WHAT IS A DEPRESSIVE DISORDER?

A depressive disorder is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks 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 is the case with other illnesses such as heart disease. This pamphlet briefly describes three of the most common 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, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.

A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.

SYMPTOMS OF DEPRESSION AND MANIA

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

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
  • Decreased energy, fatigue, being "slowed down"
  • Difficulty concentrating, remembering, making decisions
  • Insomnia, early-morning awakening, or oversleeping
  • Appetite and/or weight loss or overeating and weight gain
  • Thoughts of death or suicide; suicide attempts
  • Restlessness, irritability
  • Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Mania

  • Abnormal or excessive elation
  • Unusual irritability
  • Decreased need for sleep
  • Grandiose notions
  • Increased talking
  • Racing thoughts
  • Increased sexual desire
  • Markedly increased energy
  • Poor judgment
  • Inappropriate social behavior

CAUSES OF DEPRESSION

Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. 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 will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.

In some families, major depression also seems to occur generation after generation. 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 changes in brain structures or brain function.

People who have low self-esteem, who consistently view themselves and the world with pessimism or who are readily overwhelmed by stress, are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear.

In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic and unwilling to care for his or her physical needs, thus prolonging the recovery period. Also, a serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Later episodes of illness typically are precipitated by only mild stresses, or none at all.

DIAGNOSTIC EVALUATION AND TREATMENT

The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done, by the physician or by referral to a psychiatrist or psychologist.

Medications

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications-chiefly the selective serotonin reuptake inhibitors (SSRIs)-the tricyclics, and the monoamine oxidase inhibitors (MAOIs). The SSRIs-and other newer medications that affect neurotransmitters such as dopamine or norepinephrine-generally have fewer side effects than tricyclics. Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.

Medications of any kind - prescribed, over-the counter, or borrowed - should never be mixed without consulting the doctor. Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

Generalized Anxiety Disorder

"I always thought I was just a worrier. I'd feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn't let something go.

"I'd have terrible sleeping problems. There were times I'd wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I'd feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomachache, I'd think it was an ulcer.

"When my problems were at their worst, I'd miss work and feel just terrible about it. Then I worried that I'd lose my job. My life was miserable until I got treatment."

Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. It's chronic and fills one's day with exaggerated worry and tension, even though there is little or nothing to provoke it. Having this disorder means always anticipating disaster, often worrying excessively about health, money, family, or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day provokes anxiety.

People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. Their worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes. People with GAD may feel lightheaded or out of breath. They also may feel nauseated or have to go to the bathroom frequently.

Individuals with GAD seem unable to relax, and they may startle more easily than other people. They tend to have difficulty concentrating, too. Often, they have trouble falling or staying asleep.

Unlike people with several other anxiety disorders, people with GAD don't characteristically avoid certain situations as a result of their disorder. When impairment associated with GAD is mild, people with the disorder may be able to function in social settings or on the job. If severe, however, GAD can be very debilitating, making it difficult to carry out even the most ordinary daily activities.

GAD affects about 4 million adult Americans1 and about twice as many women as men.2 The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age.2 It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD.13

GAD is commonly treated with medications. GAD rarely occurs alone, however; it is usually accompanied by another anxiety disorder, depression, or substance abuse.2,4 These other conditions must be treated along with GAD.

Treatment of Anxiety Disorders

Effective treatments for each of the anxiety disorders have been developed through research.19 In general, two types of treatment are available for an anxiety disorder-medication and specific types of psychotherapy (sometimes called "talk therapy"). Both approaches can be effective for most disorders. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder. For example, only psychotherapy has been found effective for specific phobias. When choosing a therapist, you should find out whether medications will be available if needed.

Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.

If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased, and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? It often happens that people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.

When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn't work, the odds are good that another one will. And new treatments are continually being developed through research. So don't give up hope.

Medications Treatment of Anxiety Disorders

Effective treatments for each of the anxiety disorders have been developed through research.19 In general, two types of treatment are available for an anxiety disorder-medication and specific types of psychotherapy (sometimes called "talk therapy"). Both approaches can be effective for most disorders. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder. For example, only psychotherapy has been found effective for specific phobias. When choosing a therapist, you should find out whether medications will be available if needed.

Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.

If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased, and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? It often happens that people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.

When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn't work, the odds are good that another one will. And new treatments are continually being developed through research. So don't give up hope.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders.

Cognitive-Behavioral and Behavioral Therapy
Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. An example would be a treatment approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist may encourage them to dirty their hands, then go a certain period of time without washing. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. In another sort of exposure exercise, a person with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee. In some cases the individual with social phobia will be asked to deliberately make what appear to be slight social blunders and observe other people's reactions; if they are not as harsh as expected, the person's social anxiety may begin to fade. For a person with PTSD, exposure might consist of recalling the traumatic event in detail, as if in slow motion, and in effect re-experiencing it in a safe situation. If this is done carefully, with support from the therapist, it may be possible to defuse the anxiety associated with the memories. Another behavioral technique is to teach the patient deep breathing as an aid to relaxation and anxiety management.

Behavioral therapy alone, without a strong cognitive compo-nent, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, etc.

To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. Even for a single disorder, such as OCD, it is necessary to tailor the therapy to the person's particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign "homework" -- specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD, and social phobia.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will, so don't give up.

If you have recovered from an anxiety disorder, and at a later date it recurs, don't consider yourself a "treatment failure." Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

 

 

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