What Is Depression? People use the word depression loosely to mean a number of different moods. I prefer to use the term "clinical depression" to distinguish the type of depression that may improve with medication. Clinical depression is more than the "blues" or sadness. It is not something a person can "just get over" or talk themselves out of. Clinical depression is at least partially based on brain biochemical imbalance (we are still in early stages of understanding this) and often runs in families. Stress and psychological factors also play an important role, although we do not fully understand the causes and factors that result in clinical depression.
Common symptoms of depression include sad or irritable mood, loss of interest / energy, poor or excessive sleep and appetite, difficulty with concentration and memory, and physical complaints. Medication is often necessary in serious depression and MAY be helpful with less severe types.
Types Of Depression: There are four types of depression listed in the current Diagnostic and Statistical Manual (DSM 4 TR). The intent of this manual is to help those in the mental health field make accurate diagnoses. One of its goals is to make the diagnosis more consistent between providers. Unfortunately it is often used haphazardly.
1. Adjustment Disorder With Depressed Mood: A reaction to a stressor. (Loss of a loved one, job, physical illness, move etc.) This type of disturbed mood is usually mild and self-limiting. When symptoms last longer than 6 months another type of depression should be considered. Counseling, therapy and support may be sufficient treatment. Medication is not usually necessary.
2. Dysthymia : A chronic low-level depression. It can be very debilitating and may be a part of the personality. It also can be difficult to treat with medication; therapy is recommended.
3. Major depression: A severe form of depression with multiple symptoms as described above. Medication is necessary and usually very effective. Therapy may be helpful after acute symptoms have abated. Suicide potential must be monitored. This can be severe enough to cause psychotic (loss of reality) symptoms, such as delusions and hallucinations.
4. Bi-Polar 1 Disorder: A cycle of depression and elevation of mood (hypomania or mania). This can be very severe, with psychotic symptoms. Antidepressants may be avoided due to risk of switching the mood to mania. This condition needs expert psychiatric treatment usually with mood stabilizing medication. (By the way there is a significant amount of confusion and disagreement about this diagnosis especially between Bipolar 1 and Bipolar 2 disorders. Bipolar 2 disorder is less severe and medication is often not necessary.)
Differential Diagnosis (problems that may be confused with depression)
- Hypothyroidism (low thyroid)
- Substance abuse
- Chronic pain
- Side effects of medication
Target Symptoms Of Depression: Identifying and describing specific target symptoms is crucial if treatment is to be monitored and its' effectiveness evaluated. It is easy to forget how severe symptoms were when depression is resolved. The more specific the target symptoms are, the better to keep track of changes. Some examples of target symptoms are listed below.
- Sleep Disturbance (difficulty falling or staying asleep, awakening often during the night, early morning awakening, oversleeping)
- Concentration / Memory Problems
- Low Energy Level
- Physical symptoms
- Change in appetite (decreased or increased)
- Lack Of Motivation / Interest
- Mood Changes (sadness, anger hopelessness)
Selective Serotonin Reuptake Inhibitors (SSRIs) the most commonly used antidepressants.
SSRIs have been on the market for over 20 yrs. They increase levels of serotonin in the brain. Serotonin is a substance that allows chemical activity in the brain (neurotransmitter). Serotonin is known to play a role in depression and anxiety. SSRIs are used for treatment of depression, anxiety, Obsessive-compulsive disorder (OCD), and occasionally other illnesses. (Fibromyalgia, chronic fatigue, pain).SSRIs have much fewer side effects than the older antidepressants (tricyclics such as Elavil); they are not as lethal in overdose, and work well for most people. They are much more expensive then tricyclics. All SSRI's are effective although side effects may differ somewhat. Because individuals are different, some may react more positively to one particular medication then to another. Choosing between the SSRI'S is usually dependent on the side effect profile (see below), and the prescriber's and patient's preference and experience. They are usually the first choice in depression and often the first choice in anxiety disorders. With anxious patients it is helpful to start low and increase the dose slowly in order to minimize the side effect of activation. Anxious patients can be very sensitive to this side effect. Higher doses of medications are often needed in Obsessive Compulsive disorder and Panic disorder.
1. Prozac TM
This may be more activating initially. It has a long half-life and therefore stays in the system longer. Once a day dosing is usual; recently Prozac introduced a once a week dose.
2. Paxil TM
May be more calming initially, weight gain can be a problem. Once a day dosing is the norm.
3. Zoloft TM
May have fewer interactions with other medications. Weight gain may be a problem. May cause more stomach upset and diarrhea. Once a day dosing is the norm.
4. Luvox TM
Sometimes used for OCD, multiple dosing. Not used frequently in US. Needs higher doses that may cause drowsiness.
5. Celexa TM
Said to be "more" selective for a particular type of serotonin and therefore thought to have less side effects and interactions. May have less weight gain. Once a day dosing is the norm.
