Depressive disorders

Depression is a type of mental illness that disturbs a person's mood. It is typically characterized by persistent feelings of anxiety; sadness; helplessness; hopelessness; worthlessness; pessimism; guilt; restlessness; irritability; drastic loss of interest in pleasurable or routine activities; reduced sexdrive; fatigue; difficulty concentrating, remembering, or making decisions; body aches not caused by physical illness; weight gain or loss; and often suicidal thoughts. In clinical depression, these and other negative emotions areout of proportion to the individual's life situation and can be so profound that the sufferer loses interest in life. In severe or prolonged depression, the individual may be unable to get out of bed for days and a time, and his orher ability to perform even the most routine activities is drastically impaired. Depressive illness differs drastically from the usual moods and emotionsexperienced by most people, such as sadness, "the blues", or grief after losing a loved one. It is one of the most common and destructive illness in theUnited States. Often misunderstood by sufferers and their families alike, depression is highly treatable with modern medications by well-trained experts.

Official diagnosis of a depressive illness is based on the Diagnostic andStatistical Manual (DSM) published by the American Psychiatric Association. Now in its fourth version, this handbook officially recognizes the following types of depression:

  • Normal depressed mood and grief
  • Adjustment disorder with depressed mood
  • Mild depression (dysthymia)
  • Major depression
  • Bipolar disorder (manic-depression)
  • Seasonal affective disorder (SAD)
Disorders can be short- or long-term and may range from relatively mild to severe. Researchers estimate that associated costs, which include loss of productivity at work, hiring new personnel,medical expenses, and stress placed on families, may range from $15 to 35 billion a year.

Normal depressed mood and grief is the type of depression that accompanies a major loss, such as the death of a spouse. Symptoms may include difficulty in falling asleep, lack of appetite, and difficulty in concentrating. When following a major loss, these symptoms are healthy, even though they may be difficult to cope with.

Depression involving adjustment disorders are characterized by depressed mood, tearfulness, or feelings of hopelessness brought on by a single event (e.g., termination of a romantic relationship) or multiple events (e.g., business difficulties plus marital problems). By definition, an adjustment disorder with depressed mood begins within 3 months of the onset of the stressingevent and lasts no longer than 6 months after the triggering event or its consequences have ceased. If the stress or its consequences persist, the depression may continue.

Mild forms of depression are referred to as dysthymia (also known as dysthmic disorder or depressive neurosis) or minor depression (minor depressive disorder). These disorders may feel to the sufferer like major depression (see below), but they differ in that they last for only a brief time. Symptomsmay include poor appetite or overeating; problems sleeping or oversleeping;low energy; low self-esteem; poor concentration or difficulty making decisions; and/or feelings of hopelessness. Dysthymic disorder often begins early inlife (childhood, adolescence, or early adulthood), and many sufferers also experience major depression. There is no sure-fire cure for dysthymia. The disorder has been treated with psychotherapy, including psychoanalysis, cognitivetherapy, behavior therapy, and interpersonal therapy. Many doctors believe that some form of psychotherapy together with antidepressant medication is most helpful for most sufferers of dysthymia.

Sufferers of major depression (also known as major depressive disorderor clinical depression) experience an overwhelming and debilitating despondency that is long lasting, and that may interfere with their ability to function in the workplace, at home, or in other social situations. Individuals suffering major depression are frequently plagued by thoughts of suicide, thoughseverely depressed individuals rarely have the energy to carry out the act, being much more likely to act on their thoughts as the depression begins to subside. Untreated depression is the most common cause of suicide in the UnitedStates. No one knows exactly what causes major depression, but evidence suggest that some people inherit a tendency to develop the illness, while the illness in others may be lined to abnormal levels of hormones in the body or toa mistimed biological clock. Treatment of major depression includes medication, psychotherapy, or some combination of treatments. Variations of major depression include psychotic depression in which the sufferer experiences delusions or hallucinations; atypical depression (characterized by a mix of symptomsthat do not fit perfectly with any other existing categories) with some of the characteristics of major depression; postpartum depression (a depressive illness that develops in new mothers about 1 week to 6 months after the birthof their child), which occurs in approximately 10 percent of new mothers; postpartum psychosis with symptoms of hallucinations, delusions, and suicidal thoughts; and premenstrual dysphoric disorder (not to be confused with premenstrual syndrome or PMS), which causes women to feel deeply depressed or irritable for a week or two before or during menstruation. Major depressive disorders may begin at any age, but the average age of onset is the mid-20's.

Like major depression, bipolar illness can be life-threatening. Duringthe depressed cycle, the sufferer may be haunted with thoughts of suicide. And during the manic period, good judgment may be lost, causing the sufferer to lose complete touch with reality. Sufferers may run up huge credit card debts, and/or become sexually promiscuous during periods of mania. Symptoms of mania may include

  • Inflated self-esteem or grandiosity
  • A sharpdecrease in the need for sleep
  • A compulsion to talk
  • Racing thoughts
  • A tendency to become easily distracted
  • Rapid physicalmovements and increased activity
  • Excessive involvement in activitiesthat may have undesirable consequences
Most people with bipolar depression can be treated with medication, although the medication usually has to be continued for the rest of the patient's life (and the types of medication prescribed may have to be changed as the patient's moods vary). Without treatment, the risk of accidental death or death by suicide becomes significantly higher than for healthy people. Research has also shown that individuals who participate in psychotherapy are less likely to suffer a relapse than are those who do not. Variations of bipolar disorder include rapid cycling involving frequent swings between mania, hypomania (a mild form of mania), and depression; dysphoric mania in which the manic periods are much more subdued thanordinary mania; mixed state depression in which the sufferer experiences mania and depression at the same time; and cyclothymia (or cyclothymic disorder),which is a milder though longer lasting type of bipolar depression in whichsufferers frequently experience mood swings between hypomania and mild depression.

