Depression

Description

Alternative Names

Treatment

Depression is a treatable illness, with many therapeutic options available. Increasingly, professionals are viewing major depression as a chronic illness (i.e., the condition nearly always returns when treatment is stopped treatment). Therefore, medical intervention and help must be ongoing.

Patients with chronic depression have a number of options, including psychotherapy, antidepressants, or both. Of note, a 2002 study suggested that newer antidepressants and psychotherapy affected the same regions of the brain, which indicates they have a similar mechanism of action. The majority of people with acute depression respond to either the first or second trial of therapy.

In general, the treatment choice depends on the degree and type of depression and other accompanying conditions. It also may depend on age, pregnancy status, or other individual factors. [See Depression in Children, Depression in the Elderly, and Depression in Women.]

Unfortunately, an important 2003 study reported that even if the depression is diagnosed, only about 20% of Americas with major depression are receiving adequate treatment. Most patients are treated by their family doctor, who may not have sufficient information or training on dosages or specific agents that would be best suited for individual cases. Even worse, about half people with depression, particularly the elderly, do not receive any therapy at all. Lack of health insurance is a major factor in these low treatment rates.

Patients with Major Depression. A number of studies have supported a combination of cognitive behavioral therapy (CBT) plus antidepressants (typically an SSRI, such as Prozac) given for at least 60 days. CBT is used to resolve any residual symptoms after medication has been started. Some studies estimate that only 40% of people with chronic depression respond to medications alone compared to 60% who are given combination treatment.

For those who fail medications and psychotherapy, other techniques, such as electroconvulsive therapy (ECT), are safe and effective. In recent years, experimental procedures, such as vagus nerve stimulation and repetitive transcranial magnetic stimulation, have also been found to be effective in some cases of treatment-resistant depression.

Patients with Minor Depression. Patients with minor depression (fewer than five symptoms that persist for less than two years) may respond well to watchful waiting and supportive care. For example, one study found that newer antidepressants were only modestly helpful in older patients with mild depression. Supportive care that consists only of brief and occasional counseling sessions with the family doctor may be as helpful as antidepressants in some cases.

Patients with Depression and Other Psychiatric Problems. Other psychiatric problems often coexist with depression. If patients also suffer from anxiety, treating the depression first often relieves both problems. Those with more severe psychiatric problems, such as bipolar disorder or schizophrenia, require specialized treatments.

Patients with Depression and Medical Conditions. Depression can worsen many medical conditions and may even increase mortality rates from some disorders, such as heart attack and stroke. Depression, then, should be aggressively treated in anyone with a serious medical problem.

Patients with Depression and Substance Abuse Problems. Treating depression in patients who abuse alcohol or drugs is important and can sometimes help patients quit.

Choosing a Therapist

Most people with depression can be treated in an office setting by a psychiatrist or other therapist. Infrequently, the level of dysfunction may be serious enough to warrant hospitalization to provide protection from further deterioration or self-harm.

Mental Health Professionals. The only health professionals who can prescribe antidepressants are the following:

• Psychiatrists. (These are mental health professionals with MD degrees.)
• Any medical physician with an MD.
• Some psychiatric nurse clinicians.

Although other mental health professionals cannot prescribe drugs, most therapists have arrangements with a psychiatrist for providing medications to their patients. In general, mental health professionals are categorized by their training:

• Psychoanalysts tend to have a degree in psychiatry, psychology, or social work as well as several years of training at a psychoanalytic institute.
• Psychologists have graduate-level training, including an internship in a mental healthcare facility.
• A clinical social worker has a master's degree and two years of supervised experience in mental health and human services.
• Advanced-practice psychiatric nurses have a master's degree and can provide therapeutic services.

Tips for Selecting a Therapist:

• Patients can locate a mental health professional in their area by asking their doctor for a referral or by contacting a mental health organizations. [See Resources.]
• The patient should describe problems briefly but specifically over the phone to any prospective therapist to get a sense of whether he or she will suit the patient's needs.
• An advanced degree does not necessarily guarantee quality therapy. The patients belief in his or her health provider may be the most important component in recovery, as indicated by studies reporting that placebos relieve depression in about a third of patients and in some cases actually work better than psychotherapy.
• Patients should not be shy about considering a change in their therapist if they lack confidence in their current one.

Depression in the Elderly

Although depression in the elderly is very common, the aging process itself is unlikely to be the cause in most cases. An Italian study, for example, indicated that the very old (people who lived beyond 90 years of age) were no more likely to be depressed than younger adults. (The rate was 10% in both groups.) Studies on the cause or extent of depression in the elderly are not clear-cut.

The severity of depression in elderly patients is strongly associated with poor health and with less ability to function. In one study of older adults undergoing rehabilitation, half of whom were depressed, as their function improved so did their mood.

