Depression: A Guide for Patients and Families

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1 Depression: A Guide for Patients and Families CO-MED is a research study funded by contract N01-MH to the University of Texas Southwestern Medical Center at Dallas from the National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services. The study is being conducted at 15 regional medical centers across the country.

2 Depression: A Guide for Patients and Families This guide is intended to answer the most common questions about depression. Major depressive disorder, also known as clinical depression, is a medical disorder that affects one s ability to experience normal mood states. Depression affects approximately 11 million people in the United States today. About one in 20 Americans get depressed every year. One in every 4 5 women and one in every 8 10 men will develop clinical depression during their lifetimes, but too few will seek treatment. Effective treatments are available that relieve suffering and improve the quality of life for depressed individuals and the significant people in their lives. 1

3 WHAT IS DEPRESSION? Depression is not the result of a weakness or anyone s fault. Clinically depressed people are not able to just pull themselves together. Depression is a medical illness known as a mood disorder, and it is treatable. Clinical depression should not be confused with temporary feelings of sadness ( feeling blue or down in the dumps ) that are part of life s disappointments. Depression lasts longer; is far more severe; impairs work, relationships, physical, and other activities. In addition to a sad mood, symptoms include trouble with sleep, appetite, energy, and self-esteem. If untreated, an average episode of major depression lasts 6 9 months, although some untreated depressions become chronic and last for years. Major depression is often recurrent most patients have more than one episode. While most people fully recover, some remain depressed between full episodes. Less severe forms of depression, such as dysthymic disorder or minor depression, also 2

4 cause personal suffering and interfere with daily life. Often these less severe forms of depression become more severe over time. What causes depression? Depression is influenced by genetic, biological, and environmental factors. Most depressions are not tied to any one thing; rather, several of these issues act together. Your chances of becoming clinically depressed are higher if one or more of your family members has had a clinical depression. In fact, in identical twins, if one twin has major depression, the other has about a 60% chance of developing the disease. However, since identical twins share the exact same genes, this also tells us that genes only partly explain why some people develop clinical depression and others do not. During a depression, there are disturbances in brain cell function. Other body chemicals called hormones may also be disrupted in depressed individuals. Some people may get depressed after losing a loved one or after other sad events. While major environmental changes are not thought to cause 3

5 depression, they may trigger depression in susceptible individuals. In some people, depression occurs even when life is going well. Other possible causes of depression include general medical illnesses (e.g., thyroid disease, cancers, or neurologic diseases), other psychiatric conditions, some medications, and drinking too much alcohol or using illegal drugs. What are the symptoms of depression? People with major depression experience at least one of the following symptoms, nearly every day, for most of the day, for at least 2 weeks: Depressed mood (feeling sad, blue, or empty). Loss of interest or pleasure in activities or hobbies that were once enjoyed, including sex. They also have at least three or four of the following symptoms: Change in appetite or weight Trouble sleeping or sleeping too much Feeling restless or slowed down Loss of energy or feeling tired all of the time 4

6 Feeling worthless or guilty Problems concentrating, remembering, or making decisions Thoughts of death or suicide With depression, there are often other physical or psychological symptoms including: Headaches Other aches and pains Digestive problems Sexual problems Feeling pessimistic or hopeless Being anxious or worried Feeling irritable and short-tempered Not everyone with clinical depression has all of the symptoms listed above. Symptoms may be different from one episode to the next, and between individuals. 5

7 Are there different types of depression? People with depression vary in the number of symptoms they experience and how their daily lives are affected: Severe depression when a person has nearly all of the symptoms of depression, and the depression prevents regular day-to-day activities from getting done. Moderate depression when a person has many symptoms of depression that often keep them from doing things that need to be done. Mild depression when a person has some of the symptoms of depression, and it takes extra effort to do the things that need to be done. In addition, there are other types of depressive disorders: Bipolar Disorder. Bipolar (or manic-depressive) disorder causes an individual to experience severe down times (depression), as well as extreme, inappropriate "highs" (mania). These feelings can last from several days to a few months. These periods of time are referred to as cycles. Depressed cycles (or episodes) are when a person has some or all of the symptoms 6

