By completing this course the healthcare professional will be able to:
- Identify the physical signs of depression
- Describe the psychological effects of depression
- Identify the causes of depression
- Describe the available treatment modalities
- Identify and describe medications and their uses in treating depression
WHAT IS A DEPRESSIVE DISORDER?
A depressive disorder is an illness that affects the body, mind and soul. 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. The depressed person lacks energy, enthusiasm, patience and confidence. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.
SYMPTOMS OF DEPRESSION:
- Abnormal loss of all interest and pleasure
- Appetite or weight disturbance, either:
- Abnormal weight loss (when not dieting) or decrease in appetite.
- Abnormal weight gain or increase in appetite.
- Sleep disturbance--abnormal insomnia or abnormal hypersomnia.
- Activity disturbance-- either abnormal agitation or abnormal slowing
- Abnormal fatigue or loss of energy.
- Abnormal self-reproach or inappropriate guilt.
- Abnormal poor concentration or indecisiveness.
- Abnormal morbid thoughts of death (not just fear of dying) or suicide.
Other Symptoms: (Symptoms vary for each individual sufferer)
- constant feeling of dread
- loss of energy
- desire revenge against preserved injustices
- loss of sexual desire
- loss of interest in activities you once enjoyed
- unexplainable fears
- quick to anger/or lack of emotion
- loss of sleep/too much sleep
- overindulge in food/lack of appetite
- over spend
- over emotional
- avoid friends
- unexplained illnesses
- feelings of worthlessness
- poor concentration
TYPES OF DEPRESSION:
There are seven types of depression that we will look at. Each will be evaluated below. They are Major Depression, Dysthymia, Minor Depression, Premenstrual Dysphoric Disorder, Postpartum, Seasonal Depression and Bipolar Disorder.
The following information is based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), used by physicians and mental health experts to diagnose depression and mental illness.
Major Depression is what most people envision when they mention depression. Major depression is marked by a number of symptoms. An episode of Major Depression may occur just once; however, often it is recurrent.
It is normal to feel sadness after the death of a friend or family member. Indeed, most of us experience great sadness at times in our lives, perhaps from a divorce, moving away from family and friends, losing a job, even losing our good health due to illness. But, most people cope with these losses without becoming clinically depressed. If the sadness or depressed mood continues for a long period of time, the person may be experiencing clinical depression.
A person experiencing major depressive disorder suffers from, among other symptoms, a depressed mood or loss of interest in normal activities that lasts most of the day, nearly every day, for at least two weeks. Such episodes may occur only once, but more commonly occur several times in a lifetime. Major depression is marked by severe symptoms, such as literally being unable to drag oneself out of bed.
Additional Facts about Major Depression:
- In women the depressive episodes occur twice as frequently than men
- The risk of acquiring major depression in one's life varies by gender. Lifetime risk of major depression is 10% to 25% for women and 5% to 12% for men
- At any given time, approximately 5% to 9% of women and 2% to 3% of men suffer major depression
- An untreated episode typically lasts 4 months or longer
- Up to 15% of individuals with major depression commit suicide; depression in the elderly is even more positively associated with suicide
- Major depression can occur at any time in an individual's life. However, the average age of onset is during the mid-20s. Recently the trend is toward an earlier age of onset.
- The disorder is 1.5 to 3 times more common among close relatives as compared to the general population
- Approximately 50% of people with a primary diagnosis of major depression also have an anxiety disorder
Dysthymia is more chronic than major depression but less severe. Dysthymia symptoms are milder, yet persist longer.
Dysthymia refers to chronic depression (persistent for more than two years) of mild to moderate severity. It usually appears in childhood or adolescence, and affects about three percent of the U.S. population. Sufferers are functional but impaired, particularly in social and interpersonal relationships. Antidepressant medications are often quite helpful in treating dysthymia.
Dysthymia runs in families, although it is unclear whether this linkage is due to genetic or environmental factors, or both. Dysthymia seems to be closely related to major depression, which is the more severe and episodic form of depression. In other words, most people who have dysthymia do experience exacerbations that meet the criteria for major depression at some point in their lives, and there is a high rate of occurrence of major depression in the families of people with dysthymia.
