Depressive Disorders

Depression as a normal emotion

Depression as an abnormal emotion

Clinical pictures of depressions

Psychodynamic mechanisms of depression

Sociocultural factors in depressions

Treatment of depressions

BIBLIOGRAPHY

The term “depressive disorders” refers to a large group of psychiatric conditions whose main characteristic is an abnormal feeling of depression. This classification is broad as well as vague; it implies a definition of depression and of abnormal depression. Moreover, the word “depression” refers sometimes to an ordinary emotion, at other times to a symptom, and still at other times to a given clinical entity.

This article will discuss depression as a normal and as an abnormal emotion, clinical pictures of depressions, psychodynamic and sociocultural aspects of depression, and treatment.

Depression as a normal emotion

Depression is a common emotion, second only to anxiety in psychiatric concern and study. Often depression is referred to by such terms as sadness, melancholy, despondency, dejection, low spirit, and anguish. Although practically all human beings have at some time experienced depression, this emotional state is among the most difficult to describe and to analyze. It is a pervading feeling of unpleasantness accompanied by such somatic conditions as numbness, paresthesias of the skin, alterations of muscle tone, and decreases in respiration, pulsation, and perspiration. The head of the depressed person has the tendency to bend; the legs flex; the trunk tilts forward. The face assumes a special expression because of increased wrinkles and decreased mimic play. There is also retardation of movements, rigidity in thinking, and a general feeling of weakness.

It is, however, at the mental rather than the somatic level that depression has more specific characteristics. Whereas anxiety is characterized by an expectancy of danger, depression is accompanied by a feeling that the dangerous event has already occurred, that the loss has already been sustained. For instance, the loved person has already died, the good position has been lost, the business venture has failed, a self-concept or an ideal can no longer be maintained. There is also a more or less marked sense of despair, of unpleasant finality, as the lost object is considered irreplaceable. The loss is deemed to have repercussions on the present as well as the future. From these examples it is evident that, at least in conditions considered normal, depression seems to be a reaction to psychological processes, such as evaluations and appraisals, that have occurred at a cognitive level. The person who becomes depressed must have been able to understand and to assess the significance of certain events. Thus, cognitive and, as we shall see later in detail, social factors (inasmuch as the latter enter into complicated cognitive processes) are very important in the engendering of depression.

Such considerations would make depression a uniquely human emotion, different from more primitive emotions such as fear, rage, and some forms of anxiety that occur also in much lower animals. This point, of course, is debatable. Inasmuch as animals cannot verbalize their feelings, it is an open question whether or not the belief that animals become depressed is an anthropomorphization. A dog, for instance, may appear depressed when his master is away, but it is doubtful that this is either a feeling involving the future or a sense of loss that transcends the immediate discomfort. A feeling of deprivation rather than despair seems to be involved here. On the other hand, these uncomfortable feelings of deprivation, which even infrahuman animals are capable of experiencing, may be the precursors of human depression.

According to Arieti (1959a), depression may have functional significance. If depression had negative survival value, species capable of experiencing it probably would not have procreated themselves in the course of evolution. Other emotions have survival value; anxiety, for instance, is a warning of forthcoming danger. As with other unpleasant sensations and emotions, the function of depression is to urge the person who experiences it to alter his behavior, so that the factor engendering depression will disappear or be removed.

For example, an individual hears the news of the unexpected death of a person he loved. After he has understood and almost instantaneously evaluated what that death means to him, he experiences shock, then sadness. For a few days all thoughts connected with the deceased person will bring about a painful, almost unbearable feeling. Any group of thoughts even remotely connected with the dead person will elicit depression. The individual cannot adjust to the idea that the loved person does not live any more. And, since that person was so important to him, many of his thoughts or actions will be directly or indirectly connected with the dead person and therefore will elicit sad reactions.

Nevertheless, after a certain period of time, that individual adjusts to the idea that the person is dead. By being unpleasant, the depression seems to have a function—its own elimination. It will be removed only if the individual is forced to reorganize his thinking, to search for new ideas so that he can rearrange his life. He must rearrange especially those ideas that are connected with the departed, so that the departed will no longer be considered indispensable.

Depression as an abnormal emotion

Depression is deemed abnormal when it is excessive relative to the antecedent event or events that have elicited it; when it is inappropriate in relation to its known cause or precipitating factor; when it is a substitution for a more appropriate emotion, for instance, when it takes the place of hostility or anxiety; or, when it does not seem to have been caused by any antecedent factor of which the person is aware.

Both constitutional and psychological factors have been postulated to explain the occurrence of abnormal depressions. The constitutional factors have been studied particularly in connection with the depression that occurs in the course of manicdepressive psychosis. Slater (1936), for instance, believes that the inheritance of manic-depressive psychosis depends on a single dominant autosomal gene. To explain why the incidence of the psychosis is lower than would be expected from his hypothesis, he states that the dominant gene is a rare one. Kraines (1957) believes that the depression, as well as the manic state of manic-depressive psychosis, is due to a dysfunction (either increased or decreased function) of the diencephalon. Accordingly, the experience of depression is a “psychic response” to this diencephalic dysfunction. Elevated values for adrenal and thyroid functions, blood pressure, and pulse rate are reported frequently in depressed patients (Reiss 1954).

Arieti (1959a) has described what happens when the process of reorganizing ideas concomitant with normal depression fails. In such cases, depression, rather than forcing a reorganization of ideas, slows the thought processes that are carriers of mental pain. There appears to be a teleological or adaptational mechanism that seemingly acts with the goal of decreasing the quantity of thoughts in order to decrease the quantity of suffering. At times, the attempt to slow thought processes succeeds so well (as in the state called “stupor”) that only a few thoughts of a general and vague nature remain. These are accompanied by an overpowering feeling of melancholy. Thus, the slowing down of thought processes that have an unpleasant emotional tone is a self-defeating mechanism and, in a vicious circle, aggravates the situation instead of alleviating it.

Often, abnormal depression defensively replaces seemingly more appropriate emotions, generally anxiety or hostility. The patient appears to be more capable of coping with a feeling of depression than with anxiety or hostility.

Clinical pictures of depressions

Depressive disorders have been known since ancient times. Some of the great physicians of antiquity, like Hippocrates and Aretaeus, wrote about the conditions that are now called “psychotic depressions.” In spite of this long record in the history of medicine, no agreement has been reached about the various classifications of depressions or the nature of the various types. Following is a brief account of the different clinical pictures that have been recognized.

Reactive or psychoneurotic depression

Reactive or psychoneurotic depressions are characterized by relatively mild feelings of despondency, guilt, and self-depreciation; mild retardation and reduction of spontaneity; and the absence of hypochondrial preoccupations. These depressions seem to occur subsequent to, or as a reaction to, an unpleasant or tragic event in the life of the patient. The patient is aware of this connection. Some authors emphasize the fact that reactive depressions are not endogenous, that is, are not engendered by internal factors, such as organic or hereditary predispositions, but are consequent to external factors. In addition, the patient does not accept the depression as a way of living and, like all other psychoneurotic patients, would like to be relieved of his depressed condition.

Depressed type of manic–depressive psychosis

The depressive aspect of manic–depressive psychosis has generally received the most consideration. Although it was already recognized by Aretaeus, it was described more fully and clarified in some aspects by Kraepelin in the sixth edition of his Psychiatrie: Lehrbuch für Studierende und Ärzte, published in 1899 (see Kraepelin 1883).

This type of depression is characterized by a triad of symptoms: a pervading feeling of melancholia, disordered thought processes characterized by retardation and unusual content, and psycho-motor retardation. In addition, there are, less typically and less frequently, some somatic dysfunctions.

This type of depression occurs much more frequently in women than in men. In the majority of cases it is periodic, not permanent. Attacks of depression are separated by normal intervals.

Feeling of melancholia. The onset of the pervading feeling of melancholia is sometimes quite acute and dramatic, at other times slow and insidious. At times, it is misunderstood or unrecognized at first. When an unpleasant event, such as the death of a close relative, has occurred, a certain amount of depression is justified. However, when a certain period of time has elapsed and the depression normally should have subsided, it becomes instead more intense. The patient has an unhappy, sad appearance. He looks older than his age, his forehead is wrinkled, and his face, although undergoing very little mimic play, reveals a despondent mood. In some cases the main fold of the upper eyelid at the edge of its inner third is contracted upward and a little backward (sign of Veraguth).

The patient is often unable to describe his feeling of intense unhappiness. He may say that “his eyes have consumed all the tears” and “his life is a torment.” He experiences a desire to punish himself by destroying himself and, at the same time, to end his suffering. Suicidal ideas occur in about 75 per cent of patients, and actual suicide attempts are made by at least 10 to 15 per cent.

