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Depression and women.

To Sondra Fine *, 48, depression feels like this: "I have been immobilized, unable to formulate thought or action. Can't get out of bed most of the time. I feel terrible--hopeless, joyless, exhausted, lost."

To Terry Wise, 39, depression feels like this: "A world of apathy, a world where nothing is enjoyable, where food doesn't taste the same and the colors don't look the same."

To Esther Nitzberg, in her 60s, depression feels like this: "As if there's a weight, a shroud, a dark cloud that follows you around."

These are just three voices of the more than 12 million U.S. women who suffer from depression, (1) a disorder that strikes women nearly twice as often as men.

Depression is a wily disease, sometimes camouflaging itself as anger or fatigue, sometimes sending you to sleep all the time, or keeping you awake all night. It can come on suddenly or sneak up on you gradually. It also is a dangerous disease. In 2000, 29,350 people in the United States killed themselves. And while four times as many men as women die by suicide, women attempt suicide two to three times as often as men. (2) Plus, depression is strongly linked with other illnesses, such as heart disease and osteoporosis--diseases that women are at high risk for developing.

The good news: depression is one of the most treatable diseases doctors see. There's just one problem: people suffering from depression often don't receive adequate treatment, according to a major new study published in the June 18, 2003 issue of the Journal of the American Medical Association (JAMA).

Researchers in the study, only the second nationally representative sample of depression ever conducted in this country, held face-to-face interviews with more than 9,000 randomly selected people to determine whether they had any history of depression, the quality of the treatment they received and any other mental or physical conditions they experienced. (3)

"The real surprise," says the study's lead author, Ronald C. Kessler, PhD, professor of health care policy at Harvard Medical School, "was that well over half the people surveyed with depression had severe depression, and only 10 percent were considered mild to moderate." Yet just one in five received adequate treatment. These are the people who can't get out of bed, who seriously think about killing themselves, who can't function--people like the women described at the beginning of this article. "We're finding that less than half of them are even getting minimal treatment," Dr. Kessler says.

In the JAMA study, treatment was considered adequate if it consisted of at least eight, half-hour sessions of counseling with a mental health professional, or treatment with antidepressant drugs for at least 30 days combined with four visits to any type of physician, per depressive episode. These mirror federal guidelines for the treatment of depression by family practitioners, says Dr. Kessler.

Treatment Barriers

So why don't people who are depressed receive adequate care? One reason is they may not look for it. "There's still a very large stigma attached to mental illnesses like depression," says Steven D. Hollon, PhD, professor of psychology at Vanderbilt University in Nashville.

It's also not easy to find help, says Dr. Kessler. "There's a lot more confusion in mental health treatment than in the physical health arena," he notes. For instance, if you break your arm, you know exactly where to go for treatment; but it you feel depressed, you might choose anyone from a family practitioner to a social worker Making it more complicated is the fact that physical complaints such as vague aches and pains, which can also be symptoms of depression, may go undiscussed or undetected. (14)

It took visits to every therapist and psychiatrist in the small Oregon town where she lives before Ms. Nitzberg finally found what she calls "a straight-talking psychiatrist who is willing to give me low doses of medication in the combinations that work best for me."

If you're having trouble finding a doctor you like, check with the nearest academic medical center. Physicians there are usually tip to date on the latest drugs and therapies, often conducting clinical trials on new treatments. If finding the right medication is a problem, consider seeing a psychopharmacologist, a psychiatrist who has received additional training in the medications used to treat mental disorders.

But, finding treatment is only half the battle; the JAMA study also found that the treatment itself might be inadequate. For instance, many people interviewed in the study who had depression received just 5 milligrams (mg) of an antidepressant that should be prescribed at 20 mg. That's consistent with other studies showing that primary care physicians and nurses, who treat 70 percent of those with depression, tend to under-prescribe medication for depression, says Dr. Hollon. They also tend to keep patients on the wrong dose or wrong medication for too long before trying other drugs that may be more successful.

