Depression

What is Depression?

Depression is a mood disorder that is characterized by prolonged feelings of sadness, or an inability to feel happy. While feeling sad or having a depressed mood, especially in response to a situation, can be normal, depressive syndromes cause this feeling to continue longer than normal and usually with other associated signs and symptoms that can cause disruption in the quality of your life.

Depression is a fairly common condition, affecting 1 in 15 adults in a year, more often in women than men. Depression is usually first diagnosed in the teens to 20s, but can occur at any age.

Recognizing Depression

Depression is characterized by the presence of a combination of some or all of the following symptoms:

• Depressed mood.
• Loss of interest and enjoyment of most or all activities.
• Disordered sleep pattern- inability to sleep or sleeping too much.
• Significant change in weight or loss of appetite.
• Slowness of movement, thinking, or speech.
• Having low energy.
• Trouble concentrating and making decisions.
• Thinking often about death, having suicidal ideation, or attempting suicide.

Symptoms of depression vary from person to person and you may experience additional associated symptoms, including anxiety, low self esteem, and psychosis. In teenagers, depression commonly manifests as irritability. It may also occur in association with particular situations, such as seasonal depression or peripartum depression.

When to See A Doctor

Depression is a common but serious condition. Contact your doctor if:

You have been experiencing symptoms of depression for two weeks or more.
Your symptoms are interfering with your daily activities, work, or relationships.
Contact your doctor if you think you are having suicidal thoughts. If you feel you may hurt yourself, call 911 or your local emergency number immediately.

Treatment

The treatment of depression is usually multifaceted, but effective, especially when started early. Pharmacotherapy and Psychotherapy are the modalities used most often. In the case of severe depression that is not controlled by either, brain stimulation therapies may be used. When used alongside  these treatment modalities, self-help therapies such as relaxation techniques and exercise have also shown benefit in the treatment of depression.

Medications

There are several classes of antidepressants from which you may be treated. Antidepressants work by affecting the levels of neurotransmitters- chemicals that help your brain cells communicate and regulate mood. While the mechanisms by which the drugs work are categorized into classes, the medicines within a class are also different from one and other in how they specifically modulate the neurotransmitter levels and what side effects you may have. The choice of the antidepressant is based on the effectiveness of the drug, your co-existing conditions, and possible side effects. The medications need time to reach an effective level in the blood stream, and it can take some more than a month to create a noticeable change. It is important to stick to the medication plan as directed by your doctor for it to work.

Selective serotonin reauptake inhibitors- SSRIs (eg. Zoloft, Paxil) are the most commonly used antidepressants as they have a better safety profile. They function by increasing the amount of serotonin in the synapse (space between two neurons) by preventing it from being reabsorbed and broken down.

Common side effects of SSRIs include sexual dysfunction, drowsiness, weight gain, insomnia, anxiety, dizziness, and dry mouth. Serious side effects include suicidal ideation in young adults, and serotonin syndrome.

Serotonin nonepinephrine reuptake inhibitors- SNRIs (eg. Cymbalta, Effexor) function similarly to SSRIs as they inhibit the re-absorption and metabolism of neurotransmitters, however in addition to serotonin, they also increase the amount of norepinephrine available to the brain.

Common side effects of SNRIs include nausea, dizziness, headache, dry mouth and excessive sweating. Side effects can vary between the specific SNRIs as they inhibit the breakdown of the neurotransmitters to different degrees.

Serotonin antagonist and reuptake inhibitors – SARIs (eg. Desyrel) also increase the amount of serotonin in the synapse. However, in addition to preventing the reuptake of the serotonin, SARIs also bind to the serotonin receptors on the next neuron, preventing the serotonin from binding to them, thereby keeping the neurotransmitters in the synapse for longer.

Side effects of SARIs include drowsiness, headache, dizziness, dry mouth, and blurred vision. These medications, trazodone in particular, may be prescribed if the symptoms of depression also include trouble sleeping.

Atypical antidepressants include bupropion (brand: Wellbutrin) and mirtazapine  (brand: Remeron) whose effects do not fit in with other classes of antidepressants. Atypicals may be prescribed by your doctor if you could not tolerate the side effects of SSRIs and SNRIs or if the medicine can help other associated symptoms.