Disordered thought processes. The second important symptom concerns the content and type of thinking. Gloomy, morbid ideas leave little room for other thoughts. The patient convinces himself that he is hopeless; he has lost or will lose all his money, his family is in extreme poverty, he is incapable of working or even taking care of himself. There is no great variety in his thoughts. He gives the impression of selecting thoughts that have an unpleasant content so that his melancholic mood is retained. Quasi-delusional ideas or definite delusions may occur, often representing distortions of the body-image and hypochondriasis. The patient thinks, for example, that he has a tumor, syphilis, or tuberculosis, that he has lost his bowels, or that his brain is melting. The patient is often self-accusatory, in a delusional form. He believes that he has committed many crimes or that some crimes which have been committed by others are, indirectly, his responsibility. Especially in some Western subcultures that are permeated by intense religiosity, the ideas of guilt, sin, self-condemnation, and eternal damnation are prevalent. Hallucinations are rare in this condition and occur almost exclusively at night.

Psychomotor retardation. The third important sign of depression is retarded hypoactivity. The actions of the patient are reduced in number and are carried out at a slow pace. Talking is reduced to a minimum. Employment and household responsibilities are ignored, and appearances are neglected. When depression reaches a state of stupor, the patient cannot talk or move at all and may be mistaken for a catatonic patient.

Somatic dysfunctions. Frequent accessory symptoms are reduction in sleep, decrease in appetite, loss in weight, marked decrease in sexual desire, dryness of the mouth caused by decreased secretion of the parotid glands. A frequent subvariety of this condition, called “agitated depression,” is characterized by motor restlessness rather than hypoactivity.

Manic episodes. Kraepelin emphasized that in many patients attacks of depression alternate with, or occasionally are followed by, other attacks that seem to have contrasting characteristics. These are the manic attacks, characterized by a state of elation or euphoria, a disorder of thought processes distinguished by flight of ideas and pleasant content, and an increased mobility. Kraepelin thought that when the illness manifests itself in a complete form, both the depressed and manic attacks occur, although in different sequences. Thus he conceived both forms of attack as part of a specific clinical entity, to which he gave the name “manic–depressive psychosis.”

It was soon noticed that the manic attacks are much less frequent than the depressive ones. Perhaps the difference in frequency is not as marked as it seems. It could be, in fact, that mild attacks of mania are better tolerated or unrecognized by the patient or his relatives.

The intensity of the depression is not the only characteristic differentiating between psychotic and reactive depression. In a psychotic depression the patient accepts his depression as his way of life and feels justified in feeling as he does.

Psychotic depressions

Many depressions, even of psychotic proportions, are never preceded or followed by manic attacks. Many authors are reluctant to include such depressions in the manic–depressive syndrome. They feel that these depressions probably should have a classification unrelated to the Kraepelinian psychosis.

Except for the fact that it is not followed by manic attacks, psychotic depression is no different from the depression of the manic–depressive psychosis.

Involutional melancholia

Involutional melancholia (involutional psychosis, melancholic type) occurs in women at least three times as frequently as in men and is characterized by an intense feeling of depression that occurs around the “involutional” age. In women this age generally coincides with the menopause. However, involutional melancholia may precede or follow the menopause even by an interval of four to five years.

Involutional melancholia presents the same characteristics as the depression of the manic–depressive psychosis, with the following exceptions: (1) agitation and restlessness often substitute for, or are superimposed on, the hypoactivity, and (2) the prepsychotic personality differs from that of the manic–depressive. The patient is described as a quiet, retiring, worrisome, frugal, and rigid individual.

Kraepelin, who had originally excluded involutional melancholia from the manic–depressive category, reconsidered his views and finally included it in that group. Kraepelin thought that involutional melancholia had an unfavorable prognosis. However, as some of his contemporaries showed, this is not so. Electric shock treatment, devised by Ugo Cerletti and Lucio Bini in 1938 (Cerletti 1950), seems to be able to cure practically all cases, if by cure we mean a return to the prepsychotic level of adjustment, whatever it was.

Other types of depression

Depressions may also occur as parts of other syndromes or conditions. A depression occurring in old age is often referred to as “senile depression,” and one occurring in schizophrenia as “schizophrenic depression.” When a combination of schizophrenic and manic–depressive features occurs, the syndrome is often called “schizo–affective psychosis.”

A type of depression that is often described in the French and Italian literatures is the one called “Cotard’s syndrome,” after the neurologist J. Cotard, who first described it. Cotard’s syndrome is characterized by a depression accompanied by a delusional state of negation. Nothing exists; the world has disappeared. After the cosmic reality is denied, the physical reality of the patient himself is denied.

Spitz (1946) has described what he calls “anaclitical depression” in infants who have been separated from their mothers between the sixth and eighth months for an approximate period of three months. This type of depression seems more similar to a state or sense of deprivation, as it occurs in infrahuman animals, than to an emotional state that includes a sense of finality and despair.

Psychodynamic mechanisms of depression

Many authors feel that even if constitutional-hereditary facts are important in the etiology of depressive disorders, some experiential factors oc-curing in the early life of the patient have started psychodynamic patterns that have finally determined these conditions. Psychoanalytic studies have contributed greatly to the psychodynamic understanding of depressions. These psychodynamic mechanisms apply primarily to the depressions labeled as the depressed type of manic–depressive psychosis, psychotic depression, and involutional melancholia. It was Freud’s pupil Abraham (1912), not Freud, who introduced manic–depressive psychosis to psychoanalytic conceptions through a comparison of abnormal depression with normal grief. Both conditions are at times elicited by a loss that the person has suffered; but, whereas the normal mourner is concerned about the lost person, the depressed patient is disturbed by guilt feelings. The unconscious hostility that he had for the lost object is now directed toward himself. Abraham also assumed a regression to an ambivalent pregenital stage of object-relationship, that is, a return to an anal-sadistic stage.

Freud (1917) accepted Abraham’s idea that there is a relation between mourning and melancholia and pointed out that whereas in mourning the object was lost because of death, in melancholia there was an internal loss because the lost person had been incorporated (or introjected). The sadism present in the ambivalent relationship is then directed against the incorporated love-object.

Radó (1928) suggested that melancholia represents a desperate search for love. The ego tries to punish itself in order to prevent parental punishment.

According to Melanie Klein (1948), a “depressive position” is a normal event in the life of every child, generally at the time of weaning, that is, around the age of six months. The mother who before was seen by the child as two persons (one good and one bad), according to Klein, is at this time seen as one person; the mother continues, however, to be internalized as a good or bad object. The child is afraid that his instinctual aggressive impulses will destroy the good object, and he interprets the loss of his mother’s breast and milk at the time of weaning as the result of the destructive impulses. The inability to solve adequately this “depressive position” may, according to Klein, lead later to a pathological depression.

Arieti (1959a) found the following mechanisms in the cases that came under his attention. Very early in the life of people who are prone to become psychotically depressed there is a period of intense gratification of needs. The mother or mother-substitute is motivated by a sense of duty to be as lavish as possible in her care and affection. This attitude predisposes the child to be very receptive to others, to introject the others, and later to be an extrovert and a conformist.

At a later period but still in early childhood, generally during the second or third year of life, although in some cases even much earlier, the family situation undergoes a drastic change. The mother now takes care of the child considerably less than before and makes many demands on him. This change in the mother’s attitude may be due to the fact that in the meantime another sibling has been born, and the mother is now lavishing her care on the newborn with the same duty-bound generosity that she previously had for the patient. More often, however, the reason for the change is to be found in the personality of the mother, who believes that when a child is an infant, he has to be fully taken care of, but as soon as he shows the first signs of an independent personality, he should start to be given increasing responsibilities, a sense of duty, of obligation, and the like. No transitional stages are allowed. The child who experiences a drastic change from an atmosphere of receptivity from the others to an atmosphere of expectation by the others may undergo a trauma. He tries to find solutions or pseudosolutions. Generally he adopts one of the two following mechanisms, which he will repeat throughout his adult life. The first is an attempt to make himself even more babyish, more dependent, and aggressively dependent, so that the mother, or the important adult who later takes her place symbolically, will be forced to re-establish an atmosphere of babyhood and of early bliss. Another mechanism consists in trying to live up to the expectations of the mother, no matter how high the price, how heavy the burden. Love or the early bliss will be recaptured only by complying and working hard. If love is not obtained, the patient is at fault; he must atone or work harder.

The patient finds out later in life that these mechanisms do not work. No matter how aggressively dependent the individual becomes, he does not recapture the early bliss. No matter how compliant and hard working he is, he does not obtain what he wants. This realization brings about the depressed feeling. The actual manifest symptomatology of depression occurs when a symbolic reproduction of the early trauma takes place later in life. A loss has been sustained and the patient feels that his way of living has caused such a loss. The loss may be the death of a person important to the patient, the realization by the patient that an important interpersonal relationship has failed (generally with the spouse), or a severe disappointment in a relationship to an institution or work to which the patient has devoted his whole life. At times the loss is more difficult to evaluate; it may concern such abstract concepts as ideals, re-evaluation of the meaning of one’s life, and personal significance.