6. Lexapro TM
Similar to Celexa some feel it was manufactured because the patent on Celexa was running out. Said to work quicker then the other SSRIs.
Side Effects - SSRI's
Most SSRI's have similar side effects. Some patients do better on one than on another. This cannot be determined before a trial of the medication is given.
This is a common problem. Taking the medication with food helps and this side effect. It usually passes in time.
This is usually mild and goes away with time (about one week) if it continues it may be necessary to change medication.
3. Activation or Sedation
Patient can feel either activated (hyper, jittery) or sedated. Patients with anxiety / panic are more likely to feel activated. To avoid this start with a low dose and increase as tolerated. Sedation will often disappear with time but occasionally a change in medication is necessary.
4. Sexual dysfunction
This can be a significant problem with some antidepressants. Use may result in decreased sexual interest or ability. Most common treatments for sexual dysfunction include: drug holidays (holding the drug for one or two days once the patient is stable, (cannot be done with Prozac due to staying in the body longer), changing medication, or using an additional medication. (Some such drugs include: Periactin, Amantadine, Yohimbine, Ginkgo others. All have only limited success.) Talk to your prescriber if this is an issue for you.
5. Weight Gain
This can be a problem that is often not taken seriously enough. Weight gain may start after you have been on the medication for a while. It may be necessary to change to a different antidepressant.
6. Agitation / Aggression
There has been some anecdotal reports about patients becoming more aggressive on SSRIs. The research does not support this. However, that concern should be taken seriously, and attempts made to avoid a drug the patient is concerned about. The same is true about the reports of increased suicide.
This is an older class of antidepressants that are no longer the first choice. They can have severe side effects including sedation, weight gain, effects on the heart, and drug interactions. These drugs are used in anxiety, depression and some pain syndromes. They are much less expensive than SSRI's. These drugs are lethal in overdose!
These drugs are thought to affect a number of neurotransmitters (serotonin, dopamine, nor-epinephrine being the major ones.)
1. Wellbutrin TM
This should not be used in patients with a history of seizures. Said to cause less sexual dysfunction and weight gain. Now has a sustained release formula but still is usually given twice a day. This is the same drug as Zyban, which is used for smoking cessation. Obviously, they should not be used together.
2. Trazodone TM
This is not a very effective antidepressant; it is however very helpful for sleep and may be used in low doses for anxiety. It should be used in caution with men due to possible priaprism (This is an involuntary erection that in the worst case may not go away).
3. Effexor XR TM
Thought to have fewer interactions. Less weight gain and sexual dysfunction.
4. Serzone TM
Needs multiple dosing, may be more sedating (at least at first), and said to have less sexual dysfunction. Should not be used with Trazodone ä, Xanax ä or alcohol.
5. Remeron TM
Is said to have less sexual dysfunction and fewer interactions. Weight gain can be a problem. Used at lower doses (15 mg) this is a good sleep aid, but is not powerful enough to be an antidepressant. At higher doses no longer specifically helpful with sleep.
6. MAOI'S (monoamine oxidase inhibitor)
Another older class of antidepressants with many dietary restrictions and interactions. Not currently used very often. (I.e.: Nardil TM, Parnate TM)
Herbs & Supplements For Depression
How herbs and supplements work is not fully understood, but they have been used for thousands of years. They can be potent and should be used with care. They should not be mixed with other medications for anxiety or depression. You should let your health care provider know if you are considering taking supplements.
Research on supplements has been conducted in other countries for many years. In the US research has been slow due to the fact that pharmaceutical companies (who sponsor most research) don't see them as a moneymaker. This is changing however, and there is some research underway. Pharmaceutical companies are now starting to manufacturing prescriptions forms of some supplements. Some of the outcomes of herbal research have been contradictory, and more studies are needed. There are a number of supplements advertised for use in depression and anxiety, the following are the most well studied and most commonly used.
1. Omega 3 Fatty Acids (Fish Oil)
Some of the research on fish oil is truly remarkable. It indicates that it may be just as effective as antidepressants in treating depression. The research was done using 4000mg a day of fish oil.
S-Adenosylmethionine is a compound found in all living tissue, and is concentrated in the liver and brain. There have been a number of studies that have shown its effectiveness in depression. It is also used in hepatitis and arthritis. There have been no side effects or interactions with other medications found. SAM-e uses B12 and folate in its lowering of homocysteine levels. It is therefore suggested that adequate levels of folate and B12 be assured when taking SAM-e. The dose of SAM-e is between 800 and 1600 mg a day to treat depression. It is expensive, and many pills may need to be taken to obtain a sufficient dose. Research in the US is needed. Studies in other countries have been very favorable. (Benjamin, 2000)
3. St. John's Wort
Used for mild to moderate depression. The mechanism of action is unclear, some think it works like an SSRI or MAOI. The dose most commonly suggested is 300 mg, (standardized to .3% hypercin) three times a day. Side effects are usually mild but may include photosensitivity, emotional vulnerability, itching, and fatigue and weight increase. Alcohol, tyrosine, narcotics, amphetamines, and over the counter cold and flu remedies should probable be avoided to be on the safe side. It interacts with drugs for HIV, and some other medications that are metabolized by the liver (as many other drugs do also). The research on St. John's Wort has been generally favorable (Muskin, 2000) with one recent study questioning its effectiveness.
