Major Depressive Disorder

1 What is Depression (Major Depressive Disorder)?

Also called major depressive disorder or clinical depression, it can cause range of emotional and physical problems. Remember that feeling sad and depression are not the same.

Feeling low at some point in life is a normal occurrence. These feelings of sadness and loss are normal as long as they subside after a while and do not interfere with your daily activities.

If these depressive thoughts linger and significantly affect how you feel, think and behave, you could be having a mood disorder called depression.

Depression is a serious disease which can be treated with combination of treatment approaches that include medications, counseling or both. 

2 Symptoms

The symptoms of depression occur almost every day for at least 2 weeks. Depression can affect you only once or in series. Some symptoms that occur during an episode of depression are:

  • Feeling low, hopeless, helpless, worthless or empty
  • Irritability, restlessness and anxiety
  • Loss of interest or pleasure usually enjoyable activities, such as sex, hobbies or sports
  • Too much or too little sleep
  • Physical exhaustion
  • Increased or decreased appetite
  • Loss or gain of weight
  • Slowed thinking
  • Feelings of guilt, regret and self-blaming
  • Impaired decision making, inability to concentrate
  • Impaired memory
  • Frequent or recurrent suicidal thoughts, ideation, attempts or suicide itself
  • Physical complaints that are not justifiable such as back pain or headaches

Depression symptoms in children and teens

Apart from the common symptoms of depression, young people may also experience symptoms like:

  • Sadness
  • Irritability
  • clinginess
  • Worry
  • Aches and pains
  • Avoiding school
  • Being overweight or underweight.

In teens, symptoms may include:

  • Sadness
  • Irritability
  • Excessive negativity in thoughts
  • Anger
  • Poor academic performance
  • Alcohol or drug abuse
  • Excessive eating or sleeping
  • Self-harm,
  • Loss of interest in normally pleasurable activities
  • Social isolation

Note that attention-deficit/hyperactivity disorder (ADHD) can also make children irritable but without sadness or loss of interest. However, major depression may accompany ADHD.

Depression symptoms in older adults

Depression at any age is a serious issue which needs proper care. But in older adults, depression may not be detected or treated because it is still believed that getting sad is a part of growing older. While many older people accept this as a reality and refrain from getting treated. Symptoms of depression in older adults include:

  • Memory problems
  • Personality changes
  • Physical manifestations include aches or pain
  • Tiredness unrelated to age
  • Difficulty falling or sustaining sleep
  • Loss of appetite
  • Rumination and alienation
  • Suicidal thoughts or attempts

When to see a doctor?

If you have persistent feelings of sadness, visit your doctor immediately. If you're not ready to face your doctor, talk to a friend, partner, family member, a health care professional, a faith leader, or someone you trust.

When to get emergency help?

Thinking of hurting yourself or others? Just stop, take a deep breath and think again or call 911 or your local emergency number immediately.

Here are some options if you are going through thoughts of suicide:

  • Call your mental health specialist.
  • Call a suicide hotline number — in the U.S., call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255). Use that same number and press "1" to reach the Veterans Crisis Line.
  • Ask for immediate help from your primary doctor or other health care provider.
  • Call your friend or partner.
  • Contact a spiritual leader or someone else in your faith community.

If you find your loved one is on the verge of attempting suicide or has already made an attempt:

Do not leave him/her alone and immediately call 911 or your local emergency number immediately. Or if you can handle the situation, you can take him/her to the nearest hospital emergency room.

3 Causes

The exact cause of depression is not known. Like many mental disorders, depression develops as a result of combined effect of various factors, such as:

Biological differences

Physical abnormalities in the brain may cause depression. However, it’s not clear if these changes really cause depression.

Brain chemistry

Changes in the levels of chemical messengers in the brain, neurotransmitters, can cause depression and other psychiatric disorders.

Hormones

Hormonal changes such as those occurring during pregnancy or from menopause or thyroid problems, can either trigger or cause depression.

Genes

Your risk for depression may be affected by your genes.

4 Making a Diagnosis

The diagnosis of depression begins after you visit your primary care doctor who may refer you to a mental health specialist.

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful. List out all the symptoms.