One problem is that primary health care providers often just don't know enough about treating depression, say, Drs. Kessler and Hollon, particularly about the various medications available. In fact, many patients in the JAMA study had received anti-anxiety medications like valium and lorazepam for depression, says Dr. Kessler, even though these drugs are, at best, helpful only in the short term, and can become addictive fairly quickly.

Getting the prescription right is no easy task, admits Paula J. Clayton, MD, professor of psychiatry at the University of New Mexico in Albuquerque, even for doctors with a lot of experience treating depression. "An antidepressant generally has only a one-in-three chance of helping the person taking it recover," she says.

So how far do you go? Dr. Clayton suggests if you've been on the maximum recommended dosage of an antidepressant for four to six weeks with no improvement, or if the medication causes intolerable side effects, your doctor should try another medication and/or review other treatment options. In some cases (if side effects are not a problem), adding another medication to what you're presently taking may provide better results.

If you are just beginning treatment with an antidepressant, your physician most likely will have you return once a month for a medication "checkup," until you and your physician feel you are stabilized, Dr. Clayton says. After that, you may have checkups about ever), three months. "Suicidal patients should be seen more frequently," she says.

As for how long you should be on the medication, that depends on your own situation. Some people with chronic or recurrent depression may remain on it for life, while others may need medication only for a few months.

Esther Nitzberg has been taking a variety of medications for 20 years. Every few months, her psychiatrist adjusts dosages, switches medications, or adds another to help with her recurrent depression.

Even if adequate treatment is prescribed, however, many patients don't follow it, says Dr. Kessler. Part of that is tied up in how people feel about depression, he says. "They feel inadequate, that they're failures," not understanding that they have a brain disease caused in part by a chemical imbalance. So getting help is often a last-ditch effort. Once they start feeling better, they quit taking their drugs or stop going to therapy, even though they're not considered "adequately" treated. "When you ask them why they quit, the most common reason is 'I want to handle it on my own,'" he says. "That's something you'd never say about a broken arm."

Often, as Terry Wise learned, you can't handle depression on your own. On Christmas Day 2000, 15 months after her husband died of Lou Gehrig's disease, Ms. Wise tried to commit suicide by swallowing 60 doses of morphine, 200 Percocets and a large glass of gin. She'd tried therapy a year before, but quit. Amazingly, she woke up from her suicide attempt two days later.

With the help of a caring therapist and the antidepressant medication bupropion (Wellbutrin), Ms. Wise ascended out of the pit of depression, and has since written a book about her experience, Waking Up: Climbing Through the Darkness, scheduled for publication in December 2003 by Pathfinder Publishing. She knows she's not cured; she knows, in fact, that because she's suffered one major depressive episode, she's at high risk for becoming depressed again in the future. But now she has the tools to deal with it.

Women in the Lead

As noted earlier, women have the dubious distinction of being significantly more likely to experience an episode of severe depression to their lifetime than men, although the JAMA study shows the gender gap is closing. Ten years ago, the first national study of depression found women were twice as likely to experience depression as men; in the study published in June, they were just 1.7 times more likely.

"There is a real gender difference," says Carolyn M. Mazure, PhD, professor of psychiatry at the Yale University School of Medicine and Director of Women's Health Research at Yale. No one knows the exact reason for the disparity, nor why men seem to be catching up to women. But there are numerous theories for the higher rates in women. One, of course, has to do with the ways in which women's hormones affect certain brain chemicals that regulate mood. (See Ages and Stages on page 6 for more information.)

Another has to do with the way severe stress, like the death of a spouse or loss of a job or divorce, affects women. Dr. Mazure has conducted considerable research into this area, finding that while such stress can lead to depression for both men and women, it is three times more likely to send women into depression than men. (5)

It seems that when it comes to stress, women may be more sensitive to a wider range of events than men, including moving, a physical attack, or life-threatening illness or injury, as well as the death of a close friend or relative. Part of the reason has to do with the larger networks women have. Although these networks can provide a protective benefit against stress, they are a double-edged sword, says Dr. Mazure: if something happens to someone in the network, or to a woman's place within the network, it may trigger a depressive episode.

