A depressive disorder is an illness that involves
the body, mood, and thoughts. It affects the way a
person eats and sleeps, the way one feels about
oneself, and the way one thinks about things. A
depressive disorder is not the same as a passing
blue mood. It is not a sign of personal weakness or
a condition that can be willed or wished away.
People with a depressive illness cannot merely "pull
themselves together" and get better. Without
treatment, symptoms can last for weeks, months, or
years. Appropriate treatment, however, can help most
people who suffer from depression.
TYPES OF DEPRESSION
Depressive disorders come in different forms,
just as is the case with other illnesses such as
heart disease. This pamphlet briefly describes three
of the most common types of depressive disorders.
However, within these types there are variations in
the number of symptoms, their severity, and
persistence.
Major depression is
manifested by a combination of symptoms (see symptom
list) that interfere with the ability to work,
study, sleep, eat, and enjoy once pleasurable
activities. Such a disabling episode of depression
may occur only once but more commonly occurs several
times in a lifetime.
A less severe type of depression,
dysthymia, involves
long-term, chronic symptoms that do not disable, but
keep one from functioning well or from feeling good.
Many people with dysthymia also experience major
depressive episodes at some time in their lives.
Another type of depression is
bipolar disorder, also
called manic-depressive illness. Not nearly as
prevalent as other forms of depressive disorders,
bipolar disorder is characterized by cycling mood
changes: severe highs (mania) and lows (depression).
Sometimes the mood switches are dramatic and rapid,
but most often they are gradual. When in the
depressed cycle, an individual can have any or all
of the symptoms of a depressive disorder.
When in the manic cycle, the individual may be
overactive, overtalkative, and have a great deal of
energy. Mania often affects thinking, judgment, and
social behavior in ways that cause serious problems
and embarrassment. For example, the individual in a
manic phase may feel elated, full of grand schemes
that might range from unwise business decisions to
romantic sprees. Mania, left untreated, may worsen
to a psychotic state.
SYMPTOMS OF
DEPRESSION AND MANIA
Not everyone who is depressed or manic
experiences every symptom. Some people experience a
few symptoms, some many. Severity of symptoms varies
with individuals and also varies over time.
Depression
-
Persistent sad, anxious, or "empty" mood
-
Feelings of hopelessness, pessimism
-
Feelings of guilt, worthlessness, helplessness
-
Loss of interest or pleasure in hobbies and
activities that were once enjoyed, including sex
-
Decreased energy, fatigue, being "slowed down"
-
Difficulty concentrating, remembering, making
decisions
-
Insomnia, early-morning awakening, or
oversleeping
-
Appetite and/or weight loss or overeating and
weight gain
-
Thoughts of death or suicide; suicide attempts
-
Restlessness, irritability
-
Persistent physical symptoms that do not
respond to treatment, such as headaches, digestive
disorders, and chronic pain
Mania
-
Abnormal or excessive elation
-
Unusual irritability
-
Decreased need for sleep
-
Grandiose notions
-
Increased talking
-
Racing thoughts
-
Increased sexual desire
-
Markedly increased energy
-
Poor judgment
-
Inappropriate social behavior
CAUSES OF DEPRESSION
Some types of depression run in families,
suggesting that a biological vulnerability can be
inherited. This seems to be the case with bipolar
disorder. Studies of families in which members of
each generation develop bipolar disorder found that
those with the illness have a somewhat different
genetic makeup than those who do not get ill.
However, the reverse is not true: Not everybody with
the genetic makeup that causes vulnerability to
bipolar disorder will have the illness. Apparently
additional factors, possibly stresses at home, work,
or school, are involved in its onset.
In some families, major depression also seems to
occur generation after generation. However, it can
also occur in people who have no family history of
depression. Whether inherited or not, major
depressive disorder is often associated with changes
in brain structures or brain function.
People who have low self-esteem, who consistently
view themselves and the world with pessimism or who
are readily overwhelmed by stress, are prone to
depression. Whether this represents a psychological
predisposition or an early form of the illness is
not clear.
In recent years, researchers have shown that
physical changes in the body can be accompanied by
mental changes as well. Medical illnesses such as
stroke, a heart attack, cancer, Parkinson's disease,
and hormonal disorders can cause depressive illness,
making the sick person apathetic and unwilling to
care for his or her physical needs, thus prolonging
the recovery period. Also, a serious loss, difficult
relationship, financial problem, or any stressful
(unwelcome or even desired) change in life patterns
can trigger a depressive episode. Very often, a
combination of genetic, psychological, and
environmental factors is involved in the onset of a
depressive disorder. Later episodes of illness
typically are precipitated by only mild stresses, or
none at all.
