Depression and other Depressive Disorders

An info-article by Thomas Kurtz, MA, LMFT

This information is provided for educational purposes only. If you suffer from depression or depressive symptoms that cause you distress, call a mental health professional to provide clinical assessment and advice.

There are three types of depressive disorders recognized by mental health professionals.

Major Depression
Bipolar Disorder (what used to be called manic-depression)
Lesser Depressive Disorders

Depression affects 16% of Americans during their lifetime. It is the leading cause of health related disability in this country and the fourth leading cause of disability worldwide. About eight to ten percent of severely depressed people will ultimately commit suicide. Many other people who live with depression self-medicate with alcohol, drugs, or other mood enhancing habits. For certain depression has many victims affecting not only the individuals who suffer from it but contributing to problems in marriages and families, and on the job. Only about 50% of depressed people receive treatment. Of those who receive treatment 75-85% get better. Only 33-40% get totally well. About 15% of depressed patients show minimal response to antidepressants and are considered treatment resistant. Click here to see some reasons for treatment resistance. Long periods of untreated depression increase the risk toward recurrent episodes and chronicity of depressive symptoms.

For a diagnosis of Major Depression a person must be suffering for at least two weeks from five of nine key depressive symptoms listed below:

Depressed mood most of the day
Noticeable loss of interest in pleasurable activities
Weight loss or gain due to a distinct increase or decrease in appetite
Insomnia or hypersomnia – noticeable loss or increase in sleep
Noticeable restlessness (psychomotor agitation) or retarded / slowing of movements
Fatigue (chronic tiredness) and significant loss of energy
Feelings of worthlessness or excessive shame or guilt
Inability to think clearly, make decisions, remember things, etc. (cognitive impairment)
Recurrent thoughts of death or suicidal ideas

Moreover, the following three things must be true. The depression must:

cause “clinical significant distress” or impairment in relationships and work functioning
not be due to a medical illness or drug response
not be due to grief or bereavement

People with Bipolar Disorder have dramatic mood swings of which depression is at one polar extreme. Please click on the link for Bipolar Disorder to read more.

The so called Lesser Depressive Disorders are by no means any less serious to those who suffer from them. They include the following:

Dysthymia – chronic depression that is normally longer but less sever than major depression. Only two of the nine symptoms must be present, but for a duration of at least two years (or one year for children and adolescents). People with Dysthymia may have a history with major depression. They often have a negative, pessimistic attitude. They may also be at risk for developing major depression. Research is currently exploring the link between Dysthymia and depressive personality disorder, a personality type characterized by melancholy.

Premenstrual Dysphoric Disorder – depression that is associated with a woman’s menstrual cycle. It can be as severe as major depression but the symptoms fade with the onset of menses.

Minor Depressive Disorder – a minor case of major depression. At least two, but no more than five, depressive symptoms must exist for two weeks.

Recurrent Brief Depressive Disorder – major depression lasting for a shorter period of time. Five or more symptoms exist, but only for two days to two weeks at a time. These episodes typically run at least monthly for a year but are not tied to any menstrual periods.

Seasonal Affective Disorder (SAD) – depressive episodes during the winter, when the amount of daylight is lowest, but feeling fine during the summer months. It is believed that people suffering from SAD have too much melatonin, a brain chemical produced more abundantly in winter due to longer hours of darkness. This results in decreased serotonin. Treatment for SAD sometimes uses a 10,000 lumen lamp (light therapy) 30 minutes a day.

Mixed Anxiety-Depressive Disorder – a mixture of depressive and anxiety symptoms. Neither of the other depressive disorders or anxiety disorders can be diagnosed.

Postpsychotic Depressive Disorder– depression following a schizophrenic or psychotic episode. It is estimated that as many as 25% of schizophrenia sufferers also experience major depressive episodes.

Treatment of Depression and Depressive Disorders

The combining of cognitive behavioral therapy with appropriate medications is the most commonly accepted methods demonstrated by research for treating depressive disorders. Learning to change toxic “depressogenic” thinking and self-talk has long been established as the most effective method of talk-therapy or counseling for depressive disorders. Associated themes to this are life skills such as healthy problem solving, conflict resolution, sharing feelings and difficult emotions, and admitting to personal faults and forgiving the faults of others. Counseling or life coaching in lifestyle changes and wellness issues is also important. Learning to make changes in exercise and dietary habits is very important as is regulating sleep patterns. Learning to avoid fast food and replace diet with low glycemic index foods is essential. Foods rich in L-tryptophan and omega 3 fatty acids and supplements such as B-6, folate, selenium, and zinc all show mood improvement. Studies have shown that regular aerobic fitness (45-60 minutes three times per week) can be as effective as low dose antidepressants in some depressive people. A minimum of six hours of uninterrupted sleep is crucial to avoidance of and recovery from depression. Equally important to making lifestyle improvements is avoiding lifestyle habits that increase cortisol (stress hormone) or central nervous systemic depression. Cumulative stress and the use of tobacco, caffeine, and alcohol can significantly worsen anxiety, depression, irritability, and medication side-effects.