New research published in the July 18, 2003 issue of the journal Science also suggests that whether or not stress pushes you into depression may rest a least partly on a gene that determines how you react to the stresses of life. (6)

For Sherry Ingleside *, of central Pennsylvania, the trigger was the economic downslide in 2001. Not only had she taken early retirement from her job as a teacher, but her husband had switched jobs and was earning less. Plus, their retirement portfolio was shrinking faster than a wool sweater in the dryer. "I knew I was feeling things were worse than they were, but I couldn't shake it," she recalls.

Ms. Ingleside exhibited another characteristic of women that may explain their propensity for depression: ruminative thinking. Women are more likely than men to think distressing thoughts, and go over and over their possible causes and consequences without trying to do anything about them. (7)

Additionally, women who score high on a written test designed to rate their "concern about disapproval," were three times more likely to be depressed than men, (8) Dr. Mazure's research finds.

"Many aspects of our social interactions are really based on a sense that we want people to say we've done a good job," she explains. "And there's also a long list of literature suggesting that feeling a sense of control or mastery is really critically important to our functioning. But if you're always being told you haven't handled it well, you're never good enough, you've done it the wrong way, you start to incorporate it into your own thinking."

Finding Relief

If there's one thing you should take away from this article and this newsletter, it's that help, although sometimes difficult to find, is available and does work. All the women interviewed for this article found help for their own depression through medication, or a combination of medication and therapy, and are glad they did.

A few weeks after starting on the antidepressant citalopram (Celexa), a new antidepressant, Ms. Ingleside heard a strange sound. It was her own laughter. "It was then that I realized I hadn't heard myself laugh out loud in quite sometime."

The Many Faces of Depression

Depression affects 19 million people in the United States.

African Americans are 40 percent less likely to experience depression than Hispanic or Caucasians, although African Americans who develop depression are 30 percent more likely to suffer lasting or recurring depression than other ethnic groups.

Additionally, people living in poverty are nearly four times as likely to suffer lasting or recurring depression as those in higher socioeconomic groups. (3)

Depression Defined

The symptoms of depression include: a persistent sad, anxious or "empty" mood; loss of interest or pleasure in your regular activities, including sex; restlessness, irritability or excessive crying; feelings of guilt, worthlessness, helplessness and/or hopelessness; sleeping too much or too little; appetite and/or weight loss or overeating and weight gain; thoughts of death or suicide, or suicide attempts. (4)

Physical symptoms, such as digestive problems and vague aches and pains, may also signal depression. (14)

There are three major forms of depressive illness:

Major depression, sometimes referred to as unipolar or clinical depression, lasts at least two weeks, but may last for several months or longer and may occur several times over the lifetime.

Dysthymia. Although this form includes the same symptoms as major depression, symptoms are milder and last longer, at least two years. People with dysthymia frequently lack zest and enthusiasm for life, living a joyless and fatigued existence that seems almost a natural outgrowth of their personalities. They can also experience major depressive episodes.

Manic-depression, or bipolar disorder, is not nearly as common as the other forms of depressive illness. It involves disruptive cycles of depressive symptoms that alternate with mania. (4)

* Not her real name.

Resources

American Psychiatric Association

1000 Wilson Boulevard, Suite 1825

Arlington, VA 22209-3901

703-907-7300

http://www.psych.org

Provides a variety of resources for consumers on mental disorders.

Depression and Bipolar Support Alliance

730 N. Franklin Street, Suite 501

Chicago, Illinois 60610-7224

1-800-826-3632

http://www.dbsalliance.org

Resources available for people with mood disorders and their families, including online chat rooms and e-mail newsletter.

National Alliance for the Mentally III

2107 Wilson Boulevard, Suite 300

Arlington, VA 22201-3042

1-800-950-6264

http://www.nami.org

Advocacy organization that offers information and guidance for finding treatment.

National Foundation for Depressive Illness, Inc.

PO Box 2257

New York, NY 10116

1-800-239-1265

http://www.depression.org

Informs the public about depressive illness and treatment options.

