Depression

Summary

Identify unrealistic thoughts that depress you, and learn to think more realistically.

If you’ve ever imagined a tragedy or loss in your life, you know that thoughts can affect your mood. Thinking sad thoughts can make you feel sad. You also may have noticed how feeling sad can make you think sad thoughts.

Don’t waste a minute thinking which comes first—thoughts or feelings. If you feel gloomy, you just want to feel better.

Not every thought is true

In The Feeling Good Handbook, David Burns, M.D. explains that irrational thinking underlies most psychological problems. He breaks it down into “ABCs”:

• A = actual event, such as being reprimanded at work by your boss
• B = beliefs you have about yourself and life, such as “I’m so inadequate”
• C = consequences of your beliefs, such as feeling depressed and angry at yourself

Are you willing to apply this ABC process to your own experiences? Can you accept that the beliefs that cause you such grief may not be true?

Catch your thoughts

The next time you feel depressed, try to write down everything running through your mind. See if you can catch any of the common distortions that Burns describes:

Emotional reasoning: You assume that your negative emotions reflect the way things really are.

• “I feel hopeless, so life must really be hopeless.”
• “I feel unlovable, so I must not be worthy of love.”

Overgeneralization: You view a negative event as a never-ending pattern of defeat.

• “I was rejected by someone—I’ll never have a significant other.”
• “I’ll always feel depressed.”

Mind reading: You assume that others are reacting negatively to you without any real proof of this.

• “He isn’t smiling at me; that means he doesn’t approve of me.”
• “They wouldn’t want me to join their lunch table—they won’t like me.”

Discounting the positive: You insist that your positive qualities “don’t count.”

• “It doesn’t matter that I’m intelligent, kind, talented, etc.”

Personalization: You hold yourself responsible for events not entirely under your control.

• “My child got a bad grade—I’m a bad parent.”
• “My spouse is grumpy after work today. I’m a failure if I can’t cheer him up.”

Change your thoughts

Now your hardest task begins. If you notice a distorted thought that makes you feel depressed, rethink it. This takes regular practice. Don’t accept that all your thoughts are true. Be willing to challenge the ones that upset you:

Examine the evidence: Is there any proof that your thought is valid?

• What proof do you have that someone doesn’t like you or that it’s your fault that your child got a bad grade? Often you won’t find genuine proof.

Re-attribution: What other factors may contribute to this problem?

• Acknowledge that other people and circumstances led to your spouse’s grumpiness—it doesn’t have to be your fault.

Thinking in shades of gray: Try to remove “always” and “never” from your negative beliefs.

• Yes, you will sometimes feel depressed or be rejected, but not always.

Double-standard method: Talk to yourself as you would a friend in a similar situation.

• Do you discount your friend’s talents and strengths? Would you call him unworthy of love?

Keep plugging

Be patient and keep working to catch thoughts bring your mood low. Some of your irrational beliefs have been around a long time and might be hard to let go of right away. But it’s worth the effort to free yourself from thoughts that cause you such pain.

Remember to tell your doctor how you’ve been feeling, and don’t hesitate to enlist the help of a mental health professional as you work toward feeling better.

By Laurie M. Stewart

©2004-2022 Carelon Behavioral Health

Summary

• Mix of substance use disorders and mental health disorders
• Treatment should be well planned and client-centered

The term co-occurring disorders or COD means having at least one mental illness along with one or more substance use disorder. But there is nothing simple about having this condition. The two or more disorders will negatively impact each other. This requires that each disorder be treated separately but also at the same time. Recovery is not an easy process, but it is a goal that can be reached.

Types of COD

Substance use disorder can occur along with any mental illness. Some of the more common mental health issues linked with COD include:

• Depression
• Anxiety
• Schizophrenia
• Bipolar disorder
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)

Other disorders related to mood, anxiety, sleep, eating, and personality also often occur with COD.

Some common classes of substance use disorders include:

• Alcohol
• Nicotine
• Caffeine
• Cannabis
• Cocaine
• Amphetamines
• Sedatives
• Opioids

People with COD can have any mixture of substance use disorders and mental health disorders, but at least one of each.

Risks of COD

People with COD have certain higher risks than people with a single disorder. They also tend to be in poorer health and have a greater chance of relapse. Some of this is due to not taking or responding to treatment as well. The time and cost involved in this treatment is also higher.

Among these increased risks are:

• Violence
• Physical illness
• Psychosis
• Hospitalization
• Homelessness
• Unemployment
• Incarceration
• HIV/AIDS

Screening for COD

About half of all people with severe mental illnesses also have substance use disorders. The rate of people with substance use disorders who have mental illnesses is even higher. Despite these facts, screening for COD can be a challenge. A mental health service may not be able to spot substance use disorder. A substance use treatment center may not be able to spot mental illness. The screening process should decide whether or not the person needs to be further assessed. This assessment is then performed by a mental health doctor or other trained health care worker.

Treatment and recovery

Treatment for COD must target each disorder by itself and at the same time. This may occur in one setting or a number of settings. Treatment should be well planned and client-centered. This means the person with COD needs to be involved with all aspects of care. The type of care will depend on the types of substance use and mental disorders. It should also be tailored to the person’s unique needs and goals.

COD takes a toll on those who have it and on those around them. Coping skills must be taught to the individual as well as to her support group. Progress may be slow and sometimes hard to measure. The chance of relapse seems to always be right around the corner. Setbacks should be met with support rather than blame. The person will respond to praise much more than to guilt. Recovery is a long process that will require a group effort. It is not an easy task but it is well worth it.

Resources

Alcoholics Anonymous
www.aa.org

Narcotics Anonymous
www.na.org

National Alliance on Mental Illness
www.nami.org

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Kevin Rizzo

©2022 Carelon Behavioral Health

Summary

The most common types of therapy to treat depression are cognitive-behavioral therapy, interpersonal therapy, and psychodynamic therapy.

There are many helpful treatments for depression. One of the key things that add to care that works is getting professional help right away. An added benefit of quickly seeking help is that it can also avoid it happening again and again. There is no need to feel badly. There are proven methods to help it.

Types of therapy

The most widely used methods to treat depression are medications and counseling.

Counseling does not rely on medications. Just as there are many types of medications, there are several kinds of counseling. The three most widely used to treat depression are cognitive-behavioral therapy (CBT), interpersonal therapy (IPT) and psychodynamic therapy.

A licensed clinical psychologist, licensed clinical social worker, or licensed clinical counselor has specialized training in one of these methods. Many psychiatrists also still practice counseling. A primary care doctor can guide a person to the proper counselor who specializes in one of these therapies.

Cognitive-behavioral therapy (CBT)

The idea behind CBT is that depression stems from harmful thoughts. These bad thoughts then lead to feelings of sadness. CBT helps people with depression change or cut back on their harmful thoughts. The theory in CBT is that feelings or thoughts are what lead to your actions and moods. If thoughts are changed, then a person’s mood and actions will change.

Often people with depression view what is occurring in their life from a harmful or unrealistic way. A cognitive-behavioral therapist helps restructure such views and social relationships with others in a more positive and realistic way. CBT may seem like taking a course in that one learns new, more helpful ways to handle problems in life. The therapist offers specific things to do to change the thoughts that lead to the unhappy feelings. CBT can help people with depression point out things that may be contributing to their bad mood and then aid in changing the resulting actions that may be making the depression worse.

Signs of depression start to lessen in 10 to 20 weeks if visits are done once a week. This can vary from person to person.

