DEPRESSIVE DISORDERS

DEFINITION

Depressive disorders are mental illnesses characterized by deep, long-lasting feelings of sadness or despair. The patient may also lose interest in things that were once pleasurable. Changes in sleep patterns, appetite, and mental processes may also accompany depressive disorders. Depressive disorders are also known simply as depression or as unipolar (one-sided) depression.

DESCRIPTION

Everyone experiences feelings of unhappiness and sadness occasionally. In some cases, however, these feelings can begin to take over a person's everyday life. They cause a person's physical and mental health to deteriorate.

Experts estimate that depressive disorders affect seventeen million Americans. One in four women is likely to experience at least one episode of depressive disorder in her lifetime. The rate is about one in eight among men. Depressive disorders can strike all age groups, from children to the elderly. The average age a first depressive episode occurs is in the middle twenties.

There are two types of depressive disorders: major depressive disorder and dysthymic (pronounced dis-THIH-mik) disorder. Major depressive disorder is defined as a depressive disorder with moderate to severe symptoms that lasts two or more weeks. The symptoms of major depressive disorder include trouble sleeping, loss of interest in once enjoyable activities, change in weight, difficulty in concentrating, feelings of hopelessness, and thoughts about death and suicide. In children, the main symptom of major depressive disorder is irritability (being easily upset).

Dysthymic disorder is a chronic (ongoing) form of depression that lasts at least two years (one year in children). The average period of time the disorder lasts is sixteen years. The symptoms of dysthymic disorder tend to be mild to moderate. They may be more intense at some times than at others. A person with dysthymic disorder may go for up to two months without feeling depressed. The disorder often comes on gradually. A patient may not even remember exactly when he or she started feeling depressed. Symptoms of dysthymic disorder include problems with sleeping and eating, low self-esteem (poor feelings about oneself), trouble concentrating, and feelings of hopelessness.

Depression can also occur in bipolar disorder (see bipolar disorder entry). Bipolar is a form of mental illness in which people feel wild swings of emotions. At one moment, they may feel happy and optimistic. At the next moment, they may feel sad and depressed.

Recent scientific research indicates that the size of the subgenual prefrontal cortex (located behind the bridge of the nose) may be a determining factor in hereditary depressive disorders. (Reproduced by permission of

Electronic Illustrators Group

)

CAUSES

The causes of depressive disorders are not well understood. Most experts believe that an imbalance of neurotransmitters is a major factor. Neurotransmitters are chemicals in the brain. They are responsible for carrying messages from one part of the brain to another. The presence of too many or too few neurotransmitters can cause the brain to perform abnormally.

Environmental factors are also thought to be involved in depressive disorders. It is believed that children who are abused or neglected may later develop a depressive disorder.

Heredity also seems to play a role in depressive disorders. People whose families have a history of major depression are up to three times more likely to have the disorder themselves. Many scientists now think that genetic and environmental factors work together to cause depressive disorder. Heredity may predispose (make a person more likely to have) a person toward depressive disorder. But the condition develops only if the environment in which he or she grows up allows the condition to appear.

SYMPTOMS

Symptoms of depressive disorders vary depending whether the depression is caused by major depressive disorder or dysthymic disorder.

Major Depressive Episode

A person going through a major depressive episode feels depressed and/or loses interest in enjoyable activities. Children are more likely to feel irritable than depressed. In addition, five or more of the following symptoms appear on an almost daily basis for a period of at least two weeks:

• Significant change in weight
• Insomnia (inability to sleep) or hypersomnia (excessive sleep)
• Extreme tiredness or loss of energy
• Feelings of worthlessness and guilt that have no basis
• Diminished ability to think or to concentrate, or the loss of ability to make decisions
• Continuing thoughts of death or suicide and/or actual attempts at suicide

Dysthymic Disorder

The symptoms of dysthymic disorder occur along with other mental and physical symptoms. Up to 70 percent of dysthymic patients also have major depressive disorder. This condition is known as double depression. Some mental problems seen in people with dysthymic disorder include substance abuse (drug abuse), panic disorders (see panic disorders entry), and phobias (irrational fears). Physical problems that accompany dysthymia include multiple sclerosis (see multiple sclerosis entry), AIDS (see AIDS entry), chronic fatigue syndrome (see chronic fatigue syndrome entry), diabetes (see diabetes mellitus entry), and Parkinson's disease (see Parkinson's disease entry).

Scientists do not understand why dysthymic disorders are connected with these physical problems. They think the medical condition or the drugs used for treatment can affect the way a person's neurotransmitters operate in the brain.

In addition to feelings of depression, patients with dysthymic disorder also experience two or more of the following symptoms on an

If a person exhibits symptoms of depression on a daily basis for two years or more he or she may have dysthymic disorder. (© 1992

Science Photo Library

. Reproduced by permission of

Custom Medical Stock Photo

.)

almost daily basis for a period of two or more years (one or more years in children):

• Under-eating or overeating
• Insomnia or hypersomnia
• Low energy or fatigue (extreme tiredness)
• Low self-esteem
• Poor concentration or trouble making decisions
• Feelings of hopelessness

DIAGNOSIS

The first step in diagnosing a depressive disorder is an interview with the patient. The interview is followed by one or more tests designed to find out how depressed the patient is. Examples of these tests include the Hamilton Depression Scale, Child Depression Inventory, Geriatric Depression Scale, and Beck Depression Inventory. These tests are given by a doctor, social worker, psychologist, or psychiatrist in his or her office or in a hospital.