Symptoms of dysthymic disorder include a poor appetite or overeating, difficulty sleeping or sleeping too much, low energy, fatigue and feelings of hopelessness. People with dysthymic disorder may have periods of normal mood that last up to 2 months. Family members and friends may not even know that their loved one is depressed. Even though this type of depression is mild, it may make it difficult for a person to function at home, school or work.
How common is dysthymic disorder?
Dysthymic disorder is a fairly common type of depression. It is estimated that up to 3% of the adult population have dysthymia. Dysthymia can begin in childhood or in adulthood. No one knows why, but like most types of depression, it appears to be more common in women.
MINOR DEPRESSIVE DISORDER
Minor Depressive Disorder is a type of depression with milder symptoms than Major Depression. Although criteria for the diagnosis of Minor Depression are being researched, the DSM-IV suggests the following:
In order to be diagnosed with Minor Depressive Disorder, at least one of the following two symptoms must be consistently present for a minimum of two weeks:
- feeling down or sad
- loss of interest or pleasure in normal activities
Additionally, at least two but not more than five of the following symptoms must be present for a diagnosis:
• eating too much/ too little
• sleeping too much/ too little
• decreased energy
• sluggishness, hyperactivity or restless (e.g., jittery)
• feelings of guilt
• inability to concentrate or make decisions
• thoughts of death or suicide
Some individuals with minor depressive disorder are able to function normally, however effort is required to maintain this level of functioning. The disorder is often associated with a medical condition.
PREMENSTRUAL DYSPHORIC DISORDER
Premenstrual Dysphoric Disorder (PMDD) is a type of depressive disorder. PMDD should not be confused with Premenstrual Syndrome (PMS). PMDD is generally more severe than PMS and exhibits different symptoms. PMDD causes significant interference with one's work, school, and relationships, whereas PMS is characterized by short-term mood changes. In PMDD, symptoms usually start the week before menstruation and end a few days after menstruation begins. Some women may experience PMDD symptoms during ovulation. PMDD symptoms are similar to clinical depression, although a shorter duration distinguishes the two. While 20% to 50% of women experience PMS, it is estimated that only 3% to 5% of women suffer PMDD.
According to the DSM-IV, Premenstrual Dysphoric Disorder (PMDD) should be diagnosed if the following exist:
- Symptoms occur in most menstrual cycles during the past year - - Impaired ability to function (i.e. symptoms interfering with work, relationships, etc.)
- Symptoms absent for at least one week soon after menstruation
At least five of the following symptoms must be present for a PMDD diagnosis to be made:
- depressed mood and feelings of hopelessness
- anxiousness and worry
- mood swings
- constant irritability and anger which increases conflicts with others
- decreased interest in usual activities
- inability to concentrate
- decreased energy
- changes in appetite
- sleeping too much/ too little
- feeling overwhelmed
- physical changes (breast tenderness, swelling, headaches, weight gain, muscle or joint pain)
The term postpartum depression is commonly used to describe a range of symptoms that may occur in women after childbirth. It is not uncommon for women to experience "baby blues" in the days following delivery. In approximately 10% of pregnancies, the symptoms are serious and severe enough to meet the criteria for major depression. In rare instances, a more serious condition, postpartum psychosis occurs,
After delivering a baby, it is common for some women to experience a period of time during which they feel "blue". Approximately 70% of women experience the "baby blues". Some mothers describe this as feeling slightly "sad," "being down," or crying easily. Symptoms may include impatience, irritability, restlessness, anxiety, loneliness, low self-esteem, increased sensitivity, and heightened feelings of vulnerability. To some it can seem like a strange feeling to have, particularly after delivering a healthy baby. Mothers often think, "I should be happy, what's wrong with me?" This period of time can last from a few hours to two weeks.