Seasonal affective disorder (SAD) is a type of depression that only occurs at certain times of the year. People with this illness may feel lethargic and depressed during the winter months, but may have normal moods during the summer months. The cause of seasonal affective disorder is not well understood; some of the explanations that have been proposed include low levels of serotonin in the brain; fluctuations in the level of melatonin; and abnormal circadian rhythms. Treatment for SAD usually begins with light therapy, in which the patient sits under bright lights for a certain amount of time each day. Some times a doctor will prescribe antidepressant medication or suggest a change in lifestyle during the winter months. There are also some people who become depressed during the summer months, but this illness is much less common than SAD.

Depression is widespread among the elderly, with one study suggesting that asmany as 15 percent of all persons over the age of 65 suffer from some symptoms. But, according to some estimates, only 10 percent of such individuals needing treatment actually receive it. One reason for this is that many doctors,and many of the elderly as well, may mistake the symptoms of depression fornormal signs of aging; another is that Medicare, the standard health care coverage for the elderly, has traditionally discriminated against psychiatric benefits by offering low levels of reimbursement. To treat depression in the elderly, many doctors recommend some combination of medication and short-term psychotherapy. The use of medication to treat the elderly may be complicated by the fact that an elderly patient's body metabolizes medications differentlythan a young person's, and also by the tendency of antidepressant medications to aggravate other medical conditions such as heart disease.

Unrecognized and untreated depression can cause extreme suffering, not only to the patient, but to his or her loved ones. Depression can begin for no apparent reason and plunge the individual into a downward spiral of despair. It is a true illness, like cancer, diabetes, or high blood pressure, that can become incapacitating. An estimated 35 to 40 million people in the United Statesare expected to suffer a major depressive illness during their life-time; 25percent of these will attempt suicide within five years of onset. Anyone talking about suicide should be taken seriously and medical assistance be soughtimmediately. Depression in children often goes unrecognized: suicide is thesecond greatest cause of death in children and adolescents.

One truly unfortunate aspect of depression is that, frequently, sufferers tend to blame themselves, and neither they nor their families recognize the symptoms as an illness. Even if they do, they may not realize the necessity of appropriate treatment. This lack of understanding can cause alienation, which only adds to the pain, loss of self-esteem, and guilt feelings already causedby the depression. Depressed individuals cannot "pull themselves up by the bootstraps," and not knowing this fact only increases the patient's suffering.

As noted, the causes of depression are many and varied. Researchers believe hereditary factors predispose certain individuals to depressive illness. For example, it is found that about 50 percent of all people with bipolar disorderhave at least one parent with a history of depressive illness. In some individuals, traumatic life situations such as the break-up of a relationship, loss of a loved one, or loss of employment, triggers the depression. Lack of light in winter brings about seasonal affective disorder; and biochemical or hormonal changes appear to trigger postpartum depression in some women followingchildbirth. The fact that cyclic antidepressants, MAO inhibitors, and "thirdgeneration" medications help more than 80 percent of people treated by apparently adjusting the supply of certain neurotransmitters in the brain has ledresearchers to theorize about the role neurotransmitters play in affecting aperson's mood. For example, it has been found that both the tricyclic antidepressants and MAO inhibitors boost the concentration in the brain of the neurotransmitter norepinephrine, which fact originally led scientists to theorizethat depression was caused by a deficiency of norepinephrine. But subsequentresearch has shown that some depressed people actually have high levels of norepinephrine in their brains, leaving the mystery of the origins of depression as cloudy as ever. Other neurotransmitters that have been linked to depression include serotonin and dopamine. Other research has shown that approximately 50 percent of people experiencing depression have excessive amounts of thehormone cortisol in their blood, and that these high cortisol concentrationsare accompanied by low levels of the mood-altering neurotransmitters. Because the regulation of cortisol is controlled by the hypothalamus, some researchers have speculated that the hypothalamus or some other part of the brain that controls cortisol levels may be playing a role in causing depression.

Although depression is treatable, there is no single standard treatment. Medications are used to treat both depression and mania, especially severe majordepression and bipolar illness. As previously noted, light therapy is the treatment of choice in seasonal affective disorder. In difficult cases where thepatient is severely depressed and cannot take medication, electroconvulsivetherapy (ECT) has proven useful. Psychotherapy combined with medication is often the preferred treatment for most depressions.

When discussing treatment options with a doctor, it may be appropriate to raise any or all of the following questions:

  • What are the chances of responding positively to this treatment?
  • How long will it take for the treatment to become effective?
  • Will the treatment provide a cure, or just relieve symptoms?
  • What side effects and risks does the treatmententail?
  • What is the cost of the treatment?
  • Will the treatmentrequire any lifestyle changes?
  • What treatment alternatives exist?

Various health practitioners treat depressive disorders. About half the people with depression who are treated receive treatment from a family doctor or internist. These health practitioners are well qualified to treat mild cases of depression; and insurance providers are more likely to reimburse the cost of treatment if it is provided by a family doctor or internist. Psychiatrists,who treat severe depression, are physicians who specialize in the diagnosisand treatment of mental illness; they can prescribe medication and/or providepsychotherapy. Psychologists can provide psychological testing and psychotherapy, but they cannot prescribe medication. In addition, psychiatric nurses,social workers, and members of the clergy sometimes provide psychotherapy orcounseling.

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