ANTIDEPRESSANTS

Although some people are leery of medications many people with depressive disorders need medication, usually antidepressants. As with all things who is and isn’t appropriate for medication should be considered on an individual basis. If you are skeptical of taking medication discuss this with a therapist or doctor. The idea of a “smart pharmacotherapy” is a common concept in psychology circles today. In a word, discussions ensue about which antidepressants work with which patients. Resent research in how our brains work has identified four brain chemicals, or neurotransmitters, responsible for mood control. These chemicals are serotonin, norepinephrine, dopamine, and GABA (gamma-aminobutyric acid). Each of these brain chemicals contribute to balance brain functioning in different ways so clinicians can often tell by the depressive symptoms which medications may work better than others. For instance, depression with coexisting fear, anxiety, and worry often responds well to serotonin drugs such as Prozac, Zoloft, Paxil, Celexa, Flovoxamine, or Lexapro. Depression associated with physical complaints or pain, such as headaches, fibromyalgia, diabetic peripheral neuropathies and some low back syndromes, respond well to medications targeting serotonin and norepinephrine. Cymbalta and Effexor XR are common. Individuals who struggle with depression and associated thinking errors, impulsivity, addictive behaviors, obesity, and sexual or pleasure seeking problems may be affective by abnormal Dopamine chemistry. Wellbutrin, stimulants, Strattera, Provigil, and Mirapex may have a supporting role in treatment. It is important to reemphasize that medication of any strategy alone is not the standard for treatment of depressive disorders. Appropriately chosen psychotherapy is equally important in collaborative treatment approaches to disorders of mood.

AFFILIATE MEDICATIONS

The following medications are commonly used together with antidepressants to help control other problems associated with depression such as insomnia, anxiety, or psychosis (lost touch with reality).

Non addicting sleeping medication: Sonata, Ambien, Lunesta.

GABA-enhancing medications: Neurontin, Gabitril, Depakote-ER, Keppra, Topamax, Lamictal. These drugs are often added for quick anxiety relief.

Atypical antipsychotic medication: Abilify, Geodon, Seroquel, Risperdal, Zyprexa.

A NOTE ABOUT ANTIDEPRESANTS AND BIPOLAR DISORDER

Mood stabilizers, such a Lithium Carbonate, Depakote, Tegretol, Lamictal and atypical neuroleptics, used to treat Bipolar Disorder are radically different from antidepressants. It is critical to differentiate from depressive disorders and Bipolar Disorder. Treatment for depression using antidepressants can make Bipolar Disorder much worse. Bipolar Disorder should be suspected in anyone with a history of agitated responses to antidepressants, seasonal worsening of depression, post-partum onset of depression, rapid onset and offset of depression, and/or periods of agitated depressions alternating with psychomotor retarded depression.

Treatment Resistance

The cause of most cases of so called “treatment resistant” depression are the result of treatment that was aimed at the wrong diagnostic target or treating the wrong disorder. Sometimes what a therapist or psychiatrist thinks is depression turns out to be ADHD, an anxiety disorder, substance abuse, testosterone deficiency, perimenopause, sleep apnea, or thyroid problem. Other untreated medical problems or iatrogenic reactions to other medications can have temporal association with depression.

TECHNOPSYCHIATRY

Research continues for treatment resistant patients. Electroconvulsive therapy (ECT) was historically the last resort for severely depressed treatment resistant patients. It worked 95% of the time but resulted in memory problems and other stigmas that questioned it’s ethical use. It also was usually short lasting requiring patients to schedule periodic retreatments. An alternative method is emerging. Vagal nerve stimulators are pacemaker like devices implanted in the armpit and attached via a wire to the vagus nerve in the lower neck. It delivers periodic electrical stimulation to the vagus nerve, which in turn stimulates the limbic area of the brain. It was approved by the FDA in the summer of 2005 due to studies that showed dramatic improvement in 15% of patients after three months and 35% improvement after one year of treatment.

Thomas Kurtz, MA, LMFT
Licensed Marriage and Family Therapist.
Phone: (719)444-0250
email: tklmft@aol.com