Claiming and self-blaming depression

The psychological symptomatology of psychotic depressions has been divided by Arieti (1962) into two main types: the claiming depression and the self-blaming depression.

In the claiming depression, which has recently become more common at least in the United States, the symptomatology, although fundamentally one of depression, seems to be a gigantic claim. All the symptoms seem to have a message: “Help me; pity me. It is in your power to relieve me. If I suffer, it is because you don’t relieve me of this suffering.”

In the self-blaming type of depression the main emphasis is on self-accusation and self-depreciation. The patient feels he does not deserve help from others.

When the prepsychotic personality is of the aggressive–dependent type, the psychosis tends to be the claiming type of depression. When the prepsychotic personality is of the duty-bound, hard-worker type, the psychosis tends to be the self-blaming type.

The suicide attempt (often successful) made by patients affected by a psychotic depression has been the object of various psychodynamic interpretations. Several possibilities must be considered. (1) The suicide attempt may actually be a cry for help. The patient wants to convey this message to an important person in his life: “You have the power to prevent my death, if you wish to.” (2) The patient wants relief from suffering. (3) The patient wants to punish himself, since he feels guilt-ridden and deserving of drastic punishment. (4) The patient does not really want to kill himself but the detested person whom he has incorporated. The last explanation is the one originally proposed by Freud (1917) and the one still accepted by the orthodox psychoanalytic school. It is actually based on little clinical evidence and is not unanimously accepted by other schools.

Sociocultural factors in depressions

Sociological and cultural factors may be important in facilitating those conditions which predispose to depression, especially those of the manic–depressive type. Some psychiatrists (Bellak et al. 1952; Arieti 1959b) have noted a decline in incidence of this psychosis. For instance, in a period of 20 years (from 1928 to 1947), the percentage of first admissions to hospitals of manic–depressive psychosis in New York State was reduced from 13.5 per cent of all admissions to 3.8 per cent. Relevant information has been gathered in other parts of the world. Gold (1951) has found a relatively higher incidence of manic–depressive than of schizophrenic psychoses in the lands of the Mediterranean Basin, as well as in Ireland. He reports that in Oriental countries, especially where Hinduism and Buddhism prevail, manic–depressive psychosis is less common, but in Fiji manic–depressive patients are numerous. Gold writes further that whereas in India the incidence of manic–depressive psychosis is low and that of schizophrenia higher, the reverse is true for the Indians who have immigrated to Fiji.

Recently, however, psychiatrists have noticed, at least in the United States, an increase in the number of depressive disorders. This increase has not yet been subjected to statistical study and seems to involve depressions not typically of the manic–depressive category.

In his attempts to understand the decline of manic–depressive psychosis Arieti (1959a; 1959b) drew upon the concepts of the sociologist Riesman (1950). Manic–depressive psychosis occurs more frequently in those cultures which Riesman has called “inner-directed” and tends to disappear where this orientation is also disappearing. It is thus possible to formulate the hypothesis that an inner-directed culture evokes or increases the manic–depressive propensity.

Inner-directed society

In the inner-directed society the mother feels duty-bound and therefore at the time of the birth of the child is very much concerned with his care, permitting the child to develop strong introjective tendencies. Soon, however, the mother will start to burden the child with responsibilities and with a sense of duty and guilt. This is often made necessary by the fact that the mother now has to devote herself to another child. The bliss of paradise is lost, and life becomes a purgatory. An inner-directed personality develops in the sense that this orientation is implanted early in life by the direct and definite influence of the significant adults. Family-life and child-rearing practices are established that seem to correspond to those found in the families of manic–depressive patients.

This hypothesis, suggesting the influence of inner-directed society upon manic–depressive psychosis, receives some validation from the research of Eaton and Weil (1955) on the mental health of the Hutterites. The Hutterites are a group of people of German ancestry who have settled in the Dakotas, Montana, and the prairie provinces of Canada. The Hutterite society seems to be an inner–directed one. In a population of 8,542 people, Eaton and Weil found only 9 persons who sometime in their lives suffered from schizophrenia and 39 with mianic-depressive psychosis; that is, among the Hutterites manic—depressive psychosis occurred 4.33 times more frequently than schizophrenia, whereas in the general population of the United States the incidence of schizophrenia by far exceeds that of manic–depressive psychosis.

Treatment of depressions

Depressive disorders are generally treated with three types of therapy. (1) Psychotherapy (generally psychoanalytically oriented in the United States; in Europe, often existentially oriented) is generally administered to patients suffering from the reactive depressions, the various types of psychotic depressions provided they are of moderate intensity, and patients who are experiencing a symptom-free interval between psychotic attacks. (2) Drug therapy is employed in the treatment of moderately severe depressions. “Psychoanaleptic drugs,” such as imipramine hydrochloride, and the large group of monoamine oxidase inhibitors are among those used. (3) Electric shock therapy, commonly used prior to the advent of drug therapy, is now reserved for the most recalcitrant and stuporous cases. It is still the most frequently used treatment in involutional melancholia.

Silvano Arieti

[Other relevant material may be found inElectro-convulsive shock; Mental disorders; Mental disorders, treatment of; Psychoanalysis; Psychosis; and the biographies ofAbraham; Freud; Klein; Kraepelin.]

BIBLIOGRAPHY

Abraham, Karl (1912) 1953 Notes on the Psychoanalytical Investigation and Treatment of Manic–Depressive Insanity and Allied Conditions. Pages 137–156 in Karl Abraham, Selected Papers. Volume 1: Selected Papers on Psychoanalysis. New York: Basic Books. → First published in German.

Arieti, Silvano 1959a Manic–Depressive Psychosis. Volume 1, pages 419–454 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books.

Arieti, Silvano 1959b Some Socio-cultural Aspects of Manic–Depressive Psychosis and Schizophrenia. Volume 4, pages 140–152 in Jacob Moreno and Jules Masserman (editors), Progress in Psychotherapy. New York: Grune.

Arieti, Silvano 1962 The Psychotherapeutic Approach to Depression. American Journal of Psychotherapy 16: 397–406.

Bellak, Leopold et al. 1952 Manic–Depressive Psychosis and Allied Conditions. New York: Grune.

Cerletti, Ugo 1950 Old and New Information About Electroshock. American Journal of Psychiatry 107: 87–94.

Eaton, Joseph W.; and Weil, Robert J. 1955 The Mental Health of the Hutterites. Pages 223–239 in Arnold M. Rose (editor), Mental Health and Mental Disorder: A Sociological Approach. Prepared for a committee of the Society for the Study of Social Problems. New York: Norton.

Freud, Sigmund (1917) 1959 Mourning and Melancholia. Volume 4, pages 152–170 in Sigmund Freud, Collected Papers, International Psycho-analytic Library, No. 10. New York: Basic Books; London: Hogarth. → Authorized translation from the German.

Gold, Henry R. 1951 Observations on Cultural Psychiatry During a World Tour of Mental Hospitals. American Journal of Psychiatry 108:462–468.

Klein, Melanie 1948 Contributions to Psycho-analysis: 1921–1945. International Psycho-analytic Library, No. 34. London: Hogarth.

Kraepelin, Emil (1883) 1921 Manic–Depressive Insanity and Paranoia. Edited by George M. Robertson. Edinburgh: Livingstone. → Translated from Volumes 3 and 4 of the eighth German edition of Psychiatrie.

Kraines, Samuel H. 1957 Mental Depressions and Their Treatment. New York: Macmillan.

RadÓ, SÁndor 1928 The Problem of Melancholia. International Journal of Psycho-analysis 9:420–438.

Rseiss, Max 1954 Investigations of Hormone Equilibria During Depression. Pages 69–82 in American Psycho-pathological Association, Forty-second Annual Meeting, New York, June 1952, Depression. Edited by Paul H. Hoch and Joseph Zubin. New York: Grune.

Riesman, David 1950 The Lonely Crowd: A Study of the Changing American Character. New Haven: Yale Univ. Press. → An abridged paperback edition was published in 1960.

Slater, Eliot 1936 The Inheritance of Manic–Depressive Insanity and Its Relation to Mental Defect. Journal of Mental Science 82:626–634.

Spitz, RenÉ A. 1946 Anaclitical Depression. Psychoanalytic Study of the Child 2:313–342.

Depressive disorders

Definition

Depression and depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep , appetite, and mental processes are common symptoms of depression.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. However, when these depressed feelings start to dominate everyday life and cause physical and mental deterioration, they become what are known as depressive disorders.

There are two main categories of depressive disorders: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities they once took pleasure in, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide . In children, the major depression may often appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, non-depressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem , fatigue, trouble concentrating, and feelings of hopelessness. Parents of children suffering from dysthymic disorder may notice their child experience a fall in grades and a lack of interest in extracurricular activities that were once enjoyable.