Interpersonal therapy

IPT is a type of talk therapy that focuses on helping a person look at and better learn from past and present relationships that may have caused the depression or may be making it worse. The therapist is less directive during the sessions. He may ask more questions to help the person with depression come to her own understanding of what has happened to cause the feelings. This understanding can help to curb the unhappy feelings.

An interpersonal therapist does not offer specific tools or make recommendations as to things to do differently in one’s life. As a rule, IPT is longer term. It can be nine months to a year or longer. Some therapists like to have visits more than once a week.

The National Institute of Mental Health suggests that for mild to moderate depression, counseling may be the best choice for treatment. But, for major depression or for some people, counseling may not be enough. Some research has shown that combining antidepressant drugs with counseling is the most useful way to remedy serious depression.

Psychodynamic therapy

This is a more in-depth exploration of a person’s emotional life, attempting to find meaningful connections between painful events in the past. These events can be losses, trauma, or the development of negative self-talk leading to depression. It’s originally based on the pioneering work of Freud, and has been further developed and refined by generations of practitioners.

By Chris E. Stout, Psy.D., Clinical Professor, Department of Psychiatry, College of Medicine, University of Illinois at Chicago

©2012-2019 Carelon Behavioral Health

Source: March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7):807ﾖ820; Reynolds CF III, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ. Maintenance treatment of major depression in old age. New England Journal of Medicine, 2006 Mar 16; 354(11):1130ﾖ1138; National Institute of Mental Health.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Drugs will lift your mood only for a short while.
• If you are unhappy, it is wise to avoid alcohol and drugs.
   

Does depression make people more likely to use alcohol or drugs? Are people who use them at greater risk to get depression? The answer to both these questions is yes. For some people the mixture is a very deadly one, because depression and drug use can end in taking one’s own life. Much is known about the risky relationship between depression and drug use. Here are some of the facts.

Depression and alcohol

People, including depressed people, often turn to alcohol because of the pleasant feelings that a drink can give. It can make you feel relaxed and good. A drink of alcohol starts by increasing dopamine, a brain chemical that lifts your mood. Alcohol is really a depressant. After a while, it lowers brain chemicals such as serotonin and norepinephrine. Your brain needs these in order to avoid depression. If you are unhappy, drinking alcohol will boost your mood only briefly, and then leave you all the more depressed when it wears off.  If you are depressed and thinking about killing yourself, alcohol is even worse. Alcohol is a part of many suicides because it can make it harder to think clearly about your problems and make it more likely that you’ll act on your unhappy feelings.

Depression and other drugs

Like alcohol, some illicit drugs—including cocaine and speed—lift the mood when first used but then drop the person who uses it into painful depression. An unhappy person might turn to these stimulants to feel better, but when the drug effects wear off there is a “crash” that only adds to depression.

Opioids such as heroin or pain pills can also have a very bad effect on depression. At the start, they cause a very good feeling and seem to chase away worries. Their continued use, though, can lower energy. Withdrawal from these drugs can worsen depression, appetite, and sleep.

Marijuana, like these other drugs, can make you feel good at first, but ongoing use has been linked with low energy, anxiety, and apathy.

Often, unhappy people turn to drugs to feel better. The drugs will lift your mood only for a short while. Most often, you will need more and more drugs to get that same lift as time goes on. When the drugs wear off, your depression will be no better. It likely will even be worse. Not only that, but low spirits can hang on for months after you stop using drugs. Your body needs this time to get better from the toxic effects of the drugs.

If you are struggling with a drug problem or think you might be headed in that way, there are lots of great resources for getting help. Please think about talking with your health care provider and/or going to a 12-step meeting (such as Alcoholics Anonymous or Narcotics Anonymous) to learn more.

If you are unhappy, it is wise to avoid alcohol and drugs. You can talk with your doctor to get the help that really works for depression. Taking good care of yourself, seeking counseling with a professional who has training with treating drug and alcohol problems, or using the right kind of medications with guidance from a doctor will help you get better more quickly.

If you would like to learn more about drug use and depression, check out the website of the Substance Abuse and Mental Health Services Administration at www.samhsa.gov. For information on 12-step programs, see: www.aa.org or www.na.org.

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Pary R, Lippmann S, Tobias CR, et al. Depression and alcoholism: clinical considerations in management. South Med J. 1988 Dec;81(12):1529-33; Ward EN. Substance use disorders and late-life depression. In Ellison JM, Kyomen HH, Verma S. Mood Disorders in Later Life. Informa Healthcare, 2008, pp 197-208; http://www.samhsa.gov.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

When depression is missed, life is less enjoyable

Depression can look different in an older person. The life stresses and health problems of older adults are not the same as for other age groups. For these reasons, family members and caregivers sometimes miss depression in the elderly. When depression is missed, life is less enjoyable. Daily tasks are harder. Being with people is less fun. The chance of sickness or death is greater. 

Depression and increasing age

At any time, about one in every 25 older adults living at home has a major depression. If milder depressions are counted too, then twice as many are depressed. In nursing homes, the number of depressed elders is much higher. More elderly women than elderly men are depressed. Both may become more depressed as they get older.

Some elderly depressed people do not think of themselves as sad or down. The way they act, though, should make you think they could be depressed. Depressed people may spend less time with others and less time on hobbies and interests. They often look more withdrawn and irritable. Older adults who are depressed can worry that others are trying to hurt them. Sometimes they worry that others are stealing from them. Some depressed older adults think more slowly and look forgetful and confused. They might complain more of aches and pains. Their sleep is often worse. They may lose or gain weight. Depression brings a greater risk of suicide, especially in white men in their 80s and older. The rate of suicide in this group is more than five times the usual rate.

Check medical health

Among older adults who are depressed, it is important to check medical health. Medical problems can cause or worsen depression. When medical causes of depression are found and treated, it might improve. Thyroid problems, diabetes, high blood pressure, cancer, and infections are some of the medical causes of depression in older adults. Other older people become depressed because their diet is missing important vitamins or because their sleep is not good. Still others can be depressed because of the stresses that affect many older adults. Losing people you love usually causes grief. Sometimes grief leads into depression. Worrying about money problems or not having a good place to live can worsen depression. Having bad health with low energy or pain, too, can increase worry and depression.

Getting help

When older adults are depressed, they often look for help from a primary care doctor. This can be a good decision if it leads to treatment. Sometimes, though, a primary care doctor offers a medicine when talking would help just as much. Talk therapy helps many depressed older adults. There are special therapy approaches to depression in the elderly. These include cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy. Finding a therapist who knows one or more of these and other special approaches can be difficult but worth the extra trouble.

Sometimes, it is necessary to use medication. When a depressed older adult is thinking about suicide, out of touch with reality, or unable to remember things normally because of dementia, medications can be very important. Almost every medication used to treat depression works for many older adults too. Age does not mean that a depressed person will not get better. Older adults can have more trouble with side effects of medications. In addition, older adults are often taking other medications already. Sometimes these do not mix well with an antidepressant. Be sure that your doctor knows all the medications you are taking before adding an antidepressant.

The best news about depression in older adults is that it usually gets better with treatment. Talking, medication, care of medical problems, good diet, getting enough exercise and sleep, reducing stress, and spending more time with family and friends are all ways to reduce depression in an older adult.

By James M. Ellison, M.D., M.P.H.