Anyone who experiences cumulative negative life events, physical illness, the death of a loved one, impaired functioning, or loss of independence can become deeply depressed. The elderly are at highest risk for such events, Interestingly, in this regard, one study suggested that pessimistic elderly people are less prone to depression than their optimistic peers -- possibly because pessimists are more likely expect and therefore adapt to negative experiences than those with an optimistic personality.

Diagnosing Depression in the Elderly

Because of the complex relationship between depression, drug interactions, and serious physical illness in the elderly, an accurate diagnosis in this group is important but not always straightforward. The characteristic symptoms of depression are not always present or readily apparent in older people:

• Some older people may be aware of their depression but believe that nothing can be done about it.
• Many elderly people who are depressed may report only physical symptoms (aches and pains) or other mood states (confusion, agitation, anxiety, and irritability) related to depression rather than depression itself.
• Often they are unable or unwilling to express their feelings or are even unaware that they are depressed.
• Their symptoms are often ignored or confused with other ailments common in the elderly, including Parkinson's or Alzheimer's disease, dementia, thyroid disorders, arthritis, stroke, cancer, heart disease, and other chronic conditions.
• Depression is also a side effect of many drugs that are commonly prescribed for the elderly. It is often very difficult, then, to determine if the patients depression is a psychologic reaction to the illness, caused by the disease itself, or completely independent from the medical condition. Both physical and emotional conditions should be considered in making a diagnosis in older people.

Physical and Mental Consequences of Depression in the Elderly

Many studies have now reported strong associations between even mild depression and poorer quality of life as well as a shorter lifespan.

Risk for Suicide in the Elderly. Suicide in the elderly is the third-leading cause of death related to injury. Men account for 81% of these suicides, with divorced or widowed men at highest risk.

Effects of Depression on the Ability to Function. A 2000 study indicated that even mild depressive symptoms in people aged 65 and above are associated with a higher risk of becoming disabled and having a lower chance of recovery.

Heart Disease and Heart Attacks. Depression increases the severity of a heart attack and may even impair a patient's response to medication for heart disease. Although people with heart disease may certainly become depressed, this does not explain entirely the link between the two problems. The data are now suggesting that depression itself may be a true risk factor for heart disease as well as its increased severity. A number of studies have suggested that depression has biologic effects on the heart, including a higher risk for blood clotting, changes in heart rate, and impaired blood flow to the heart (particularly in response to mental stress). A study in 2001, for example, reported an association between depression and a greater risk for death from heart problems even in people without a history of heart disease. A 2002 study reported a higher risk for heart failure in women -- although not in men -- with depression. It should be noted that simply treating depression does not improve survival rates after a heart attack --only treating heart disease does this.

The more severe the depression, the more dangerous to the health, although even mild depression, including feelings of hopelessness, experienced over many years, may harm the heart, even in people with no early signs of heart disease.

Stroke. Depression has also been linked to a higher risk for having a stroke and lower survival rates after one. In one 2000 study, for example, patients with severe depression had a 73% higher risk for stroke, and those with moderate depression had a 25% higher risk than average. The risk for stroke in depressed African Americans in the study was notable, 160% higher than average. Furthermore, a 2001 study confirmed that self-reported negative mood symptoms correlated with increased mortality up to two years after a stroke. Some research has suggested that injuries in the brain after a stroke can cause depression, although a 2003 study reported the same rates of depression after a stroke as after a heart attack. More research is needed to determine if some common factors in both events may increase the risk for depression.

Mental Decline. Depression in the elderly is associated with a decline in mental functioning, regardless of the presence of dementia. Depression may be a predictor or even a cause of Alzheimer's disease. Brain scans in the elderly, for example, have reported greater atrophy in the brains of depressed individuals than in those of nondepressed ones.

Osteoporosis. Some studies have linked past and current major depression with bone-density loss in women. One explanation for this association is that depressed women have higher levels of the stress hormone cortisol, which may contribute to bone density loss.

Treating Depression in the Elderly

Some experts recommend only psychotherapy or attention intervention for elderly patients with mild depression. In many older patients, a regular exercise program may be sufficient to improve mood.

Ideally, elderly people with more serious depression should be treated with a combination of psychotherapy and antidepressants on an ongoing basis. And the treatment should be ongoing. Unfortunately, such intensive treatment is not often available to elderly patients. Furthermore, even with this approach, many elderly patients do not achieve remission or even significant improvement.

The use of antidepressants in the elderly can also be problematic:

• Tricyclics are as effective and less expensive than SSRIs, but they have more adverse effects. Specifically, they pose a higher risk for adverse effects on the heart and possibly the lungs. (The older tricyclics, e.g., amitriptyline and imipramine, have other severe side effects in older adults.)
• SSRIs have fewer side effects than tricyclics. A 2002 study using sertraline (Zoloft) suggested it was safe and effective for treating depression in heart attack patients. Of possible significance for people with heart disease or stroke are studies suggesting that SSRIs may reduce the risk for blood clotting and so help protect the heart. More research on the effects of SSRIs on the heart is needed. Contrary to common belief, SSRIs do not appear to pose any lower risk for falls than the older tricyclic antidepressants. (The effect of the newer antidepressants on falling is not yet known.) In any case, patients with Parkinson's may want to avoid SSRIs because they can increase the risk for tremor and other symptoms of the disease.

