Depression

Written by Shabir

1. Introduction 

Depression is a complex medical disorder and has been recognized since the days of Hippocrates. The disorder has been portrayed in movies, literature and the arts for many centuries. No one culture or ethnic group is immune from the ravages of depression. In the 1950s and 60s, depression was categorized into two types, endogenous and neurotic (reactive). Endogenous depression is caused by something inside the body, perhaps genetic or maybe just plain bad luck. Neurotic or reactive depression has a definitive external precipitating factor, such as the death of a spouse, friend, child or loss of a job. In the 1970s and 80s, the global impact of depression was fully realized and the focus of attention shifted from the cause of depression to its effects on the afflicted individuals and their treatment.

Today, most health care experts agree that irrespective of the classification, depressive disorder is a syndrome (group of symptoms) that reflects a sad mood over and above normal sorrow or grief. More specifically, the sadness of depression is characterized by a larger intensity and duration and by more intense symptoms and functional disabilities than is seen in normal.

Women are three times as prone to developing depression compared to men. As to why this is so is not known but many theories are postulated. Some believe that this is due to sex hormones; others claim that it is psychological or social but the bottom line is that men and women are biochemically different. Recent statistics from the National Institute of Mental Health indicate that close to 19 million Americans over the age of 18 suffer from major depression.

Even though most people agree that heart disease and diabetes are a major health problem, mental disorders, like depression are infact even a bigger health problem and cost the health care system billions of dollars each year, in terms of treatment, lost production and absenteeism. Infact, depression has overtaking arthritis and hypertension and in terms of its morbidity and mortality. Suicide secondary to depression, is the third leading cause of death in 10- to 24-year-olds.  The sad thing is that the majority of individuals with depression never seek treatment and may cultures view a diagnosis of a mental illness as Taboo. When depression is left untreated, the prognosis is poor as the symptoms only worsen- leading to untold suffering, despair and eventually suicide.

The symptoms of depression are classic and are characterized not only by negative thoughts, moods, and behaviors, but also by specific physical bodily functions. These signs and symptoms include:

• Excessive sleeping
• Early morning waking
• Crying spells
• Decreased sex drive or desire
• Weight gain
• General body aches, headaches, muscle pains
• Sadness
• Lack of enjoyment from things that were once pleasurable
• Feelings of hopelessness
• Difficulty concentrating
• Difficulty making decisions
• Thoughts of death, suicide, or self-mutilation

Depression is typically first diagnosed by a primary care physician an often the diagnosis is missed, because the symptoms may be vague and not clear cut. In addition, all experts agree that depression is often under treated.

2. Factors that contribute to depression include:

• Genetic: a genetic link has been identified in individuals with bipolar depression but not everyone with major depression has a family history. In many cases, there is no family history of depression. Even if the gene for depression is identified, it is purely academic.
• Stress: any stressful event like loss of a job or death of a family member can trigger depression
• Medications. There are numerous medications that can cause depression including birth control pills, drugs to treat hypertension, use of sedatives, alcohol and other illicit drugs
• Illnesses. Having a chronic medical illness or a diagnosis of cancer, heart disease, stroke, diabetes, Alzheimer's disease, places one at a high risk for depression
• Personality. There are some personality traits that are more prone to depression. These individual typically have low self esteem, overly dependent and unable to tolerate any stress.
• Postpartum depression. This is a very common cause of depression in birthing mothers and has often led to horrendous killing of infants. The condition may present with severe feelings of depression, anxiety, anger or gross incompetence. The condition is still not always recognized and the majority of these women remain untreated.
• Sex Hormones. It is now known that the female sex hormone, estrogen, is related to depression. This may explain why females are more prone to depression than men.

The diagnosis of depression is strictly based on the recognition of certain characteristic signs and symptoms affecting your mood state, thinking patterns and physical well-being. There are no blood tests or radiological tests to confirm the presence of depression.

3. Current medical treatment

Depression is an illness in which an alteration of brain chemicals, called neurotransmitters, has occurred. Changes in the levels of these neurotransmitters have been strongly linked to one’s mood and behavior. Anti depressants are thought to correct some of the chemical imbalances present in a depressive illness.

