The cashier at the grocery store.
Your spouse or a loved one.
They’re people you encounter in your daily life. They’re also the faces of depression.
Depressive disorders can affect anyone, from all walks of life. Each year about 6.7 percent of American adults age 18 and older—nearly 15 million people—experience major depressive disorder, according to the National Institute of Mental Health (NIMH). And each year another 3.3 million American adults (1.5 percent of the population) suffer from dysthymia, a chronic, milder form of depression.
Depression is more than just sadness. It can be a debilitating illness that erodes your entire way of life. Also, a growing body of evidence suggests that depression’s effects extend beyond the mind and may even place you at greater risk of other medical complications.
“The ‘bumper sticker’ message would be, ‘Depression Kills,’” says Dr. Bruce L. Rollman, of the University of Pittsburgh School of Medicine. “There has been a lot of research that shows that primary care patients and cardiac patients who have depression have higher rates of mortality. They’re more likely to be hospitalized and go to the emergency room and just do worse overall.”
The key to avoiding the more severe complications of depression and other mood disorders, experts say, is first to recognize the signs of depression and promptly find the appropriate treatment regimen that can improve your mood and restore your quality of life.
Why you’re depressed
Depression has evolved from being something mentioned only in hushed tones to becoming the subject of open discourse, as celebrities and other public figures relate their battles with mood disorders. Yet, perhaps as the result of the stigma that for years was attached to depression, many people with a depressive disorder hesitate or fail to seek the treatment they need.
“Usually, whenever we see patients with depression, they are in crisis, and most of the time the crisis occurs because people don’t seek help when they first notice the symptoms,” says Diana Lowry, director of the Highlands Hospital Behavioral Health Care Unit, in Connellsville. “Usually, by the time they seek help, it’s gotten too bad and sometimes even too late.”
Depression is not a sign of weakness, nor is it manufactured. Rather, like other chronic medical conditions, it has a physiologic basis.
The nerve cells, or neurons, in your brain and throughout your body rely on chemicals known as neurotransmitters to send messages between the cells. Neurotransmitters such as serotonin, norepinephrine and dopamine play a role in everything your brain oversees, from memory, movement and thinking to sleep, pain perception and your mood. Experts believe that depression and other mood disorders may result from deficiencies in neurotransmitters. Likewise, hormones (which help regulate your response to stress) and environmental factors may contribute to depression.
“It’s no different than having diabetes or a number of other health problems that people would not think twice about getting help for,” Lowry says. “We don’t go out and ask for diabetes or cancer or heart disease. People don’t go out and ask for depression. So there should be no more of a stigma attached to seeking help for depression than there would be going to a doctor to seek help for the flu or bronchitis.”
Not just in your head
Depression can affect all areas of your life. It can damage your relationships with your spouse, children and other family members, and also strain friendships. It can lead you to abandon your hobbies and other pleasurable activities. It can prompt you to trade your ambitions for lethargy.
“There can be a huge impact on your quality of life, with depression affecting occupational and financial matters, family interactions, and your own personal goals, wishes and desires,” says Dr. Dilip N. Chandran, of West Virginia University’s Department of Behavioral Medicine & Psychiatry. “People will talk about depression sapping their motivation to do anything for fun. A lot of times people with depression will just not do things. They say they have no desire to enjoy anything.”
Depression may cause you to disregard your hygiene and other aspects of your personal well-being, including your overall health. Some evidence suggests that people with depression have more difficulty adhering to medication regimens and managing other co-morbid medical conditions they might have.
In some cases, Rollman says, depressed patients somatize their condition, or perceive their depression symptoms as physical manifestations, such as upset stomach, irritable bowel syndrome, muscle aches or migraine headaches. Some people somatize their mood as chest discomfort—a broken heart.
“These are the people who get referred for stress tests, and oftentimes nothing is found to explain their symptoms, which is very frustrating for patients and doctors,” Rollman explains. “Depression is thought of only after everything else is ruled out, but it’s so common.
