Trillian's Depression Page

All people experience periods of sadness. Usually these last for only one to several hours or days. Often the cause of this lowered mood is obvious; sometimes it occurs for no reason. Some people experience more prolong periods of sadness following the loss of a friend or family member. This is usually described as grief or bereavement. A depressive illness is a persistent lowering of mood lasting for several weeks  at a time, and  accompanied by a specific group of physical and psychological symptoms. This may cause serious physical, psychological and social problems, and requires specific treatment.

Any of the following may be part of a depressive illness:

Major depression is a one-episode illness for about half the people who suffer from it, but for the other half, it is a recurring illness. For most people with recurrent depression, the symptoms disappear completely between episodes but for a third of people with depression, there are lingering symptoms between episodes.

Although about 25% of all individuals experience some form of affective disturbance, the lifetime risk for clinically identifiable mood disorder is 8 to 9%. One third develop a chronic course and, of the remaining 5 to 6%,  at least 2/3 experience recurrent episodes. This means that for most sufferers, the illness will recur or pursue a protracted course. The rates are higher in women in a 2:1 ratio for the predominantly depressive forms of illness, and nearly even in bipolar disorder. Bipolar conditions, for which 1% of the population is at risk, usually begin in the teens, 20s, and 30s; unipolar conditions begin, on average, a decade later than their bipolar counterparts. Recent epidemiologic findings in the USA suggest a cohort effect, whereby those born in the latter part of this century have higher rates of depression and suicide, often associated with higher rates of substance abuse. Although some of this increase is probably due to easier ascertainment of depression in younger individuals, the comorbid substance abuse and poorly understood environmental factors may have contributed to the younger age shift. 

Depression is among the most prevalent psychiatric conditions, varying from about 25% in public mental institutions to nearly 50% in outpatient and private psychiatric practice, and it may account for as much as 10% of all patients seen in non psychiatric medical settings. Culture, social class, and race have not been shown to make significant differential contributions to the incidence of mood disorders. However, sociocultural factors seem to modify the clinical manifestations; eg, somatic complaints, worry, tension, and irritability are more common in the lower socioeconomic classes; guilty ruminations and self-reproach are more characteristic of depressions in Anglo-Saxon cultures; and in some Mediterranean and African countries, as well as in American blacks, mania tends to manifest itself more floridly.

Major depression can have many causes. Psychological factors that increase the risk of depression include difficulty expressing anger effectively, experiencing losses, poor self-esteem, strong dependency needs, poor interpersonal skills and a pessimistic view of oneself and the world.

Genetic inheritance is an important factor for many people, as is a high level of stress.

In recent years, it has become abundantly clear that depression also involves a very specific chemical imbalance in the areas of the brain that are responsible for mood and emotion.

A recent study of adult twins and their families suggests that depressive symptoms are influenced modestly by heredity and hardly at all by common childhood environment. One group of twins, with an average age of 60, was recruited with the help of the American Association of Retired People; another group, with an average age of 30, was drawn from the Virginia Twin Registry. About 15,000 twins and 15,000 members of their families answered a mailed questionnaire, rating themselves for typical depressive symptoms (such as sadness, physical complaints, apathy, and insomnia). Scores on this questionnaire were known to be highly correlated with a standard test for clinical depression, a psychiatric diagnosis of major depression, and a risk of future depression.

The correlation for depressive symptoms was highest among identical twins. It indicated a heritability (proportion of the variance, or individual differences, explained by heredity) of 37% in the AARP and 30% in the Virginia Twin Registry group. The correlation among fraternal twins was about half as strong. Heritability estimates based on twins alone were confirmed by the responses of  other genetically related family members. The results for genetically unrelated family members were also revealing. In-laws were entirely uncorrelated for depressive symptoms, but husbands and wives were about as highly correlated as fraternal twins. Since this similarity did not become greater with more years of marriage, the authors believe   it resulted not from mutual influence but from assortative mating-the tendency to marry someone similar to oneself. A smaller sample of 4,500 twins answered the questionnaire again 14 months later. When both sets of answers were counted, heritability rose to 56% in the AARP group of twins and 52% in the Twin Registry group. That is, symptoms appeared more highly heritable when they persisted and therefore implied a stable predisposition or temperament.

By contrast, childhood environment apparently contributed nothing to individual variation. Despite the large number of people studied and the variety of family relationships, there was no evidence that having grown up at the same time in the same home with the same parents, having lived in the same neighborhood, or having attended the same schools caused adults to report similar symptoms of depression. Whatever effects parents, school, and neighborhoods may have had, they were either quite different in different children of the same family or did not persist until the children grew up.

