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.
