How to recognize and treat depression

Everyone feels “blue” or “low” once in a while. It’s a normal healthy reaction to the disappointments, losses, and separations that occur in everyone’s life. But it is one thing to be down in the dumps and quite another to be depressed. Sadness is normal, but depression is a major illness.

Depression prevents pleasure, saps energy, and interferes with daily life. It is a complex disorder that has many causes. Heredity (“blue genes”), imbalances in neurotransmitters (chemicals that brain cells use to communicate with one another, such as serotonin  and norepinephrine), hormones, and life experiences are among the factors that play a role. Anyone can get depressed, and many of us do.

Diagnosing Depression

Doctors have little trouble spotting full-blown depression. These people are withdrawn, lethargic, preoccupied with themselves, and plagued by thoughts of illness and death. They often neglect their appearance, hygiene, and nutrition. Physical symptoms are also common, including problems with sleep, appetite, and bowel function. Aches and pains are common, as is weight loss. But if symptoms are atypical, depression can be hard to diagnose. To help doctors recognize depression for what it is, the American Psychiatric Association (APA) has developed standards for the diagnosis.

At least one of these two symptoms should be present, according to the Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV):

• Depressed mood.

• Severely diminished in, or pleasure from, activities that are usually pleasurable.

In addition, at least four of these seven symptoms should be present:

1) Substantial change in appetite or weight loss, or (less commonly) excessive sleep.

2) Fatigue or loss of energy.

3) Diminished physical activity or (less commonly) agitation.

4) Impaired ability to think, concentrate or make decisions.

5) Diminished self-esteem with feelings of worthlessness or inappropriate guilt.

6) Recurrent thought of death or suicide.

To find out if you’re depressed, your doctor will ask about your symptoms and observe your mood, appearance, and energy level. In fact, old-fashioned listening and looking are the best diagnostic tools, but it’s also important for your doctor to evaluate your general health and medications. The following are some of the medical problems that can trigger depression.

• Medications. Older antihypertensives, steroids, tranquilizers and sleeping medications, antihistamines, stomach acid blockers, digitalis, drugs for abnormal heart rhythms, beta blockers, levodopa, pain relievers.

• Substance-related problems. Alcohol, cocaine, withdrawal from stimulants (including nicotine and caffeine).

• Endocrine and metabolic disorders. Thyroid disease, adrenal gland disease, diabetes, testosterone deficiency, high blood calcium, low blood sodium, lead toxicity.

• Neurologic disorders. Alzheimer’s disease and other dementias, strokes, head injuries, Parkinson’s disease, brain tumors, multiple sclerosis, seizure disorders.

• Infections. Mononucleosis, HIV and other viral infections, Lyme Disease.         • Nutritional deficiencies. Vitamin B12 deficiency.

• Malignancies. Pancreatic cancer and other tumors.

• Cardiovascular disease. Heart failure.

• Other disorders. Chronic pain from any cause, lupus, polymyalgia, fibromyalgia, chronic fatigue syndrome, sleep apnea.

Getting help

Depression has many faces. Shakespeare identified it as “the sad companion, dull-eyed melancholy.” Sir Winston Churchill recognized his as a “black dog: that turned up unexpectedly.” TV’s Mike Wallace felt that his depression was an “endless darkness.” But many people have a hard time recognizing their own depression. Robin Williams, however, was the opposite. Early on, he was very open about his addictions (drugs and alcoholism) and his depression.

Depression is an illness and, like other illnesses, it can be treated. Because depression interferes with daily function and can lead to problems that range from heart disease to suicide, it should be treated. Unfortunately, the illness makes people withdrawn, worthless, and lethargic, so they are often slow to seek and accept help.

If you think you or your loved one may be sliding into depression, ask for help. Your doctor can diagnose depression and can successfully treat many patients with a combination of friendly support and modern medications. They can refer patients to psychiatrists for severe depression; more healthy lifestyles can also help. Your doctor will help you decide what’s best for you.