Depression also can occur in bipolar disorder , an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Demographics

The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that one out of every 33 children may suffer from depression. Among adults 18 and older, depressive disorders affect an estimated 18.8 million Americans each year. Women are twice as likely to suffer from a depressive disorder than men; approximately 12.4 million American women and 6.4 million men deal with depression. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

According to the U.S. Surgeon General, major depression occurs in about 5 percent of children between age nine and 17, and at any one point in time, 10 to 15 percent of U.S. children and adolescents experience some symptoms of depression.

Causes and symptoms

The causes behind depression are complex and as of 2004 not fully understood. While an imbalance of certain neurotransmitters—the chemicals in the brain that transmit messages between nerve cells—is believed to be key to depression, external factors such as upbringing may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence , a pattern of low self-esteem and negative thinking may emerge. From that, a lifelong pattern of depression may follow.

Heredity seems to play a role in who develops depressive disorders. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals pre-disposed to depressive disorders, but environmental circumstances often may trigger the disorder as well.

External stressors and significant life changes such as chronic medical problems, death of a loved one, or divorce or estrangement of parents also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Common red flags that children may be experiencing a depressive disorder include a sudden decline in grades and/or disinterest in schoolwork, avoidance of friends, loss of interest in extracurricular activities, and withdrawal from family.

Major depressive episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

• significant change in weight
• insomnia or hypersomnia (excessive sleep)
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness or inappropriate guilt
• diminished ability to think or to concentrate, or indecisiveness
• recurrent thoughts of death or suicide and/or suicide attempts

Dysthymic disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70 percent of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders , social phobias , and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS , hypothyroidism , chronic fatigue syndrome, diabetes, and post-cardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years) or one year or more for children:

• under-eating or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or trouble making decisions
• feelings of hopelessness

When to call the doctor

Just like adults, children have days when they are feeling down. But if those blue or bad moods begin to interfere with schoolwork and daily living and start to increase in frequency, parents or caregivers need to seek help from their child's doctor. If a child or teen reveals at any time that they have had recent thoughts of self-injury or suicide, professional assistance from a mental healthcare provider or care facility should be sought immediately.

Diagnosis

In addition to an interview, a clinical inventory or scale such as the Child Depression Inventory (CDI) or the Child Depression Rating Scale (CDRS) may be used to assess a child's mental status and determine the presence of depressive symptoms. Tests may be administered in an outpatient or hospital setting by a pediatrician, general practitioner, social worker, psychiatrist, or psychologist.

Treatment

Major depressive and dysthymic disorders are typically treated with antidepressants or psychosocial therapy. Psychosocial therapy focuses on the personal and interpersonal issues behind depression, while antidepressant medication is prescribed to provide more immediate relief for the symptoms of the disorder. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed child or adolescent.

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety , diarrhea , drowsiness, headache , sweating, nausea , and insomnia all are possible side effects of SSRIs. As of 2004, fluoxetine was the only SSRI (and the only antidepressant drug) approved by the U.S. Food and Drug Administration for use in children and adolescents with major depressive disorder. However, physicians may prescribe other SSRIs in younger patients in an off-label use of these drugs.

In 2004, fluoxetine and nine other antidepressant drugs came under scrutiny when the FDA issued a public health advisory and announced it was requesting the addition of a warning statement in drug labeling that outlined the possibility of worsening depression and increased suicide risk. These developments were the result of several clinical studies that found that some children taking these antidepressants had an increased risk of suicidal thoughts and actions. The FDA announced at the time that the agency would embark on a more extensive analysis of the data from these clinical trials and decide if further regulatory action was necessary.

Older classes of antidepressant drugs—(tricyclic antidepressants (TCAs), heterocyclics, and monoamine oxidase inhibitors (MAOIs)—do not have any substantial demonstrated effectiveness in pediatric populations and have potentially serious side effects that make them undesirable for child and adolescent use.

For severe depression that does not respond well to antidepressant, mood stabilizer drugs (e.g., lithium, carbamazepine, valproic acid) may be recommended.

Psychotherapy

Psychotherapy, or talk therapy, involves analyzing a child's life to bring to light possible contributing causes of the present depression. During treatment, the therapist helps the patient to become aware of his or her thinking patterns and how they came to be, and works with them to develop healthy problem solving and copying skills. In very young patients, a therapist may use toys , games, and dolls as a vehicle for helping a child express her emotions. This type of therapy, sometimes referred to as play therapy, is useful in children who may not have the developmental capacity or language skills to express the thoughts and feelings behind their depression.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing the depressed patient's thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them and then retrains the depressed individual to recognize the thinking and react differently to it.

Electroconvulsant therapy

Electroconvulsive therapy (ECT) is only considered after all therapy and pharmaceutical treatment options have been unsuccessful, and even then it is a treatment of last resort, typically employed when a patient has become catatonic, suicidal, or psychotic as well as depressed.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under anesthesia, and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, also has been reported in ECT patients.

Alternative treatment

St. John's wort (Hypericum perforatum ) isused throughout Europe to treat mild depressive symptoms. Unlike traditional prescription antidepressants, this herbal antidepressant has few reported side effects. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll showed that about 41 percent of 15,000 science professionals in 62 countries said they would use St. John's wort for mild to moderate depression. The usual adult dose is 300 mg three times daily and may be lowered for children and adolescents.

In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without side effects of stomach upset.

Parents and caregivers of children who suffer from depression should consult their child's physician before administering any herb or dietary supplement. Some supplements can interfere with the action of other prescription and over-the-counter medications. In addition, some supplements may not be appropriate for use in children with certain medical conditions.

A report from Great Britain published in 2003 emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression.

Nutritional concerns

Poor nutrition , especially eating habits that lead to overweight or obesity in children, can also contribute to depression. A 2003 study in the journal Pediatrics found that children who are substantially overweight for long periods of time are more likely to suffer from depression. Whether the depression causes the weight problem or the weight issue triggers the depression was not completely clear.

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 depressed patients. After each major depressive episode, the risk of recurrence climbs significantly: 50 percent after one episode, 70 percent after two episodes, and 90 percent after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment of antidepressants and/or therapy.

Prevention

Good nutrition, proper sleep, exercise, and family support are all important to a healthy mental state, particularly in children. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention for children with depression can be effective in avoiding the development of more severe psychological problems later in life.

Parental concerns

Children who are diagnosed with depression should be reassured that the condition is quite common and that it is due to factors beyond their control (i.e., genetics, neurochemical imbalance) rather than any fault of the child. For those children and teens who feel stigmatized or self-conscious about their depression, arranging psychotherapy sessions outside school hours may lessen their burden. Any child prescribed antidepressants should be carefully monitored for any sign of side effects, and these should be reported to their physician when they do occur. A dosage adjustment or medication change may be warranted if side effects are disruptive or potentially dangerous.

KEY TERMS

Hypersomnia —An abnormal increase of 25% or more in time spent sleeping. Individuals with hypersomnia usually have excessive daytime sleepiness.

Neurotransmitter —A chemical messenger that transmits an impulse from one nerve cell to the next.

Psychomotor agitation —Disturbed physical and mental processes (e.g., fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation —Slowed mental and physical processes characteristic of a bipolar depressive episode.

See also Bipolar disorder.

Resources

BOOKS

Barnard, Martha Underwood. Helping Your Depressed Child. Oakland, CA: New Harbinger Publications, 2003.

Diagnostic and Statistical Manual of Mental Disorders,4th ed., text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, 2000.

Shaffer, David, and Bruce Waslick, eds. The Many Faces of Depression in Children and Adolescents. Arlington, VA: American Psychiatric Publishing, 2002.

PERIODICALS

"A Natural Mood-Booster that Really Works: A Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health (July 2003): 22.

"FDA Approves Once-daily Supplement." Biotech Week (September 24, 2003): 6.

"Try Alternatives Before Using Antidepressants." GP (September 29, 2003): 12.

Vitiello, B., and S. Swedo. "Antidepressant Medications in Children." New England Journal of Medicine 350, no. 15 (April 8, 2003): 1489–91.

ORGANIZATIONS

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Web site: <www.psych.org>.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002–4242. Web site: <www.apa.org>.

Depression and Bipolar Support Alliance (DBSA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. Web site: <www.dbsalliance.org>.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201–3042. Web site: <www.nami.org>.

National Institute of Mental Health (NIMH). Office of Communications, 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 20892–9663. Web site: <www.nimh.nih.gov>.

WEB SITES

Larsen, Willow. "The Obesity-Depression Link." Psychology Today (May 30, 2003). Available online at <www.psychologytoday.com/htdocs/prod/ptoarticle/pto-20030527-000010.asp> (accessed December 26, 2004).

U.S. Food and Drug Administration. "Antidepressant [links]." Available online at <www.fda.gov> (accessed December 26, 2004).

Paula Ford-Martin Teresa Odle

Depressive Disorders

Definition

Depression or depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.