National Institute of Mental Health

6001 Executive Boulevard

Bethesda, MD 20892-9663

1-866-615-6464

http://www.nimh.nih.gov

The premier federal research institution for the study of mood disorders; consumer information available.

National Mental Health Association

2001 N. Beauregard Street, 12th Floor

Alexandria, VA 22311

1-800-969-6642

http://www.nmha.org

Provides information about medication, treatment and patient rights.

Postpartum Support International

http://www.postpartum.net

Offers online support and educational forum, including chat rooms and consumer information.

Depression Treatment Options

The treatment of depression received a huge boost 15 years ago with the introduction of Prozac, or fluoxetine, the first in a class of new drugs called selective serotonin reuptake inhibitors, or SSRIs, that have far fewer side effects than the older antidepressants. The old ones are still around and have their place in depression treatment.

They are not all the same, however, nor are they comparable in terms of their effectiveness or side effects, as the chart below shows. (10)

Drugs, however; are just one part of the treatment puzzle, with studies finding that 10 to 30 percent of patients taking antidepressants are partially or totally resistant to the treatment (although switching to different medications often resolves the resistance). (11) Various forms of therapy, particularly interpersonal psychotherapy (IPT), a less intensive form of traditional psychotherapy, and cognitive behavioral therapy (CBT), in which you learn to alter your perception of the world, are also recommended for treatment of depression, either alone or in conjunction with medication. (10) (These therapies are described in more detail on page 7.) Some studies also find therapy to be as effective as medicine for some mild or moderate depression. (9)

For patients with major depression that doesn't respond to drugs or therapy, electro-convulsive therapy (ECT), commonly referred to as "shock therapy," may be tried. ECT is one of the most misunderstood and feared depression-related treatments despite the fact it is also the best-studied and most effective treatment for this form of severe depression. The most common side effect is short-term memory loss or confusion. (10)
MEDICATION FOR DEPRESSION

Medication Class/Type * How it Works

Selective Serotonin Reuptake Blocks reuptake of serotonin,
Inhibitors (SSRIs). Includes allowing more of this
fluoxetine (Prozac, Sarafem), neurotransmitter to remain
sertraline (Zoloft), paroxetine available to the brain
(Paxil), citalopram (Celexa),
escitalopram oxalate (Lexapro)

Monoamine oxidase inhibitors Inhibits the action of monoamine
(MAOIs). Includes phenelzine oxidase, an enzyme that breaks
(Nardil), isocarboxazid down neurotransmitter.
(Marplan), tracylpromine
(Parnate)

Tricyclics (TCAs). Includes Either inhibits norepinephrine
imipramine (Tofranil), reuptake or both norepinephrine
desipramine, (Norpramin), and serotonin reuptake.
nortriptyline (Pamelor),
amitriptyline-HCI (Elavil),
maprotiline (Ludiomil)

Mixed reuptake inhibitors. Bupropion appears to regulate
Includes bupropion (Wellbutrin) transmission of both
and venlafaxine (Effexor) norepinephrine and dopamine,
 while venlafaxine appears to
 inhibit the reuptake of those two
 chemicals as well as serotonin

5-HT modulators. Includes Strong effects on blocking 5-HT (a
nefazodone (Serzone) and precursors of serotonin) serotonin
trazodone (Desyrel) receptors.

Norepinephrine and 5-HT Block serotonin receptors.
modulators. Includes mirtazapine
(Remeron)

What Studies Show Potential Side Effects & Warnings

During initial stages of taking Sexual side effects, nervousness,
the medicine, about 10 to 20 nausea, diarrhea, insomia.
percent of patient quit because
of side effects.

Particularly effective for Dry mouth. Can cause life-
patients who don't respond to threatening interactions with
more conventional treatments. aged cheese and meats, and with
 common over-the-counter
 medications, such as some flu and
 cold remedies.

About 30 percent of people stop Can be lethal with just small
taking TACs due to side effects overdose and may require blood
such as fainting, weight gain and tests to monitor levels.
headaches.