Depression in Children and Adolescents

Depressed children often suffer in silence, and depression may be evident only from reports of problems in school. It is also often difficult for adults to believe that children can be chronically depressed. Symptoms for depression in children often differ from those in adults and may include the following:

• An inability to enjoy favorite activities.
• Persistent sadness.
• Increased irritability.
• Complaints of physical problems, such as headaches and stomachaches.
• Poor performance in school.
• Persistent boredom.
• Low energy.
• Poor concentration.
• Changes in eating and/or sleeping patterns.
• A greater tendency to bully others. (Anxious children are more often bullied.)

Risk Factors for Depression in Children and Adolescents

Depression can occur in children of all ages, including preschoolers, although adolescents have the highest risk (about 20%). Risk factors for depression in young people include having parents, particularly mothers with depression. Early negative experiences and exposure to stress also pose a risk for depression. Sometimes depression develops after a physical illness. In adolescents, feeling alienated from parents is a strong predictor for depression.

Consequences of Depression in Children and Adolescents

Outlook for Future Emotional Problems. Adolescents who have depression are at significantly higher risk for substance abuse, recurring depression, and other emotional problems such as bipolar disorder in adulthood.

Risk for Suicide in Adolescents. Suicide is the third most common cause of death among adolescents, and is one of the most devastating events than can happen to a family. Suicide is most commonly associated with depression in young people but it is also commonly associated with anxiety, psychosis, substance abuse, or impulsivity. More girls attempt suicide but more boys succeed, most often because they choose guns or violent methods while girls tend to overdose, which is more treatable. Nevertheless, attempts are major risk factors for a later suicide. Any expression of suicidal intent should be treated very seriously.

The following are danger signs in young people:

• Withdrawal from friends.
• Sudden decrease in school performance.
• Loss of interest in activities that were previously pleasurable.
• Unusual irritability.
• Unusual changes in sleep or eating habits.

Risk factors for suicide include a history of neglect or abuse, history of deliberate self-harm, a family member who committed suicide (nearly always one who shared a common mood disorder), access to firearms, are in communities where there have been recent outbreaks of suicide in young people. A romantic break-up is often the trigger for a suicidal attempt in teenagers. Feeling connected with parents and family protected young people with depression in one study, regardless of gender or ethnicity.

In one study, adolescents failed to seek help for suicidal thoughts for the following reasons:

• They believed nothing would help.
• They were reluctant to tell anyone they had problems.
• They thought it was a sign of weakness to seek help.
• They did not know where to go.

Parents should not hesitate to seek professional help for their children if they suspect they are thinking about killing themselves. This is a medical emergency and requires immediate treatment.

Behavioral therapies and antidepressants are promising treatments for preventing suicide but need study. It is important to note that there has been a decline in adolescent suicides over the past decade, which some experts attribute to the increased use of antidepressants in this population. Reports in the popular press of an increased risk for suicide with SSRIs are unproven and a 2003 study found no association between SSRIs and suicide.

Treating Depression in Children and Adolescents

Studies suggest that when children or adolescents are treated, up to 80% recover. Still, between 25% and 50% of such young people have a recurrence of depression within two years of the first episode.

Mild to Moderate Depression. Children and adolescents with mild to moderate depression should receive psychotherapy before medications are tried. Cognitive therapy may be the best approach for children and adolescents with depression. (It may even be helpful in preventing depression in young people whose parents have a history of depression.) One study suggested, however, that there was very little difference in success rates among three major forms of psychotherapy: cognitive-behavioral therapy, family therapy, or supportive therapy. All achieved about an 80% recovery, with a 30% recurrent rate an average of 4 months after recovery.

Severe Depression. The American Academy of Child and Adolescent Psychiatry recommends the SSRI antidepressants for children and adolescents with very severe depression that does not respond to psychotherapy. Many SSRIs appear to be safe and effective, but at this time Prozac is the only one to be approved for children over seven and for adolescents.Some of the newer antidepressants, such as nefazodone and venlafaxine, may also be safe and effective in children.

(Tricyclic antidepressants do not tend to be beneficial in adolescents and children and they have many side effects. MAOIs are also not commonly prescribed.)

For optimal results, SSRIs should be combined during the early acute phase with a mixture of psychotherapies, including cognitive-behavioral, interpersonal, and psychodynamic therapies. Initial drug treatments should continue for at least six months, and a maintenance phase should last another year or longer.

Of some concern is a 2002 study suggesting that SSRIs may delay or impair growth in children. More research is needed on this issue. Reports in the popular press of an increased risk for suicide with SSRIs are unproven Still, the FDA warns physicians to stay alert to any signs of suicidal thought or behavior in people staking SSRIs. [For more information, seeBox Suicide and SSRIs.]