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Psychiatry and Depression
By Jason Machalicky, MD

How do I distinguish between depression and normal variations in mood?
Everyone has felt fed up, miserable, or sad at times. These feelings can come and go
and don’t interfere too much with all of life’s activities and responsibilities. There
may or may not be a clear reason for the feelings, but regardless, people usually
figure out a way to manage them. In depression, however, these feelings don’t
readily improve. They can last for weeks or months, and start to interfere with daily
responsibilities. People with depression can struggle with persistently low mood, low
energy, loss of enjoyment in activities, difficulty sleeping and eating, feelings of guilt,
poor concentration, irritability, and even thoughts of suicide. Some may experience
other symptoms, such as agitation, anxiety, and physical problems like headaches
and stomach aches. Children also can have depression, but it tends to be more
characterized by irritability and loss of interest in previously enjoyed activities.
What causes depression?
There are several factors that can cause or contribute to depression. Stressful
circumstances, physical illness, genetics, prior negative life experiences, and alcohol
and drug use can all play a role in causing or perpetuating depression.
What can I do to help myself?
Depending on your individual circumstances, finding someone to talk with about your
problems can be helpful. Finding ways to reduce stress, such as by reducing your
obligations and responsibilities can also be an option. Other strategies for helping
your mood might include exercising regularly, practicing relaxation strategies such as
meditation or prayer, eating well, avoiding alcohol and drugs, and getting enough
sleep. Other forms of self-help include reading books or leaflets and looking for self-
help computer/internet programs.
When should I seek help?
You should consider seeking help if you notice your feelings seem worse than usual
or don’t seem to be getting any better. Also, you should seek help if your feelings
and symptoms interfere with your work, interests, and relationships. Finally, you
should seek help if you are struggling with thoughts life isn’t worth living or thinking
of suicide.
What kind of help is available?
Besides self-help strategies, two forms of professional treatment are therapy and
antidepressant medications. There are several empirically-validated forms of therapy
for treating depression to include cognitive-behavioral therapy (CBT), problem-
solving therapy, and interpersonal psychotherapy. These forms of depression therapy
can be provided in different settings such as individual therapy, couple’s therapy,
family therapy, and group therapy. For mild to moderate depression, any of these
therapies are good options. Antidepressant medication can also be a good option,
particularly in moderate to severe depression. In these cases, a person may be more
able to benefit from therapy when taking medication, as antidepressant medication
can lift some of the fog and sadness of depression that can sometimes interfere with
successful therapy. Studies have shown in general, people with depression have the
best chance of getting better by using a combination of both therapy and medication.
Relapse rates have been found to be higher when antidepressant medication is used
alone without therapy, likely because in therapy you also learn and improve coping
skills and strategies. Many people choose to take an antidepressant because of ease
of use and cost, depending on the medication.
What Can I Expect From an Antidepressant?
Antidepressants work by altering the concentration of brain neurotransmitters in the
synapses. Two neurotransmitters in particular, serotonin and norepinephrine, have
been associated with mood. Newer antidepressants can be categorized into those
medications that primarily affect serotonin (called selective serotonin reuptake
inhibitors or SSRIs) such as Prozac, Zoloft, and Celexa, and those medications that
affect serotonin and/or other neurotransmitters such as norepinephrine and
dopamine (non-SSRIs). These include medications like Effexor, Wellbutrin, Cymbalta,
and Remeron.
In addition to depression, antidepressants can be helpful for several other diagnoses,
including anxiety disorders, panic attacks, obsessive-compulsive disorder,
posttraumatic stress disorder, and eating disorders. In general, SSRIs are usually the
first choice for treating depression due to their mild side effects and lower cost. Side
effects, such as nausea and anxiety, tend to be mild and wear off after a few days to
weeks. SSRIs can have sexual side effects, too. There has also been controversy
regarding whether antidepressants worsen suicidal thinking and behavior in children
and teens. At this point, the general consensus is for most people, these medications
can be safe and helpful when taken as prescribed, but for a small percentage of
people, the medication can make things worse. For this reason, children prescribed
these medications should be monitored closely, which is a good reason to have a
trained child psychiatrist work with your child.
Your psychiatrist might choose one of the non-SSRIs for a variety of reasons,
including a person’s preference, wanting to avoid certain side effects (for example,
Remeron has a side effect of sleepiness and weight gain), having a history of a
family member responding well to a certain antidepressant, wanting to target
concurrent medical problems (Cymbalta is thought to help treat the pain associated
with fibromyalgia, and Wellbutrin is helpful for people wanting to quit smoking, for
example), wanting to avoid any drug interactions with other medicines a person is
taking, and finally, lack of success with the SSRIs.
Antidepressant medication, like therapy, does not work immediately. In general, it
can take four to six weeks of consistent use before a person obtains maximum
benefit from the medication. For people with other psychiatric conditions, such as
obsessive-compulsive disorder, panic attacks and anxiety, the medication can take
up to six to twelve weeks to have full effect. A given antidepressant typically has
about a 50-65% chance of being helpful and is dependent on a person taking it as
prescribed. Though these medications are not addictive, stopping them abruptly can
lead to withdrawal symptoms such as flu like symptoms, vivid dreams, dizziness,
stomach upset, anxiety, and a return of the depression. It is therefore recommended
you discuss a taper off the medication with your doctor and engage in therapy during
that time period. Psychiatrists can work in concert with your therapist to manage
your care, so your use of medication and therapy is well-coordinated and most
beneficial to you.


Q/a - spring 2002

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