“Let’s say you have a 30-year-old having chest pain,” he continues. “It would be very important to ask about depression, co-morbid anxiety or another mood disorder and not just refer the person for a stress test, where the likelihood of a younger person having true heart disease is relatively low.”
Nevertheless, depression is becoming a growing concern in the cardiac realm, as research supports a link between the mood disorder and the development of heart disease and worse outcomes among patients with cardiovascular disease. Depression is a common occurrence among people with heart failure, those who have suffered a heart attack or stroke, or those who have undergone bypass surgery or other major cardiac procedures.
In a scientific statement published online Feb. 24 in the journal Circulation, a panel of experts commissioned by the American Heart Association recommended that depression be considered a risk factor for death and other adverse outcomes in patients with cardiovascular disease.
The link between depression and cardiovascular risk may be due to a number of factors, including poor self-care (depressed people may be less likely to manage cardiovascular risk factors, such as high blood pressure, cholesterol and diabetes), a delay in seeking treatment, nonadherence to established disease-prevention measures, and physical inactivity. Depressed patients also are more likely to engage in unhealthy habits, such as smoking or alcohol/drug abuse, which may have deleterious effects on cardiovascular health.
“If you think about depression and not feeling well, it’s very common to want to escape that feeling,” Chandran says. “You can engage in all types of risky behaviors, like substance abuse, gambling, or shopping sprees, to escape that feeling.”
Are you depressed?
Everyone experiences sadness from time to time. The death of a loved one, loss of a job, the ending of a relationship or other life stressors can cause episodes of depression.
Clinical depression is a prolonged feeling of helplessness or hopelessness that causes impairment and often cannot be linked to one specific contributing factor. Depression can range in severity from dysthymia to major depressive disorder, the leading cause of disability among people ages 15 to 44, according to the NIMH.
“Some people just have a bad day. They’re stressed, they broke up with their boyfriend, or their job is at risk, and they may have an adjustment disorder,” Rollman says. “True depression is impairing. It impairs how people work and their relationships with other people.”
The symptoms of depression can vary from person to person. Many exhibit the hallmark symptoms of sadness, low energy and a loss of interest in usually pleasurable activities. Others also may experience irritability, restlessness or anger, feelings of regret or worthlessness, and cognitive problems, such as difficulty concentrating, making decisions or remembering things. Depression also may manifest as changes in appetite and significant weight gain or loss. (To gauge your likelihood of depression, see the “Warning Signs” chart on Page D1). In the most severe cases, a depressed patient may entertain persistent thoughts of suicide or death. Such thoughts should prompt an immediate visit to the emergency room, Lowry says.
“If you have depression, you don’t want to delay things too long,” Chandran adds. “If you have these symptoms that last for a few weeks, make sure to have your primary care doctor check them out to make sure it’s not something else.”
For instance, a number of medications—such as some anti-seizure and anti-anxiety medicines, certain blood pressure and cholesterol-lowering drugs, and opioid pain relievers, among others—may cause depression-like symptoms, so be sure to review your medications with your doctor. Also, your physician must rule out other medical conditions that can mimic depression. Your doctor will review your personal and family medical history, perform laboratory tests, and consider any environmental factors that may contribute to your depression.
“The big thing is that not everyone with mood symptoms has major depression that requires treatment with medications,” Rollman cautions. “We don’t want to over-treat people for depression. Confirm with your doctor that it’s really major depression because [antidepressant] medications are probably best reserved for people with the most symptoms. There may be other things you can do that can really make a difference and help you feel better.”
Treatment for depression depends on the severity and cause of your condition. Counseling and talk therapy (psychotherapy), using a variety techniques, are generally the first-line treatments for people with depression. Among the most effective methods is cognitive behavioral therapy (CBT), based on the idea that changing the way you think can help you feel and act better. In CBT, a therapist helps you to identify negative thoughts or behaviors and replace them with positive ones.