There are various classes of anti depressant drugs. Once the medication is started it is continued for at last 3-12 months or longer. Premature cessation of the medications can cause a relapse of the syndrome. Generally these medications are slowly tapered off to allow for the body to make an adjustment

There are approximately 20 antidepressants currently available and approved for the treatment of depression. Antidepressants are generally classified by the chemical properties of the drug. The drugs are classified as Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic Antidepressants (TCAs) or Monamine Oxidase Inhibitors (MAOIs). The tricyclics and MAOIs have been around for more than 40 years and are just as effective as the newer SSRIs. However, their use has declined because of their potent side effects. However, some patients do tolerate these medications very well and n such cases, there is no reason to change the medication to the newer ones. Infact these anti depressant medications are quite fussy, for some unknown reason, not all individuals have the same response and there is a lot of trial and error required in selecting the best medication for an individual.

Major types of antidepressant drugs include:

• Tricyclic antidepressants (TCAs). These were the first drugs used to treat depression. Besides treating the depression, the medications are excellent for neuropathic pain control and inducing sleep. Because of their side effects, the use of these drugs has declined today. Side effects include dry mouth, blurred vision, increased fatigue and sleepiness, weight gain, muscle twitching (tremors), constipation, bladder problems such as urine retention, dizziness, daytime drowsiness, increased heart rate, decreased libido.
• Monoamine oxidase inhibitors (MAOIs) are another class of older antidepressants. These drugs are most effective in people with depression who do not respond to other treatments. However, they do have some side effects which can be life threatening. Eating foods which contain cheese, beverages like wine, and medications can interact with an MAOI. For this reason these antidepressants are now relegated to the history books. Serious side effects may include headache, fast heart rate, chest pain, neck stiffness, nausea and vomiting.
• Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice to treat depression. They work by altering the amount of a chemical in the brain called serotonin. Decreased libido including low sex drive or inability to have an orgasm are common but reversible side effects. Other problems include dizziness, headaches, nausea, insomnia and feeling jittery.
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are another newer form of antidepressant medicine. They treat depression by increasing availability of the brain chemicals serotonin and norepinephrine. Side effects include drowsiness, blurred vision, lightheadedness, strange dreams, constipation, fever/chills, headache, increased or decreased appetite, tremor, dry mouth and nausea.

Electroconvulsive therapy (ECT

ECT has been used for many years to treat depression. The procedure requires one to be sedated and then an electric current is passed through the brain for 30-60 seconds. A convulsion is induced under controlled conditions. The procedure is not painful and takes about 30 minutes. ECT is most useful for those with depression resistant to drug therapy, those with severe depression or those who are at very high risk for suicide. It may also be combined with anti depressant therapy to provide a synergistic effect. The clinical effects of ECT are not seen immediately evident and usually take 2-3 weeks for the patient to see a change in his/her mood. Unfortunately, ECT is not a cure for depression and repeat treatments are required as maintenance therapy.

The most common side effects is short term memory loss which resolves in a few weeks.

Psychotherapy

Despite newer anti depressant medications, depression still is difficult to treat and some individuals need alternative therapy. Many forms of psychotherapy are currently used to help depressed individuals. The types of therapy may include talking, cognitive and behavior modification. These therapies are designed to help the individual resolve conflicts, regain confidence and help to unlearn patterns of behavior that contribute to depression. These sessions generally are done once a week for 12-20 weeks. These psychodynamic therapies are very useful in resolving the individual’s internal psychological conflicts that many have been etched in the brain during childhood. Life long therapy is beneficial in individuals who have negative or self injurious behavior.

4. Nutrition and Depression

While many health care workers are aware that there is a link between some physical illness and nutrition deficiency, not many people are aware that mental disorders also have a nutritive link. Most believe that mental illness are strictly emotional and have no metabolic or biochemical association. Nutrition, however, may play a greater role in depression than what one believes. Some health care workers believe that nutrition can play a key role, both in the onset, severity, and duration of depression, including daily mood swings.

Many of the same food patterns that come before depression are the same food patterns that occur during depression. These patterns may include skipping meals, poor appetite, and a desire for sweets. People who are rigid in their eating and follow very low carbohydrate diets also may be at risk for developing symptoms of depression, because the brain neurotransmitters (tryptophan and serotonin), that are involved in modulating depression are obtained from carbohydrate rich foods. Almost all anti-depressant drugs work by increasing the levels of these brain neurotransmitters.

