilt. They may be negative and irritable or be openly hostile and aggressive. Children also may try to stay away from school and complain of illnesses such as headaches or stomach-aches. They may talk about wanting to be dead or committing suicide. Depressed teens may abuse alcohol or drugs to feel better.

Depression in teens often co-occurs with other disorders such as anxiety or eating disorders.

Early diagnosis and treatment are important for depressed children. A combination of medication and psychotherapy is successful in treating childhood depression.

How can I help a loved one who is depressed?

When someone you love is depressed your support and encouragement plays an important role in their recovery. Because depression is serious, but treatable, the first step is to encourage them to get treatment.

Other steps you can take include; learning as much as you can about the condition so you can distinguish the symptoms from the person,talk to your loved one about the illness, offer emotional support and understanding, and listen carefully. Offer hope and encouragement. Never ignore comments about suicidal thoughts. Understand that you can’t rescue your loved one or “fix” them. You are not responsible and your loved one has to ultimately be responsible for their own recovery.

Take care of yourself; you may be experiencing a number of difficult emotions related to their depression, which you need to deal with. Form a strong support network for yourself, so that you are not overwhelmed.

How can I help myself if I am depressed?

Know the symptoms, recognise that you need help and then seek help. Early intervention has been shown to help the pace of recovery. Try to keep active and eat healthily. Try to break tasks, which may be overwhelming, down into smaller tasks. Have compassion on yourself. Spend time with people you love who will support and encourage you. Try not to isolate yourself.

Have patience, understand that treatment takes time; you will improve gradually not suddenly.

Continuously educate yourself about depression.

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