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Depression

General

Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behavior, feelings and sense of well-being. People with depressed mood can feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, ashamed or restless. They may lose interest in activities that were once pleasurable, experience loss of appetite or overeating, have problems concentrating, remembering details or making decisions, and may contemplate, attempt or commit suicide. Insomnia, excessive sleeping, fatigue, aches, pains, digestive problems or reduced energy may also be present.

Some common types of depression are:

  • Major Depressive Disorder
  • Dysthymic Disorder
  • Bipolar Depression
  • Postpartum Depression
  • Seasonal Affective Disorder

Major depression is a depressive disorder of moderate to severe severity that lasts for two or more weeks. Patients may have disturbed sleep, loss of interest to their activities, reduction or increase of weight, difficulty to concentrate, feelings of worthlessness and despair, persistent thoughts of death and suicide.

Dysthymic disorder is a persistent, chronic depression that lasts for two more years. The symptoms here are different in relation to severity. Someone with this disorder can feel well for two months but the symptoms are reset. Furthermore, the intensity of depressive symptoms is not heavy so that the individual can function properly in everyday life. Usually the dysthymic disorder starts slowly and people may not realize when depressive symptoms appear. People with dysthymia may also experience major depressive episodes.

Bipolar depression can occur in the context of bipolar disorder (mood disorder).

The post partum depression can happen throughout the year after the birth of the newborn and its intensity varies from slight to very severe. One in eight new mothers suffer postpartum depression experience. The factors that contribute to this state are:

  • Hormonal fluctuations of pregnancy, childbirth and lactation
  • Physical exhaustion due to intermittent sleep
  • Loss of independence
  • Financial burden
  • Change of relations with a partner, friends and family

Seasonal Affective Disorder. Depression is more common during the winter months and in the Northern Hemisphere, a finding that suggests that brain chemistry is affected by exposure to sunlight. Studies show that the light by impacting on the retina stimulates the formation of chemicals that improve mood. Besides depression, sufferers of seasonal affective disorder have increased appetite, weight gain and withdrawal from the people. During Spring usually their mood improves.

Most people who suffer from depression can be helped. Although depressive disorders have no single treatment, medication and/or psychotherapy (cognitive-behavioral, psychoanalytic and stress management being the most common techniques) can help the person to handle the depressive symptoms and recover. 80-90% of treated persons can be relieved from the symptoms. Without treatment, symptoms can last for weeks, months or years.

  • Prolonged sadness or unexplained outbursts of crying
  • Significant changes in appetite
  • Excessive sleep or difficulty sleeping
  • Apathy and pessimism
  • Loss of energy and guilt
  • Feelings of worthlessness
  • Weakness in concentration
  • Loss of pleasure
  • Withdrawal from family and friends
  • Unexplained physical pains
  • Repetitive thoughts of death or suicide

For Major Depressionat least five of these symptoms need to be present for at least two weeks. For Dysthymia, the most lasting depression form, two or more of the symptoms of depression need to last for at least two years (one year if it is for children) and the person feels low for more days compared to those feeling better.

Women are at least twice as likely to become ill from depression than men. Hormones may play a role. The hormonal factors together with changes in their cycle, pregnancy, miscarriage and periods like the post partum, pre-menopausal and menopause play their role.Depression in women may relate to burdens such as occupation, household, being in a single-parent family setting, responsible for the upbringing of their children and the care of elderly parents.

The one-dimensional approach to finding the causes of depressive disorders is simplistic, perhaps unfortunate. But research has indicated several factors that trigger depression.