Depressive symptoms may last more than two weeks and be more severe. Instead of feeling "slightly down," mothers may feel miserable, being tearful daily, have problems sleeping (not attributed to the baby), lose interest in activities, feel listless, lose their appetite, and feel hopeless. If this situation lasts more than two weeks, a new mother may be experiencing postpartum depression. Presently it is unknown, exactly why some mothers experience postpartum depression. However, a number of factors are thought to be involved in the development of postpartum depression.
• A "let-down" after childbirth
• No longer carrying the baby inside of you.
• Worrying about caring for a new baby.
• Stress related to the responsibilities and expectations associated with a new baby
- Drastic changes in hormone levels and other biologic substances as the body switches from pregnancy back to its usual state.
- Thyroid levels may also drop after birth, producing symptoms of depression, such as mood swings, severe agitation, fatigue, insomnia, and anxiety.
- Sleep deprivation and exhaustion from taking care of a new baby may also play a role.
Additional symptoms of postpartum depression:
- restlessness, irritability, excessive crying
- depression, anger
- inability to sleep, extreme exhaustion
- unintended change in weight or appetite
- difficulty concentrating, remembering, or making decisions
- an excessive amount of concern or disinterest in the baby
- feelings of inadequacy, guilt, and worthlessness
- a fear of harming the baby or oneself
- a loss of interest or pleasure in usual activities (including sex)
- ability to function impaired
- Postpartum depression is more likely to occur in women who have experienced PMS.
- Women with postpartum depression are encouraged to get plenty of rest and not isolate themselves.
- Women are also encouraged to seek emotional support.
- It is extremely important that mothers are aware of this condition because:
- Treatment exists, if left untreated; the symptoms may worsen and persist.
- When not addressed, depression can take away the joy of motherhood.
- Depression can also negatively effect the growing interactions between the mother and her new baby.
Postpartum psychosis is relatively rare, occurring in 1 of 500 to 1 of 1000 births. Postpartum psychosis should be considered a serious medical situation. The onset of postpartum psychosis is stricken suddenly with confusion, fatigue, agitation, mood changes, feelings of hopelessness, shame, delusions, hallucinations, and mania.
Major Depression can be seasonal. Individuals may experience depression during certain times of the year. The mood of those suffering Seasonal Depression typically worsens as the days get shorter.
According to the DSM-IV, a Seasonal Depression diagnosis can only be made if the depressive episodes occur during certain periods of the year. In most cases, these depressive episodes occur in the fall or winter and are resolved during the remainder of the year. However, some individuals experience depressive episodes during the summer.
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.
More than 2 million American adults, or about 1 percent of the population age 18 and older in any given year, have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.
What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic mood swings—from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.Signs and symptoms of mania (or a manic episode) include:
- Increased energy, activity, and restlessness
- Excessively "high," overly good, euphoric mood
- Extreme irritability
- Racing thoughts and talking very fast, jumping from one idea to another
- Distractibility, can't concentrate well
- Little sleep needed
- Unrealistic beliefs in one's abilities and powers
- Poor judgment
- Spending sprees
- A lasting period of behavior that is different from usual
- Increased sexual drive
- Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
- Provocative, intrusive, or aggressive behavior
- Denial that anything is wrong
A manic episode is diagnosed if elevated mood occurs with 3 or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, 4 additional symptoms must be present.Signs and symptoms of depression (or a depressive episode) include:
- Lasting sad, anxious, or empty mood
- Feelings of hopelessness or pessimism
- Feelings of guilt, worthlessness, or helplessness
- Loss of interest or pleasure in activities once enjoyed, including sex
- Decreased energy, a feeling of fatigue or of being "slowed down"
- Difficulty concentrating, remembering, making decisions
- Restlessness or irritability
- Sleeping too much, or can't sleep
- Change in appetite and/or unintended weight loss or gain
- Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
- Thoughts of death or suicide, or suicide attempts
A depressive episode is diagnosed if 5 or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms).
Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression.
People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.
In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.