©2012-2021 Carelon Behavioral Health

Source: Lawrence J, Davidoff DA, Kennedy JS, et al. Diagnosing depression in later life. In Ellison JM, Kyomen HH, Verma S. Mood Disorders in Later Life. Second Edition. Informa Healthcare. Informa Healthcare, 2007. pp 1-14; Gallo J, Rabins P. Depression without sadness: Alternative presentations of depression in late life. Am Fam Physician 1999; 60:820ﾖ826; Burkhart KS. Diagnosis of depression in the elderly patient. Lippincotts Prim Care Pract 2000; 4:149ﾖ162.

Summary

Depression can be caused by:

• Brain chemicals
• Life events and stress
• How we see ourselves

There are many ideas about what causes sadness that is bad enough to be called a sickness. One idea is that depression is caused by a chemical imbalance. Since we are made of chemicals, this might be true. There are many ways the chemicals can become uneven.

Another idea is that depression runs in families. Scientists have shown that you are more likely to get it if a parent, brother, or sister has had a serious depression. Some people are born with traits that cause brain cells under many kinds of stress to have problems. These kinds of problems can change the levels of vital brain compounds. Those compounds, which include norepinephrine, serotonin, and dopamine, are the main regulators of mood. 

Understanding brain chemicals

Brain chemicals can be affected by medicines when they are misused, and by street drugs. Some medications can lower brain chemicals that are vital in keeping the mood steady and good.

Brain compounds are also affected by diseases like hormone problems, cancer, infections, digestive/dietary disorders and serious sleep problems. Low thyroid, high blood sugar, lung cancer, viral infections like mono, certain food intolerances or vitamin deficiencies, and some sleep problems can make people feel unhappy and show signs of depression. Alcohol and other recreational drugs also change brain compounds. Even if alcohol can be helpful to health when used in appropriately small amounts, drinking too much over time can bring on low spirits..

The role of life events and stress

Chemical changes are not the whole story. If they were, it would be rare to meet an identical twin with depression whose brother or sister did not have it. Research on depression teaches us that it can also be caused by hard life events. When a loved one dies, for example, the grief can turn into serious sadness that lasts. When a relationship is lost, or a good job ends, depression sometimes arises.

Very bad long-term stress, like caring for a sick relative, can cause low spirits. Scary or cruel events during childhood can cause low spirits later on. Social isolation can also lead into or add to depression. All these kinds of events can be even worse on people whose brain chemistry is more at risk than that of others. Medications alone may not be enough to help a person who has been under great stress. Talking with a trained therapist can help a lot.

How we see ourselves

The ideas that we have about ourselves often shape our moods and actions. We all have ways we see ourselves and expect things to happen. For example, you may have had a painfully cruel childhood during which you were physically beaten. You may come to feel that you are deserving of criticism or punishment. This belief can bring on or worsen a low mood. Ideas about ourselves are very strong in this way.

When we think about all these kinds of causes at the same time, we are understanding depression as a combination of several things. They and other forms of treatment can affect biology and health problems. The psychological part of this term is about those ideas we form and sometimes cherish about ourselves. They can be harmful to the way we see ourselves. The social part is about long-lasting problems relating to others as a result of the sickness. At the same time, these viewpoints offer a way to learn the causes of depression and to think over many choices for care.

By James M. Ellison, M.D., M.P.H.

©2012-2021 Carelon Behavioral Health

Depression is a word that can mean different things. The meaning depends on how the word is used. Most of us feel “down” or “blue” some days. You might say you are “depressed” when you are upset, angry, or sad about something. For many people, though, depression is much worse than having a bad day. More than one in 20 adults have this more serious and lasting depression at any given time. When depression hangs on for a long time and includes symptoms in addition to low mood, we call it a disorder or illness.

The illness of depression lasts more than two weeks at a time. If you have depression in this way, which is called major depressive disorder, you usually feel low every day. You sleep badly. Food does not taste as good to you. You do not have enough energy to do your usual chores. Depression makes you lose interest in things you used to like. It is hard to concentrate. You can feel nervous or “out of it.” You might wish you were dead. Depression is one of the main reasons that people kill themselves. When depression is especially bad, with what are called “psychotic features,” you might even hear voices that other people do not hear.

Depression can take different forms

The illness of depression can take different forms. The way it looks depends on who is depressed. Children, for example, may not know how to talk about feeling depressed. They might show it instead with their behavior. They might cry more or get into more fights, or not do their schoolwork as well as they once did. Older people who may not be able to remember or think properly, too, might show depression with upsetting behavior. 

Some people with depression get better and worse over days instead of staying depressed for weeks at a time. This kind of depression can be just as bad as the kind that lasts. The depression keeps coming back and that can be frustrating and painful. Some adults with this kind of depression eat more instead of less, and sleep more instead of less. If your depression is like this, you may think it is due to some disappointing thing in your life. This kind of depression, though, is more than a reaction to things in your life. This pattern of feeling better and worse all the time sometimes means that you have the illness of depression.

Some people who get depressed may not need much sleep. They get very busy. They may spend too much money. Sometimes they do risky or strange things. Severe behavior like this is called manic. People who get depressed and manic can have manic depressive disorder or bipolar disorder. That is a different type of mood issue. The treatments are not the same. Treating someone who is bipolar like someone with depression can be the wrong way to go.

Depression is treatable

If you do not treat depression, it might go away on its own. But it often stays the same or gets worse. This is dangerous because depression that lasts can affect a person’s health badly. It can take the fun out of life. It can make it hard or impossible to hold a job. It can put lots of stress on relationships. It can even lead to earlier death, from suicide or sickness.

But depression is very treatable. Talking to a trained therapist can really help. For people who need medication, there are now lots of good choices. Making healthy lifestyle choices, too, is helpful. Getting enough sleep, exercise, good food, and time with people is very important for helping depression. It is also important to reduce stress and make time for fun.

If you have depression that is serious, please make sure you talk with someone about how to get the help you need.

By James M. Ellison, M.D., M.P.H.

©2012-2022 Carelon Behavioral Health

Summary

• Differs from acute depression in duration and also in the seriousness of its effects.
• Social and work factors as well as medical conditions can look like chronic depression.

During the past two weeks, have you felt down, depressed or hopeless? During these same two weeks, have you felt little interest or pleasure in doing things you normally like to do? If your answer to either of these questions is yes, then you may be experiencing depression. 

Depression that is bad enough to interfere with your work or getting along with other people is a serious problem. It robs life of joy and hope. Getting through the day becomes a painful task. Depression is hard on you and on others who care about you. It can even set the stage for a serious medical health problem. Depression that makes work or your social life hard is called chronic depression when it lasts a long time. Chronic depression doesn’t usually get better without treatment. If you don’t know that help is needed, though, you won’t look for it. So how do you know if you have chronic depression?

What is chronic depression?

Chronic depression is the label for a few different conditions. Each of these lasts at least two years without a significant break. A major depressive episode that lasts this long is one pathway to chronic depression. It includes low mood or loss of pleasure for at least two weeks, and is present every day or most of each day, along with at least five other symptoms. These include changes in sleep, changes in appetite, loss of interest, low energy, poor concentration, reduced or restless activity, or suicidal thoughts or actions. Major depressive episodes last at least two years in one of every five people. If you have gotten partly better, you still may have chronic depression if you never got back to wellness.  