  • Genetic factors. Some of the depressive disorders are associated with genes and therefore may to some extent be inherited.
  • Chemical-Biological reasons. There may be an imbalance in chemical agents-substances in the brain failing to serve an intact communication between nerve cells.
  • Stressful life events. Any kind of change in human life, good or bad, can cause depression. The promotion at work can cause depression as well as its loss. The birth of a child may trigger depression as well as his/her death.
  • Pharmaceutical reasons. Depression can be caused by medications taken for other reasons such as cortisone, antihypertensives, immunosuppressives etc.
  • Organic reasons. Changes in the functioning of various body systems may be accompanied by emotional changes. Medical conditions such as stroke, heart attack, cancer, Parkinson’s disease, endocrinopathies can cause depressive disorder. Other times, depression may be the first symptom of a serious disease such as cancer of the pancreas.
  • Substance abuse. It is estimated that 25% of people who abuse substances suffer from major depression. With the drugs and alcohol, people try to be self treated from the mental nature of their problems, and the use of substances by itself aggravates the depressive symptomatology.
  • Issues of self-esteem. People with low self-esteem, who constantly perceive themselves and the world throughout pessimism or feel overwhelmed by stress, are vulnerable to depression.

Most commonly, the combination of genetic, psychological and environmental factors contributes to create a depressive disorder. Subsequent episodes of depression can arise from milder form of stressful events, sometimes even without clear cause.

A basic first step is the recognition and the acceptance that the depressive individual has stopped being, feeling and functioning as he used to in the past(out of depression).A second equally important notification is that

First of all you should be examined medically so as all organic factors that can cause depression be excluded. For instance, thyroid dysfunction, electrolyte imbalance, autoimmune diseases, some types of cancer can be disguised as a depressive disorder. Additionally, any type of medicine you are taking should be checked whether they somehow cause or participate in your depression.

ATTENTION

The above mentioned basic diagnostic steps can be made only by a psychiatrist.

General directives for the treatment of depression. (You should notice that the treatment should be tailored to the individual needs of each patient)

Depression severityType of therapy
LightPsychotherapy alone
or
Medication alone
or
Psychotherapy and Medication
ModeratePsychotherapy and Medication
SeverePsychotherapy and Medication
or Electroconvulsive therapy

 

ATTENTION: These directives are based on the treatment guidance of American Psychiatric Association and are only indicative of the suggested algorithms.

The total duration of the psychotherapy is tailored to the individual needs, capacities and potential of both therapists and clients.

As far as the pharmacotherapy is concerned with regard to the first depressive episode, it should be maintained for at least 6 months to a year after the symptoms have fully abated.

With regard to the 2nd depressive episode, the pharmacotherapy should be maintained for 2-3 years in the same dosage needed for the symptoms to start remitting.

After the 3rd or more depressive episodes the pharmacotherapy should continue indefinitely, unless psychotherapy proves efficient enough to eliminate the re occurrence of depressive episodes.

Depending on the duration and severity of depression, the psychiatrist, if necessary, apart from psychotherapy, may prescribe antidepressants. These are chemicals that act in the brain as messengers and aim at restoring the chemical equilibrium between neurobiological brain nerve cells. All legally prescribed agents can be effective. But they do not work in an exactly same manner on every man because the neurobiologikal mechanisms of human beings differ from each other. Sometimes you may need to test several types of medication or combinations to find relief from depressive symptoms. Antidepressant medications need 2-4 weeks to implement their antidepressant action.

SSRIs

The SSRIs or serotonin reuptake inhibitors, increase levels of a substance, called serotonin, in the brain that improves mood. Well-known SSRIs is paroxetine (seroxat) fluvoxamine (Dumirox), citalopram (seropram), s-citalopram (cipralex, entact), sertraline (Zoloft). The SSRIs apart from depressive disorders can help in anxiety disorders as well, such as obsessive-compulsive disorder, social phobia, panic disorder, generalized anxiety disorder. These drugs generally have few side effects; most of them resolving with time when continuously administered. If however you are concerned about any adverse reactions do not hesitate to contact your doctor.