As to which foods affect mood and cause depression is not fully known but some individuals are more sensitive than others. In general, foods such as refined carbohydrates (simple sugars, chocolates) provide immediate but temporary mood uplift. These foods have to be eaten continuously to sustain the mood elevation. This may not be practical and safe in the long run as one can easily gain weight. Other options are to eat complex carbohydrates such as cereals, pasta, fruits and vegetables. Although, not as appetizing as chocolates, they are more likely to have a more prolong mood elevating benefit.

Evidence has shown that the manufacture of brain chemicals which play a role in mood is dependent on the presence of essential vitamins. Deficiency of vitamin B is known to prevent the synthesis of these brain chemicals. However, deficiency of vitamins as a whole is very rare in North America and no correlation has been seen in children with vitamin deficiency and depression. In addition, a number of medications also interfere with vitamin functions in the body. There are some alternative health care workers who recommended mega doses of vitamins for individuals with mental disorders. It is well known that several vitamin deficiency disorders are associated with nerve disorders but a link to mental disorders has not been proven. These vitamin deficiencies are rare in North America and only seen in strict vegetarians. Todate, there is no evidence to show that vitamins deficiency can cause mental disorders. In North American Society where food is abundant and where obesity is endemic, it is hard to justify another nutrient supplement in a population which is already busting at the waist.

Minerals, like vitamins, have been linked to mental health disorders. Unfortunately, like the vitamins there is no strong scientific evidence to show a link between the two. There is no doubt that these essential micro nutrients have an essential role in daily living but their role in depression is lacking. However, there is little harm in taking daily supplements of iron, magnesium or zinc.

Other nutritional agents which have been sold as a treatment for depression include the Omega-3 fatty acids, tyrosine, tryptophan, chromium and trimethyl-glycine (TMG) and s-adenosyl methionine (SAM). It is difficult to known the benefits of these agents because all the reports are anecdotal and many cases are reported by individual who actually manufacrure these products. Until proper studies are done, reports of benefits of these products should be taken with a grain of salt.

5. Alternative therapy

There is not a lot of strong evidence that any type of alternative treatment is effective for treating moderate to severe depression. For some people, however, these therapies may used as an addition to other treatments -- providing relaxation, relief from depressive symptoms, and helping you cope with depression. Examples of alternative therapies include acupuncture, guided imagery, chiropractic treatments, yoga, hypnosis, biofeedback, aromatherapy, relaxation, herbal remedies, massage, and many others. While none of them can cure depression, they may be an adjunct in the treatment of depression. All of them are designed to resolve inner conflicts, ease the pain, relieve the anxiety and help cope with stressful situation.

Herbal Remedies

There are a variety of herbal therapies believed to treat many illnesses. For depression, St. John's wort and ginkgo biloba are the most talked about. Neither of these herbs have any science behind the treatment of depression and all reports remain anecdotal. Most psychiatrists warn that taking herbal supplement without adequate knowledge may worsen the disorder. Today, herbal supplements are not a replacement therapy of depression but may be taken as additional supplements.

Self help

Depression may be a mental illnesses but it does have many physical symptoms. Most individuals remain exhausted, tired, helpless and have a feeling of hopelessness. To divert these negative thoughts, there are some self help maneuvers that can ago a long ways in the treatment of depression. These include:

• not setting unrealistic goals
• not accepting undue responsibility for everything
• associated with family because they will understand your predicament
• enroll in activities that make you feel better (exercise, yoga, movies, social activities)
• avoid making drastic changes n life (change jobs, marriage, divorce- one may not be too objective in times of depression)
• understand that your disease can be treated with time

Future

We are not on the verge of curing depression yet, but we have acquired a lot of new knowledge which will hopefully improve the treatment of depression. Genetic markers of depression are being sought and newer drugs which work on specific areas of the brain will soon be available. One has to understand, being sad and feeling bad are part of the human emotional senses and we can not entirely remove these feeling, but hopefully we will be able to lessen these depressive feeling and the pain of constantly feeling sad.