Description

Everyone experiences feelings of unhappiness and sadness occasionally. But when these depressed feelings start to dominate everyday life and cause physical and mental deterioration, they become what are known as depressive disorders. Each year in the United States, depressive disorders affect an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 10-20% lifetime prevalence, compared to 5-10% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.

There are two main categories of depressive disorders: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities they once took pleasure in, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide. In children, the major depression may appear as irritability.

While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, non-depressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem, fatigue, trouble concentrating, and feelings of hopelessness.

Depression also can occur in bipolar disorder, an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.

Causes and symptoms

The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmitters—the chemicals in the brain that transmit messages between nerve cells—is believed to be key to depression, external factors such as upbringing (more so in dysthymia than major depression) may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence, a pattern of low self-esteem and negative thinking may emerge. From that, a lifelong pattern of depression may follow. A 2003 study reported that two-thirds of patients with major depression say they also suffer from chronic pain. A 2004 study linked severe obesity with major depression. Another study showed a strong relationship between smoking and depression among teens.

Heredity seems to play a role in who develops depressive disorders. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals pre-disposed or prone to depressive disorders, but environmental circumstances often may trigger the disorder.

External stressors and significant life changes, such as chronic medical problems, death of a loved one, divorce or estrangement, miscarriage, or loss of a job, also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.

Major depressive episode

Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:

• Significant change in weight.
• Insomnia or hypersomnia (excessive sleep).
• Psychomotor agitation or retardation.
• Fatigue or loss of energy.
• Feelings of worthlessness or inappropriate guilt.
• Diminished ability to think or to concentrate, or indecisiveness.
• Recurrent thoughts of death or suicide and/or suicide attempts.

Dysthymic disorder

Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70% of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders, social phobias, and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis, AIDS, hypothyroidism, chronic fatigue syndrome, Parkinson's disease, diabetes, and post-cardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.

Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years), or one year or more for children:

• under or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or trouble making decisions
• feelings of hopelessness

Signs of Depression

Lack of interest or pleasure in daily activities

Significant weight loss (without dieting) or weight gain

Difficulty sleeping or excessive sleeping

Loss of energy

Feelings of worthlessness or guilt

Difficulty in making decisions

Restlessness

Recurrent thoughts of death

Diagnosis

In addition to an interview, several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, social worker, psychiatrist, or psychologist.

Treatment

Major depressive and dysthymic disorders are typically treated with antidepressants or psychosocial therapy. Psychosocial therapy focuses on the personal and interpersonal issues behind depression, while antidepressant medication is prescribed to provide more immediate relief for the symptoms of the disorder. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia all are possible side effects of SSRIs. In early 2004, a joint panel of the U.S. Food and Drug Administration (FDA) issued stronger warnings to physicians and parents about increased risk of suicide among children and adolescents taking SSRIs.

Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side-effects, which may include persistent dry mouth, sedation, dizziness, and cardiac arrhythmias. Because of these side effects, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs can be lethal if ingested all at once, so these drugs may not be a preferred treatment option for patients at risk for suicide.

Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid potentially serious hypertensive side effects.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion should not be prescribed to patients with a seizure disorder. Side effects of the drug may include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia. Other possible side effects of trazodone include dry mouth, gastrointestinal distress, dizziness, and headache. In 2003, Wellbutrin's manufacturer released a once—daily version of the drug that offered low risk of sexual side effects or weight gain.

Psychosocial therapy

Psychotherapy explores an individual's life to bring to light possible contributing causes of the present depression. During treatment, the therapist helps the patient to become self-aware of his or her thinking patterns and how they came to be. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.

Cognitive-behavioral therapy assumes that the patient's faulty thinking is causing the current depression and focuses on changing the depressed patient's thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them, and then retrains the depressed individual to recognize the thinking and react differently to it.

Electroconvulsant therapy

ECT, or electroconvulsive therapy, usually is employed after all therapy and pharmaceutical treatment options have been explored. However, it is sometimes used early in treatment when severe depression is present and the patient refuses oral medication, or when the patient is becoming dehydrated, extremely suicidal, or psychotic.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, also has been reported in ECT patients.

Alternative treatment

St. John's wort (Hypericum perforatum ) is used throughout Europe to treat depressive symptoms. Unlike traditional prescription antidepressants, this herbal antidepressant has few reported side effects. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll showed that about 41% of 15,000 science professionals in 62 countries said they would use St. John's wort for mild to moderate depression. Although St. John's wort appears to be a safe alternative to conventional antidepressants, care should be taken, as the herb can interfere with the actions of some pharmaceuticals. The usual dose is 300 mg three times daily.

Homeopathic treatment also can be therapeutic in treating depression. Good nutrition, proper sleep, exercise, and full engagement in life are very important to a healthy mental state.

In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. The usual dosage is 200 mg to 400 mg twice daily. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without the side effects of stomach upset and decreased sexual desire.

In 2003, a report from Great Britain emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise programs, and watchful waiting before subscribing antidepressant medications for mild depression.

Prognosis

Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80-90% of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly—50% after one episode, 70% after two episodes, and 90% after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment of antidepressants and/or therapy.

Research has found that depression may lead to other problems as well. Increased risk of heart disease has been linked to depression, particularly in post-menopausal women. And while chronic pain may cause depression, a 2004 study in Canada revealed that depression also may lead to back pain.

Prevention

Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize symptoms of depression and to take an active part in their treatment program. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention for children with depression is effective in arresting development of more severe problems.

KEY TERMS

Hypersomnia— The need to sleep excessively; a symptom of dysthymic and major depressive disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to depressive disorders.

Psychomotor agitation— Disturbed physical and mental processes (e.g., fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation— Slowed physical and mental processes (e.g., slowed thinking, walking, and talking); a symptom of major depressive disorder.

Resources

PERIODICALS

"Depression Can Lead to Back Pain." Biotech Week, March 24, 2004: 576.

"Depression May Be a Risk Factor for Heart Disease, Death in Older Women." Women's Health Weekly, March 4, 2004: 90.

"FDA Approves Once-daily Supplement." Biotech Week, September 24, 2003: 6.

"FDA Panel Urges Stronger Warnings of Child Suicide." SCRIP World Pharmaceutical News, February 6, 2004: 24.

Jancin, Bruce. "Chronic Pain Affects 67% of Patients With Depression: 'Stunning' Finding in Primary Care Study." Internal Medicine News, September 15, 2003: 4.

"National Study Indicates Obesity Is Linked to Major Depression." Drug Week, February 13, 2004: 338.

"A Natural Mood-booster that Really Works: a Group of Noted Researchers Found that the Supplement SAMe Works as Well as Antidepressant Drugs." Natural Health, July 2003: 22.

"Researchers See Link Between Depression, Smoking." Mental Health Weekly, March 1, 2004: 8.

"St. John's Wort Healing Reputation Upheld." Nutraceuticals International, September 2003.

"Try Alternatives Before Using Antidepressants." GP, September 29, 2003: 12.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. 〈http://www.apa.org〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (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. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. 〈http://www.nimh.nih.gov〉.

Depressive Disorders

Definition

A depressive disorder is defined by the National Institute of Mental Health (NIMH) as an illness that involves the body, mood, and thoughts. It encompasses feelings of overwhelming sadness and despair that persist or intensify over time.

Description

Occasional feelings of unhappiness or sadness are normal, but when such feelings dominate everyday life, causing physical and mental deterioration, they are termed depressive disorders. In Caring For The Mind, The Comprehensive Guide to Mental Health, Dianne and Robert Hales state that comparing everyday blues to clinical depression is like comparing a cold to pneumonia. Nearly 19 million American adults, approximately 10% of the population, suffer from depression in any given year. Less than one of three of these will ever pursue, or receive, medical care. In a survey conducted by the National Mental Health Association, it was found that nearly half of those surveyed believed that depression was not an illness, but rather a personal emotional weakness. However depressive disorders are valid illnesses that require treatment and can literally be life-threatening: Fifteen percent of all people diagnosed as being depressed actually do commit suicide. Thirty percent may make unsuccessful attempts.

Categories of depression include:

• major depression
• seasonal affective disorder
• bipolar disorder
• dysthymia

• depression due to a general medical condition
• postpartum depression
• substance-induced depression

Major depression

Major depression can be mild, moderate or severe, and the rating of its severity is based upon the number of symptoms the person has, and how seriously these symptoms affect their lives. Typical symptoms are:

• lack of interest in once-enjoyable activities
• loss or gain of weight
• difficulty concentrating or making decisions
• feelings of worthlessness and hopelessness
• changes in sleep patterns, either insomnia or hypersomnia

People with major depression may be preoccupied with death or suicide. In children, it may manifest itself as irritability or acting out. According to the National Comorbidity Survey, major depression is the single most common mental illness in the United States, affecting one in ten Americans, and women twice as often as men. Ten to 15% of people over 65 and 25% of those in nursing homes show symptoms, and NIMH estimates that better than half of elderly Americans who suffer from major depression do not receive appropriate treatment.

