ASK THE DOCTOR: Depression is more than a 'blue' mood
By DR. JIM MITTERANDO
The Patriot Ledger

Q. I have been feeling down lately. It seems every fall and winter I feel blue but this year is worse. I'm not sure how I'm going to make it through till spring.

A. This time of year - with days getting shorter, and winter and the holidays approaching - is a common time for depression to set in.

Depression affects one in four women and one in eight men. It's an illness that involves the body, mood and thoughts. It affects the way you eat and sleep, the way you feel about yourself and the way you think.

Depression 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 depression cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months or years.

People with depression have at least several of the following symptoms:

- No interest or pleasure in things you used to enjoy, including sex
- Trouble concentrating and making everyday decisions
- Feeling sad or numb
- Crying easily or for no reason
- Trouble with motivation
- Feeling worthless or guilty
- Increased isolation from family and friends
- Change in appetite; unintended change in weight
- Problems sleeping, or wanting to sleep all of the time
- Increased anxiety
- Feeling tired all of the time
- Thoughts about death or suicide.

If you have several of these persistent symptoms, see your doctor or a therapist.

What causes depression

Your brain has chemical messengers (serotonin and norepinephrine) that help control your moods. When you don't have enough of these chemicals or your brain doesn't respond to them properly, you may become depressed.

Depression can be genetic (meaning it can run in families). Depression also can be linked to events in your life, such as the death of a loved one, a divorce or losing a job.

Most times, depression can simply creep up with no major life event causing it.

Decreased sunlight exposure with shorter days in the winter can cause chemical changes in the brain that make most people have the winter blues. Some people are more susceptible to depression with these chemical changes and experience what is called seasonal affective disorder.

Taking certain medicines, abusing drugs or alcohol, or having other illnesses can also lead to depression. 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.

Depression is not caused by personal weakness, laziness or lack of willpower. Many hormonal factors may contribute to the higher rate of depression in women - particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, perimenopause and menopause.

In fact, drugs affecting serotonin (Prozac, Sarafem, Zoloft, Paxil, Celexa) can help with symptoms of premenstrual syndrome (PMS). Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

I will address treatment of depression including medications and counseling in my next column, two weeks from today. Bear in mind that medications and counseling take one to two months to fully work. During that time it is important to help yourself.

Depression makes you feel exhausted, worthless, helpless and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and do not accurately reflect the actual circumstances. Negative thinking will disappear as your depression responds to treatment replaced by more positive thoughts.

- Set realistic goals in light of the depression and assume a reasonable amount of responsibility.
-Break large tasks into small ones, set some priorities, and do what you can as you can.
-Try to be with other people and to confide in someone.
- Participate in activities that may make you feel better.
-Exercise, go to a movie, a ballgame, or participate in religious or social activities.
- Expect your mood to improve gradually, not immediately. Feeling better takes time.
-Postpone important decisions until the depression has lifted. Before deciding to make a significant transition - changing jobs, moving, getting married or divorced - discuss it with others who know you well and have a more objective view of your situation.
-Let your family and friends help you.
-Avoid alcohol and recreational drugs, which will make the depression worse.
- Take your medication daily and realize it takes time to work.
- Seek counseling.
- Call your doctor, therapist, family, friend, priest or rabbi if you think you may harm yourself or simply dial 9-1-1 or the suicide hotline.

When helping a friend or family member with depression, make sure they seek treatment. This may involve encouraging them to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs.

On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

Offer emotional support through understanding, patience, affection and encouragement. This can be real difficult when the person is very depressed and not wanting to reach out. Engage the depressed person in conversation and listen carefully.

Do not disparage their feelings, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's therapist.

Invite the depressed person for walks, outings, to the movies and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon.

The depressed person needs diversion and company, but too many demands can increase feelings of failure. Do not accuse the depressed person of faking illness or of laziness, or expect him or her "to snap out of it." Eventually, with treatment, most people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

My next column, in two weeks, will discuss treatments including counseling, antidepressants, light therapy, exercise and stress reduction techniques.

Treatment of Depression

My last column (Nov. 13) addressed the signs of depression. Today, I will discuss treatment of depression that includes counseling, antidepressant medication, light therapy, exercise and stress reduction techniques.

Depression can be treated with medicine or counseling, or both. I find often a combination of medication and therapy to be the most effective.

Counseling can help people gain insight into and resolve their problems. People can learn how to better cope with stress, obtain more satisfaction in their life and how to unlearn behavioral patterns that contribute to unhappiness or stress. Counseling can help prevent depression from happening again.