“Our thoughts and feelings can lead to our behaviors and moods,” Chandran says. “With CBT, you basically want to challenge people’s thoughts and their perception of their thoughts and find a better way to get their thoughts more positive.”
Lowry also recommends group therapy for depression: “It’s a very effective means of treatment. It helps people to realize that they’re not alone and that there are other people experiencing or who have experienced what they’re going through. It offers a support system and a chance to talk, tell your story and get feedback.”
In more severe cases of depression or if non-medicinal treatment alone does not sufficiently relieve depression symptoms, doctors will combine talk therapy with antidepressant medications. The drugs work by correcting chemical imbalances in the brain and restoring levels of the key neurotransmitters involved in mood regulation. Today, most physicians prescribe one of two major classes of antidepressants:
· Selective serotonin reuptake inhibitors (SSRIs), including citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft).
· Serotonin and norepinephrine reuptake inhibitors (SNRIs), including duloxetine (Cymbalta), venlafaxine (Effexor) and desvenlafaxine (Pristiq).
Another potential antidepressant option is bupropion (Wellbutrin), which can treat a range of conditions and may be a good choice if, along with depression, you need help to quit smoking. The drug also may be used in combination with an SSRI or SNRI.
As with any medication, the antidepressants can cause a range of side effects: nausea, dizziness, dry mouth, fatigue, constipation, sleeping problems, excessive sweating, headache and loss of appetite, among others.
Patients may see some improvement with the medications within a week or two, but most patients need four to six weeks to gain significant benefit from the medications, Chandran explains. Many times, he says, patients will remain on antidepressants for about six to nine months, but sometimes longer.
“If the symptoms are profound enough, you’d want to have some type of medication, or at least offer that,” he says.
“The general rule is patients get better with counseling and medications together versus either one separately. A lot of times we’ll do both together.”
Lowry and her colleagues at Highlands Hospital offer holistic treatments, such as guided imagery and relaxation and deep-breathing techniques, to complement traditional depression treatments. Some people also turn to a number dietary supplements and herbal remedies, including fish oil supplements, folic acid and St. John’s wort, among others — to relieve their depression.
Tell your doctor about your use of supplements, as some may interact adversely with any medications you take.
Rather than taking dietary supplements, Rollman recommends eating a nutritious diet rich in fruits, leafy green vegetables, nuts, whole grains and omega-3 fatty acids (found in fatty fish such as salmon, mackerel and tuna, as well as walnuts and flaxseed). Some evidence suggests that taking these dietary steps and other healthful lifestyle measures (see Action Points) can have positive effects on your mood.
“There are no data that supplements help,” he says. “I don’t advocate taking any supplements. What I do advocate is eating a balanced diet and eliminating sugary food and junk foods.”
Another key to recovering from depression is your support system, including family and friends. Depression affects not only you, but also the people in your life, Chandran says.
He encourages people with depression to accept support from friends and family, and for friends and family to be understanding about their loved one’s depression. “There are a lot of reactions that we can have to someone going through depression that can make things worse if we get angry with them,” he says. “If you do see people who are depressed, a lot of times it’s important to say you can help, to let them know that there are places to get help and to keep an open mind and let them know that depression is like any other chronic illness, like diabetes or high blood pressure, that needs attending to and treatment.”
Rollman also recommends seeking out online support groups and other Internet-based resources (see chart, “Online help”).
By having a strong support system, making positive lifestyle changes and seeking prompt, effective treatment, the outlook for most patients with depression is positive, Chandran says. “There are many people who have had depression, and they get treated and they bounce back really well,” he says. “They make lifestyle changes and continue to have counseling and learn ways to cope, and they do fine. It varies, obviously, but I feel the prognosis is pretty good.”
“Just be alert for early sympto ms because the earlier you catch depression, the better it can be treated and the less chance that it will become severe,” Lowry adds. “Know the signs and symptoms, and don’t be afraid to reach out because there are people who are willing to help you and will not judge you.”