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Lowdown on Depression

Thirty-three-year-old Saritza Velilla of Frisco, Tex., was just 7 years old when she first started feeling worthless. As the years went by, these feelings intensified and she became more withdrawn from social activities. But it wasn't until 1996 that Velilla was diagnosed with clinical depression, and only recently that she found relief from her ongoing symptoms.

"I always felt outside the mainstream," she remembers. "I could feel alone in a roomful of people." Velilla grew up for the most part with a great void in what she calls "that important emotional need" for parental care, affection, or attention. "Without those bonds in place," she says, "I did not develop emotionally and had trouble relating to others."

Velilla is not alone in grappling with the consequences of mental illness. An estimated 22 percent of Americans 18 and older--about 1 in 5 adults--have a diagnosable mental disorder in any given year, according to the National Institute of Mental Health (NIMH). To complicate matters, many people struggle with more than one mental disorder at a time. The pain and suffering that goes along with these illnesses is felt not only by those who have a disorder, but also by the people who care about them.

Family members often watch their loved ones cycle in and out of treatment, on and off medications, and, in some cases, in and out of jail. Pete Earley of Fairfax, Va., says that if medical experts had responded to his son's mental condition as quickly as law enforcement reacted to his criminal behavior, his son would be receiving therapy instead of facing a possible prison term.

Earley's son has bipolar disorder--also called manic-depressive illness--a form of mental illness different from Velilla's that can cause extreme shifts in mood, energy and functioning. Earley says his son is frequently delusional, paranoid, and psychotic. If he discontinues his medications, he exhibits bizarre, irrational behavior.

According to the NIMH, most people with a depressive illness do not get the help they need, although the great majority--even those whose depression is severe--can be helped. Without treatment, the symptoms of depression can last for weeks, months, or even years. With treatment, many people can find relief from their symptoms and lead a normal, healthy life.

More Than a Mood Swing Clinical depression, one of the more common categories of mental illnesses, is a serious brain disorder that affects the way nearly 19 million American adults feel, think, and interact. In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is extreme and persistent and can interfere significantly with a person's ability to function. People with depression cannot merely "pull themselves together" and get better. Depression cannot be willed or wished away.

There are three main types of clinical depression: major depressive disorder; dysthymic disorder; and bipolar depression, the depressed phase of bipolar disorder. Within these types are variations in the number of associated mental symptoms, and their severity and persistence.

A person experiencing major depressive disorder suffers from, among other symptoms, a depressed mood or loss of interest in normal activities that lasts most of the day, nearly every day, for at least two weeks. Such episodes may occur only once, but more commonly occur several times in a lifetime.

Unlike major depressive disorder, dysthymic disorder--a chronic but less severe type--doesn't strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesn't interfere with everyday tasks, people with this milder form of depression rarely feel like they are functioning at their full capacities.

Bipolar disorder cycles between episodes of major depression, similar to those seen in major depressive disorder, and highs known as mania. In a manic phase, a person might act on delusional grand schemes that could range from unwise business decisions to romantic sprees. Mania left untreated may deteriorate into a psychotic state.

For Earley, one of his son's recent psychotic episodes played out in a burglary charge. The pair was headed home from a local hospital where doctors had refused to treat him involuntarily. Earley's son suddenly leapt from their moving car, ran away, and broke into a stranger's house. After throwing a potted plant through a glass door and smashing some furniture, he then ran upstairs and drew himself a bubble bath. Earley says his son has never been in trouble with the law before and that he did not take anything from the house.

It's Not 'All In The Head' Because the symptoms, course of illness, and response to treatment vary so much among people with depression, doctors believe that depression may have a number of complex and interacting causes.

Some factors include another medical illness, losing a loved one, stressful life events, and drug or alcohol abuse. Any of these factors also may contribute to recurrent major depressive episodes.

Modern brain imaging technologies are revealing that neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly in people with depression. Imaging studies also indicate that critical neurotransmitters--chemicals used by nerve cells to communicate--are out of balance.

Moreover, genetics research suggests that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. The hormonal system that regulates the body's response to stress also is overactive in many depressed people.

Research conducted in the fields of psychiatry, behavioral science, neuroscience, biology, and genetics, including studies of twins, lead scientists to believe that the risk of developing mental illness increases if another family member is similarly affected, suggesting a hereditary component.