Diagnosis of Bipolar Disorder
Like other mental illnesses, bipolar disorder cannot yet be identified physiologically—for example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of symptoms, course of illness, and, when available, family history. The diagnostic criteria for bipolar disorder are described in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV)
Descriptions offered by people with bipolar disorder give valuable insights into the various mood states associated with the illness: Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?Hypomania: At first when I'm high, it's tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and gestures are suddenly there… uninteresting people, things become intensely interesting.
Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes.Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.
Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.Signs and symptoms that may accompany suicidal feelings include:
- talking about feeling suicidal or wanting to die
- feeling hopeless, that nothing will ever change or get better
- feeling helpless, that nothing one does makes any difference
- feeling like a burden to family and friends
- abusing alcohol or drugs
- putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
- writing a suicide note
- putting oneself in harm's way, or in situations where there is a danger of being killed
If you know someone is suicidal:
- call a doctor, emergency room, or 911 right away to get immediate help
- make sure the suicidal person, is not left alone
- make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm
While some suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.
What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment. The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder.
When 4 or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.
Can Children and Adolescents Have Bipolar Disorder?
Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder.
Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms. Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.
What Causes Bipolar Disorder
Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness. Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling. In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.
It appears likely that many different genes act together, and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.
How Is Bipolar Disorder Treated?
Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to a doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.
Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M.D.) with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.Medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder. everal different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.
- Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
- Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.
- Newer anticonvulsant medications, including lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are being studied to determine how well they work in stabilizing mood cycles.
- Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
- Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20 Therefore, young female patients taking valproate should be monitored carefully by a physician.
- Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.
Treatment of Bipolar Depression
Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. Therefore, "mood-stabilizing" medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.
- Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
- Certain bipolar medications and supplements taken together may cause adverse reactions.
To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan.
People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.
Medication Side Effects
Depending on the medication, side effects may include weight gain, nausea, tremor, reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth.
As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.
- Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
- Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members.
- Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms.
- Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
- As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.
A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.
Do Other Illnesses Co-occur with Bipolar Disorder?
Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders. Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.
Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder. Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment.
How Can Individuals and Families Get Help for Bipolar Disorder?
Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric nurses, can assist in providing the person and family with additional approaches to treatment. Help can be found at:
- University—or medical school—affiliated programs
- Hospital departments of psychiatry
- Private psychiatric offices and clinics
- Health maintenance organizations (HMOs)
- Offices of family physicians, internists, and pediatricians
- Public community mental health centers
People with bipolar disorder may need help to get help.
- Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
- A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.
- Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
- A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
- Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.
- In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
- Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
- Family members of someone with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
- Many people with bipolar disorder benefit from joining support groups. Families and friends can also benefit from support groups.
Criteria for Major Depression with Seasonal Pattern:
• Seasonal Depression is more prevalent in high latitude locations.
Younger people are more likely to experience Seasonal Depression in winter months than older people.
Women have a higher rate of Seasonal Depression than men (60%-90% of seasonal depression patients are women).
symptoms of Major Depression which occur only at certain times of the year (see Major Depression for a list of symptoms)
symptoms completely disappear during other times of the year
the depression must have occurred during the last two years
seasonal episodes of Major Depression outnumber depressive episodes unrelated to the season throughout a person's lifetime
episodes are unrelated to events associated with specific seasons
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 stressors or none at all.
Depression in Women
Women experience depression about twice as often as men. Many hormonal factors may contribute to the increased rate of depression in women-particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.
A recent study showed that in the case of severe premenstrual syndrome (PMS), women with a preexisting vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were re-introduced, they again developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.
Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and requires active intervention. Treatment by a sympathetic physician and the family's emotional support for the new mother are prime considerations in aiding her to recover her physical and mental well-being and her ability to care for and enjoy the infant.
Depression in Men
Although men are less likely to suffer from depression than women, three to four million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.
Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.
Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.
Depression in the Elderly
Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging.
Depression in the elderly, undiagnosed and untreated, causes needless suffering for the family and for the individual who could otherwise live a fruitful life. When he or she does go to the doctor, the symptoms described are usually physical, for the older person is often reluctant to discuss feelings of hopelessness, sadness, loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss.