4. Ginkgo Biloba
Ginkgo is used for resistant depression in elderly, early Alzheimer's disease, impotence, cerebral vascular insufficiency and peripheral circulatory disorders. Ginkgo should be standardized to 6% terpene lactones, 24% ginkgo flavones glycosides. The suggested dose for prevention is 120-160 mg a day in divided doses. Up to 240 mg a day may be used in Alzheimer's or resistant depression. Side effects have not been reported. May be helpful for sexual dysfunction with SSRIs. This will thin your blood and increase blood flow, should be stopped a few days before surgery. There are over 400 published studies with Ginkgo in studies of circulation. (Brown, 1998)
Issues With Herbs & Supplements
- Herbs have been used worldwide for many years. Although they are thought to be "natural", remember, allergic reactions, side effects and interactions with other drugs/herbs/supplements are possible.
- There is a lack of standards in manufacturing and often it is difficult to know exactly what you are getting or how it has been processed. Name brands you are familiar with should be used.
- Some Herbs can be dangerous (as can some medications). Read and understand labels, the active ingredient should be "standardized" although this is no guarantee.
- Herbs may have interactions with other drugs, side effects and possibly dangerous effects on pregnancy. They should be considered seriously, and researched carefully before use. Under dosing is also a common problem, (both with medication and herbs) as is not giving herbs in a sufficient dose or enough time to work.
- Cost is a factor as herbs can be expensive and are not covered by insurance.
- Combination herbs should be used with care and only if one is sure of the dosage of all ingredients.
Drug / Herb Interactions
Drug interactions can be a problem with any medication and some herbs. Herbs should not be mixed with drugs for the same condition. Information is being discovered at a rapid rate about interactions. There is much we have to learn and caution is advised in the use of herbs. Discussion with health care providers who are knowledgeable or at least open to these ideas can helpful. If your health care provider is not willing to consider and be open to learning about herbs perhaps you should consider a change of provider.
- Some people may be slow metabolizes and need lesser doses.
- Over the counter drugs should be used with care when taking herbs.
- Grapefruit Juice has been found to interact with many drugs, and probably herbs.
- Caffeine may interact with some drugs and herbs.
- Alcohol should not be mixed with most medications and some herbs.
Helpful Hints For Prescribers And Patients When Using Medications / Herbs
- A full trial is crucial of medications, and supplements is important and often not done. This means a full dose should be prescribed for a sufficient length of time. There is some information that indicates frequent starting and stopping antidepressant medications may lead to ineffectiveness.
- Monitor target symptoms in order to determine effectiveness.
- Change one medication at a time in order to clearly identify the effect of each one.
- Consider cost and the patient's insurance
- There is less suicide risk by overdose when using SSRI's then tricyclics.
- In anxious patients start low; increase slowly (but not too slowly, in order to avoid discouragement due to length of time needed for improvement)
- Understand and consider side effects when choosing a medication. This will help to know what to expect, reduce anxiety, and decrease early discontinuation.
- The first treatment for depression should be 8-12 months in length, and there is a 50% relapse rate after that. A second treatment regimen should last 18 months and has a 70% relapse rate. After this medication may be needed for life.
- Try to avoid unrealistic expectations about medications.
- If you medical provider is not willing to talk with you about these issues, perhaps you should seek a new one!
- Always tell your health care provider when you are taking supplements of any kind!
Benjamin, S. (2000). Cam Spotlight SAM-e For Depression and More? Patient Care for the Nurse Practitioner March, 22-26.
Blumenthal, M. Goldberg, A. Brinckmann (Eds). (2000) Herbal Medicine, Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications.
Brown, D. (1998?) Phytotherapy, Herbal Medicine meets Clinical Science. Bothell, Washington: Bastyr University, Continuing Professional Education Program
Diagnostic and Statistical Manual of Mental Disordrs DSM-IV-TR (Text Revision) (2000) American Psychiatric Association
Physicians Desk Reference (2006) Thompson Healthcare.
Keegan, L (2001) Healing with Complementary & Alternative Therapies. New York: Delmar.
Muskin, P. (2000) Complementary and Alternative Medicine in Psychiatry, Washington, DC: American Psychiatric Press.