It is important to find a therapist that you are comfortable talking with. Finding the right therapist is like shopping for a car - it is an individual choice. After a few visits, if you do not "connect," you may need to find another therapist.

I believe licensed social workers (LICSW) and psychologists (PhD) provide better therapy than many psychiatrists (MD) who these days often simply prescribe drugs. Family doctors, internists, nurse practitioners and psychopharmacologists commonly prescribe antidepressants, provide guidance and can recommend a good, local therapist.

Treating depression involves a team approach where the therapist and health care provider can communicate. I find psychiatrists more useful with more complex mental health problems and when several drugs are required for treatment. Psychopharmacologists simply prescribe drugs and often work well with a therapist though I feel, sometimes, they may recommend drugs too readily.

There is no single best antidepressant drug with many antidepressants having similar effectiveness. However, a medication that works for someone else might not work for you. Clinicians choose antidepressants based on your family history and the match between your symptoms and the medication's side effects. After this, it is simply giving it a try, knowing that one-quarter to one-third of people will require a change in the medication.

Health care providers often prescribe selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft) and citalopram (Celexa), as the first-line treatment for depression because they have fewer serious side effects.

They seem to work by increasing the availability of the neurotransmitter serotonin in your brain.

Drugs similar to SSRIs include serotonin and norepinephrine reuptake inhibitors (SNRIs), such as nefazodone (Serzone), trazodone (Desyrel) and venlafaxine (Effexor), and dopamine reuptake inhibitors, such as bupropion (Wellbutrin).

The older tricyclic antidepressants (Elavil, Norpramin and Pamelor) are used less frequently after other drugs do not work or to take advantage of their sedative side effects.

I often find people reluctant to take antidepressant medications because they feel it is a sign of weakness, or that people will think they are crazy or that the medication will change who they are.

Depression is not a sign of weakness nor craziness. Antidepressants will not change your personality or make you a different person.

The goal of treatment with antidepressants is to get you feeling back the way you used to feel. They are not "pep" or "happy" drugs. Often the response to these medications is subtle. You will notice that things do not bother you as much. You will become less isolated and begin enjoying the things you used to like to do.

Antidepressants are slow to work. You may see a response in two weeks, but many people don't see a full benefit for six to eight weeks. If your response to medication isn't resulting in satisfactory progress after six to eight weeks, your health care provider may suggest increasing the dose, changing the drug or adding a second drug.

You may experience side effects at first, such as stomach cramps, diarrhea or fatigue, but they tend to lessen after a couple of weeks. Decreased sex drive or decreased ability to have orgasm can occur with SSRIs but resolve when the medication is stopped.

People, often, are tempted to stop medication too soon. You may feel better and think you no longer need the medication. It is important to continue the medication at least 6 to 9 months to prevent a recurrence of the depression.

Antidepressant drugs are not habit-forming. Many antidepressants must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly.

I find the best time to come off medications is during the spring or summer when the days are longer and people's moods are optimal. Unfortunately, depression frequently recurs; people with recurrent depression may require chronic usage of antidepressants to prevent relapses.

I have seen antidepressant medications help many people. Antidepressants, though, are not a panacea. They help the underlying chemical cause of depression; but you need to address necessary lifestyle changes such as exercise, stress reduction and counseling to address underlying issues to fully treat depression.

Stress reduction can be achieved with different coping strategies worked out through counseling. Also, yoga and meditation are very helpful in promoting wellness and relaxation.
Exercise helps with stress reduction and also releases chemicals in the brain that help reduce depression.

Women around menopause often find that hormone replacement with estrogen often helps with depression and mood swings. Thyroid medications can help depression that is related to an underactive thyroid gland (called hypothyroidism) which is more common in women.

St. John's wort may be helpful in mild depression but a recent study showed it was not as effective as compared to prescription medications in treating more severe depression. As with many supplements, purity and quantity can be a concern since it is not regulated.

Light therapy may help if you have seasonal affective disorder (SAD). This disorder involves periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Fewer hours of sunlight may affect chemicals in the brain which contribute to depression.

Making an effort to get outdoors during daylight for 30 minutes daily often helps this problem.

f you are unable to get outside, then you can use a specialized type of bright light that mimics sunlight and is safe.

A Canadian company called Northern Light sells these lights for around $200, which should be used 30 minutes daily. You can purchase the light on the web site at www.northernlight-tech.com.

Dr. Jim Mitterando is a family doctor at Health Care South/Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.

Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.

Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.

Copyright 2001 The Patriot Ledger
Transmitted November 27, 2001