There is emerging evidence that major depression can develop in prepubertal children and that it is a significant clinical occurrence among adolescents. Recent epidemiologic studies have shown that a large proportion of adults experience the onset of major depression during adolescence and early adulthood.

Myrna M. Weissman, Ph.D. of Columbia University (a NARSAD Established Investigator and 1994 Selo Prize Co-Winner) has found an increased prevalence of major depression as well as a variety of other psychiatric problems in the children of depressed parents compared with those of normal parents. Specifically,she has discovered that the onset of major depression was significantly earlier in both male and female children of depressed parents (mean age of 12.7 years) compared with those of normal parents (mean age, 16.8 years). She has also observed sex differences in rates of depression to begin in adolescence. Before 10 years of age, she found a low frequency and equal sex ratio, however by 16 years of age, there was a marked increase in major depression in girls, as compared to boys of the same age. The essential features of mood disorders are the same in children as in adults, although children exhibit the symptoms differently. Unlike adults, children may not have the vocabulary to accurately describe how they feel and, therefore may express their problems through behavior. The following behaviors may be associated with mood disorders in children :

Somber Appearance, almost ill-looking; they lack the bounce of their nondepressed peers. They may be tearful or spontaneously irritable, not just upset when they do not get their way. They make frequent negative self-statements and are often self-destructive

Disruptive behavior, possible academic difficulties, and peer problems. Increased irritability and aggression suicidal threats, and worsening school performance. Parents often say that nothing pleases the children, that they hate themselves and everything around them

As with adult depression, diagnosis of depression in children is not as clear-cut as it is for other ailments. There is no test that can be given which will positively say that an individual has depression, much less pinpoint the cause(s). The medical community still knows relatively little about the brain, how it works, and what makes it malfunction. In fact, anti-depressant properties of certain medications were discovered by accident in the 1950s while seeking a cure for tuberculosis.

We do know that certain children have risk factors in their lives which could predispose them to depression or could "trigger" depression. Among these are a family history of mental illness or suicide, abuse (physical, emotional or sexual), chronic illness and the loss of a parent at an early age to death, divorce or abandonment. However, some infants exhibit depressive symptoms at an early age before most of these factors come into play, so there is an argument to be made for depression being wholly chemical in some children. Each child's depression is individual, and causes will be different for each one. The depression could be wholly chemical, wholly due to psychological factors, or a combination of the two. More important than the cause is identifying the illness and treating it.

Many researchers believe that mood disorders in children and adolescents represent one of the most under-diagnosed group of illnesses in psychiatry. This is due to several factors :

1. children are not always able to express how they feel.

2. the symptoms of mood disorders take on different forms in children than in adults.

3.mood disorders are often accompanied by other psychiatric disorders which can mask depressive symptoms,and many physicians tend to think of depression and bipolar disorder as illnesses of adulthood.

7-14% of children will experience an episode of major depression before the age of 15.

20-30% of adult bipolar patients report having their first episode before the age of 20. Out of 100,000 adolescents, two to three thousand will have mood disorders out of which 8-10 will commit suicide

An estimated 2,000 teenagers per year commit suicide in the United States, making it the leading cause of death after accidents and homicide. According to David Schaffer, M.D., of Columbia University ( a NARSAD Established Investigator), suicidal behavior is uncommon before puberty, with the incidence of suicide  attempts reaching its peak at around age 15 and becoming less common by the late teens. Studies of adolescent suicides in New York, Pittsburgh and Finland indicate that approximately 90 percent of the teenagers who commit suicide have a psychiatric diagnosis, most often a form of mood disorder and/or alcohol or substance abuse. As in adults, suicide attempts occur more often in females (a ratio of 9 to 1), with overdose and wrist-cutting the most common means. Completed suicide occurs more often in males (a ratio of 3 to 1), usually white males, with shooting (62 percent) and hanging (19 percent) the most common means.

It is important for children suffering from mood disorders to receive prompt treatment because early onset places children at a greater risk for multiple episodes of depression throughout their life span. Children who experience their first episode of depression before the age of 15 have a worse prognosis when compared with patients who had a later onset of the disorder.

At the present time, there is no definitive treatment for the spectrum of mood disorders in children, although some researchers believe that children respond well to treatment because they readily adapt and their symptoms are not yet entrenched. Treatment consists of a combination of interventions.

Medications can be useful for cases of major depression or childhood onset mania, and psychotherapy can help children express their feelings and develop ways of coping with the illness. Some other helpful interventions that may be used are educational and family therapy.