Common side effects of SSRIs are:

  • Headache
  • Tremor
  • Anxiety
  • Trouble concentrating
  • Nausea
  • Diarrhea
  • Dry mouth
  • Change in body weight
  • Weakness
  • Sweating
  • Problems sleeping
  • Sexual dysfunction

SNRIs

The SNRIs or serotonin and noradrenaline reuptake inhibitors work in a similar way to the SSRIs except that they increase not only serotonin’s but noradrenaline’s brain levels; the later knowon for its antidepressant effect. Known SNRIs are venlafaxine (Efexor), Duloxetine (Cymbalta, Xeristar). These medicines are also newer and considered to impact effectively both on depressive and anxiety disorders.

Common side effects of SNRIs are:

  • Headache
  • Anxiety
  • Nausea
  • Constipation
  • Problems sleeping
  • Increase of blood pressure
  • Sexual dysfunction

They most commonly are transient and abate.

TRICYCLIC

Tricyclic antidepressant drugs category is older but they are more likely in relation to the SSRIs and SNRIs to cause side effects such as sedation, dry mouth and constipation. Tricyclic medications target the neurotransmitters serotonin and noradrenaline, but not as selectivelly as the newer drugs. Some tricyclics are amitriptyline (Saroten), Doxepin (Sinequan), nefazodone (Nefirel), chlorimipramine (Anafranil).

These side effects may be:

  • Dizziness
  • Dry mouth
  • Sedation
  • Blurry vision
  • Constipation
  • Trembling limbs
  • Sweating
  • Headache
  • Tachycardia
  • Hypotension
  • Weight gain
  • Sexual dysfunction

MAOIs

Because monoaminooxidase inhibitors, MAOIs, can have life-threatening interactions with other drugs or with specific foods, they are rarely prescribed in patients. Their prescription tend to limit to cases where reatment of depression with other categories of antidepressants has failed. Moclobemide is characteristically referred as a typical MAO.

CAUTIONIf you are on MAO let your doctor know, especially should he prescribe to you another medication for any other condition. Also ask your doctor to advise you about the foods that you should avoid (rich in tyramine such as various types of cheese, pickles, chocolate, wine, avocados etc.)

CAUTION

  • If you are on other antidepressants as well as formulations with anxiolytic action such as St. John wort, Ecstasy or other analgesics, let your doctor knw. There is a risk of dangerous interactions.
  • Patients who are being treated with antidepressants should be constantly checked for possible paradoxical increase of suicidal thoughts and behaviors, especially when changing to another medication or dose.

Your doctor may encourage you to engage in this type of treatment as part of the overall treatment for depression. Psychotherapy or “speech therapy” may sometimes be sufficient in itself in mild to moderate forms of depression. Other times it can be combined with medication. Patients with severe depression will not benefit from psychotherapy unless depressive symptoms with the help of drugs start to fade.

The psychotherapist/psychiatrist/psychologist/social worker can help with psychotherapy as long as it is appropriately trained. The psychiatrist as a doctor-and if he is trained in psychotherapy-can also offer you psychotherapy and monitor the medication.

Physical exertion is a great way to improve your mood and reduce the symptoms of depression. Exercise raises levels of neurochemicals, called endorphins, in the brain and help improve mood, sleep quality, reduce muscle tension and stress. Finally you feel better with yourself, you feel energetic, and ultimately you are going to have more control over yourself.

Electroconvulsive therapy (ECT) has been very successful in the treatment of unipolar and bipolar depression. However, due to the convenience of medicines and the stigma accompanying the application of electroconvulsive therapy, it is applied when all previous therapeutic means have been exhausted. ECT is performed under full anesthesia and after administration of muscle relaxants to prevent convulsions. The treatment involves the administration of electrical tests to the brain through implanted electrodes. Although the exact mechanism is not known it is believed that the electrical current alters the electrochemical environment in the brain resulting in improved depression. Headache, nausea, confusion and temporary memory loss are referred to as side effects of the method

“For the sick psyche, speech is the best treatment”

|Menandros 3rd Century BC|

Contact Psychiatrist-Psychotherapist Karanikas Evangelos

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