Bupropion: Substantially lower Nausea, headaches. Venlafaxine
incidence of sexual side effects may results in sexual side effects
compared to SSRIs; may be as well as a risk of elevated
particularly useful for treatment blood pressure.
of depressions characterized by
weight gain, loss of energy and
oversleeping. Venlafaxine: Seems
to be better than SSRIs at
treating major depression.

Improves sleep and has a low risk Sudden drop in blood pressure upon
of sexual side effects. standing, headaches, daytime
 drowsiness. In rare cases,
 nefazodone may cause liver damage.

Relieves symptoms sooner than the Weight gain and daytime
SSRIs. drowsiness.

* Not all drugs within a class are listed

Source; Hollon, SA, Michael ET, Markowitz, JC. "Treatment and
Prevention of Depression." Psychological Science in the Public
Interest. Nov. 2003 3(2):39-70.


Depression Across the Lifespan

Researchers are fairly sure that one main reason for the nearly 2:1 disparity in depression rates between women and men lies in women's hormones. Here's how depression is associated with the major hormonal milestones in a woman's life.

Adolescence. No one knows why the depression gender gap begins in adolescence, or why it occurs so quickly. One theory is that girls going through puberty experience greater distress and are more vulnerable to stress than pre- or post-pubertal girls, says Meir Steiner, MD, PhD, professor of psychiatry and behavioral neurosciences and obstetrics and gynecology at McMaster University in Hamilton, Ontario.

* Menstruation. About 75 percent of premenopausal women experience some symptoms of premenstrual syndrome (PMS), such as irritability. (12) But three to eight percent of those women experience premenstrual dysphoric disorder, or PMDD, a much more severe form of PMS that greatly interferes with their daily life. The interaction of hormones with neurotransmitters is probably at play, notes Dr. Steiner.

For instance, evidence suggests that women with increased sensitivity of the serotonin system have a higher risk of developing PMDD, since the fluctuations in estrogen and progesterone levels that occur premenstrually have a direct effect on the availability of serotonin precursors. So, it's no surprise that drugs that affect the serotonin system (specifically selective serotonin reuptake inhibitors, or SSRIs) very effectively treat severe PMS and PMDD. The U.S. Food and Drug Administration has already approved two such drugs to treat PMDD: fluoxetine (Sarafem) and sertraline (Zoloft).

* Pregnancy and postpartum. Rates of depression in pregnant women mirror those of nonpregnant women, small wonder since the overall onset of depression peaks between the ages of 25 and 44--prime childbearing years. (10,13)

These days, doctors are likely to recommend antidepressants for pregnant women who are depressed or who want to continue taking their medication, since research indicates no increased risk of birth defects from in utero exposure to SSRIs or tricyclic antidepressants.

Postpartum depression is also a concern. Although many women experience a mild case of the "blues" after giving birth (between 26 and 85 percent, depending on the study) (9) about 10 to 15 percent of women have more significant depressive symptoms in the first weeks following birth. Most of these episodes clear up without treatment within three to six months (although you should still seek help if your symptoms last longer than two weeks). But about one in every 500 to 1,000 women will experience what's called postpartum psychosis, severely affecting her ability to function. In some extreme cases, it may lead to suicide or the murder of the baby. (12)

There is almost a definite link between the enormous psychological, physiological and hormonal changes that occur in a woman's body just after birth and these mood changes, notes Dr. Steiner, with the sharp fall in estrogen that occurs days after delivery possibly triggering a postpartum psychosis in vulnerable women.

* Perimenopause, menopause and beyond. The perimenopausal stage, those months or even years just before menopause, are another high-risk time for depression in women, both for those with a history of depression and those without. (13)

The increased risk is likely related to dropping estrogen levels, says Dr. Steiner, because estrogen has direct effects on the central nervous system.

Being a woman 65 and older does not, in and of itself, put a woman at greater risk for depression. In fact, epidemiological surveys suggest that older adults have lower rates of depressive disorders than do other age groups. However, an estimated 10 to 20 percent of older women experience clinically significant depressive symptoms, with rates particularly common among women who are hospitalized or who are being treated on an outpatient basis for some physical illness. It may also result from side effects of medication, pain or physical or mental limitations. (7)

It's important to note, however, that depression is not a normal part of aging, and that the same treatments that work so well for younger women work just as well for older women. (7)

Treating Depression.