In some cases of depression, the symptoms were never bad enough to be called major depression. Yet they interfered with work or social life. They were not explained by other health conditions. Depressed mood was present most of the day, more days than not, for at least two years. At least two additional problems were also present during this time. These could be appetite that was too low or too high, too little or too much sleep, low energy, low self-esteem, poor concentration, or feelings of hopelessness. During the two years, depressive symptoms did not lift for longer than two months at a time. This form of depression is called persistent depressive disorder (or dysthymia). If it started first and a major depressive episode came later, this is called double depression.

What causes chronic depression?

Depressive symptoms aren’t always caused by the disease of depression. It is important to know when other causes are present because the treatment approach may be different. Some life situations, for example, can make a person feel depressed all the time. If you are in a difficult job or relationship, or worried all the time about your health or finances, you cannot enjoy your life as fully as possible.

If you were harmed or traumatized as a child, or if you get very anxious, your symptoms may look like chronic depression. Some medical problems such as low thyroid functioning, heart disease, anemia or lung disease can drain your energy and look like depression. Some sleep problems, such as breathing trouble during sleep called sleep apnea, can cause symptoms like depression. Drugs such as alcohol, antihypertensives and steroids can create symptoms that look like it too. 

Many people with chronic depression never get evaluated or treated. Some individuals consider signs and symptoms of depression to be a natural part of the aging process. Others associate these symptoms with their culture and/or other social beliefs. If you think you have chronic depression, please seek help from your doctor or a mental health specialist. That way, you have a good chance to feel better, enjoy life more, and function more successfully.

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Pignone MP, Gaynes BN, Rushton JL, et al. Clinical guidelines: Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;136:765-776; Torpey DC, Klein DN. Chronic depression: Update on classification and treatment. Current Psychiatry Reports 2008;10:458-464; Murphy JA, Byrne GJ. Prevalence and correlates of the proposed DSM-5 diagnosis of chronic depressive disorder. J Affective Disord 2012;doi:10.1016/j.jad.2012.01.033

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Keep an ear open for suicidal feelings, thoughts and actions.
• Encourage a depressed person to find treatment and stick with it.
• Support healthy choices and activities, and help sustain hope.

If you are like most people, you have a friend or relative who has chronic depression. We call depression chronic when it lasts two years or longer. The effects of depression on your work, social life, self-care and health can be devastating. Chronic depression is treatable, but it usually won’t go away without help.

What can you do to make things better for someone with chronic depression? Here are a few suggestions:

Avoid blame, shame and denial. A person who has been depressed for a long time often starts to feel guilty and responsible for not getting better. There are steps to take that can improve matters, but clinical depression is a medical disease and not appropriate for blame or shame.

You can help someone with chronic depression by being a good and supportive listener. Let them know you are concerned, but avoid the temptation to give lots of advice in order to “fix” the problem. Support, encouragement, praise for steps forward, and continued engagement can make the difference between life and death for your friend.

Keep an ear open for suicidal thoughts. Do not dismiss expressions of hopelessness or suicidal feelings. If you hear comments such as, “There’s no point in going on” or “I don’t know why I keep trying,” ask directly about suicidal thoughts or plans. You can decide the best way to ask, but some possibilities are: “Are you feeling like you’d be better off dead?” “Have you thought about ending your life?” or “Do you feel that you’re in danger of hurting yourself?” Suicidal comments are often a plea for help and your concerned response may save a life. Also be on the alert if someone begins to give away her possessions or finds ways to say “goodbye” by visiting relatives or friends she has not seen in a while.

Be aware that asking about suicide does not increase the risk of someone attempting it. In fact, not asking about it may keep you from reaching out to help a friend or loved one.

Support healthy lifestyle choices. A depressed person neglects self-care, sleep, proper diet, exercise, social interactions and enjoyable activities. Avoid stressing your friend, but notice and encourage good choices. Make a healthy meal together, or go for a walk and spend time outside. Take a class together. Find a social event that you can share. Arrange a fun outing to a baseball game or to a museum or a picnic. As the weeks or month pass, resist the urge to withdraw. Over time, your support becomes more and more valuable as other friends may distance themselves from a depressed person. 

Find help. Your depressed friend or relative may find it difficult to get needed help. Avoidance, expense, insurance restrictions and clinician unavailability all get in the way of finding treatment. Psychotherapy with or without medicine is often the best way to treat chronic depression. But it may be confusing to find your way to a mental health clinician with the right skills and with an approach that wins your confidence and trust.

Sitting with your friend and helping to make calls to clinicians, or even to a concerned primary care doctor, is often very helpful. It may even be a good idea to accompany your friend to that first, often most difficult, appointment. Offer to drive if that will make it easier. That way, if your friend allows it, the clinician can hear information that only you may be able to provide. Also, if treatment seems to be bogged down for too long a time, suggest that your friend seek a consultation. A fresh view from another skilled clinician may help to get things back on track.

Consider the role of spirituality. Many individuals rely upon their faith to get them through difficult times or life challenges. Spirituality can help in cases of chronic depression. It may help answer the question of purpose or meaningfulness in one’s life. It can also be a source of comfort when answers are not easy to come by. Studies have shown that spirituality can help to reframe traumatic events to make them more manageable. Building an understanding based on healthy perspectives may help the way we see a particular event in a way that makes sense for us. This can help decrease posttraumatic symptoms.

Be a voice of hope! The famous commander, Captain James Lawrence, urged his men during a dangerous naval battle, “Don’t give up the ship!” Chronic depression is a treatable disease and many people will get better with healthy lifestyle choices and skilled treatment. Being a voice of hope for someone who is discouraged takes time and energy. Your support and caring will mean the world to someone dear to you and will help them along the way to recovery.

Resource

Depression and Bipolar Support Alliance

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Gelenberg AJ, Kocsis JH, McCullough JP et al. The state of knowledge of chronic depression. J Clin Psychiatry 2006;67(2):179-184.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Avoid adding shame and blame to depression.
• Keep your expectations reasonable.
• Support healthy habits.

Even though depression is common and very serious, lots of people who have it do not get help. If you know someone who is depressed, you can help them get on the path to recovery. Even if they are already getting help, you can give support that will make their recovery easier.

Here are some things to think about:

Avoid adding shame and blame to depression. When you feel ashamed, it’s harder to ask for help. Many depressed people feel like failures. They blame themselves for feeling sad. They think it is their fault that they are depressed. Sometimes a person makes bad choices that end up making life much more stressful. There are ways in which a person’s behavior can increase depression. But it is important, when helping someone who is depressed, to avoid adding shame to the depression.

Support your friend in getting the right kind of help. Everyone can have a bad day, or a bad week, but when low mood and other signs of depression persist, do not look the other way and hope for things to get better on their own. Help is available from many sources. Your friend might want to start with their primary care clinician, or a psychiatrist, if possible. Do not buy into the idea that everything will be alright without getting the right kind of help — too often that is not true.

Keep your expectations reasonable. When your loved one is depressed, they will not feel like doing everything they used to enjoy. They might get tired easily, or lose interest, or not have fun doing things that you used to like doing together. While they are depressed, they will not get as much pleasure out of a good meal, a night out together, intimacy or a good conversation.

Try not to get too disappointed, or to expect too much while the depression is bad. On the other hand, keep in mind that a depressed person often enjoys things more than they thought they would. With some encouragement and cheerleading, you can still do things together. In fact, it is a very good idea to try. A depressed person often avoids doing unnecessary things like having fun, and you can help out by making sure to arrange fun activities that are not too demanding.