Recognizing how depressive symptoms in older people are often missed, many health care professionals are learning to identify and treat the underlying depression. They recognize that some symptoms may be side effects of medication the older person is taking for a physical problem, or they may be caused by a co-occurring illness.
If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling life. Recent research suggests that brief psychotherapy (talk therapies that help a person in day-to-day relationships or in learning to counter the distorted negative thinking that commonly accompanies depression) is effective in reducing symptoms in short-term depression in older persons who are medically ill.
Psychotherapy is also useful in older patients who cannot or will not take medication. Efficacy studies show that late-life depression can be treated with psychotherapy. Improved recognition and treatment of depression in late life will make those years more enjoyable and fulfilling for the depressed elderly person, the family, and caretakers.
Depression in Children
Only in the past two decades has depression in children been taken very seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, grouchy, and feel misunderstood.
Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary "phase" or is suffering from depression. Sometimes the parents become worried about how the child's behavior has changed, or a teacher mentions that "your child doesn't seem to be himself."
In such a case, if a visit to the child's pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed.
Required Reading: Depression in Adolescence
Understanding chemical imbalances in the brain and how they play a role in depression is crucial. Inside the brains are neurons which interact with one another. Neurotransmitters, which are chemical messengers, carry messages between the nerves and the receptor sites and neurons. The instructions are carried out depending on the specific neurotransmitter and where it is released and utilized by the brain. The instructions are to either continue with the electrical impulse, to speed it up or slow it. The neurotransmitters regulate mood, cognitive thought and sensory experiences. Scientists believe that an imbalance in serotonin, one of these neurotransmitters, may be an important factor in the development and severity of depression.
Who hasn’t experienced childhood trauma? Well, some have experience years of continuing trauma at the hands of others. Some have experienced isolated incidents, such as the death of a family member, a car accident or divorce of their parents. The length and severity of the trauma is not as meaningful as the kind of support received by the victim of the trauma.
A typical recovery period for the death of a significant other can be two or more years. The cycle of loss can best be described using the Kubler-Ross model of loss. First comes Denial. No, this really did not happen. The next stage is anger. Bitterness is felt over the loss. The third stage is bargaining. This should have happened to me instead. Why did it have to happen to the victim? The forth stage is depression and the last stage is acceptance. Kubler-Ross believes that one moves in and out of these five stages as the loss is experienced.
Dramatic hormonal changes, sleep deprivation, mood swings and feelings of loss, shame and guilt may be prevalent during menstruation. The sufferer may cry uncontrollably, experience sudden mood swings and experience an inability to cope with her situation she may feel confused, irritable or anxious.
As a women’s body begins to produce less estrogen her moods can shift. She may feel physically tired and discomfort from the symptoms of menopause.
Medical problems known to cause depression are anemia, hypothyroidism, chronic infection, substance abuse, medication side effects, including but not limited to, oral contraceptives and antihypertensive.
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.
A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.
A diagnostic evaluation should include a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Some people with milder forms may do well with psychotherapy alone. People with moderate to severe depression most often benefit from antidepressants. Most do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems, including depression. Depending on the patient's diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have proven effective for depression.
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.
Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for at least 4 to 9 months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust. One should never stop taking an antidepressant without consulting the doctor for instructions on how to safely discontinue the medication. For individuals with bipolar disorder or chronic major depression, medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly.
For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.
Medications of any kind - prescribed, over-the counter, or borrowed - should never be mixed without consulting a doctor. Other health professionals who may prescribe a drug-such as a dentist or other medical specialist-should be told of the medications the patient is taking. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.
Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has reexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol®) and valproate (Depakote®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania.
Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.
WHERE TO GET HELP
In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for an emotional problem.
Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.
- Family doctors
- Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and outpatient clinics
- University- or medical school-affiliated programs
- State hospital outpatient clinics
- Family service, social agencies, or clergy
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
Additional Reading: Depression: A Journey of Discovery
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