8 of major depressive disorder, while manic cycles (or episodes) are characterized by elevated (sometimes irritable) mood, increased energy, and decreased need for sleep. However, in between the highs and lows, individuals often feel completely normal. Dysthymic Disorder. Dysthymic disorder is a chronic (long lasting) less severe depressed state that persists for at least two years. The long-term, chronic symptoms of dysthymia, while not completely disabling, do impair daily function and prevent persons from reaching their potential. Clinical (or major) depressive episodes may occur on top of the dysthymic disorder sometimes called "double depression." Seasonal affective disorder (SAD). People with SAD experience the symptoms of clinical depression, but only at particular times of year (usually late fall and winter). As winter approaches, people with SAD typically begin to sleep for longer periods of time, and they withdraw from social activities. They are more likely to binge on carbohydrates and may gain 10 to 20 pounds during the winter months. But once spring comes, they experience renewed energy, 7

9 usually lose the weight they have gained, and experience minimal or no depressive symptoms. Who is likely to get a clinical depression? Depression may strike anyone. However, research suggests that certain groups are at greater risk for the illness. Women are about twice as likely to develop a clinical depression than men especially during their reproductive years. Some women get depressed during pregnancy, or following delivery. Postpartum (after delivery) depressions range from more minor "blues" to severe psychoses (for example, a person hears or sees things that aren t there or develops fixed false beliefs about reality). The "blues" are very common but are time limited (3 10 days). They go away without any treatment. About 5 10% of women in the months following delivery develop a major depression that requires professional treatment with antidepressant medications and/or psychotherapy. Psychotic depressions occur in one in 500 to one in 1,000 women within 30 days 8

10 following delivery. In those cases, intensive treatment is necessary. Persons with close relatives who have recurrent (repeated) episodes of major depression or bipolar disorder are at greater risk for depression. Persons with a personal history of depression are at greater risk for more episodes of depression. The elderly are not more likely to develop a depression than younger people, but depression in the elderly may easily be mistaken for senility, stroke, or other medical problems. Many people assume that depression is just part of getting older. It is not. Furthermore, some medications may cause depression in both older and younger adults. To recognize and treat depression in older adults requires great care, since the risk of medication side effects (problems) is higher, and potentially hazardous interactions among medications are more likely to occur (since older adults often take many medications). About 7 14% of children will experience an episode of major depression before the age of 15. The beginning of puberty is a risk period especially for young women. While symptoms of depression in young people are similar to those 9

11 of adults, the symptoms may be harder to recognize. Younger children often express their sadness and sorrow through behavioral changes rather than through talking. Some withdraw socially, while others experience irritability, anger outbursts, and poor school performance including skipping school. Some antidepressant medications as well as psychotherapy (talk therapy) appear to be effective with this age group. HOW IS DEPRESSION TREATED? There are many effective treatments available for depression today. Despite this fact, many clinically depressed people never seek treatment. Some are embarrassed not wanting to ask for help. Others simply may not recognize the need for treatment. Still others may believe that no effective treatments are available. Why seek treatment for depression? Depression is a treatable disease. Treatment reduces the pain and suffering of depression (80 90% success rates). Eventually, almost all depressed patients get relief from their 10

12 symptoms and return to their normal life, sometimes in a matter of weeks. As with other medical illnesses, the longer treatment is delayed, the more difficult it is to treat depression. Seeking early treatment prevents the depression from becoming more severe and may help prevent the recurrence (return) of depression. Treatment can prevent many serious consequences of depression including suicide. People who have depression are 30 times more likely to commit suicide than the general population. However, when depression is successfully treated, the thoughts of suicide go away. While it may be necessary to try more than one treatment, in almost every case, an effective treatment can be found. How do I seek treatment for depression? General health care providers can successfully treat many people with depression. Family physicians or mental health professionals are often the first source of help. 11