Q Lately, I've been very irritable and I don't enjoy the activities I used to. I think I might be depressed, but I'm embarrassed about getting help.

A Depression is a medical condition just like hypertension, diabetes and other conditions. You must address depression in the same manner that you would these conditions and be open with your physician. Depression is not your fault and you are not weak.

You should also know that there is hope, and that you can begin the journey to wellness, but first you have to step beyond the stigma associated with mental illness. Talk to your family physician about next steps. He or she will determine if you have major depression and whether he or she will treat it or refer you to someone else who will.

Q My doctor just put me on an antidepressant but I'm worried that it might make me gain weight.

A Weight gain is a cause for concern for many women due to the history of the older antidepressants. So it's important that you have an open discussion regarding your worries with your physician. There are a host of newer antidepressants that do not cause much, if any, significant weight gain when taken. Also keep in mind that the weight gain ascribed to medication may actually be caused by inactivity, a byproduct of depression itself.

--Sharon Allison-Ottey, MD

COSHAR Foundation Inc.

Baltimore, MD

Q I was recently diagnosed with depression. How do I know which type of therapy to try?

A Interpersonal therapy, or IPT, is a relatively new, well-researched therapy designed to target depression. One major focus of IPT is defining depression as a mental illness, a treatable condition that is not the patient's fault. It focuses on events that occurred after early childhood, and uses the connection between current life events and the beginning of depression to help you understand and overcome war depression.

It also helps you reverse the cycle of depression--social withdrawal, fatigue, poor concentration and further negative life events--by developing positive life events. Numerous studies find that IPT is very effective in treating depression, in most cases equally or more effectively than treatment with medication. However, both together--medication and IPT--appears to be most effective.

The same can be said for cognitive behavior therapy (CBT), which involves learning how to talk back to your negative beliefs and how to be more adaptable. CBT appears to be about as effective as medications and, quite possibly, longer lasting. People seem to learn things in CBT that reduce their risk for subsequent depressions even after treatment ends.

There are other promising therapies, but IPT and CBT are two of the best according to scientific research.

--Steven D. Hollon, PhD

Professor of Psychology

Vonderbilt University

Nashville, TN

References

(1) Narrow WE. "One-year prevalence of depressive disorder among adults 18 and over in the U.S.: NIMH ECA prospective data." Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. Unpublished table.

(2) Weisseman MM, Bland RC, Canino GJ, et al "Prevalence of suicide ideation and suicide attempts in nine countries." Psychological Medicine, 1999; 29(1):9-17.

(3) Kessler RC, Berglund P, Demler O, et al. National Comorbidity Survey Replication. "The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)." JAMA 2003 Jun 18;289(23):3095-105.

(4) "Depression: What Every Woman Should Know." NIMH. Updated Feb. 6, 2003. http://www.nih.gov. Accessed July 16, 2003.

(5) Maciejewski PK, Prigerson HG, Mazure CM. "Sex differences in event related risk for major depression." Psychol Med. 2001 May;31(4):593-604.

(6) Caspi A, Sugden K, Moffitt TE, et al. "Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene." Science 2003 Jul 18;301(5631):386-9.

(7) Summit on Women on Depression, October 5-7, 2000 American Psychological Association. http://www.apa.org Accessed July 10, 2003.

(8) Mazure CM, Bruce ML, Maciejewski PK, et al. "Adverse life events and cognitive-personality characteristics in the prediction of major depression and antidepressant response." Am J Psychiatry. 2000 Jun;157(6):896-903.

(9) "Depression: A guide to diagnosis and treatment." National Guideline Clearinghouse. http://www.guideline.gov Accessed July 20, 2003.

(10) Hollon, SD, Michael ET, Markowitz, JC. "Treatment and Prevention of Depression" Psychological Science in the Public Internet. Nov 2003 3(2):39-70.