Support healthy habits. Your depressed friend is probably neglecting themself in lots of ways. You can help by encouraging them to take good care of themself. Avoid being a nag or a pest about it, but praise your friend when they make the effort to get enough sleep, eat a healthy meal, exercise, get to the doctor or counselor, or make time to enjoy being with the people who care about them. If they are not careful about taking their medications because of how bad they feel, they will not benefit from taking them.

Let them know that sticking to good health habits, including taking their medicine as they are supposed to, is important. Reducing stress is another way that your friend can help themself. Encourage and support them in finding ways to make their life simpler and less stressful.

Support helpful treatment. If your loved one needs treatment and has found someone to provide counseling, medications or both, your encouragement is important. Participating in counseling or taking medications for depression can be very helpful, but these treatments take time to work. You have to stick with them long enough. You have to get to the counseling sessions, and you have to take the medicines as you are supposed to do.

If there are problems such as feeling that the therapist is not helping or that the medicines are causing bad side effects, it is important to let the person treating the depressed person know. You can help your depressed friend get the most benefit from treatment by encouraging them to let others know if they are not getting enough help, or the right kind of help, from what they are doing.

Your loved one or friend may not be so much fun to be with when depressed, but do not give up. Your support and help can really make a difference in helping them recover.

By James M. Ellison, M.D., M.P.H.

©2012-2022 Carelon Behavioral Health

Summary

Protect yourself from absorbing other people’s negative moods, with:

• Strong coping skills
• Knowledge and understanding
• Healthy lifestyle
• Patience

You may have an upbeat attitude and a near-perfect life but sooner or later, you’re going to encounter negative people. These are people who can turn smiles to tears and a holiday into tragedy. They blame, complain or start fights at the slightest provocation.

They may be your friends or your co-workers. You might be married to one. They may be smart or average, big or little, young or old. What they may have in common is some level of depression.

Depression is not “caught” by infection, like the flu. But if you’re around angry, sad or fearful people, you may start feeling the same way. 

But, there’s a big difference between feeling down and being clinically depressed, which is a serious medical condition affecting family and personal relationships, work or school life, sleeping and eating habits, and general health.

At some point in our lives, we all drive through at least a few of life’s potholes, and most people do it without crashing. You may be temporarily upset by problems or disappointments, but you bounce back.

A person with clinical depression, on the other hand, can’t stop feeling worthless, guilty, helpless, hopeless or regretful. They may have no energy or enthusiasm for work or family, be unable to form friendships or intimate relationships, and show no interest in the future.

How do you “get” clinically depressed?

Sometimes it’s brought on by a medical condition, such as diabetes or hypothyroidism. Or, it might be the side effect of a prescription drug, alcohol or recreational drugs. Marijuana, for example, is a depressant. Depression seems to run in families, suggesting an inheritable biological component. Some people fall into depression after a tragic event. 

Studies show the roots of most clinical depression can be traced to childhood, where we learn to think, interpret and respond to events.

A child learns early on how to handle—or not handle—stress later in life. They study adults around them, and learn by their example. They can absorb their inappropriate behaviors and negative thinking, then practice them. If their parents are depressed, they might never learn appropriate ways to combat stress.

If a child is surrounded by combative, sad or fearful people, they learn to fight or hide their feelings. If ignored, neglected or overprotected, they may never learn to build successful relationships.

If they’re told over and over in words or actions that they aren’t smart, strong or attractive, they may grow up without the resilience they need to fend off negative thoughts.  

What we can do

Since no one has a perfect childhood and stressful situations pop up in everyone’s life, we all must build coping skills. If we didn’t learn them as children, we can do it as adults. The healthier we are emotionally, the less likely we will be to slip into negative patterns, especially if we find ourselves living or working with people who have depression.

To keep someone else’s mood from hijacking your own emotional well-being:

Set boundaries: If someone talks incessantly about their bad situation, try to change the subject or assert yourself kindly.

Seek positive friends: Take this as seriously as choosing healthy food, exercising and sleeping well.

Prepare for bad times: You will face problems in your life. Determine what coping tools work for you, then stock your emotional-health arsenal.

Be careful what you think about: Don’t exaggerate small problems. Try to think positively.

Get physical: Exercise. The simplest way to reset your mood is to take a walk.

Don’t take another person’s ups and downs personally: It’s not about you. 

Don’t badger: Be patient. If a person who is depressed asks for help, give it. Put a key in the lock, but let them open the door.

Knowledge is power: Empower yourself by understanding depression, and getting your own needs met.

Live well: Follow a healthy diet. Get enough sleep.

Do something: Go to a movie, spend time with friends. Have fun and be glad you are able to enjoy life. 

By Paula Hartman Cohen

©2010-2021 Carelon Behavioral Health

Summary

• Both disrupt normal life.
• Bipolar disorder is depression plus mania.
• Bipolar disorder is often mistreated as depression.

Everyone feels down now and then. We all have our good days and our bad days. A hard day at work or at school can leave you feeling low. A bad relationship, or ending a good one, can also make you feel down. If these low periods last more than two weeks and are causing problems in your life, you may have clinical depression.

Symptoms of depression

Some of the signs include:

• Lack of energy and interest
• Increased sadness
• Losing interest in cleanliness
• Anger and worry
• Eating too much or too little
• Sleeping too much or too little
• Low self-esteem
• Trouble paying attention and making choices
• Withdrawal
• Thoughts of killing oneself
• Unable to enjoy things that brought happiness before
• Feelings of worthlessness or guilt
• Being agitated or slowed down

Clinical depression is also known as unipolar depression or major depressive disorder. This means a person only has periods of low moods. Someone who has both low (depressed) moods and high (manic) moods or a combination of both is said to have bipolar disorder. While in a low period, this person will have signs of depression. At other times, he will show signs of mania. If both happen at the same time, it is called a mixed state. A milder form of mood elevation, hypomania, can be linked to depressive episodes. This is called bipolar type II.

Symptoms of mania

Some of the signs include:

• Boosts of high energy and activity
• Hasty or aggressive behavior
• Rapid thoughts and speech
• Exaggerated ego
• Being overly hopeful
• Increased irritability
• Restlessness
• Less need for sleep
• Impulsive or reckless behavior
• Overuse of drugs or alcohol
• Spending money, buying things they cannot afford
• Distractibility
• More talkative than usual or pressure to keep talking

These periods of mania do not always happen right away. Sometimes it is years before a person with bipolar disorder feels these “highs.” Once a person does have manic episodes, she doesn’t always see it as a problem. She may initially like how she feels during these times and may only seek help when feeling unhappy. It is often the people who know the person well who first suspect something is wrong.  The person with bipolar mania or hypomania may be angry and disagree with the family or friend who calls the mania to their attention.

All of this makes it hard to diagnose and sometimes years can pass until the proper diagnosis is made. Sometimes many bouts of low spirits can happen before the first manic episode. Many people with bipolar disorder are treated as having unipolar depression only. They may show only partial response to treatment. If they do not respond well to antidepressant treatment or experience anxiety, irritability, or other symptoms of mania, they should notify their doctor right away. Medications will most likely need to be discontinued and others prescribed. This is one reason why a daily chart keeping track of mood, energy, and other factors such as sleep is important. It gives a good map for the person and doctor to understand what is happening and to work together for effective treatment.

Getting a proper diagnosis

Besides depression, there are other illnesses that make the detection of bipolar disorder hard. Attention-deficit/hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD) are among them. Other social phobias and anxiety disorders often co-exist with it. Drug and alcohol use disorders can further complicate the diagnosis.