Depression in Women
Women experience depression about twice as often
as men.1 Many
hormonal factors may contribute to the increased
rate of depression in women particularly such
factors as menstrual cycle changes, pregnancy,
miscarriage, postpartum period, pre-menopause, and
menopause. Many women also face additional stresses
such as responsibilities both at work and home,
single parenthood, and caring for children and for
aging parents.
A recent NIMH study showed that in the case of
severe premenstrual syndrome (PMS), women with a
preexisting vulnerability to PMS experienced relief
from mood and physical symptoms when their sex
hormones were suppressed. Shortly after the hormones
were re-introduced, they again developed symptoms of
PMS. Women without a history of PMS reported no
effects of the hormonal manipulation.6,7
Many women are also particularly vulnerable after
the birth of a baby. The hormonal and physical
changes, as well as the added responsibility of a
new life, can be factors that lead to postpartum
depression in some women. While transient "blues"
are common in new mothers, a full-blown depressive
episode is not a normal occurrence and requires
active intervention. Treatment by a sympathetic
physician and the family's emotional support for the
new mother are prime considerations in aiding her to
recover her physical and mental well-being and her
ability to care for and enjoy the infant.
DIAGNOSTIC EVALUATION
AND TREATMENT
The first step to getting appropriate treatment
for depression is a physical examination by a
physician. Certain medications as well as some
medical conditions such as a viral infection can
cause the same symptoms as depression, and the
physician should rule out these possibilities
through examination, interview, and lab tests. If a
physical cause for the depression is ruled out, a
psychological evaluation should be done, by the
physician or by referral to a psychiatrist or
psychologist.
Treatment choice will depend on the outcome of
the evaluation. There are a variety of
antidepressant medications and psychotherapies that
can be used to treat depressive disorders. Some
people with milder forms may do well with
psychotherapy alone. People with moderate to severe
depression most often benefit from antidepressants.
Most do best with combined treatment: medication to
gain relatively quick symptom relief and
psychotherapy to learn more effective ways to deal
with life's problems, including depression.
Depending on the patient's diagnosis and severity of
symptoms, the therapist may prescribe medication
and/or one of the several forms of psychotherapy
that have proven effective for depression.
Medications
There are several types of antidepressant
medications used to treat depressive disorders.
These include newer medications chiefly the
selective serotonin reuptake inhibitors (SSRIs) the
tricyclics, and the monoamine oxidase inhibitors (MAOIs).
The SSRIs and other newer medications that affect
neurotransmitters such as dopamine or norepinephrine
generally have fewer side effects than tricyclics.
Sometimes the doctor will try a variety of
antidepressants before finding the most effective
medication or combination of medications. Sometimes
the dosage must be increased to be effective.
Although some improvements may be seen in the first
few weeks, antidepressant medications must be taken
regularly for 3 to 4 weeks (in some cases, as many
as 8 weeks) before the full therapeutic effect
occurs.
Side Effects....
Antidepressants may cause mild and, usually,
temporary side effects (sometimes referred to as
adverse effects) in some people. Typically these are
annoying, but not serious. However, any unusual
reactions or side effects or those that interfere
with functioning should be reported to the doctor
immediately. The most common side effects of
tricyclic antidepressants, and ways to deal with
them, are:
-
Dry mouthit is helpful to drink sips of
water; chew sugarless gum; clean teeth daily.
-
Constipation bran cereals, prunes,
fruit, and vegetables should be in the diet.
-
Bladder problems emptying the bladder
may be troublesome, and the urine stream may not
be as strong as usual; the doctor should be
notified if there is marked difficulty or pain.
-
Sexual problems sexual functioning may
change; if worrisome, it should be discussed with
the doctor.
-
Blurred vision this will pass soon and
will not usually necessitate new glasses.
-
Dizziness rising from the bed or chair
slowly is helpful.
-
Drowsiness as a daytime problem this
usually passes soon. A person feeling drowsy or
sedated should not drive or operate heavy
equipment. The more sedating antidepressants are
generally taken at bedtime to help sleep and
minimize daytime drowsiness.
PSYCHOTHERAPIES
Many forms of psychotherapy, including some
short-term (10-20 week) therapies, can help
depressed individuals. "Talking" therapies help
patients gain insight into and resolve their
problems through verbal exchange with the therapist,
sometimes combined with "homework" assignments
between sessions. "Behavioral" therapists help
patients learn how to obtain more satisfaction and
rewards through their own actions and how to unlearn
the behavioral patterns that contribute to or result
from their depression.
Two of the short-term psychotherapies that
research has shown helpful for some forms of
depression are interpersonal and
cognitive/behavioral therapies. Interpersonal
therapists focus on the patient's disturbed personal
relationships that both cause and exacerbate (or
increase) the depression. Cognitive/behavioral
therapists help patients change the negative styles
of thinking and behaving often associated with
depression.