Children suspected of mood disorders should be evaluated by a child psychiatrist, or if one is not available an adult psychiatrist who has experience in treating children. It is important that the clinician has had special training in speaking with children, utilizing play therapy, and can treat children in context of a family unit.

Depression in the aging and the aged is a major public health problem. It causes suffering to many who go undiagnosed,and it burdens families and institutions providing care for the elderly by disabling those who might otherwise be able-bodied. What makes depression in the elderly so insidious is that neither the victim nor the health care provider may recognize its symptoms in the context of the multiple physical problems of many elderly people. Depressed mood, the typical signature of depression, may be less prominent than other depressive symptoms such as loss of appetite, sleeplessness, anergia, and loss of interest and enjoyment of the normal pursuits of life. There is a wide spectrum of depressive symptomatology as well as types of available therapies

Because of the many physical illnesses and social and economic problems of the elderly, individual health care providers often conclude that depression is a normal consequence of these problems, an attitude often shared by the patients themselves. All of these factors conspire to make the illness underdiagnosed and, more importantly, undertreated.

Depression in late life occurs in the context of numerous social and physical problems that often obscure or complicate diagnosis and impede management of the illness. There is no specific diagnostic test for depression so that an attentive and focused clinical assessment is essential for diagnosis. Because elderly depressed people often do not present themselves for evaluation or because their depressive symptoms are not typical, the illness is underdiagnosed and under rated. This is particularly true when it is secondary to physical illness, even though these secondary depressive symptoms also respond to treatment.

Estimates of depression in elderly people vary widely as a function of setting, threshold of diagnosis, and definition of depression; however, there is a consensus that the size of the problem is underestimated.The highest rates are found in nursing homes and other residential care settings. Risk factors appear to operate similarly in young and old, although the hallmark of depression in older people is its comorbidity

with medical illness. The course of recovery and frequent recurrence is similar in young and old; however,suicide is dramatically increased in elderly depressed, as is mortality from other causes.

Depressed elderly people should be treated vigorously with sufficient doses of antidepressants and for a sufficient length of time to maximize the likelihood of recovery. Maintenance treatment with antidepressants should be continued with the same doses that produced remission of the acute episode. ECT is often effective for depression in the elderly but is generally underused or unavailable. Psychosocial treatments can also play an essential role in the care of elderly patients who have significant life crises, lack social support, or lack coping skills to deal with their life situations. These approaches may also be indicated in patients who cannot or will not tolerate biologic treatments.

The system of care currently provided to elderly depressed persons is inadequate, fragmented, and passive. Ageist attitudes among some health care providers compromise their ability to recognize depression in their elderly patients and to intervene in an appropriate and timely fashion. The prevalence of depression is particularly high among patients in nursing homes, but staff in many of these facilities are not equipped to recognize or treat depressed patients.

Families and primary care physicians remain at the front line in recognizing depression and facilitating patient access to professional help; however, large numbers of elderly people live alone, have inadequate support systems, or do not have contact with a primary care physician. The isolation of these individuals compounds their depression, and specialized efforts are needed to locate and identify them and to provide in-home care relevant to their needs. Although lack of services is a major problem, a greater problem may be our inability to deliver services to those community-dwelling elderly people who need them the most.

The recognition of depression may be more difficult in late compared with early life. In the elderly age group, both clinicians and patients may incorrectly attribute depressive symptoms to the aging process. They may not fully appreciate the degree of impairment because of lower functional expectations in the post-retirement years. The particular constellation of symptoms may differ because elderly persons may more readily report somatic symptoms than depressed mood. Because both the patient and the evaluating clinician are often more concerned about concurrent medical conditions, depressive symptoms may be overlooked. Finally, the concomitant presence of dementia may compromise accurate recognition and reporting of symptoms. As a result, depression is often underdiagnosed in elderly people,despite a high frequency of potentially treatable depressive symptoms.

Depression in late life frequently coexists with multiple chronic diseases and disabilities, for example, cancer, cardiovascular disease, neurological disorders, various metabolic disturbances, arthritis, and sensory loss. These conditions create psychosocial concerns, medical and physiologic burdens, and functional disabilities  that may directly contribute to the pathogenesis of depressive symptoms as well as complicate treatment. However, current data indicate that depressive symptoms may respond to treatment in many of these patients.