Write down your key medical information. Mention any recent trauma or stressful event in your life, if any. Write down the names of all your medications, vitamins or supplements. Ask a friend or a family member to accompany you during the visit.

Make a list of the questions to ask your mental health provider

Some typical questions can be:

  • Could depression be most likely causing my symptoms?
  • What are the tests needed?
  • Is there any treatment that is likely to suit me?
  • Do I need to follow any restrictions?
  • Do I need to see a psychiatrist or other mental health provider?
  • What are the side effects of the medications you're recommending?

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your mental health provider who might ask you typical questions like:

  • When did the symptoms first appear?
  • How long have you been going through low moods?
  • Do you have mood fluctuations or it generally remains low?
  • Do you experience moods swings?
  • Have you ever thought of suicide during your low times?
  • Does your condition affect your daily life or relationships?
  • Do you have a family history of depression or another mood disorder?
  • Do you have any other mental or physical health conditions? If so, please describe.
  • Do you take alcohol or recreational drugs?
  • How’s your sleep? Is it the same or has changes?
  • Does anything improve or aggravate your symptoms?

Following exams and tests are used to exclude other causes behind your symptoms, establish the diagnosis and identify any related complications:

Physical exam

Along with general physical exam, it includes a conversation between you and your doctor, about your health condition.

Lab tests

It includes various tests such as a complete blood count or a thyroid test to detect if your thyroid is working properly.

Psychological evaluation

Your doctor can ask about your symptoms, thoughts, feelings and behavior patterns. You may also need to fill out a questionnaire.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

It is manual on mental disorders published by the American Psychiatric Association, which provides diagnostic criteria for many mental disorders including depression. Insurance companies follow this manual when reimbursing for treatment.

5 Treatment

For depression treatment, a combination of medications and psychological counseling (psychotherapy) show promising outcomes.

The treatment options for depression include:

Medications

  • Selective serotonin reuptake inhibitors (SSRIs): SSRIs such as fluoxetine, paroxetine, sertraline, citalopram and escitalopram are given at the beginning of therapy.
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): Some drugs of this class are duloxetine, venlafaxine, desvenlafaxine and levomilnacipran.
  • Norepinephrine-dopamine reuptake inhibitors (NDRIs): Bupropion, a drug of this class does not cause any sexual side effects, common with SSRIs.
  • Atypical antidepressantsTrazodone and mirtazapine due to their sedating effect, are taken in the evening. Newer members of this class include vortioxetine and vilazodone.
  • Tricyclic antidepressants: They are effective but have more severe side effects and are used if newer medications do not improve the symptoms. Examples include imipramine, nortriptyline, amitriptyline, doxepin, trimipramine and desipramine.
  • Monoamine oxidase inhibitors (MAOIs): MAOIs such as tranylcypromine, phenelzine and isocarboxazid are used when other medications fail. Follow a strict diet when taking MAOIs as interactions with certain cheeses, pickles and wines, birth control pills, decongestants and certain herbal supplements, can be fatal. Selegiline is available in the form of a skin patch, which causes fewer side effects. Remember MAOIs should not be taken with SSRIs.

Combinations of medications for depression include a combination of

  • Two antidepressants
  • A mood stabilizers or antipsychotics and an antidepressant.
  • Anti-anxiety and stimulant medications and an antidepressant.

Which medication is right for you?

Finding the answer takes time. Also, medications take time to show their full effects. Have patience till you find the medication that best suits your needs.

You may also try genetic tests to find out how your body responds to a particular antidepressant.

What should you know about antidepressants?

  • Don’t abruptly discontinue any antidepressant. Talk to your doctor to know further about discontinuation of antidepressant.
  • Some antidepressants can cause harm to the developing baby or nursing child.

Antidepressants and increased suicide risk

All antidepressant should carry a black box warning, the strictest warning for prescriptions. Children, teenagers and young adults below 25 develop suicidal tendencies during the first weeks after starting or changing the dose. If your loved one is taking antidepressant, keep a close eye on him/her. If s/he develops suicidal thoughts, immediately contact your doctor or get emergency help. Note that antidepressants are meant to improve your mood. Side effects of these drugs slowly reduce over time.

