Depression is a serious health condition that is under-recognized. It is not a normal state of being. When you are depressed you are at risk of complications, including death.
While some cases of depression are the result of environmental factors, that is, the stresses and circumstances in a person's life, other cases result from an identifiable and measurable chemical imbalance in the brain.
Neurochemical disorders can be mild or severe, but they tend to be responsible for most severe cases of depression, usually marked by major changes in personality, detachment from reality and similar symptoms. A neurochemical imbalance might be especially suspect when the person's circumstances don't seem to warrant sadness or anxiety, in general, life seems "good."
Difficult to Diagnose Some Disorders
Historically, depression caused by neurochemical brain disorders has not always been identified as such. Diagnoses by general practitioners have been more likely to list a change in circumstances or a failure of coping mechanisms as primary underlying factors. But more recently, thanks to research by the National Institute of Mental Health and other organizations, medical and mental health professionals have greatly improved their ability to identify and cite neurochemical imbalance as the base cause of a patient's depression.
The result of this improvement in knowledge and identification has been an improvement in the accuracy of doctors' diagnoses, which in turn has improved treatments and results for patients.
Recent research into the causes of and treatments for depression suggests that short-term psychotherapies, sometimes called "talking" therapies, often may be as effective as anti-depressant medication for treating mild, moderate and occasional severe cases. In the more severe cases of depression, where there are an array of serious psychological (e.g., deep despair, suicidal ideas or plans) and physical symptoms (e.g., problems with sleep, loss of appetite and weight, diminished concentration and memory), where the condition has been persistent or where there is evidence that someone is experiencing ever greater functional difficulties, beginning treatment with medication appears to be the first-line choice.
A Combination of Treatment Plans
The reported best long-term outcomes for individuals with recurrent depressions have been achieved using a combination of medication and one of the available "evidence-based" psychotherapies (e.g., cognitive-behavioral therapy, interpersonal psychotherapy). Occasionally individuals will need to change medication when they have had little or no response, or have suffered problematic side effects. For those who have achieved a partial or incomplete response but not full remission (the complete disappearance of symptoms), many specialists suggest augmenting the therapy with a second medication using one of the different classes of anti-depressants.
Once again, not every case of depression is related to a chemical disorder in the brain. It is also worth noting that many anti-depression medications have side effects that must be taken into account. The question for anyone depressed because of a neurochemical imbalance is, "Do the benefits outweigh the risks?" This assessment should be made by the patient in conjunction with his or her doctor.
It might turn out that the best treatment for a neurochemical imbalance and the resulting depression is a combination of medication, "talking" therapy, and the development of life skills to manage and overcome future episodes of depression.
Depression Can Cause a Major Personal Disability
Depression can be a neurochemical disease causing major personal disability. It is the No. 2 cause of disability in the world.
It's as universal as hair on our heads: No one wants to think of himself or herself — or to be thought of — as mentally ill. When symptoms arise, we're likely to ignore them as long as possible. And when we can't ignore them anymore, we'll attribute them to stress, middle age and the weather — anything but a lapse in our mental health.
But increased familiarity with the issues surrounding mental health, plus a growing body of research, are dissolving the stigma historically attached to a diagnosis of depression. These factors are helping to improve the knowledge about mental health among general practitioners, which means fewer cases are misdiagnosed. That has expanded the pool of qualified and accredited medical experts who can properly treat depression. With this greater level of clarity and "legitimacy," insurance companies are doing a better job of acknowledging depression as a treatable illness and acting accordingly.
Depression remains a commonly unrecognized health condition. People, understandably, would rather avoid a diagnosis of mental illness. Not every physician is ready to blame depression for mood swings, anxiety and other similar symptoms. The mental health discipline — what it knows and how it addresses mental illnesses — is not as precise as, say, an ear, nose and throat specialist or a cancer specialist. Insurance coverage of all aspects of treatment is not always readily available. There is still some ground to cover before depression gains full "respectability" as a diagnosable and treatable disease.
Meanwhile, mental health experts say, there is substantial evidence that depression can have serious consequences for the sufferer, as well as the people in his or her circle of influence. It isn't the same as a passing "blue mood." It doesn't indicate some sort of weakness or "shortcoming" in the affected person. It can't be willed or wished away — you don't simply "pull yourself together" and get on with life. Without treatment, symptoms can go on for years. Proper treatment, however, can help most people with depression.
The road to recovery starts with recognition and acceptance of the symptoms as potentially consistent with depression. Those symptoms can include one or more of the following:
- Persistent, sadness, anxiety or "empty" moods.
- Feelings of guilt, hopelessness, worthlessness or pessimism.