Depression in late life occurs in the context of numerous social, developmental, and biological diversities. Advancing age is accompanied by loss of important social support systems due to death of spouse or siblings, retirement, or relocation of residence. At the biologic level, there is variability in the regulation of  homeostasis, organ system reserve, immunologic responsiveness, and body composition. These sources of heterogeneity have major implications for risk of illness, diagnosis, and treatment. For example, levels of antidepressant drugs and toxic metabolites may be disproportionately increased in the "old-old," making this subgroup particularly vulnerable to adverse side effects.

In general, psychiatrists agree that severely depressed patients do best with a combination of medications and psychotherapy. Medications relieve the symptoms of depression quickly, while psychotherapy can help the patient deal with the illness, easing some of the potential stresses that can trigger or exacerbate the illness.

Dynamic Psychotherapy is based on the premise that human behavior is determined by one's past experience (particularly in childhood), genetic endowment and current life events. It recognizes the significant effects of emotions, unconscious conflicts and drives on human behavior.

Interpersonal Therapy is based on the theory that disturbed social and personal relationships can cause or precipitate depression. The illness, in turn, may make these relationships more problematic. IPT helps the patient understand his or her illness and how depression and interpersonal issues are related. There is some evidence in controlled studies that IPT as a single agent is effective in reducing symptoms in acutely depressed patients of mild to moderate severity.

Behavior therapy involves activity scheduling, self-control therapy, social skills training, and problem solving. Behavior therapy has been reported to be effective in the acute treatment of patients with mild to moderately severe depressions, especially when combined with pharmacotherapy.

The cognitive approach to psychotherapy maintains that irrational beliefs and distorted attitudes toward the self, the environment and the future, perpetuate depressive affects and that these may be reversed through CBT. There is some evidence that cognitive therapy reduces depressive symptoms during the acute phase of less severe forms of depression.

Examples of Cognitive Distortions in depressed people :

1. ALL-OR-NOTHING THINKING: You see things in black and white categories. If your performance falls short of perfect, you see yourself as a total failure.

2. OVERGENERALIZATION: You see a single negative event as a never-ending pattern of defeat.

3. MENTAL FILTER: You pick out a single negative detail and dwell on it exclusively so that your vision of all reality become darkened, like the drop of ink that discolors the entire beaker of water

4. DISQUALIFYING THE POSITIVE: You reject positive experiences by insisting they "don't count" for some reason or another. In this way you can maintain a negative belief that is contradicted by your everyday experiences.

5. JUMPING TO CONCLUSIONS: You make a negative interpretation even though there are no definite facts that convincingly support your conclusion.

* Mind Reading: You arbitrarily conclude that someone is reacting negatively to you, and you don't bother to check this out.

* The Fortune Teller Error: You anticipate that things will turn out badly, and you feel convinced that your prediction is an already established fact.

6. MAGNIFICATION (CATASTROPHIZING) OR MINIMIZATION: You exaggerate the importance of things (such as your goof-up or someone else's achievement) or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called the "binocular trick."

7. EMOTIONAL REASONING: You assume that your negative emotions necessarily reflect the way things really are: "I feel it, therefore it must be true."

8. SHOULD STATEMENTS: You try to motivate yourself with shoulds and shouldn'ts, as if you had to be whipped and punished before you could be expected to do anything. "Musts" and "oughts" are also offenders. The emotional consequence is guilt. When you direct should statements toward others, you feel anger, frustration, and resentment.

9. LABELING AND MISLABELING: This is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself: "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him: "He's a goddam louse." Mislabeling involves describing an event with language that is highly colored and emotionally loaded.

10. PERSONALIZATION: You see yourself as the cause of some negative external event which in fact you were not primarily responsible for

ECT is primarily used for severely depressed patients who have not responded to antidepressant medicines, and who frequently have psychotic features, acute suicidality, or food refusal. It can also be used for patients who are severely depressed and have other chronic general medical illnesses which make taking antipsychotic medications difficult. Changes in the way ECT is delivered have made ECT a better tolerated treatment.

There is a period of time following the relief of symptoms during which discontinuation of the treatment would likely result in relapse. The NIMH Depression Collaboration Research Program found that four months of treatment with medication or cognitive behavioral and interpersonal psychotherapy is insufficient for most depressed patients to fully recover and enjoy lasting remission. Their 18-month follow-up after a course of treatment found relapses of between 33 and 50 percent of those initially responding to a short-term treatment.

The current available data on continuation of treatment indicate that patients treated for a first episode of uncomplicated depression who exhibit a satisfactory response to an antidepressant should continue to receive a full therapeutic dose of that medication for at least 6-12 months after achieving full remission.

The first eight weeks after symptom resolution is a period of particularly high vulnerability to relapse. Patients with recurrent depression, dysthymia or other complicating features may require a more extended course of treatment.