Depression.

During any 6-month period, 9 million American adults suffer from a depressive illness. The cost in human suffering cannot be estimated. Depressive illnesses often interfere with normal functioning and cause pain and suffering not only to those who have a disorder, but also to those who care about them. Serious depression can destroy family life as well as the life of the ill person.

Possibly the saddest fact about depression is that much of this suffering is unnecessary. Most people with a depressive illness do not seek treatment, although the great majority - even those with the severest disorders - can be helped. Thanks to years of fruitful research, the medications and psychosocial therapies that ease the pain of depression are at hand.

Unfortunately, many people do not recognize that they have a treatable illness. Read this flyer to see if you are one of the many undiagnosed depressed people in this country or if you know someone who is. The information briefly presented here may help you take the steps that may save your own or someone else's life.

What is A Depressive Disorder?

A depressive disorder is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

Types of Depression

Depressive disorders come in different forms, just as do other illnesses, such as heart disease. This pamphlet briefly describes three of the most prevalent types of depressive disorders. However, within these types there are variations in the number of symptoms, their severity, and persistence.

Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, sleep, eat, and enjoy once pleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime. A less severe type of depression, dysthymia, involves long-term chronic symptoms that do not disable, but keep you from functioning at "full steam" or from feeling good. Sometimes people with dysthymia also experience major depressive episodes.

Another type is bipolar disorder, formerly called manicdepressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder involves cycles of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mama may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when an individual is in a manic phase. Bipolar disorder is often a chronic recurring condition.

Symptoms of Depression and Mania

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Also, severity of symptoms varies with individuals.

Depression

* Persistent sad, anxious, or "empty" mood

* Feelings of hopelessness, pessimism

* Feelings of guilt, worthlessness, helplessness

*Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex

* Insomnia, early-morning awakening, or oversleeping

* Appetite and/or weight loss or overeating and weight gain

* Decreased energy, fatigue, being "slowed down"

* Thought of death or suicide; suicide attempts

* Restlessness, irritability 

* Difficulty concentrating, remembering, making decisions

* Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Mania

* Inappropriate elation

* Inappropriate irritability

* Severe insomnia

* Grandiose notions

* Increased talking

* Disconnected and racing thoughts

* Increased sexual desire

* Markedly increased energy

* Poor judgement

* Inappropriate social behavior.

Causes of Depression

Some types of depression run in families, indicating that a biological vulnerability can be inherited. This seems to be the case with bipolar. Studies of families, in which members of each generation develop bipolar disorder, found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder has the illness. Apparently additional factors, possibly a stressful environment, are involved in its onset.

Major depression also seems to occur, generation after generation, in some families. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with having too little or too much of certain neurochemicals.

Psychological makeup also plays a role in vulnerability to depression. People who have low seff-esteem, who consistently view themselves and the world with pessimism, or who are readily overwhelmed by stress are prone to depression.

A serious loss, chronic illness, difficult relationship, financial problem, or any unwelcome change in life patterns can also trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder.

Diagnostic Evaluation and Treatment

The first step to getting appropriate treatment is a complete physical and psychological evaluation to determine whether you have a depressive illness, and if so what type you have. Certain medications as well as some medical conditions can cause symptoms of depression and the examining physician should rule out these possibilities through examination, interview, and lab tests.

A good diagnostic evaluation also will include a complete history of your symptoms, i.e., when they started, how long they have lasted, how severe they are, whether you've had them before and, if so, whether you were treated and what treatment you received. Your doctor should ask you about alcohol and drug use, and if you have thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and if treated, what treatments they may have received and which were effective.

Last, a diagnostic evaluation will include a mental status examination to determine if your speech or thought patterns or memory have been affected, as often happens in the case of a depressive or manic-depressive illness.

Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Some people do well with psychotherapy, some with antidepressants. Some do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems. Depending on your diagnosis and severity of symptoms, you may be prescribed medication and/or treated with one of the several forms of psychotherapy that have proven effective for depression.

At times, electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life-threatening or who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. The treatment is given in the hospital under sedation so that people receiving ECT do not feel pain.

Antidepressant Medications

Three groups of antidepressant medications are most often used to treat depressive disorders: tricyclics, monoamine oxidase inhibitors (MAOIs), and lithium. Lithium is the treatment of choice for bipolar disorder and some forms of recurring, major depression. Sometimes your doctor will try a variety of antidepressants before finding the medication or combination of medications most effective for you. Sometimes the dosage must be increased to be effective. Also, new types of antidepressants are being developed all the time, and one of these may be the best for you.

Patients often are tempted to stop medication too soon. It is important to keep taking medication until your doctor says to stop, even if you feel better beforehand. Some medications must be stopped gradually to give your body time to adjust. For individuals with bipolar disorder or chronic major depression, medication may have to become part of everyday life to avoid disabling symptoms.

Antidepressant drugs are not habit-forming, so you need not be concerned about that. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if you are getting the correct dosage. Your doctor will want to check the dosage and its effectiveness regularly.

If you are taking MAO inhibitors, you will have to avoid certain aged, fermented, or pickled foods. Be sure you get a complete list of foods you should not eat from your doctor and always carry it with you. Other forms of antidepressants require no food restrictions.