(11) Ables AZ, Baugbman OL 3rd. "Antidepressants: update on new agents and indications. Am Fam Physician. 2003 Feb 1;67(3):547-54 Review.

(12) Steiner M, Dunn E, Born L. "Hormones and mood: from menarche to menopause and beyond." J Affect Disord. 2003 Mar;74(1):67-83.

(13) Altshuler LL, Cohen LS, Moline ML, et al. Expert Consensus Panel for Depression in Women. The Expert Consensus Guideline Series. "Treatment of depression in women." Postgrad Med. 2001 Mar;(Spec No):1-107. Review.

(14) Greden JF. "Physical Symptoms of Depression: Unmet Needs." J Clinical Psychiatry 2003;64(suppl 7).

Depressed? Talk to Your Health Care Professional

Rona Barrett. Halle Barry. Delta Burke. Barbara Bush. Sheryl Crow. Ellen DeGeneres. Queen Elizabeth. All extremely accomplished women. All with a history of depression. All successfully treated. Don't be afraid to add your name to this list. You'd be in good company

Depression is an extremely treatable disease. More than 80 percent of people who receive successful treatment recover from a depressive episode.

But with depression, perhaps more than with most diseases, successful treatment depends on you as much as on your health care professional. You have to be willing to seek out treatment, work with your health care professional to pinpoint a diagnosis, develop a treatment plan and follow the recommended treatment. All this requires that you communicate effectively with your health care professional about your illness.

Years ago, our medical system was based on a paternalistic model, in which doctors told us what to do and we listened. No more. Now the relationship between you and your physician or other health care professional should work as a partnership. That's never more important than when you're dealing with a disease like depression, for which there is no simple blood test or x-ray for diagnosis, only your own feelings and sense of what's "normal" about yourself. So it's important you find the right medical professional for you.

As you search for a health care professional, keep in mind that you have a right to expect certain things, including privacy, confidentiality and respect, sensitivity to your needs and cultural background, an understandable explanation of your condition and treatment options and the freedom to express yourself. Also know that you have the freedom to find another health care professional if things don't work out.

Be honest with your health care professional. Talk about how you've been feeling, eating and sleeping, and how it differs from your usual routine.

Bring up any major changes that have occurred in your life lately, such as relationship problems, a job loss or an illness. Tell him or her if you're drinking or using any drugs, and be honest about any thoughts of death, suicide or self-harm you've had, now or ever. If you're too depressed to communicate so specifically, consider bringing someone who knows you well to share observations about how the illness affects you.

Also make sure you share which medications (prescribed and over-the-counter, including herbs and vitamins) you're already taking. Either bring them with you to the appointment or bring a list of types and dosage. This is very important since medication is often a part of treatment for depression and you want to avoid any possible interactions.

If you feel uncomfortable with the medical professional you've chosen, or you think the treatment isn't working, don't be afraid to find someone else to work with. In fact, 25 percent of women polled in a 1996 Commonwealth Fund survey said their health care professional had "talked down to them," while 17 percent said their symptoms "were all in your head."

Believe me, depression is not all in your head. It is a very real, very dangerous disease; one for which you deserve the very best in treatment. Don't let anyone convince you otherwise.

Questions to Ask Your

Health Care Professional

* Can my depression be cured?

* Will my depression come back?

* What are my treatment choices?

* How long will I need treatment?

* How can I find out if my insurance will pay for treatment?

* (If you're seeing a primary care physician) Should I see a specialist for my depression?

If medication is prescribed:

* How and when should I take the medicine and for how long?

* Are there any side effects associated with this medication?

* What foods, drinks, other medicines, or activities should I avoid while taking this medicine?

* What symptoms should prompt me to call you?

* Are there any reasons I should stop the medication?

* Is there any danger when stopping this medication?

Pamela Peeke, MD, MPH NWHRC Medical Advisor

Dr. Peeke is a Pew Foundation Scholar in Nutrition and Metabolism. and Assistant Clinical Professor of Medicine at the University of Maryland in Baltimore. She writes about health and lifestyle issues important to all women.
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