Psychotherapy

It is a talk therapy which involves talking about your condition and related issues with a mental health provider. Other types of psychotherapy such as cognitive behavioral therapy or interpersonal therapy can also be used to manage symptoms.
Other treatments for depression include:

Electroconvulsive therapy (ECT)

This therapy is used in severe and medication-resistant depression or in patients with serious suicidal tendencies. This therapy aims to treat depression by altering the functions of neurotransmitters, which is done by passing electrical currents through the brain. It can cause side effects like headache and temporary memory loss.

Transcranial magnetic stimulation (TMS)

TMS is used when antidepressants become ineffective. It uses magnetic pulses to stimulate brain nerve cells that are involved in mood regulation and depression.

6 Prevention

Simply, depression cannot be prevented but risks can be minimized.

To minimize the risk, you may:

  • Work on to keep stress under control and to boost your self-esteem.
  • Stay close to family and friends.
  • Get immediate treatment when depression peeps into your life.
  • Prevent relapse through long-term maintenance treatment.

7 Alternative and Homeopathic Remedies

Remember alternative remedies used for depression cannot replace medications.

Following supplements have been used in depression:

Supplements

Some supplements used in depression include:

St. John's wort

It’s a popular depression treating supplement that has not yet been approved by the Food and Drug Administration (FDA) to treat depression in the U.S. People with mild or moderate depression may benefit from St. John’s wort.

  • DON’T use St. John’s wort along with other antidepressants.
  • DON”T use St. John’s wort if you are taking

SAMe (S-adenosylmethionine)

FDA has not yet approved SAMe as a depression-treating agent. It may trigger mania in people with bipolar disorder.

Omega-3 fatty acids

They are healthy fats found in cold-water fish, flaxseed, flax oil, walnuts and some other foods. More research are needed to establish its role in depression treatment.

NOTE: FDA monitoring for nutritional and dietary products is not as strict as that for medications. You may take these products only after consulting your doctor gives an "OK".

Mind-body techniques

Some of these techniques that might help you include:

These therapies alone cannot treat depression. Rather, they can be used along with medication and psychotherapy.

8 Lifestyle and Coping

Depression is a disease that requires medical help, but simple lifestyle changes can sometime work wonders in improving your condition and preventing relapse.

Here are some tips:

  • Stick to your treatment plan: DON’T skip any medication, psychotherapy sessions or appointments.
  • Expand your knowledge about depression.
  • DON’T miss the warning signs.
  • Stay away from alcohol and recreational drugs.
  • Take a good care of yourself by taking healthy food, exercising and sleeping well.

Here are some tips to help you cope better with the condition

  • Simplify your life. Don’t strain and be practical.
  • Write a diary to express your feelings and emotions.
  • A good book is your best friend
  • Connect to organizations working to provide education and counseling, such as the National Alliance on Mental Illness (NAMI) and the Depression and Bipolar Support Alliance, offer education, support groups, counseling and other resources to help with depression.
  • Don't walk away from people and surrounding.
  • Learn stress management techniques like meditation, progressive muscle relaxation, yoga and tai chi.

9 Risks and Complications

There are several risks and complications associated with depression.

Risks

  • Age: Depression is common in the teens, 20s or 30s, but it can affect person of any age.
  • Sex: Women seem to be at a greater risk compared to men.
  • Personality traits, such as low self-esteem, self-critical or pessimistic
  • Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a loved one, a damaged relationship, or financial problems
  • Childhood trauma or depression
  • A history of depression, bipolar disorder, alcoholism or suicide Being lesbian, gay, bisexual or transgender in an unsupportive situation
  • History of other mental health disorders, such as anxiety disorder, eating disorders or post-traumatic stress disorder
  • Alcohol and drug abuse
  • Serious or chronic illness, including cancer, stroke, chronic pain or heart disease
  • Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before discontinuing any medication)
  • Untreated depression can cause negative impact on every aspect of your life.

Complications

  • Excess weight or obesity, which can lead to heart disease and diabetes
  • Pain and physical illness
  • Alcohol or substance abuse
  • Relationship and family problems,
  • Work or school problems
  • Social isolation
  • Suicidal tendencies
  • Self-harm, such as cutting
  • Premature death from other medical conditions
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