DEPRESSION IN OLDER ADULTS. Depression in older adults not only causes distress and suffering but also leads to impairments in physical, mental, and social functioning. Despite being associated with excess morbidity and mortality, depression often goes undiagnosed and untreated. The startling reality is that a substantial proportion of older patients receive no treatment or inadequate treatment for their depression in primary care settings, according to the National Institutes of Health. Part of the problem is that depression in older people is hard to disentangle from the many other disorders that affect older people, and its symptom profile is somewhat different from that in other adults.

DEPRESSION IN CHILDREN AND ADOLESCENTS. In children and adolescents, the most frequently diagnosed mood disorders are major depressive disorder, dysthymic disorder, and bipolar disorder. Because mood disorders such as depression substantially increase the risk of suicide, suicidal behavior is a matter of serious concern for clinicians who deal with the mental health problems of children and adolescents. The incidence of suicide attempts reaches a peak during the mid-adolescent years, and mortality from suicide, which increases steadily through the teens, is the third leading cause of death at that age, according to the Centers for Disease Control and Prevention (CDC). Depressed children are sad, they lose interest in activities that used to please them, and they criticize themselves and feel that others criticize them. They feel unloved, pessimistic, or even hopeless about the future; they think that life is not worth living, and thoughts of suicide may be present. Depressed children and adolescents are often irritable, and their irritability may lead to aggressive behavior. They are indecisive, have problems concentrating, and may lack energy or motivation; they may neglect their appearance and hygiene; and their normal sleep patterns are disturbed.

Seasonal affective disorder (SAD)

The unique characteristic of SAD is when the depression occurs. Incidences usually occur at a specific time each year. SAD can be either unipolar, showing depressive symptoms only, or bipolar, having cycles of depression and elevated mood. SAD typically begins in the autumn, when the days grow shorter, and continues through the winter, ending in the spring. A less common form begins in the spring and ends in early fall. The NIMH estimates that ten million Americans have SAD.

Bipolar disorder

Close to two million Americans are diagnosed as having bipolar disorder, or manic depression, a mental illness that is characterized by cycles of giddy elation and despondency. Approximately one-fifth of all depressive disorders are termed bipolar. People suffering from bipolar illnesses often first exhibit hypomania, a mild state of mania, in which they are often able to accomplish a great deal, go without sleep, and exhibit extreme self-confidence. As the disease progresses, they may cycle into full-blown mania and engage in much more dangerous behavior, such as wild spending sprees, promiscuous sexual activity, substance abuse, and other self-destructive behaviors. This euphoric phase is followed by the depths of classic depression.

Dysthymia

Dysthymia, or chronic mild depression, has been described as sadness that will not end. There has been debate among mental health professionals for several years as to whether dysthymia is a truly separate entity from major depression, and the answer remains unclear. NIMH studies have shown that three-quarters of those diagnosed with dysthymia also had other disorders, including major depression, panic or anxiety disorders, and substance abuse. The National Comorbidity Survey suggested that approximately 6% of Americans will develop this disorder in their lifetimes.

Depression due to a general medical condition

Many people are not aware that physical disease can cause depression. One of the significant differences in this type of depression is that patients continue to feel good about themselves, and complain that the depression is interfering with their normal life activities.

Postpartum depression

It is not unusual for a new mother to have what is termed baby blues shortly after giving birth. This involves feeling sadder than usual, crying easily, and typically occurs in the first seven to 10 days after birth. However, about 1% of all new mothers develop a true mental illness, postpartum depression, between a month and a year after giving birth. The symptoms are similar to major depression, but some women may develop more serious complications, including hallucinations and delusions.

Substance-induced depression

Many different medications, both legal and illegal, can cause depression. Alcoholism has long been linked closely with depression, but it is now known that one in four alcoholics suffered from depression before they ever drank, and will remain depressed whether they drink again or not, unless the depression is treated.

Causes and symptoms

As study of the brain and nervous system has advanced, it has become known that depression is a complicated biological process that interrupts the normal balance of neurotransmitter, or messenger chemicals such as norepinephrine or serontin.

Major depression

Heredity appears to be strongly linked to major depression. As a rule, the rate of depression between family members of a person suffering from major depression is one to three times higher than in families where there is none. An identical twin is 66% more likely to become depressed if the other twin develops the illness. However, therapists can often see predictable patterns of behavior that lead to depression. Life traumas such as grief also seem to lead to major depression.

Most older patients with symptoms of depression do not meet the full criteria for major depression. The new diagnostic entity of minor depression has been proposed to characterize some of these patients. Minor depression is not yet recognized as an official disorder. Since depression is more difficult to assess and detect in older adults, research is needed on what clinical features might help identify older adults at increased risk for sustained depressive symptoms and suicide.

Despite some similarities, childhood depression differs in important ways from adult depression. Psychotic features do not occur as often in depressed children and adolescents, and when they occur, auditory hallucinations are more common than delusions. Associated anxiety symptoms, such as fears of separation or reluctance to meet people, and somatic symptoms, such as general aches and pains, stomachaches, and headaches, are more common in depressed children and adolescents than in adults with depression.

Seasonal affective disorder

SAD is common in northern climates. It is nearly nine times more prevalent in New Hampshire as in Florida, indicating that the altered brain chemistry that produces the depression is related to the decrease in light in northern climates during the winter. However, the cause of SAD is still under investigation.

Bipolar disorder

Bipolar disorders are believed to be caused by abnormal functioning of the brain. Heredity is considered a major factor.

Dysthymia

Like other depressions, dysthymia has been related both to hereditary chemical imbalances within the brain and to traumatic events in life, often going back to childhood. Some research has linked dysthymia to attention deficit hyperactivity disorder (ADHD) and conduct and personality disorders.

Depression due to a general medical condition

Among the physical illnesses capable of causing depression are cancer, heart disease, hormonal problems (such as thyroid disorders), Alzheimer's and Parkinson's disease, brain tumors, head injuries, infectious illnesses, and malnutrition/vitamin deficiency.

Postpartum depression

This type of depression appears related to changes in hormonal chemistry that affect a woman's brain chemistry.

Substance-induced depression

Among the substances that are capable of causing depression are:

• alcohol
• minor tranquilizers such as valium
• heroin and other narcotics

• antihistamines
• anticancer drugs
• steroids and corticosteroids
• anti-seizure medications such as dilantin or depakot
• anti-inflammatory drugs
• cocaine, when its initial elevation in mood has passed
• estrogen
• L-dopa, a drug used to treat Parkinson's disease

Diagnosis

Many people go to their primary care practitioner with complaints of insomnia, lack of appetite, or other physical complaints only to discover that what they actually have is depression. A thorough physical examination is needed, including a family history of depression, the person's use of alcohol or other drugs, and medications being taken. Psychological testing and a mental status examination may be conducted. Several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, nurse, social worker, psychiatrist, or psychologist. The guidelines for diagnosing depression are found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Treatment

Major depression, dysthymia, and seasonal affective disorder are all treated effectively with psychosocial therapy of various kinds and antidepressant drugs.

Antidepressants

Antidepressant medications, without any other type of treatment, are estimated to relieve the symptoms of 60-70% of clinically depressed people. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea, drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia are all possible side effects of SSRIs.

Tricyclic antidepressants (TCAs) are older and less expensive medications than SSRIs, but they have more severe side effects, including persistent dry mouth, sedation, dizziness, and irregular heartbeat. Because of these, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs is potentially lethal, so these drugs are questionable treatment options for patients at risk for suicide.

Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) and phenelzine sulfate (Nardil) block the action of monoamine oxidase, a central nervous system enzyme. Patients taking MAOIs must restrict foods high in tyramine (found in red wine, aged cheeses, and meats) from their diet to avoid potentially serious hypertension.

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion should not be prescribed for patients with seizure disorder. Side effects of the drug may include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia.

Psychosocial therapy

Psychotherapy explores an individual's life to bring to light possible contributing causes of the present depression. During treatment, the therapist facilitates an awareness of thought patterns and how they developed. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem-solving and coping skills.

Electroconvulsant therapy

ECT, or electroconvulsive therapy, is normally employed after other treatment options have been explored. But it may be used sooner if severe depression, suicide risk, or psychosis is present, or if the person is unable or unwilling to take medication. About half of those who do not improve from other therapies recover after having ECT.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following ECT. Memory loss, typically transient, is reported by ECT patients.

Phototherapy

Phototherapy, or exposure to fluorescent light bulbs installed in a metal box with a plastic screen ten to twenty times brighter than indoor lighting, has proven effective in treating SAD. Phototherapy is often combined with other treatments such as medication or psychosocial therapy. The person sits in front of this light box for anywhere from one-half hour to two hours.