A physical exam and lab tests are needed to rule out other illnesses. Next, a full mental evaluation may be needed. Your doctor might send to you to a psychiatrist. It’s key to give them a full list of symptoms and any family history of mental illness. It is a good idea to bring a loved one with you who can also give key information. Keeping a life chart to track daily moods, sleep patterns, and life events can be helpful for watching the symptoms and for informing treatment possibilities.

Getting the right treatment

Bipolar disorder is usually a lifelong illness. Like high blood pressure or diabetes, it does not go away on its own. There may be time between episodes, but they will most likely return throughout one’s lifetime. Failure to treat bipolar disorder tends to make it worse. Treatment during quiet periods of the illness is important to avoid further episodes. Mood stabilizers and talk therapy are most often used. Sometimes, electroconvulsive therapy (ECT), where an electric impulse to the brain is given under anesthesia, is very helpful.  

Prescribed antidepressants may cause mania symptoms to re-occur. Antidepressants and mood stabilizers may also add to suicidal thoughts in people with bipolar disorder. Close monitoring is needed, and these symptoms should be reported right away to your health care provider. A daily chart helps.

People respond differently to medicines. Sometimes changes are needed if the drugs are not working or stopped working. Be patient and work with your doctor to find out what is best for you. When properly diagnosed and treated, bipolar disorder can be controlled. Once you begin feeling better, make sure you keep on taking the medicine as prescribed. This will help avoid relapses and let you live a healthy and productive life.

Resources

The Balanced Mind Foundation
www.dbsalliance.org/site/PageServer?pagename=bmpn_landing

Depression and Bipolar Support Alliance
www.dbsalliance.org/

Mood Disorder Questionnaire
www.dbsalliance.org/MDQ

National Institute of Mental Health/Bipolar Disorder
www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

National Suicide Prevention Lifeline
Call the toll-free, 24-hour hotline at 1-800-273-TALK (1-800-273-8255) to talk with a trained counselor.

By Kevin Rizzo

©2012-2019 Carelon Behavioral Health

Source: Depression and Bipolar Support Alliance, www.dbsalliance.org/site/PageServer?pagename=home; National Institute of Mental Health, www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml; National Library of Medicine National Institute of Health, www.nlm.nih.gov/medlineplus/ency/article/000926.htm; American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Reviewed by Cynthia Scott, MD, Physician Advisor, Beacon Health Options

Summary

Questions to ask:

• Is this a repeat?
• What has happened?
• What can you see besides sadness?

Anyone can think of life events that would make you sad or mad, take away your energy, and even make you question the meaning of your life. We don’t want to call every passing low mood depression because we’d be making an illness out of what might be a normal way of feeling under bad conditions. Not every sad or mad feeling is depression that needs to be checked out by a doctor or therapist. So how can we tell the difference?

Here are some general questions to think about when you’re trying to decide:

Is this a repeat? Depression is an illness that may come back. Once you’ve had it and recovered, your chance of another depression is higher than for someone who never had it. If someone has had the illness of depression in the past, new changes in mood and actions sometimes mean that it has returned.

How long has it been going on? That has to be one of the biggest questions to ask when trying to spot a serious depression. If you feel sad for a day or two or even a week before getting back into the swing of things, that is likely not the illness of depression so much as a reaction to life events. The disease of depression, with few exceptions, has to be there for a couple of weeks before we can be sure that the problem is more than normal sadness.

What has happened? We each react in our own ways to the things that happen in our lives. Disappointments make us sad or upset. When high hopes for the holidays are not met, for example, a person can have the “holiday blues.” When someone is going through very hard times, it is not surprising to see him weighed down by his pain and worries.

A special situation of loss happens when a loved one leaves or dies. This special type of sadness, called grief, can last for weeks or even months. Sometimes grief becomes depression over time. But unlike depressed people, those who are grieving feel their sadness in “waves” rather than nonstop low mood. Their sadness may get suddenly worse when reminded of their loss. They most often don’t have thoughts about taking their own life or losing touch with reality. But sometimes grief can make a person think about dying to rejoin her lost loved one.

Grief is about losses, while depression goes much further than sadness over a loss. Losses or disappointments that are worse and more recent affect us more strongly. Even the most awful losses move each of us differently. We always have to keep in mind that a person experiencing grief might also be depressed at the same time. 

What can you see besides sadness? The illness of depression affects many parts of a person’s behavior, not just mood. Changes in sleep, interest, appetite, energy, concentration, feelings of guilt, and the will to live, occur more with depression than with simple sadness. A person who feels low and can’t be cheered up even by happy events such as time with a friend may have the illness of depression. When a person talks about taking one’s own life or wishing to be dead, or when she is hearing things such as voices that others don’t hear, this means the person might be dealing with depression and not just the blues.

If you ask these questions, you might be able to figure out whether a person’s unhappy mood is coming from the blues or is a real illness in need of treatment.

By James M. Ellison, M.D., M.P.H.

©2012-2021 Carelon Behavioral Health

Summary

All of these treatments come with side effects, but in most cases the side effects are an acceptable trade-off for the relief of depression.
 

Antidepressants are drugs that safely and successfully treat depression or major depressive illness. They can be used along with talk therapy, but they are often the only treatment a depressed person gets. Drugs and talk therapy have different benefits. Using them at the same time is often better than using just one.

Talk therapy can help a person see herself in new ways. It can help her better deal with stressful feelings, thoughts, events, memories, and relationships.

Drugs can help to cut back on signs of low mood such as crying, loss of fun, low energy, poor sleep, changes in eating, poor focus, and worry. Some drugs used to treat low mood can help cut back on even more serious signs like hearing voices or having thoughts of killing oneself. In rare cases, some of these drugs also have been said by some to increase these thoughts.

Role of the FDA

The U.S. Food and Drug Administration (FDA) is the government agency that monitors and approves new drugs. They make sure that drugs are safe for doctors to give to people. They also make sure that the drugs do what they are supposed to do.

The FDA has approved more than 25 drugs to treat major depressive illness. They fall into different groups.

Monoamine oxidase inhibitors (MAOIs)

MAOIs block the breakdown of major brain chemicals. Phenelzine (Nardil®) and tranylcypromine (Parnate®) are the most widely used.

These can be very helpful, mainly for people who are both nervous and sad. But they can cause unsafe reactions when given with certain foods or other drugs.  A doctor will provide additional information on this before prescribing them.

Tricyclic antidepressants (TCAs)

Of the TCAs, nortriptyline and desipramine are the most common ones used.

Like MAOIs, TCAs can help both worry and low spirits. They can also have some bad side effects. They can make people lightheaded or tired. They can add to feelings of hunger. Less commonly, they can cause harmful physical reactions such as heart rhythm problems or trouble having a bowel movement. Also, they can be deadly when taken in an overdose.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs treat low mood and some forms of worry without the same serious side effects of TCAs or MAOIs. But they can cause other problems like increased bleeding, lighter sleep, nightmares, and sexual problems.

Fluoxetine (Prozac®), the first of these, has helped many people. Its success led to competition from other new antidepressants with a similar type of action: sertraline (Zoloft®), paroxetine (Paxil®), fluvoxamine (Luvox®), citalopram (Celexa®), escitalopram (Lexapro®), and vilazodone (Viibryd®). They are known for targeting only one brain chemical.