Never mix medications of any kind - prescribed, over-the-counter, or borrowed - without consulting your doctor. Be sure to tell your dentist or any other medical specialist who prescribes a drug that you are taking antidepressants. Some of the most benign drugs when taken alone can cause severe and dangerous side effects if taken with others. Some drugs, like alcohol, reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor.

Antianxiety drugs, such as Valium, are not antidepressants. They are sometimes prescribed along with antidepressants; however, they should not be taken alone for a depressive disorder. Sleeping pills and stimulants, such as amphetamines, are also inappropriate.

Be sure to call your doctor if you have a question about any drug or if you are having a problem you believe is drug related.

Side Effects

Antidepressants may cause mild and, usually, temporary side effects in some people. Typically these are annoying, but not serious. However, unusual side effects or those that interfere with functioning should be reported to your doctor. The most common side effects, and ways to deal with them, are:

* Dry mouth - drink lots of water; chew sugarless gum; clean teeth daily.

* Constipation - eat bran cereals, prunes, fruit, and vegetables.

* Bladder problems - emptying your bladder may be troublesome, and your urine stream may not be as strong as usual; call your doctor if there is any pain.

Sexual problems - sexual functioning may change; if worrisome, discuss with your doctor.

* Blurred vision - this will pass soon; do not get new glasses.

* Dizziness - rise from bed or chair slowly.

* Drowsiness - this will pass soon; do not drive or operate heavy equipment if feeling drowsy or sedated.

Psychotherapies

There are many forms of psychotherapy effectively used to help depressed individuals, including some short term (10-20 weeks) therapies. "Talking" therapies help patients gain insight into and resolve their problems through verbal "give-and-take" with the therapist. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to their depression.

Two of the short term psychotherapies that research has shown helpful for some forms of depression are Interpersonal and Cognitive/Behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.

Psychodynamic therapies, sometimes used to treat depression, focus on resolving the patient's internal psychological conflicts that are typically thought to be rooted in childhood. In general, the severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with psychotherapy for the best outcome.

Helping Yourself

Depressive disorders make you feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect your situation. Negative thinking fades as treatment begins to take effect. In the meantime:

* Do not set yourself difficult goals or take on a great deal of responsibility.

* Break large tasks into small ones, set some priorities, and do what you can as you can.

* Do not expect too much from yourself too soon as this will only increase feelings of failure.

* Try to be with other people; it is usually better than being alone.

* Participate in activities that may make you feel better.

* You might try mild exercise, going to a movie, a ballgame, or participating in religious or social activities.

* Don't overdo it or get upset if your mood is not greatly improved right away. Feeling better takes time.

* Do not make major life decisions, such as changing jobs, getting married or divorced, without others who know you well and who have a more objective view of your situation. In any case, it is advisable to postpone important decisions until your depression has lifted.

* Do not expect to snap out of your depression. People rarely do. Help yourself as much as you can, and do not blame yourself for not being up to par.

* Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.

Family and Friends Can Help

Since depression can make you feel exausted and helpless, you will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effect. They won't mean to hurt you, but they may say and do things that do. It may help to share this pamphlet with those you most care about so they can better understand and help you.

Helping the Depressed Person

the most important thing anyone can do for the depressed person is to help him or her get appropriate diagnosis and treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always report them to the depressed person's therapist.

Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness, or expect him or her "to snap out of it." Eventually, with treatment, most depressed people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

Where to Get Help

A complete physical and psychological diagnostic evaluation will help you decide the type of treatment that might be best for you. Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services. Check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "hospitals," or "physicians" for phone numbers and addresses.

* Family doctors

* Mental health specialists, such as psychiatrists, psychologists,

social workers, or mental health counselors 

* Health maintenance organizations

* Community mental health centers

* Hospital psychiatry departments and outpatient clinics

* University - or medical school - affiliated programs

* State hospital outpatient clinics

* Family service/social agencies

* Private clinics and facilities

* Employee assistance programs

* Local medical and/or psychiatric societies

Further Information Write to: D/ART/Public Inquiries National Institute of Mental Health Room 15C-05 5600 Fishers Lane Rockville, MD 20857 Street New York, NY 10014 National Depressive and Manic Depressive Association Merchandise Mart, P.O. Box 3395 Chicago, IL 60654 National Mental Health Association 1021 Prince Street Alexandria, VA 22314-2971

National Alliance for the Mentally Ill 2101 Wilson Boulevard, Suite 302 Arlington, VA 22201

This flier was written by Marilyn Sargent, Office of Scientific Information, National Institute of Mental Health (NIMH) for the Depression/Awareness, Recognition, and Treatment (D/ART) program. D/ART is a professional and public education program sponsored by NIMH in collaboration with private organizations and citizens. D/ART's goals include the alleviation of symptoms through effective treatment for the millions of Americans who suffer from depressive disorders each year. The program is based on more than 40 years of research on the diagnosis and treatment of depressive disorders. Message The National Institute of Mental Health (NIMH), is the U.S. Government agency that supports and conducts research to improve the diagnosis, treatment, and prevention of mental illness. NIMH-supported studies alleviate suffering and bring hope to people who have a mental disorder, to those who are at risk of developing one, and to their familes, friends, and coworkers. Thus mental health research benefits millions of Americans and reduces the burden that mental disorders impose on society as a whole.

Lewis L. Judd, M.D.

Director, NIMH