Alternative treatment

St. John's wort (Hypericum perforatum) is used throughout the world to treat depression. In Germany, St. John's Wort is the most widely used antidepressant. This herbal antidepressant has few reported side effects, but some users have experienced high blood pressure, headaches, stiff neck, nausea, and vomiting. NIMH is currently involved in a three-year study of its efficacy. However, in February 2000, a public health advisory was issued by the Food and Drug Administration (FDA) stating that St. John's wort may interact with other medications commonly prescribed for heart disease, depression, seizures, and certain cancers, as well as anti-rejection drugs used for transplant patients. Healthcare providers were advised to alert their patients to the risk of this interaction.

Holistic treatment can also be very therapeutic in treating depression. Good nutrition, proper sleep, exercise, and full engagement in life are very important to a healthy mental state.

Prognosis

Untreated or improperly diagnosed depression is the number one cause of suicide in the United States. Yet treatment can result in dramatic improvement for between 75-80% of patients, and should be clearly evident within three to four months. Five to 10% of patients still report depression two years after initially being treated, but there are varying reasons for this, including medication noncompliance and alcohol abuse. The risk of recurrence climbs significantly with each episode.

Prevention

Education is crucial for patients with depressive disorders. They must learn to recognize symptoms and to take an active part in their treatment. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Physical exercise and staying connected to self-help support groups have both been shown to be effective in preventing depression. Early intervention with children with depression is effective in arresting development of more severe problems.

Health care team roles

Psychiatrist

Psychiatrists are licensed medical doctors who have undergone a three-year psychiatric residency. They diagnose depression, determine appropriate treatment, and provide psychotherapy and support for patients. Education on the nature of depression, and the various treatment options available, are important adjuncts to the therapy they provide.

Primary care practitioner (PCP)

Though depression is a mental illness, depression may be diagnosed by primary care practitioners because depressed patients often exhibit distinct physical symptoms. Psychiatrists frequently become involved only after a consultation is requested. The importance of a psychiatric referral for further evaluation cannot be overstated. It can literally save a severely depressed person's life.

Registered nurse (RN), psychiatric nurse, or licensed practical nurse (LPN)

Both RNs and LPNs must complete a prescribed nursing course and pass a state examination. RNs typically have a degree in nursing, and psychiatric nurses have additional training specific to their field. Both RNs and LPNS are the health care team members who are most involved with depressed patients in outpatient clinics and in psychiatric units, where patients at risk for suicide must be monitored. Observational skills, empathy, and the ability to listen are necessary assets for nurses. Education about depression typically comes from both physicians and nurses.

Social workers

Social workers are usually either certified (CSW) or licensed clinical social workers (LCSW). A two-year graduate degree, specialized training that includes supervised clinical work with the mentally ill, and state licensure are typical requirements. Social workers often conduct supportive groups or programs that help people vent feelings or work on ways to better be able to cope.

Mental health assistants

These are staff members on inpatient psychiatric units who have been provided with special training in order to assist with the care of people with mental illness. They normally aid patients with day-to-day needs, accompany them to appointments or for walks if necessary, help deal with crises, and assist professional staff in providing care.

KEY TERMS

Clinical depression— Depression that is serious enough to require psychiatric intervention and treatment.

Hypersomnia— The need to sleep excessively; a symptom of dysthymic and major depressive disorder.

Neurotransmitter— A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to depressive disorders.

Psychomotor agitation— Disturbed physical and mental processes (fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation— Slowed physical and mental processes (slowed thinking, walking, and talking); a symptom of major depressive disorder.

Resources

BOOKS

Fink, Candida, and Joe Kraynak. Bipolar Disorder for Dummies New York: Wiley Publishing, 2005.

Parker, Gordon, and Vilava Manicavasgar. Modelling and Managing the Depressive Disorders: A Clinical Guide Cambridge, United Kingdom: Cambridge University Press, 2005.

Parker, James N., and Philip M. Parker. Major Depressive Disorder: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References San Diego: Icon Health Publications, 2004.

Thase, Michael E., and Susan S. lang. Beating the Blues: New Approaches to Overcoming Dysthymia and Chronic Mild Depression Oxford, United Kingdom: Oxford University Press, 2003.

PERIODICALS

Armstrong, Michael. "On Delusions: The Torment and the Euphoria." CrossCurrents—The Journal of Addiction and Mental Health (Autumn 2004): 11.

Kita, Joe. "The New Depression." Men's Health (January 2001): 104.

Ryan, Neal D. "Treatment of Depression in Children and Adolescents." The Lancet (Sept. 10, 2005): 933-940.

Walters, Paul. "GP Clinical: Seasonal Affective Disorder." GP (Jan. 21, 2005): 52.

Whybrow, Peter. "Mood Swings: A World-Renowned Expert on Bipolar Disorder Discusses the Latest Research Demontrating That Thyroid Hormone Can Have a Positive and Profound Effect on Mood in Bipolar Patients." Saturday Evening Post (July-August 2005): 36-42.

Zoellner, Tom. "America, the Bipolar." Best Life (May-June 2005): 86.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. www.aacap.org.

American Psychiatric Association (APA). 1000 Wilson Blvd., Suite 1825, Arlington, VA, 22209-3901. (703) 907-7300. apa@psych.org. 〈http://www.psych.org〉.

American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5500. 〈http://www.apa.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). Room 8184, MSC 9663, 6001 Executive Blvd., Bethesda, MD 20892-9663. (301) 443-4513. 〈http://www.nimh.nih.gov/〉.

Depressive disorders

Definition

A depressive disorder is defined by the National Institute of Mental Health (NIMH) as an illness that involves the body, mood and thoughts. It encompasses feelings of overwhelming sadness and despair that persist or intensify over time.

Description

Occasional feelings of unhappiness or sadness are normal, but when such feelings dominate everyday life causing physical and mental deterioration, they are termed depressive disorders. In Caring For The Mind, The Comprehensive Guide to Mental Health, Dianne and Robert Hales state that comparing everyday blues to clinical depression is like comparing a cold to pneumonia . Nearly 19 million American adults, approximately 10% of the population, suffer from depression in any given year. Less than one of three of these will ever pursue, or receive, medical care. In a survey conducted by the National Mental Health Association, it was found that nearly half of those surveyed believed that depression was not an illness, but rather a personal emotional weakness. However depressive disorders are valid illnesses that require treatment and can literally be life-threatening: Fifteen percent of all people diagnosed as being depressed actually do commit suicide. Thirty percent may make unsuccessful attempts.

Categories of depression include:• major depression

• seasonal affective disorder
• bipolar disorder
• dysthymia
• depression due to a general medical condition
• postpartum depression
• substance-induced depression

Major depression

Major depression can be mild, moderate or severe, and the rating of its severity is based upon the number of symptoms the person has, and how seriously these symptoms affect their lives. Typical symptoms are:

• lack of interest in once-enjoyable activities
• loss or gain of weight
• difficulty concentrating or making decisions
• feelings of worthlessness and hopelessness
• changes in sleep patterns, either insomnia or hypersomnia

People with major depression may be preoccupied with death or suicide. In children, it may manifest itself as irritability or acting out. According to the National Comorbidity Survey, major depression is the single most common mental illness in the United States, affecting one in ten Americans, and women twice as often as men. Ten to 15% of people over 65 and 25% of those in nursing homes show symptoms, and NIMH estimates that better than half of elderly Americans who suffer from major depression do not receive appropriate treatment.

Seasonal affective disorder (SAD)

The unique characteristic of SAD is when the depression occurs. Incidences usually occur at a specific time each year. SAD can be either unipolar, showing depressive symptoms only, or bipolar, having cycles of depression and elevated mood. SAD typically begins in the autumn, when the days grow shorter, and continues through the winter, ending in the spring. A less common form begins in the spring and ends in early fall. The NIMH estimates that ten million Americans have SAD.

Bipolar disorder

Close to two million Americans are diagnosed as having bipolar disorder, or manic depression, a mental illness that is characterized by cycles of giddy elation and despondency. Approximately one-fifth of all depressive disorders are termed bipolar. People suffering from bipolar illnesses often first exhibit hypomania, a mild state of mania, in which they are often able to accomplish a great deal, go without sleep, and exhibit extreme self-confidence. As the disease progresses, they may cycle into full-blown mania, and engage in much more dangerous behavior, such as wild spending sprees, promiscuous sexual activity, substance abuse, and other self-destructive behaviors. This euphoric phase is followed by the depths of classic depression.

Dysthymia

Dysthymia, or chronic mild depression, has been described as sadness that will not end. There has been debate among mental health professionals for several years as to whether dysthymia is a truly separate entity from major depression, and the answer remains unclear. NIMH studies have shown that three-quarters of those diagnosed woth dysthymia also had other disorders, including major depression, panic or anxiety disorders, and substance abuse. The National Comorbidity Survey suggested that approximately 6% of Americans will develop this disorder in their lifetimes.

Depression due to a general medical condition

Many people are not aware that physical disease can cause depression. One of the significant differences in this type of depression is that patients continue to feel good about themselves, and complain that the depression is interfering with their normal life activities.