Treatment: Talk therapies

A variety of techniques are available. Here’s a summary of two of the best:

• Interpersonal psychotherapy. The goal is to understand life stresses and personal relationships that may have triggered depression and to bolster the patient’s ability to overcome these problems and resume normal, happy function.

 • Cognitive behavioral therapy. The therapist teaches the patient to replace negative thoughts with positive ones and to overcome barriers to successful functioning in social and interpersonal situations.

Treatment: Medications

Medications have revolutionized the treatment of depression, which sometimes allow primary care physicians to treat the illness. Since depression is so common, it’s not surprising that many drugs are available. And since no two patients are alike, your doctor will decide which one is best for you.  Although some effects begin much sooner, most patients won’t notice improvement for two to four weeks. Doctors will often treat for about six months, and then taper the dose before stopping therapy. If symptoms recur, the drug is usually resumed for six to 12 months or, if necessary, longer. If one type of drug is ineffective or if troublesome side effects occur, the doctor will switch to another medication. As people with major depression begin to improve and gain energy on medication, the possibility for suicide may increase in patients who are at risk. Closed monitoring by relatives and mental health professionals is important, particularly for children and adolescents; the popular SSRI (selective serotonin uptake inhibitor) anti-depressants, such as Prozac and Zoloft, appear to reduce the risk of suicides in adults.

Even with modern therapy, depression is a chronic condition. According to a 2009 study, the average duration of a bout of major depression is 18 months; 35 percent of patients recover in less than a year, and 60 percent recover within two years.  But it’s time well spent; in addition to improving the quality of life, successful treatment of major depression appears to reduce the overall mortality rate in older adults. That’s not surprising since depression is strongly linked to an increase in coronary artery disease.

The major anti-depressants are all effective, but they differ in how easy they are to use and in their side effects and drug interactions. A list of possible side effects will make any medicine scary. Remember, though, that depression is a serious illness and that these medications are both safe and effective when used with customary care.

Treatment: Supplements and lifestyle

Although many supplements are touted for depression, only St. John’s Wort (Hypericum perforatum) has shown benefit. It may have a limited role in the initial treatment of mild depression, but it can produce side effects, and it should not be used for serious depression or in combination with prescription anti-depressants.

A healthy lifestyle can help many illnesses. Depression is no exception. Moderate exercise, supportive interpersonal interactions, positive life experiences, and even interactions with animals can all be helpful. Trouble is, people with major depression can have a hard time getting started on any of these. But lifestyle adjustments can slow the slide into depression or help speed recovery. And a healthy body is always good for the mind.

Depression in older people

One of the biggest obstacles to successful treatments of depression in older adults is that the condition often goes unnoticed in seniors. Symptoms such as sadness, crying, and a lack of interest in activities the person previously enjoyed are some of the better-known signs of depression, but older people often do not have the classic melancholic presentation of depression seen in younger patients.

“Instead, depression in seniors may manifest in a more physical form, with symptoms including generalized pain, fatigue, headache, and gastric distress,” says Dr. Daniel McGonigle of the Department of Psychiatry of the Mount Sinai School of Medicine in New York. “Other symptoms include unexplained weight loss or gain, an increase or decrease in appetite or sleep, feelings of worthlessness or guilt, and difficulty concentrating.

Sometimes people know that they are depressed but fail to address it with their doctors. “Older patients may simply be more reluctant to report a low mood, possibly for cultural and generational reasons,” says Dr. McGonigle. “They may adopt a ‘grin and bear’ attitude — however, depression is a chronic medical illness in the same way that hypertension and diabetes are,  and it should be treated just as aggressively.” If you suspect that you may be suffering from depression, inform your doctor so that you can be evaluated. As the case of Robin Williams clearly demonstrated, it is vital to recognize and treat depression.

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Sources: Mount Sinai School of Medicine, Healthy Aging, March 2013 and www.health.harvard.edu.