- Lost interest in once-pleasurable things — hobbies, sex, locales, etc.
- Decreased energy or fatigue.
- Difficulty concentrating, remembering or making decisions.
- Trouble sleeping or changes in sleep patterns.
- Changes in appetite, diet or weight.
- Thoughts of death or suicide.
- Restlessness or irritability.
- Persistent physical symptoms — headaches, digestive disorders, chronic pain — that don't respond to routine treatment.
Not every person will experience the same symptoms. The number and severity of symptoms varies among individuals and over time. Not every set of symptoms leads to a similar diagnosis or requires the same treatment. But for those people who have been thoroughly examined by a knowledgeable mental health physician and received a diagnosis of depression, acceptance of that fact is the first step to recovery.
Types of Depression and Their Treatments
Remission is the goal of treatment for depression. When depression is treated properly, benefits can include significant symptom reduction and even remission, as well as overall improved health and quality of life. Treatments include medication, psychotherapy and other therapy including electroconvulsive therapy.
Depression can be caused by a number of different factors and manifest itself in a number of different ways. For that reason, a number of different treatment regimens are employed. Choice of treatment will depend on a variety of factors: the underlying cause of the depression, the severity of symptoms, the physician's recommendation and the patient's preference. Psychotherapy, medicines and electroconvulsive therapy have all been found to be effective in treating depression.
The National Institute of Mental Health segments depression into three categories:
Major Depressive Disorder
Commonly identified by a combination of the symptoms listed above. Symptoms interfere with one's ability to work, study, sleep, eat and enjoy once-pleasurable activities. A major depressive episode might occur just once, but it's more likely that such episodes will occur periodically during a lifetime. This condition could require long-term treatment.
A less severe type of depression, dysthymia is marked by long-lasting or long-term symptoms that are plainly noticeable but don't seriously disable the person. Working or functioning successfully is possible, but there are limitations including a feeling of general malaise. Many people with dysthymia are known to experience infrequent — but serious — episodes of major depression.
Also known as manic depression, characterized by cyclical mood changes — extreme highs (mania) and extreme lows (depression) — but with periods of normality in between. When in the manic cycle, a person can be overactive, talkative and have a great deal of energy. When in the depressive cycle, the person can exhibit any of the symptoms common to depression. Bipolar disorder often affects judgment, thinking and behavior in ways that can cause social disruptions or interpersonal difficulties.
The general classifications of treatment are:
Also referred to as the "talking" therapies, variations include cognitive behavioral therapy and cognitive psychotherapy. In general, psychotherapies rely on interviews, discussions, question-and-answer sessions and similar "on the couch" activities. The goal is to help patients talk through their illness and their circumstances, overcoming unwarranted fears, feelings of anxiety or inadequacy and the like. Patients can also be trained in certain life skills that help them recognize, address and overcome aspects of their depression and lead more well-adjusted lives.
Medicines developed to treat depression are often approached with care due to the much-documented and much-publicized side effects some of them cause. However, the mental health community, supported by research, endorses the use of anti-depressants for their beneficial effects. Their use, based on the particular diagnoses of particular patients, coupled with their proper utilization under risk management models, can result in highly favorable outcomes. In some cases — primarily depression caused by neurochemical imbalance — they might be essential for a favorable outcome. In other cases, a combination of treatments that includes these medicines will help assure the best outcome. Usually, several weeks of treatment by medication must pass before full therapeutic effect can be measured. The process is sometimes short-circuited by patients who halt their anti-depressant regimens due to concerns surrounding their continued use. This undermines their benefits as well as the overall goals of treatment.
Electroconvulsive Therapy (ECT)
Sometimes characterized as the most dramatic approach to curing mental illnesses, statistically ECT is the most effective treatment for depression. Patients who have opted for ECT commonly report high satisfaction after initial doubts. Many say the impact of the procedure is "nothing" compared to the illness it overcomes. Some 80 to 90 percent of people with severe depression improve dramatically with ECT. ECT involves producing a seizure in the brain of a patient under general anesthesia by applying electrical stimulation to the brain through electrodes placed on the scalp. Repeated treatments are necessary to achieve the most complete anti-depressant response. Memory loss and other cognitive problems are common yet typically short-lived side effects of ECT. While some people report lasting difficulties, modern advances in ECT technique have greatly reduced the side effects of this treatment compared to those of earlier decades.
In all cases, decisions about treatment should be made in the most thorough and open manner, with full participation by the patient, the patient's family, the patient's doctor and the mental health experts involved — as well as input from patient advocacy groups and others as appropriate.
This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, N.Y.), West 175 and the University of Rochester Medical Center.
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