Bupropion increases the amount of dopamine and norepinephrine in the brain by preventing them from being reabsorbed by the neuron and broken down. Side effects of bupropion include dry mouth, nausea, trouble sleeping, and decreased appetite. It can also increase the risk of seizures if you have a history of seizures or a medical condition that may also cause seizures.

Mirtazapine increases the amount of serotonin and norepinephrine by increasing their release. Side effects of mirtazapine includes dry mouth, drowsiness, and an increase in appetite, which often results in weight gain. The drowsiness caused by mirtazapine may be helpful if your symptoms include trouble sleeping.

Tricylic antidepressants- TCAs (eg. Elavil, Anafranil, Sinequan) are older class of  antidepressants. They function by blocking the uptake and breakdown on serotonin and norepinephrine, thereby increasing the amount available to the brain.

TCAs can cause common side effects, such as dry mouth, sexual dysfunction, and constipation. However, they can also cause serious side effects such as damage to the heart and increase the risk of seizures. Because of the risk of these side effects and the availability of safer antidepressants, TCAs are now prescribed less often.

Monoamine oxidase inhibitors- MAOIs (eg. Marplan, Emsam) are also an older class of depressants no longer prescribed commonly. MAOIs block monoamine oxidase, an enzyme that inactivates the chemical messengers dopamine, serotonin, and norepinephrine. This increases the amount of the neurotransmitters available to the brain.

The risk and severity of side effects make the use of MAOIs less appealing. Drug interactions with MAOIs can cause serotonin syndrome, a potentially dangerous condition caused by the presence of too much serotonin. Restriction of certain foods, including any fermented foods, aged cheese, soy sauce, tofu, and over ripe fruits and vegetables, is necessary as the interaction with MAOIs can cause a life threatening increase in blood pressure.

In addition to antidepressants, depending on the severity and type of symptoms, other drugs may be used in combination, such as anti-anxiety medications, antipsychotics, and Lithium.

Psychotherapy

Psychotherapy can be very effective in the treatment of depression, and may be used alone, or in combination with medications. There are several types of psychotherapy that may be employed by your therapist or doctor to help you:

Cognitive behavioral therapy (CBT)- To help identify and change thought processes that are contributing to your depression.

Interpersonal psychotherapy (IPT)- To examine your relationships, how you interact with others, and how your thought affect them, in order to learn how to improve them.

Behavioral activation- Behavioral activation may be used to help you come out of isolation and overcome symptoms of depression related with decreased activity.

Family/Couples therapy- To provide your family or partner with information to help them understand depression in order to work with you on things contributing to your depression.

Problem Solving- Problem solving involves understanding the problems affecting your life and developing a plan to help solve them.

Psychodynamic therapy- A form of therapy that involves going through childhood or previous life events to understand how they are influencing your symptoms, and working on them.

Supportive psychotherapy- To provide support during hard times, and boost your self esteem and skills to improve symptoms of depression.

Brain Stimulation Therapies

Neuromodulation through brain stimulation therapies are also used to treat depression. They may be implemented by your doctor if your symptoms are severe or if they have not improved with other treatments.

Electroconvulsive therapy (ECT) Involves running an electric current through the brain (under anesthesia) using electrodes placed on the skull to induce a controlled seizure. This technique has shown to help generate changes in the brain which can improve the symptoms of depression. ECT has minimal side effects which may include some confusion and short-term memory loss.

Repetitive transcranial magnetic stimulation (rTMS)- Uses a magnet to activate the brain using an alternating current through a metal coil to generate a magnetic field and produce an electric current to a specific part of the brain. No anesthesia used during the procedure. Side effects include some discomfort at the site the magnet is placed, mild headache, or mild lightheadedness. Seizures are a rare, but serious side effect.

Magnetic seizure therapy (MST) was developed using the technologies of ECT and rTMS. It involved the induction of a seizure as in ECT, but uses magnetic pulses instead of electricity. MST is also conducted under anesthesia. Side effects are similar to ECT, with confusion, headache, and memory loss, but a