Postpartum depression

It is not unusual for a new mother to have what is termed baby blues shortly after giving birth. This involves feeling sadder than usual, crying easily, and typically occurs in the first seven to 10 days after birth. However, about 1% of all new mothers develop a true mental illness, postpartum depression, between a month and a year after giving birth. The symptoms are similar to major depression, but some women may develop more serious complications, including hallucinations and delusions.

Substance-induced depression

Many different medications, both legal and illegal, can cause depression. Alcoholism has long been linked closely with depression, but it is now known that one in four alcoholics suffered from depression before they ever drank, and will remain depressed whether they drink again or not, unless the depression is treated.

Causes and symptoms

As study of the brain and nervous system has advanced, it has become known that depression is a complicated biological process that interrupts the normal balance of neurotransmitters, or messenger chemicals such as norepinephrine or serontin.

Major depression

Heredity appears to be strongly linked to major depression. As a rule, the rate of depression between family members of a person suffering from major depression is one to three times higher than in families where there is none. An identical twin is 66% more likely to become depressed if the other develops the illness. However therapists can often see predictable patterns of behavior that lead to depression. Life traumas such as grief also seem to lead to major depression.

Seasonal affective disorder

SAD is common in northern climates. It is nearly nine times more prevalent in New Hampshire as in Florida, indicating that the altered brain chemistry that produces the depression is related to the decrease in light in northern climates during the winter. However, the cause of SAD is still under investigation.

Bipolar disorder

Bipolar disorders are believed to be caused by abnormal functioning of the brain. Heredity is considered a major factor.

Dysthymia

Like other depressions, dysthymia has been related both to hereditary chemical imbalances within the brain and to traumatic events in life, often going back to childhood. Some research has linked dysthymia to attention deficit hyperactivity disorder (ADHD) and conduct and personality disorders .

Depression due to a general medical condition

Among the physical illnesses capable of causing depression are cancer , heart disease, hormonal problems (such as thyroid disorders), Alzheimer's and Parkinson's Disease , brain tumors, head injuries, infectious illnesses, and malnutrition/vitamin deficiency.

Postpartum depression

This type of depression appears related to changes in hormonal chemistry that affects a woman's brain chemistry.

Substance-induced depression

Among the substances that are capable of causing depression are:

• alcohol
• minor tranquilizers such as valium
• heroin and other narcotics
• antihistamines
• anticancer drugs
• steroids and corticosteroids
• anti-seizure medications such as dilantin or depakot
• anti-inflammatory drugs
• cocaine, when its initial elevation in mood has passed
• estrogen
• L-dopa, a drug used to treat Parkinson's disease

Diagnosis

Many people go to their primary care practitioner with complaints of insomnia, lack of appetite, or other physical complaints only to discover that what they actually have is depression. A thorough physical examination is needed, including a family history of depression, the person's use of alcohol or other drugs, and medications being taken. Psychological testing and a mental status examination may be conducted. Several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, nurse, social worker, psychiatrist, or psychologist. The guidelines for diagnosing depression are found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Treatment

Major depression, dysthymia, and seasonal affective disorder are all treated effectively with psychosocial therapy of various kinds and antidepressant medications.

Antidepressants

Antidepressant medications, without any other type of treatment, are estimated to relieve the symptoms of 60–70% of clinically depressed people. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety, diarrhea , drowsiness, headache, sweating, nausea, poor sexual functioning, and insomnia are all possible side effects of SSRIs.

Tricyclic antidepressants (TCAs) are older and less expensive medications than SSRIs, but they have more severe side effects, including persistent dry mouth, sedation, dizziness, and irregular heartbeat. Because of these, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs is potentially lethal, so these drugs are questionable treatment options for patients at risk for suicide.

Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) and phenelzine sulfate (Nardil) block the action of monoamine oxidase, a central nervous system enzyme. Patients taking MAOIs must restrict foods high in tyramine (found in red wine, aged cheeses, and meats) from their diet to avoid potentially serious hypertension .

Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion should not be prescribed for patients with seizure disorder . Side effects of the drug may include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure , and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia.

Psychosocial therapy

Psychotherapy explores an individual's life to bring to light possible contributing causes of the present depression. During treatment, the therapist facilitates an awareness of thought patterns and how they developed. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.

Electroconvulsant therapy

ECT, or electroconvulsive therapy, is normally employed after other treatment options have been explored. But it may be used sooner if severe depression, suicide risk, or psychosis is present, or if the person is unable or unwilling to take medication. About half of those who do not improve from other therapies recover after having ECT.

The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following ECT. Memory loss, typically transient, is reported by ECT patients.

Phototherapy

Phototherapy , or exposure to fluorescent light bulbs installed in a metal box with a plastic screen ten to twenty times brighter than indoor lighting, has proven effective in treating SAD. Phototherapy is often combined with other treatments such as medication or psychosocial therapy. The person sits in front of this light box for anywhere from one-half hour to two hours.

Alternative treatment

St. John's wort (Hypericum perforatum) is used throughout the world to treat depression. In Germany, St. John's Wort is the most widely used antidepressant. This herbal antidepressant has few reported side effects, but some users have experienced high blood pressure, headaches, stiff neck, nausea, and vomiting. NIMH is currently involved in a three-year study of its efficacy. However, in February 2000, a public health advisory was issued by the Food and Drug Administration (FDA) stating that St. John's wort may interact with other medications commonly prescribed for heart disease, depression, seizures, and certain cancers, as well as anti-rejection drugs used for transplant patients. Healthcare providers were advised to alert their patients to the risk of this interaction.

Holistic treatment can also be very therapuetic in treating depression. Good nutrition , proper sleep, exercise , and full engagement in life are very important to a healthy mental state.

Prognosis

Untreated or improperly diagnosed depression is the number one cause of suicide in the United States. Yet treatment can result in dramatic improvement for between 75–80% of patients, and should be clearly evident within three to four months. Five to 10% of patients still report depression two years after initially being treated, but there are varying reasons for this, including medication noncompliance and alcohol abuse. The risk of recurrence climbs significantly with each episode.

Prevention

Education is crucial for patients with depressive disorders. They must learn to recognize symptoms and to take an active part in their treatment. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Physical exercise and staying connected to self-help support groups have both been shown to be effective in preventing depression. Early intervention with children with depression is effective in arresting development of more severe problems.

Health care team roles

Psychiatrist

Psychiatrists are licensed medical doctors who have undergone a three-year psychiatric residency. They diagnose depression, determine appropriate treatment, and provide psychotherapy and support for patients.

KEY TERMS

Clinical depression —Depression that is serious enough to require psychiatric intervention and treatment.

Hypersomnia —The need to sleep excessively; a symptom of dysthymic and major depressive disorder.

Neurotransmitter —A chemical in the brain that transmits messages between neurons, or nerve cells. Changes in the levels of certain neurotransmitters, such as serotonin, norepinephrine, and dopamine, are thought to be related to depressive disorders.

Psychomotor agitation —Disturbed physical and mental processes (fidgeting, wringing of hands, racing thoughts); a symptom of major depressive disorder.

Psychomotor retardation —Slowed physical and mental processes (slowed thinking, walking, and talking); a symptom of major depressive disorder.

Education on the nature of depression, and the various treatment options available, are important adjuncts to the therapy they provide.

Primary care practitioner (PCP)

Though depression is a mental illness, depression may be diagnosed by primary care practitioners because depressed patients often exhibit distinct physical symptoms. Psychiatrists frequently become involved only after a consultation is requested. The importance of a psychiatric referral for further evaluation cannot be overstated. It can literally save a severely depressed person's life.

Registered nurse (RN), psychiatric nurse, or licensed practical nurse (LPN)

Both RNs and LPNs must complete a prescribed nursing course and pass a state examination. RNs typically have a degree in nursing, and psychiatric nurses have additional training specific to their field. Both RNs and LPNS are the health care team members who are most involved with depressed patients in outpatient clinics and in psychiatric units, where patients at risk for suicide must be monitored. Observational skills, empathy, and the ability to listen are necessary assets for nurses. Education about depression typically comes from both physicians and nurses.

Social workers

Social workers are usually either certified (CSW) or licensed clinical social workers (LCSW). A two-year graduate degree, specialized training that includes supervised clinical work with the mentally ill, and state licensure are typical requirements. Social workers often conduct supportive groups or programs that help people vent feelings or work on ways to better be able to cope.

Mental health assistants

These are staff members on inpatient psychiatric units who have been provided with special training in order to assist with the care of people with mental illness. They normally aid patients with day-to-day needs, accompany them to appointments or for walks if necessary, help deal with crises, and assist professional staff in providing care.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.

Hales, Dianne, and Hales, Robert E., M. D. Caring For the Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books, 1996.

Maxmen, Jerrold S., and Nicholas G. Ward. "Mood Disorders." In Essential Psychopathology and Its Treatment, 2nd ed. New York: W.W. Norton, 1995.

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

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

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/>.

Joan M. Schonbeck