B Sanford. Depression. The Internet Journal of Health. 1999 Volume 1 Number 1.
It is estimated that as many as 1 in 10 Americans will suffer from depression at some point during their lifetime, affecting twice as many females as males. This is a staggering number. Unfortunately, will never seek traditional medical care for an illness which, for the most part, responds readily to treatment. Thus, there are potentially millions of untreated individuals in this country suffering the trials of a very treatable malady.
The term “depression” covers a wide range of illness, from mild to moderate to severe, even life-threatening, forms. However, they all share common psychological, behavioral, cognitive, physical, and emotional manifestations. Differences between depression subtypes depend upon the range of severity, frequency, and duration of these defining attributes. For example, normal bereavement or grief reaction is a mild form of transient depression that may occur following the death of a loved one. The feelings of loss, grief, and anger may be very strong. The person may feel very “low” or “depressed”. They may even experiencing vegetative symptoms such as sleep disturbances or changes in eating habits, but the normal, healthy individual is physically, emotionally, and psychologically able to endure such difficult periods without becoming ill. These symptoms, as well as others such as loss of libido, changes in weight, changes in bowel habits, increased irritability, difficulty concentrating, memory impairment, feelings of worthlessness and hopelessness, loss of interest in previously enjoyable activities, low self-esteem, and self-reproach, are experienced by those with more severe forms of depression.
Moderate forms of depression include dysthymia, cyclothymia, and seasonal affective disorder (SAD). Dysthymic individuals typically demonstrate low-grade depressive symptoms that may last, continuously or intermittently, for years. Cyclothymics demonstrate similar signs and symptoms as dysthymics but their course of illness cycles, with times of low-grade depressive illness alternating with periods of relatively illness-free health. SAD refers to the occurrence of mild to moderate depressive symptoms that occur during winter months, and often bordering fall and spring months, when the length of daily sunlight is short. Typically, these symptoms lift, as the days grow longer. However, some experience year-long depressive symptoms which are exacerbated during the winter.
Major depressive disorder, or severe depression, is a very serious illness with possible grave complications. It may occur continuously or intermittently. Symptom severity is greater than that of the milder forms of depression discussed above and there is a greater incidence of vegetative symptoms. This illness can be utterly crippling: the individual may not be able to continue work or even properly care for himself. The most frightening and ominous manifestation is suicidal ideation: this includes recurring thoughts of death and suicide, formulating a suicide plan, and an actual suicide attempt. A shocking 15% of untreated or poorly treated patients with severe depression succeed in committing suicide. Furthermore, the recurrence rate for major depression is a dreadful 80%. Thus, the average patient will likely require some form of treatment throughout his entire life. Complicating this is the fact that many people outside the medical community - and, sadly, some within it - have difficulty accepting major depression as a chronic health deficit similar to better-known, better-accepted illnesses such as diabetes, heart disease, and asthma. Thus, many suffer in silence.
Treatment for depression depends on the sub-type from which the individual suffers. For the person struggling with a bereavement process, medical intervention is usually not required. For more severe forms of depression, classic treatment modalities include pharmacologic (drug) intervention and psychotherapy. There are various forms of the latter, including psychoanalysis (e.g., classic Freudian), cognitive therapy, and behavior modification therapy. These are reserved for more difficult levels of depression that may require further intervention in addition to prescribed drug regimens. For severe, refractory depression (i.e., forms that do not respond adequately to traditional medical treatment), electroconvulsive treatment (ECT) may be considered.
Prescribed medications are by far the most prevalent form of treatment for depression. In general, most antidepressant medications work by influencing levels of specific chemicals within the brain (these neurotransmitters enable individual nerve cells within the body’s nervous system to communicate with one another). There are four major classes of antidepressant medications: selective serotonin-reuptake inhibitors (SSRIs), tricyclics, and monoamine oxidase inhibitors (MAOIs). The fourth class is a heterogeneous group made up a collection of dissimilar medications. SSRIs, as its name describes, increases the amount of one neurotransmitter, serotonin, within the brain. Prozac, an SSRI, is the most often prescribed antidepressant. Other popular SSRIs include Paxil and Zoloft. Tricyclic drugs increase the brain’s levels of another neurotransmitter, norepinephrine; these include Elavil, Pamelor, and Tofranil. MAOIs, such as Parnate, Marplan, and Nardil, increase levels norepinephrine, dopamine (yet a third neurotransmitter), and serotonin. Drugs that fall into the heterogeneous group include Wellbutrin, lithium, anti-convulsants, and others. As with any medication, from antacids to morphine, all antidepressants have specific side-effects that must be carefully considered before these drugs are prescribed.
In the 1980’s, pharmacologic treatment for depression typically began with a tricyclic antidepressant. Today, an SSRI is usually the first medication employed. Further pharmacologic treatment usually includes the addition of a second drug from another group and/or switching medications within the same group. For extreme, refractory cases - as described earlier - a last resort may be ECT. In this form of treatment, the patient is anesthetized and a small, well-controlled seizure is stimulated by supplying a mild electrical stimulus to the brain. Although the exact mechanism of action is not currently known, it is thought that ECT may affect the brain’s levels of the neurotransmitters detailed above.
For those diagnosed with SAD, a unique form of treatment is available in addition to the pharmacologic ones listed above. Because symptom occurrence is inversely related to natural sunlight exposure, it has been found that providing an acute exposure to specific forms of bright, artificial light during the day can lessen and in some cases completely relieve, depressive symptoms. This treatment is well-established in the medical community and continues to be pursued in current biomedical research.
Finally, with the recent explosion in interest in alternative healthcare products and services today, many individuals are looking to this field to search for over-the-counter (OTC) herbal remedies for their maladies. Examples include saw palmetto for men with urinary difficulties secondary to prostate disease, echinacea to aid in fighting colds and other viral illnesses, and gingko to improve short-term memory. Extracts from St. John’s wort (a small flowering plant) are available as an OTC supplement for the treatment of mild to moderate depression. Interestingly, it is the most widely employed antidepressant agent in Germany, superceding even Prozac. German studies have demonstrated that St. John’s wort can be effective for some patients with mild to moderate depression, either used alone or in combination with other pharmacologic agents. However, no broad-based trials have yet been completed in the United States, although there are a few ongoing studies such as one that is sponsored by the National Institutes of Health. Thus, its safety (although it is presumed to be very safe) and effectiveness is not yet completely detailed. An important warning: When taking an OTC remedy, whether St. John’s wort or vitamin C, it is very important to keep your physician properly informed in order to avoid any possible interactions with other medications or OTC products you may currently be taking. One last caveat: the Food and Drug Association lists herbal remedies as “supplements,” and as such does not impose the strict guidelines and requirements as it does for prescribed pharmaceuticals. Thus, different brands of St. John’s wort or any other herbal product may well have different concentrations and purities of their active constituent(s). Take care to examine the labels and compare.