Serotonin norepinephrine reuptake inhibitors (SNRIs)

Scientists trying to increase drug benefits invented those that change two brain compounds, norepinephrine and serotonin. These serotonin norepinephrine reuptake inhibitors (SNRIs) include venlafaxine XR and venlafaxine (Effexor XR® and Effexor®), duloxetine (Cymbalta®), and desvenlafaxine (Pristiq®). They can have side effects like or a little worse than SSRIs. But they also sometimes help people who have not been helped by SSRIs.

Buproprion (Wellbutrin®) increases the release of norepinephrine and dopamine in the brain. Many doctors think it is most useful for depression without anxiety.

Mirtazapine (Remeron®) is great for anxiety but can make people tired or hungry.

Drugs and other treatments

There is no perfect drug. Not only do they all have side effects, but also none will help everyone who takes it. However, about two out of every three people who try one drug will get much better with it.

Studies have taught doctors some good ways of treating depression that doesn’t get better with the first method. When it is possible to add one more drug or switch to some other type, it is likely that 80 percent or more of people with major depression will get much better.

When drugs are given along with talk therapy, the mixture of benefits can be very helpful too. When these treatments fail, electroconvulsive therapy can be helpful. All of these treatments come with side effects. In most cases the side effects are an acceptable trade-off for the relief of low mood.

Before starting drug treatment, please remember to check your prescription drug coverage to find out which drugs are covered under your plan.

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Stahl SM. Stahlﾒs Essential Psychopharmacology. Cambridge University Press, 2008. pp 453-666; Ellison JM, Sivrioglu EY, Salzman C. Pharmacotherapy of late-life depression: evidence-based Recommendations. Informa Healthcare pp 239-290.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Depression is often the reason for suicide among men.
• Men avoid talking about their feelings.

Depression can affect anyone, male or female, young or old, but in different groups of people it does not look the same. It has been known for a long time that more women than men go through depression. In recent years, people have studied how it affects men. Depression is important to spot in men because four out of five suicides happen in men and depression is often the reason for killing oneself. Even when depressed people don’t end their lives, they miss much of the joy.

Depression in men has special causes, a different look, some bad problems, and its own treatment differences. Here are facts about each of the ways in which depression in men is not the same.

Depression in men can have special causes

Men have often relied on work not only for earnings but also for good self-esteem. Women more often have a strong support group of family and friends. Men who run into problems at work, or become unable to work because of an injury or illness, can take it very hard. Men often find it very hard to stop work at retirement age for the same reason. They may have failed to make friendships that could help them. They may have focused on work and not developed other hobbies and interests that would prepare them to enjoy life in retirement. Depression related to work and self-esteem can be seen in women too.

Depression in men has its own “look”

Women who are depressed often cry and talk about the sadness, low energy, and loss of fun. A depressed man may not want anyone to see him as weak or out of control. His depression takes a different form. He may show a bad temper or even anger instead of sadness. He might have trouble working. He might blame a physical problem such as arthritis for pain that is more than you would expect with that illness. He might get into alcohol or drugs, or unsafe behavior. Men are less likely to ask for help. Their depression might not be recognized for this reason—even by their doctor.

Depression in men can have very bad outcomes

Men who are depressed take their own lives at a very high rate. Women who make suicide attempts more often take pills, but men more often shoot themselves. This more dangerous method is one of the reasons why men die from suicide four times as often as women, even though more women try to take their own lives.

Depression in men might need different treatments

Men sometimes avoid getting in touch with their feelings and do not choose talk therapy for that reason. Other things that help ease depression, such as exercising regularly, getting the right amount of sleep, reducing stress, and keeping in touch with others may be better ways to start treating a man with a milder case. For more severe depression, the same antidepressants help both men and women.

Therapy is commonly used to treat people with depression. There are many types of therapy methods that can be used. People with depression might do best with the therapy that is the best match for them.

Men sometimes get depressed because of low levels of the male hormone testosterone. Low levels are more common among men who are getting older. When testosterone gel or shots are used to bring the level up to normal, depression sometimes gets better in people who had low levels.

In all these ways, depression in men has special qualities. Some of these qualities can lead to misdiagnosis and also the wrong healing process if depression is not recognized for what it is.

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: “Men and Depression”, available at http://www.nimh.nih.gov/health/publications/men-and-depression/index.shtml

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Electroconvulsive therapy
• Vagal nerve stimulation
• Repetitive transcranial magnetic stimulation
• Magnetic seizure therapy
• Deep brain stimulation

Five non-drug therapies are available to treat depression.

Electroconvulsive therapy (ECT)

Seizures like those seen in people with epilepsy happen when the electrical activity of the brain goes out of control. Seizures can be a sign of illness, but they can also be a tool for improving health.

As early as 1934, a Hungarian psychiatrist named von Meduna found ways to cause seizures in mentally ill people. He had a theory that induced seizures would treat mental disorders in a way that was safer and more controlled than the seizures that occurred within the illness. In 1938, two Italian psychiatrists began using electric current to cause the seizures. This was a safer way that was easier to control. This treatment is called electroconvulsive therapy because it uses electrically-caused seizures, which are also called convulsions, in a way that is therapeutic.

ECT has been portrayed as a violent treatment in some movies, but the modern form of treatment is safe for most people. There are some health conditions (such as brain tumor) that make ECT more dangerous or too unsafe to try. ECT is not painful. The seizure takes place after medications have been used to put the person to sleep. Many people who have been helped by ECT ended up thinking it was not a bad experience. Some people felt their memories were harmed either for a short time or a longer time. The short-term memory problems, which are more common, usually go away after a few weeks.

ECT is useful when drugs have not helped or when delusions are present. It is also used when a person is so unhappy that he will not eat or stay safe. Sometimes, when treatment needs to work quickly, ECT can help a person regain safety in a hurry. We do not know for sure how ECT works, but one idea is that the seizures jumpstart the brain cells so that they make more of the chemicals that the brain needs. Most people who get ECT are able to stop after a small number of sessions. Some people are helped by longer and less frequent sessions.

Vagal nerve stimulation (VNS)

You may have heard about the vagus nerve because of how it is involved in certain types of fainting. People who faint at the sight of blood, for example, are having signs that involve activity of the vagus nerve. It is a very long nerve that connects the brain with internal organs such as the stomach and intestines. It carries messages from the brain to these organs, and also from the organs to the brain. 

For the treatment called VNS, an electrical machine that sends a small electrical impulse to the brain is put under the person’s skin. VNS was created as a treatment for epilepsy, but some research shows that sending an electrical impulse up the vagus nerve into the brain can also help depression in some people. Like ECT, VNS can help increase brain chemicals that help fight depression.

VNS is approved by the U.S. Food and Drug Administration to treat some depressions. It is approved when the depression has lasted at least two years, is very bad or keeps returning, and has not gotten better after at least four other treatments. Not all care providers agree about the value of VNS. It calls for surgery to put the impulse generator in place. Side effects of VNS include infection, voice changes, neck pain, or changes in breathing and swallowing.

Repetitive transcranial magnetic stimulation (rTMS)

In high school, you likely learned about how you can make electricity flow in a wire that is moved through a magnetic field. In rTMS, a magnetic device is used to make electrical currents flow in the brain. Some, but not all of the studies show that rTMS works well. The FDA has approved its use to treat depression that has not gotten better after use of at least one antidepressant.

In the U.S., rTMS is sometimes used as an alternative to ECT, though many experts think ECT is a stronger treatment. Also, the number of people who know how to give rTMS is limited. The good points about rTMS are that no anesthesia is needed and there are no drug side effects. Sometimes rTMS can cause a headache, tingling, or even a seizure, though this is rare.

