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How Do I Know If I Have It?

Although very common, depression is often ignored or misdiagnosed and left untreated. Such inattention can be life-threatening; major depression in particular has a high suicide rate.

Studies show that 74% of people seeking help for depression go to their primary care physician, and that 50% of these cases are misdiagnosed. Of the cases that are correctly diagnosed by a primary care doctor, 80% are given too little medication for too short a time. Some of this mishandling may occur because patients seek a doctor's help with — and physicians prescribe for — physical symptoms, such as sleep problems, fatigue or weight loss, without considering depression as a possible root cause.

Tests should also be made to rule out any organic factors — such as nutrient deficiencies, underactive thyroid or hormone levels, reactions to drugs (either prescription or recreational) — that can produce similar symptoms.

The elderly are at greatest risk of being overlooked or misdiagnosed. Frequently, primary care physicians, and the elderly themselves, dismiss symptoms of depression as a part of growing old or categorize it as senile dementia — an irreversible condition that causes loss of memory and concentration. Sometimes, both depression and dementia are part of the picture. But depression, unlike dementia, can be treated effectively and is reversible, so it is important to recognize depression in the elderly population.

For all of these reasons, it is important to be clear and honest with your healthcare provider about your symptoms and response to treatment. If symptoms do not improve within four to eight weeks of treatment, tell your doctor that you would like to see a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms — and always if you have thoughts about death or hurting yourself or someone else — you should see a psychiatrist.

What Are the Treatments?

The stigma depression carries drives many people to hide it, try to tough it out, or self-medicate with alcohol, drugs, or herbal remedies. To effectively treat depression, see a good mental health professional and get a correct diagnosis and treatment plan. Many treatments are available. They vary according to the cause of the depression and its severity.

Major depression and dysthymia are usually treated with a combination of psychotherapy and antidepressants. Psychotherapy aims to teach patients how to overcome negative attitudes and feelings and to encourage them to return to normal activities. Drug therapy is intended to moderate or correct chemical imbalances that affect moods.

Medication

The group of antidepressants most frequently prescribed today are drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors (SSRIs), the group includes Paxil, Prozac, Celexa, Lexapro and Zoloft. Effexor, Remeron and Cymbalta are three additional antidepressants that are fairly new and also act on serotonin and norepinephrine regulation through alternative mechanisms. Wellbutrin, a drug from another class that appears to affect dopamine regulation, is another effective antidepressant. For children and adolescents, the SSRIs are often the drugs of choice.

The tricyclics, which have been used to treat depression since the 1950s, are another option, although they are apt to have more unpleasant side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. Because adolescents do not tolerate side effects well and tend to stop taking their medication, tricyclics are not recommended for them. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine, a tricyclic antidepressant, so caution should be taken when this medication is prescribed to this population. Tricyclics include imipramine and amitriptyline, as well as nortriptyline, doxepin and desipramine.

The third group of antidepressants, the monoamine oxidase (MAO) inhibitors, have also proved effective. MAO inhibitors work more quickly than the tricyclics, but they have more severe side effects and require a change in diet; severe high blood pressure can occur if patients on MAO inhibitors eat foods containing tyramine — such as cheese, many beans, and various alcoholic beverages. MAO inhibitors are usually prescribed only if the SSRIs and the tricyclics fail to bring improvement.

Lithium carbonate, which is the drug commonly used for manic depression, is used to treat depression as well. Ongoing research is producing other medications that may target other brain receptors to treat depression in the near future.

Electroconvulsive therapy (ECT) involves the application of an electric shock through electrodes on the head. The shock is not felt by the patient, who is anesthetized. Although doctors are still uncertain exactly how ECT works, its controversial techniques have been refined in the past 20 years and it is thought to be as safe as drugs — and in some cases more effective. Although ECT is usually considered only after all other options have been considered — because it may require hospitalization and general anesthesia — or if rapid results are vital, as with suicidal patients or those who refuse to eat or drink, it can be very useful means of treating severe depression. Usually given three times a week for two weeks, treatments generally don't extend beyond six to 12 sessions.

Another option for the treatment of depression has been the use of strong magnetic currents passed through the brain. This is called transcranial magnetic stimulation or rTMS. Although still considered somewhat investigational, it has been used effectively at times to treat major depression. Another investigational treatment has been the use vagal nerve stimulators. Both these treatments may be considered when depression does not respond to other forms of treatment.

Psychotherapy
For many patients, psychotherapy is an important part of treatment. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression.

Commonly used forms of psychotherapy are cognitive, behavioral and interpersonal therapies. Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively. Behavior therapies concentrate on changing patterns of behavior that can help you manage your symptoms better. Interpersonal therapies help you examine your relationships and how they affect the mood disorder.

Exercise
Exercise should be a part of any therapy for depression. It improves blood flow to the brain, elevates mood and relieves stress. Even if used alone, it can often bring startling results. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20-30 minutes three to four times a week.

Nutrition and Diet

Because depressive symptoms can be exacerbated by nutritional deficiencies, good nutrition is important. Pay attention to eating a well-balanced diet. Eliminating wheat, dairy, alcohol, sugar or caffeine from their diets has helped some people, but this is not proven to treat depression. You can eliminate those foods one at a time from your diet and note whether your depression improves. It may help to keep a symptom diary. Quitting smoking is also advised.

Alternative Medicine

As with any alternative or complementary medicine, check with your physician before starting any remedies listed below, especially if you are taking other medications or treatments.

Herbal Remedies

St. John's wort, a well-studied herb, can be helpful in treating mild-to-moderate depression. It's effectiveness, however, is uncertain. Several studies, including one published in the March 2005, issue of the British Medical Journal, show St. John's wort as successful at improving symptoms as prescription medications, but with far fewer side effects. Other reports show that the herb isn't any better than placebo in treating depression. Although it is considered safe, St. John's wort can be potentially dangerous if taken with other antidepressants (esp. SSRI's), with certain medications used for treating HIV or with cyclosporine, a drug used in organ transplant patients, or with anticoagulant drugs. S-adenosyl-methionine (SAME-e), another herbal remedy is also said to be useful for depression although no conclusive medical studies have been done to date.

Although ginkgo biloba is typically used to improve memory and ease confusion, it has proven in some cases to work better than placebo for the symptoms of depression, and is approved by the German government's Commission E for this purpose.

Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to consult a doctor. This is especially true if you are taking prescription medications for the same or other conditions.

Mind/Body Medicine

Many mind/body practices are helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the Asian exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you and practice daily.

Massage

Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed adolescents received massage therapy, their stress hormone levels changed, their brain activity was positively affected and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program.

Acupuncture

The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown it markedly lessens symptoms. Acupuncture can be a valuable alternative if you are unable to take antidepressants or have not found them helpful.