TREATMENT

Depressive disorders are treated by one or more of three methods: drugs, psychosocial therapy, or electroconvulsive (pronounced ih-LEK-tro cun-VUL-siv) therapy (ECT). Many drugs seem to work because of changes they produce in the way neurotransmitters work in the brain. Psychosocial therapy consists of interviews between the patient and a trained specialist to find out the causes of a person's depression. ECT makes use of severe electrical shocks to treat a person's depression.

Antidepressants

One group of drugs used to treat depression is called selective serotonin re-uptake inhibitors (SSRIs). These drugs increase the amount of serotonin (pronounced sehr-uh-TOE-nun) in the brain. Serotonin is a major neuro-transmitter. Some side effects of SSRIs include anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia (see insomnia entry).

Another group of drug is the tricyclic antidepressants (TCAs). They are less expensive than SSRIs, but they have more side effects. These side effects include dry mouth, dizziness, and heart problems. Because of these effects, TCAs are often not recommended for elderly patients. They are also not recommended for suicidal patients since, if they are taken in large quantities, they cause death.

Monoamine oxidase inhibitors (MAO inhibitors) also act on chemicals present in the brain to relieve the symptoms of depression. One risk in using MAO inhibitors is that they react with certain foods, such as aged cheese and meats, to produce dangerous side effects.

Psychosocial Therapy

The purpose of psychosocial therapy is to discover possible causes for a person's depression. A therapist helps the patient to understand himself or herself better. This self-understanding may help the patient overcome the problems that led to depression.

One form of psychosocial therapy is called cognitive-behavioral therapy. The therapist helps the patient to recognize thought patterns (such as thinking about suicide) that lead to depression. The patient is then trained to change those negative thought patterns to positive patterns. If successful, this therapy can help relieve the symptoms of depression.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is usually a treatment of last resort. It is tried when neither drugs nor psychosocial therapy have been very helpful with a patient. In rare cases, it is used if a patient refuses to take oral medication (drugs taken by mouth) or the patient is suicidal or out of touch with reality.

ECT consists of a series of electrical shocks administered to a patient's brain. The patient is first put to sleep with a general anesthetic and is given muscle relaxants. The muscle relaxants prevent violent responses to the electric shock that can result in broken bones. ECT is accompanied by a number of side effects, such as headache, muscle soreness, nausea, confusion, and memory loss.

No one knows how ECT works or what effects it has on the brain. In fact, some experts believe that the treatment is too dangerous to use with patients. Under the best circumstances, they say, it should be tried only in the most serious cases that do not respond to any other form of treatment.

Alternative Treatment

The herb known as St. John's wort is used throughout Europe to treat depression. Unlike prescription drugs, it has few side effects. Thus far, there is no scientific evidence about the effectiveness of this herb for the treatment of depression.

Some simple methods for increasing one's mental health include a healthy diet, proper sleep, exercise, and participation in many interesting daily activities.

PROGNOSIS

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80 to 90 percent of all patients. The occurrence of a single episode of depression increases the chances of another such episode. After one episode, a person is 50 percent more likely to have a second episode. After a second episode, the risk rises to 70 percent for a third episode. And after a third episode, the risk reaches 90 percent for yet another episode. For this reason, patients with recurrent (repeated) episodes may require long-term treatment with drugs and/or psychosocial therapy.

PREVENTION

The basic causes of depression, such as problems with brain chemicals and heredity, may not be preventable. But anyone who has experienced the feelings of depression can do a great deal to prevent the disorder from developing. People can be taught to recognize the symptoms of depression and to know how to prevent the condition from becoming worse. In many cases, simply staying with a medication program can relieve many of the symptoms of depression. With children, the sooner treatments begin, the more likely they are to be effective.

See also: Bipolar disorder, seasonal affective disorder.

FOR MORE INFORMATION

Books

Copeland, Mary Ellen. The Depression Workbook: A Guide for Living With Depression and Manic Depression. Oakland, CA: New Harbinger Publications, 1992.

O'Connor, Richard. Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You. Boston: Little Brown, 1997.

Thompson, Tracy. The Beast: A Reckoning with Depression. New York: G. P. Putnam, 1995.

Thorne, Julia. You Are Not Alone: Words of Experience and Hope for the Journey Through Depression. New York: Harperperennial Library, 1993.

Whybrow, Peter. A Mood Apart. New York: Harper Collins, 1997.

Periodicals

Miller, Sue, "A Natural Mood Booster." Newsweek (May 5, 1997): pp. 74–75.

Organizations

American Psychiatric Association (APA). Office of Public Affairs. 1400 K Street, NW, Washington, DC 20005. (202) 682–6119. http://www.psych.org.

American Psychological Association (APA). Office of Public Affairs. 750 First St., NE, Washington, DC 20002–4242. (202) 336–5700. http://www.apa.org.

National Alliance for the Mentally Ill (NAMI). 200 North Glebe Road, suite 1015, Arlington, VA 22203–3754. (800) 950–6264. http://www.nami.org.

National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826–3632. http://www.ndmda.org.

National Institute of Mental Health (NIMH). 5600 Fishers Lane, Rm. 7C-02. Bethesda, MD 20857. (301) 443–4513. http://www.nimh.nih.gov/.

Web Sites

"Ask NOAH About: Mental Health." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/mentalhealth/mental.html (accessed on October 7, 1999).