13 The local health department, community mental health center, hospital, clinic, or university medical center can help or give guidance on where to go for treatment. Sometimes specialized treatment is needed because the first treatment does not work, a combination of treatments is needed, or the depression is severe or lasts a long time. Hospitalization for the treatment of depression is rarely needed. Sometimes hospitalization is needed because other general medical conditions may affect the treatment. People with severe depression may need hospital care to adjust their medicine. Also, people who are at great risk for suicide need the safety of the hospital until those feelings pass and treatment begins to work. Rarely, depression is accompanied by psychotic symptoms, such as delusions and hearing voices, which may warrant inpatient treatment. Hospitalization, if needed, is often only for days to a few weeks. Early treatment, before the depression becomes severe or chronic (persistent), lowers the need for hospitalization. 12

14 How is the diagnosis made? Self-report questionnaires can be used to screen for depression. To make an accurate diagnosis of depression, your health care provider will ask you about your: symptoms, general medical history, and family history of general medical and mental disorders. The health care provider may also give you a physical examination and conduct some basic laboratory tests to determine if there is a physical cause for the depression. Your health care provider will then treat the depression or refer you to a mental health specialist for further evaluation and treatment. What are the phases of treatment? Treatment is divided into three steps: Acute treatment aims to remove the symptoms of depression until a person feels well and is able to function. During acute treatment, which may last for several months, outpatient visits may occur weekly or several times a month. 13

15 Continuation treatment aims to prevent the current depressive episode from relapsing (returning). Continuation treatment typically involves visits every month or two for about 6 9 months. Maintenance treatment, which aims to prevent new episodes of depression (a recurrence), is especially helpful if there have been previous depressive episodes or if the depression has been chronic (long lasting). Visits typically occur every 2 3 months. Maintenance treatment may be necessary for one or more years. What treatment methods are available? There are a number of approaches to treating depression. The choice of treatment depends on patient and clinician preferences, what is thought to cause the depression, prior treatment history, family history of treatment, the general medical status of the patient, as well as other factors. Medications are commonly used to treat depression. There are many antidepressant medications available. Psychotherapy, or "talk" therapy, is another common treatment. Research has shown that 14

16 several specific forms of psychotherapy are effective for depression including cognitive, behavioral, and interpersonal therapy used alone or combined with antidepressant medications. These are structured, goaloriented forms of therapy that typically require sessions. Electroconvulsive therapy (ECT) is sometimes used for more severe forms of depression, especially if other treatments have not worked well. A mild electrical stimulation of the brain is used to cause a brief seizure. Since patients are asleep during the treatment, they do not feel or remember anything about it. Six to 12 treatments are given, typically over 2 4 weeks. Some patients experience memory problems, which typically improve over time after the ECT is discontinued. Exercise may have a beneficial effect in patients with mild to moderate depression, but it is not usually helpful for severe depression. Exactly why exercise helps in the treatment of depression is unclear. Exercise for the treatment of depression usually includes regular aerobic sessions lasting at least half an hour, three or more times a week. 15

17 Light Therapy uses a special kind of light (broad-spectrum light) to give people the effect of having a few extra hours of daylight each day. Specially made light boxes or light visors are used to provide this light. Light therapy sometimes helps people who have mild or moderate seasonal depression. A specialist should provide this type of treatment. Whether or not natural or herbal treatments such as St. John s Wort or SAMe are helpful for some milder forms of depression is under study. However, if you are using these types of remedies, be sure to tell your doctor, as they may not mix well with standard antidepressants. Do not get discouraged if the first treatment does not help your symptoms; there are other treatments that you can try. While there are a variety of treatments to choose from, antidepressant medications and psychotherapy are the most common treatment choices. What are antidepressants? Antidepressants are medications approved for the treatment of clinical depression. Antidepressants are 16