This was the case for 34-year-old Susan Poage of Thornton, Colo. She recently was diagnosed with clinical depression, like her mother before her. Poage recalls a dismal childhood.

"There was a lot of silent crying, promiscuity, alcohol and drugs," she says, "and I don't remember having any good times." With the help of her doctor and a five-year struggle with drug therapy, Poage today is managing her symptoms of depression, including thoughts of suicide.

Despite strong evidence for genetic susceptibility, scientists still don't know the number of genes that might be involved in making someone more likely to develop a mental disorder. Identification of these genes has proved to be extremely difficult.

Similarly, the role of environmental effects in the development of mental illness remains largely unknown.

Diagnosing Depression Medical professionals generally base a diagnosis of mental illness on the presence of certain symptoms listed in the 4th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The symptoms listed for a major depressive episode include:

  • sadness
  • loss of interest or pleasure in activities once enjoyed
  • change in appetite or weight
  • difficulty sleeping or oversleeping
  • physical slowing or agitation
  • energy loss
  • feelings of worthlessness or inappropriate guilt
  • difficulty thinking or concentrating
  • recurrent thoughts of death or suicide.

A person is clinically depressed if he or she has five or more of these symptoms and has not been functioning normally for most days during the same two-week period.

Dysthymic disorder is diagnosed when depressed mood persists for at least two years (one year in children) and is accompanied by at least two other symptoms of depression.

The episodes of depression that occur in people with bipolar disorder alternate with mania, which is characterized by abnormally and persistently elevated mood or irritability. Symptoms of mania include overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, physical agitation, and excessive risk-taking. Because bipolar disorder requires different treatment than major depression or dysthymia, obtaining an accurate diagnosis is extremely important.

Treating Depression Finding the right treatment for depression can be as difficult as convincing someone that they need help. However, according to the NIMH, clinical depression is one of the most treatable of all medical illnesses.

Because it is currently against the law in Virginia, where the Earleys live, to force someone into medical treatment, Earley must rely on his son's willingness to take his medicines. Typically, bipolar patients periodically stop taking their medications.

"Part of my son's illness," Earley explains, "is believing he is perfectly fine when he goes off his medicines.

"Even though it was obvious that my son was clearly out of his mind, the law still insisted that he was capable of deciding whether or not he needed treatment," says Earley. "In these cases, you are asking an irrational person to make a rational decision. It's like expecting a person with a broken leg to run a marathon."

Today, most people with depression can be treated successfully with antidepressant medications, "talk" therapy (psychotherapy), or a combination of the two. Experts agree that successful treatment also hinges on early intervention. And early treatment increases the likelihood of preventing serious recurrences.

Drug Treatment Existing antidepressant drugs are known to influence the functioning primarily of either or both of two neurotransmitters in the brain--serotonin and norepinephrine. Older medications--tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs)--affect the activity of both of these neurotransmitters simultaneously. Their disadvantage is that they can be difficult to tolerate due to significant side effects, or, in the case of MAOIs, dietary and medication restrictions.

Newer medications, such as the selective serotonin reuptake inhibitors (SSRIs), have fewer side effects than the older drugs, making it easier for people, including older adults, to adhere to treatment. Both generations of medications are effective in relieving depression, although some people will respond to one type of drug, but not another.

"Clinicians tell us that different drugs seem to work for different people," says Thomas Laughren, M.D., team leader for the review of psychiatric drugs in the Food and Drug Administration's Division of Neuropharmacological Drug Products. "And it's difficult to predict which people will respond to which drug or who will experience what side effects." So, Laughren says, it may take more than one try to find the appropriate medication. "Now that we've made a distinction between different depression subtypes, this seems to have stimulated additional drug research. Drug companies are also conducting more longer-term studies in depression, and this is important since depression tends to be a chronic illness."

Although some improvement may be seen in the first few weeks, antidepressants usually must be taken regularly for three to four weeks (and sometimes longer) before full therapeutic benefits occur. "If we had a better understanding of the biological basis for depression, it would help in the discovery of newer antidepressants that hopefully would work faster and better," says Laughren. "Unfortunately we do not really understand the mechanism for the antidepressant drugs."

The medication most often used to treat bipolar disorder is lithium (Eskalith, Lithane, Lithobid, Cibalith-S). Lithium evens out mood swings in both directions--from mania to depression, and depression to mania. It is used not just for manic attacks or flare-ups of the illness, but also as an ongoing maintenance treatment for bipolar disorder.

Non-Drug Treatments In psychotherapy, also called "talk therapy," a person discusses with a mental health professional the feelings, thoughts and behaviors that seem to cause difficulty. The goal of psychotherapy is to help people understand and manage their problems so that they can function better.

"Finding a therapist who believes in recovery is the first step," says Velilla. "Someone who can teach you to think differently and learn new behaviors." She believes that her feelings of neglect, coupled with the eventual divorce of her parents, ultimately triggered many of her bouts with depression. Her own divorce some years later, she says, only heightened her feelings of worthlessness. "My therapist finally put a name to what I'd been feeling since I was 7 years old."

Psychotherapy can help people with bipolar disorder, and their families, identify early warning signs and manage emotional stress, which may help prevent a bipolar episode.

Richard O'Connor, Ph.D., a psychotherapist in Canaan, Conn., and the author of several books on depression, believes that people need to help themselves "break the bad habits in their lives that set them up for depression." Waking up and going to sleep at the same time each day, for example, might help those people prone to bouts of insomnia due to irregular sleep patterns.

A depression sufferer himself, O'Connor came to this belief after many of the people he was treating "thought it was too late for them to help themselves, and they wanted us to pick up the pieces," he says. "People are responsible for their own recovery. They must learn to take care of themselves and structure their lives so that they're less likely to trigger an episode."

When people are unresponsive to psychotherapy and medications, or the combination of the two works too slowly to relieve severe symptoms, such as psychosis or recurring thoughts of suicide, electroconvulsive therapy (ECT) may be considered. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a 30-second seizure within the brain; however, the person does not consciously feel the stimulus. Three sessions per week typically are given for full therapeutic benefit. Like antidepressants, ECT is believed to affect the chemical balance of the brain's neurotransmitters.

Interest is rapidly growing as well in the use of herbs for treating depression. But, according to a study published in the April 10, 2002, issue of the Journal of the American Medical Association, an extract of the popular herb St. John's wort was no more effective for treating major depression of moderate severity than an inactive pill (placebo). The multi-site trial, involving 340 people, also compared the FDA-approved antidepressant drug Zoloft (sertraline) to a placebo as a way to measure how sensitive the trial was to detecting antidepressant effects. Since Zoloft was also found to be no different than the placebo in that study, Laughren says it can best be thought of as a "failed study" that isn't informative about the antidepressant effectiveness of St. John's wort.

The NIMH cautions people who think they may be depressed not to use dietary supplements without first being evaluated by a psychiatrist or examined by a physician. The risks, according to the institute, can outweigh any potential benefits.

Following Prescribed Treatment Antidepressant drugs are not considered to be candidates for abuse. However, as is the case with any type of medication, use of antidepressants must be carefully monitored to make sure the correct dosage is being given. Care also is needed when antidepressants are discontinued.

As is often seen with antibiotics, people may be tempted to stop antidepressants too soon. They may feel better and think they no longer need the medication, or they may believe the medication isn't working. But quickly stopping certain antidepressants is linked to side effects ranging from flu-like symptoms to sensory disturbances. As a result, new labeling, as specified by the FDA, recommends that patients taper off these medications slowly. If a person encounters problems going off a drug, he or she is advised to consult a physician rather than reduce dosage without supervision.

After spending 11 days in the hospital following the burglary, Earley's son was released to his parents. He is currently awaiting trial on two counts of felony breaking and entering and destruction of property. He is attending a 15-week treatment program that includes routine medications, and he now has a job and hopes to return to college to finish his education.

"He doesn't want to be delusional," says Earley. "He's embarrassed and ashamed about what happened. But now he's got no choice but to admit that he is sick and always will be. The question is, will that be enough to keep him taking his medications?"

When a patient and the health-care provider think that medication can be discontinued or scaled back, they will discuss how best to ease off the medication gradually.

The NIMH says it is important to keep taking prescribed medication until it has had a chance to work, even though side effects may appear before antidepressant activity does.

As for Velilla, "I'm still not taking any medication," she says, "but I think I may not need it after all. I continue to read books that will inspire and give me tools to deal with life. I feel like I am making progress in counseling and in all areas of my life and that makes me feel pretty good and optimistic about recovering."

By Carol Lewis
FDA Consumer Magazine
January-February 2003

Reviewed by athealth on February 5, 2014.