18 thought to work by correcting the function of brain cells (neurons) by changing chemical or physiological imbalances in the brain in clinical depressions. Norepinephrine, dopamine, serotonin, and other neurotransmitters (chemical messengers) are believed to be involved in causing the symptoms of depression. Antidepressants change the function or levels of these neurotransmitters, thereby treating the depression. Each of the four classes of antidepressant medications does this process in a different way: Selective Serotonin Reuptake Inhibitors (SSRIs): citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). Serotonin is a neurotransmitter that helps transfer information from one brain cell (neuron) to another. The SSRIs work by changing the function of the serotonin system(s) in the brain correcting imbalances in this neurotransmitter. Each SSRI has a unique chemical structure, and they have different side effects in different people. Tricyclic Antidepressants (TCAs): amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Adapin or Sinequan), imipramine (Tofranil), 17

19 nortriptyline (Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil). The nine tricyclics all have a common three-ring or "tricyclic" chemical structure and work in similar ways, but they are not identical. These antidepressants change the function of both the norepinephrine and serotonin brain systems by blocking the reabsorption of these neurotransmitters by specific neurons. TCAs also affect other neurotransmitters unrelated to depression which is why TCAs produce higher rates of side effects. Monoamine Oxidase Inhibitors (MAOIs): phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan). MAOIs work by slowing the natural breakdown of norepinephrine and serotonin. Therefore, these neurotransmitters are allowed to bathe the neurons for longer periods of time than otherwise would have occurred. Special dietary and other precautions are needed when taking the MAOIs. Always tell every physician, dentist, or other health care professional if you are taking an MAOI. Do not take any over-the-counter medicines or herbal medicines without checking with your doctor who is prescribing the MAOI. 18

20 Novel Antidepressants: bupropion (Wellbutrin and Wellbutrin SR), duloxetine (Cymbalta), mirtazapine (Remeron), trazodone (Desyrel), and venlafaxine (Effexor and Effexor XR). Each of these newer medications has a structure that makes it unique as compared to other antidepressants. Bupropion has no direct effect on serotonin. It may work by affecting norepinephrine and dopamine. Duloxetine affects both norepinephrine and serotonin brain systems. Mirtazapine has complex effects on norepinephrine and serotonin. Trazodone has a different way of working, primarily through their effects on serotonin. Venlafaxine acts on both the serotonin and norepinephrine systems. Are antidepressant medications effective? Yes. Six to eight of every ten patients with depression can improve by taking antidepressant medications. One person may respond to one and not to another antidepressant. One of the benefits of having more than one antidepressant is that if the first medicine doesn't work or causes intolerable 19

21 side effects, there is still a good chance that the second or third medicine will. Before trying another medication however, it is essential to make sure that the dose and duration of the first medicine have been adequate. If individual antidepressants are ineffective, combinations of antidepressants can be effective, or other medications can be added to the antidepressant (augmentation) to help. How is an antidepressant selected for depression? Your symptoms, medical history, and family history all help determine the best medication for you. However, it may take a while to find the best one for you with the least side effects. You and your health care provider can find the proper type and amount of medicine that you need. There are several things to discuss with your health care provider before beginning antidepressant therapy: Medical history. Do you have any other general medical conditions? Heart disease, thyroid problems, diabetes, other hormone disorders of the nervous system, or other diseases may cause or worsen depression. Any general medical 20

22 condition you have may be important, so be sure to tell your doctor about all current medical conditions, even if you do not consider them to be serious. Psychiatric history. Also review with your doctor any history of psychiatric illness in your family, especially depression, mania, or alcohol or substance abuse. Medication. Any medication you are taking may be important, so tell your doctor about all of your medications including any nonprescription medicines, vitamins, dietary supplements, and herbal remedies. Some medications contribute to depression. Others may interact in a negative way with antidepressants. Tell your doctor about any antidepressants taken in the past. If you have taken a certain antidepressant that worked for you in the past, the same drug may be a logical choice. Likewise, medicines you tried in the past that did not work for you should probably be avoided. Allergies. Tell your doctor if you have ever had an allergic reaction or intolerance to an antidepressant or any other medicine. 21

23 Occupation and activities. Do you routinely operate dangerous equipment or need to drive a vehicle? Sometimes antidepressants may interfere with the ability to concentrate or cause sleepiness, but often these effects are temporary. Alcohol Use/Substance Abuse. It is important to tell your doctor if you are using any drugs or drinking alcohol. The use of drugs and/or alcohol may contribute to or worsen your depression. These substances may also interfere with the action of antidepressants. For women only. Let your doctor know if you are pregnant, or if there is a possibility you could become pregnant while you are taking antidepressants. Also, tell your doctor if you are breast-feeding or plan to breast-feed while on medications. Some antidepressants may be safely used during pregnancy and breast-feeding, but this should be discussed with your doctor before becoming pregnant. Your answers to these questions guide your health care provider in managing the depression with you. 22

24 Are laboratory tests necessary before starting antidepressant therapy? Maybe. Depending on your medical history, age, and the antidepressant medicine being considered, your health care provider may want you to have some blood tests (often including a test of thyroid function) and an electrocardiogram (ECG or EKG). How rapidly do antidepressant medications work? On average, it takes around 7 14 days for an antidepressant medicine to start to show any beneficial effect. The initial week or two is an adjustment period when side effects may be more apparent. After about 2 4 weeks, however, side effects usually fade or go away and the depression begins to improve. However, some people may not start to improve for 8 weeks. 23

25 What if the first treatment doesn t work? Do not get discouraged if you are not feeling better early in the treatment. The first treatment is likely to work for you. However, about half of patients need to go through a next step or two before finding the treatment best suited for them (improves symptoms with few or no side effects). If a treatment is not effective after a period of time, it can often be modified or changed. There are many treatments to try. How long should I take antidepressant medication? Once an effective, well-tolerated (low side effect) medicine is found, it should be continued for an additional 6 9 months for all patients. The reason to continue the medicine is to prevent a relapse. Do not stop the medicine once you are feeling better. For some patients, a longer maintenance phase is called for to prevent a new episode (a recurrence) of depression. This may be necessary for one year or longer. 24

26 More than half of patients with one depressive episode will have another one sometime in the future. This risk of more episodes increases with the number of episodes. If a person has had three depressive episodes, the chances of a fourth episode are 90%. Each person must work individually with a doctor to determine the best course of treatment. What are the potential side effects of antidepressant medications? Antidepressants are not addicting or habit forming. They do not cause an abnormal high feeling in depressed or nondepressed people. However, antidepressants, like all medications, do have side effects (problems caused by the medicine). No one patient gets all of the side effects. Some people have no noticeable side effects. Side effects typically occur early in treatment and often go away or improve with time. 25

27 Each class of antidepressants has different side effects. Side effects may include: Sleepiness Increased heart rate Dizziness Trouble sleeping Dry mouth Muscle tremors/twitches Blurred vision Jitteriness Constipation Sexual difficulties Urinary hesitation Headache Weight gain/loss Diarrhea Increased/decreased Nausea or vomiting appetite Skin Rash Anxiety Sweating Very serious side effects are rare. If side effects are a problem, your health care provider can help. Changes can be made in: The amount of medicine you take. Reducing the amount of medicine taken can sometimes lessen side effects. The type of medicine you take. Trying a different medicine can result in fewer or less bothersome side effects. 26

28 The time of day you take your medicine. Taking medicine at night instead of in the morning (or vice-versa) can sometimes be helpful. How the medicine is taken. Dividing a single daily dose into smaller amounts to be taken at different times of the day can sometimes improve side effects. Other medications you take. Sometimes a medication can be added to help reduce the side effects of an otherwise very effective antidepressant. On the other hand, sometimes side effects are relieved by reducing the doses of other medications that are interacting with the antidepressant. What is psychotherapy? Psychotherapy involves talking with a trained therapist to help you identify and solve your problems, modify your attitudes, or change your behavior. Psychotherapy helps people better manage or eliminate the symptoms of depression, cope better with life s problems, improve their self-image, and better accomplish life goals. 27

29 Skills learned in therapy may help patients to identify and perhaps prevent recurrences of clinical depression. Psychotherapies aimed at treating depression usually take sessions. The therapist may be your physician or another clinician, such as a psychologist, social worker, nurse, or counselor who works closely with your physician. Forms of psychotherapy include: individual (only you and a therapist), group (with other people), couples (you and a spouse/partner), or family therapy (you and loved ones). What are the different types of psychotherapy? There are several types of psychotherapy currently available. Supportive Psychotherapy reinforces a patient's strengths and offers reassurance. Psychodynamic Psychotherapy deals with unresolved unconscious conflicts believed to be 28

30 causing the depression. Psychodynamic psychotherapy may use such techniques as dream interpretation and free association to help people better understand themselves and solve their problems. Interpersonal Psychotherapy focuses on the patient's current relationships and seeks to work on the skills to improve them. Cognitive Therapy deals with unrealistic patterns of thinking associated with depression. This type of therapy focuses on identifying and correcting the exaggerated negative beliefs or assumptions that are often made when people are depressed. Behavior Therapy aims to change unhelpful behaviors that may cause or worsen the depression. Positive behaviors are encouraged and reinforced, while negative behaviors are discouraged. How do I get the most out of psychotherapy? For psychotherapy to be most effective, keep your appointments, be honest and open, do the assigned tasks in between sessions, and let your therapist know how the treatment is working. 29

31 Psychotherapy may work within a few sessions for some people, but for others it may take 8 10 weeks before any real effects are noticed. More than half of the patients with mild to moderate depression do very well with psychotherapy. Psychotherapy, as with medication treatment, does not work for everyone. If you do not feel any better after 6 weeks, or if you are not completely well by 12 weeks, you and your health care provider/therapist can consider other treatment options. If your depression gets better with psychotherapy, you and your therapist should decide if additional treatment is needed to focus on other problems you may be facing, and if so, for how long. Combining medicine and psychotherapy Although psychotherapy is very helpful for many patients with mild to moderate depression, more severely or chronically depressed patients may need both an antidepressant medication and psychotherapy. 30

32 Medicine is used to treat the symptoms of depression, while psychotherapy may help the symptoms or help to deal with the associated problems in a person s life. More than half of patients feel better after 6 10 weeks with combined treatment. Combined treatment is also an option for patients with a partial response to either medication or psychotherapy alone. EDUCATION: LEARNING TO COPE WITH DEPRESSION The more you and your loved ones know about depression, the better you will be able to cope with it. How often should I talk with my health care provider? When treatment starts, you will likely see your health care provider every few weeks to check on the dosage of the medicine, to check on side effects, and to see if the treatment is helping. As you begin to feel better, less frequent visits are needed. 31

33 Regardless of the appointment schedule, contact your clinician immediately if you: have violent or suicidal impulses; have changes in your mood, sleep, energy, side effects, or other medicines you take; think you might be pregnant; develop a general medical illness; or have a need for surgery or extensive dental work. What if I have concerns about my treatment? Concerns and questions about treatment are common. If at any time you are worried about your treatment, tell your health care provider. If you feel a treatment is not working or is causing serious side effects, tell your doctor immediately. Adjustments and changes in your treatment can be done if needed. Do not stop treatment abruptly. A gradual reduction in the treatment makes it easier for your body to adjust. 32

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