Magnetic seizure therapy (MST)

In MST, a strong magnetic field (stronger than in rTMS) is used to cause a seizure like that in ECT. This treatment is still experimental, but studies show that it is a good treatment for depression. With MST, it is necessary for the person to be put to sleep before the seizure, but researchers are hoping that MST will help treat depression faster and with fewer side effects than when ECT is used.

Deep brain stimulation (DBS)

DBS is another experimental treatment. It may turn out to be very powerful in helping people whose depression did not get better with the other treatments. Wires are put into special areas of the brain that are important for the control of mood. Electrical signals are sent from a generator in the person’s chest through the wires and into the brain.

DBS is a harder treatment to get because a smaller number of experts have been trained to use it. Also, DBS calls for brain surgery to put the wires in place and also surgery to put the impulse generator in place. These operations, and the use of the DBS stimulator, can have side effects including brain bleeding, infection, confusion, and changes in movement or sleep.

Still, DBS is an important advance because some people whose depressions did not get better with lots of other treatments have gotten much better this way.

Resource

National Institute of Health
www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Seiner SS, Burke A. “Electroconvulsive therapy and neurotherapeutic treatments for late-life mood disorders” in Ellison JM, Kyomen HH, Verma S. Mood Disorders in Later Life. Informa Healthcare, 2008, pp 29-314; http://www.nimh.nih.gov/health/topics/brain-stimulation-therapies/brain-stimulation-therapies.shtml.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

The “baby blues” refer to a period of mild mood changes. PPD is more severe and requires immediate attention.

Is it just the “baby blues”?

The “baby blues” is a common, normal experience that many new mothers go through. It is a brief period of mild mood changes that includes feelings of mild sadness or “the blues” as well as feeling weepy and moody. Some reports suggest that as many as 80 percent of new moms go through the baby blues.

Most all mothers of newborns will not be able to sleep, feel tired, and perhaps feel trapped or worried. Women with the baby blues may also have appetite changes, feel cranky, nervous, or have worries about being a good mother. All of these feelings are normal during the first few weeks after giving birth.

After having a baby, a woman’s body changes quickly—hormone levels drop, breast milk comes in, and most women feel tired. These changes can cause the baby blues.

The baby blues are not an illness. They will go away on their own without treatment. What can help is reassurance, support from family and friends, rest, and time. Lack of sleep can make the blues worse. It is important for a new mother to rest when possible, even if it just a short nap.

The baby blues are very different from postpartum depression.

Postpartum depression (PPD)

Depression that happens after the birth of a baby is called postpartum depression (PPD).

PPD is more serious than the baby blues. It calls for active treatment and emotional support for the new mother. It should not be ignored.

Women are vulnerable to getting PPD after having a baby due to the hormonal and physical changes that happen to a woman’s body after the baby is born. The new and demanding job of caring for a new baby can also be overwhelming. This, too, can lead to feelings of sadness. For a few months after having a baby, a mother has a higher chance of getting mental disorders, including depression.

It is common for women who have gone through it in the past to have also had depression at other times. Some women have it during their pregnancies, but it often goes undetected.

It is estimated that 10 percent to 15 percent of women get PPD.

Symptoms

Signs of PPD include:

• Feeling sad or depressed
• Feeling more irritable or angry with those around you
• A hard time bonding with your baby
• Feeling nervous or panicky
• Problems eating or sleeping
• Having upsetting thoughts that won’t leave your mind
• Feeling as if you are “out of control” or “going crazy”
• Feeling like you never should have become a mother
• Worrying that you might hurt your baby or yourself

Effects of PPD on children

While the main focus of PPD is on the mother, it is also important to think about its effects on the parent-baby relationship. Untreated PPD may result in conflicting actions in caring for the baby or other children in the home. Women with PPD often focus more on the bad side of child care and thus have poor plans to deal with stress and parenting.

Support and guidance from others, as well as professional treatment can aid the mother in learning better parenting methods. Help with coping, planning, and positive reframing can help lower stress levels.

Mothers with PPD should be given a great deal of emotional support as well. They should be allowed to vent in a way that supports their coping skills, but avoid self-blaming.

Getting help

If a new mom suspects she has PPD, she should seek professional help from a psychiatrist right away. The earlier PPD is diagnosed, the sooner it can be treated. Just “waiting for it to pass” is not the best way to treat it. There are many treatment choices, including talk therapies and medications.

Women can have depression while pregnant as well as have PPD. This is very true if they have a prior history of depression. Being pregnant does not cure or prevent depression. Most women with a history of depression will likely relapse during pregnancy if they stop taking their antidepressant medicine either before conception or early in the pregnancy. This can put both the mother and baby at risk.

It is important for pregnant women to have their doctors work together on the best care. They can balance the risks and benefits of using antidepressants while pregnant. Such medications do pass between the mother and the growing fetus.

A mother’s depression can have physical effects on the fetus. Questions remain about how antidepressants affect a growing fetus or nursing baby. Many pregnant or postpartum women choose not to take antidepressant drugs and instead do talk therapy. Women who stop taking antidepressants during pregnancy increase their chance of getting depression again.

Many mothers who breastfeed may have concerns about taking medicine while breastfeeding. The woman should talk to the doctor who is prescribing the drug. The doctor may prescribe an antidepressant that is typically recommended for breastfeeding mothers, such as paroxetine, sertraline, or nortriptyline.

Repeat occurrences and prevention

Women who had PPD after past pregnancies may be less likely to get PPD again if they take antidepressants after they have the baby.

Having good social support from family, friends, and co-workers may help lessen the seriousness of PPD. But even all this may not prevent it.

Screening tests may help spot depression or risks for depression early on.

Resource

Support groups may be helpful, but they should not replace medicine or talk therapy.

Postpartum Support International
800-944-4PPD (4773)
www.postpartum.net

By Chris E. Stout, Psy.D., Clinical Professor, Department of Psychiatry, College of Medicine, University of Illinois at Chicago

©2012-2021 Carelon Behavioral Health

Source: Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, Suri R, Burt VK, Hendrick V, Reminick AM, Loughead A, Vitonis AF, Stowe ZN. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Journal of the American Medical Association. 2006 ;295(5):499-507; Maguire J, Mody I. GABAAR plasticity during pregnancy: relevance to postpartum depression. Neuron. 2008 Jul 31; 59; National Institute of Mental Health; Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009;200:357-364. Cohen L, Altshuler L, Harlow B, Nonacs R, Newport DJ, Viguera A, Suri R, Burt V, Hendrick AM, Loughead A, Vitonis AF, Stowe Z. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Journal of the American Medical Association. 2006 Feb 1; 295(5): 499-507. Cassano P, Fava M. Depression and public health, an overview. Journal of Psychosomatic Research. 2002 Oct; 53(4): 849-857. Calvete E, Cardenoso O. Marcus SM, Flynn HA, Blow F, Barry K. A screening study of antidepressant treatments and mood symptoms in pregnancy. Archives of Women’s Mental Health. 2005 May; 8(1): 25-27. Austin M. To treat or not to treat: maternal depression, SSRI use in pregnancy and adverse neonatal effects. Psychological Medicine. 2006 Jul 25; 1-8.

Summary

• Deal with stresses.
• Make time for fun.
• Stay active.

If you have been through a depression, you might remember that the hardest thing was thinking you would never feel better. It is difficult but very important to remember that most depressed people do get better. You have to hold on to hope, and remember that depression is a treatable illness.

Keep in mind that depression does not improve much without help. Depending on your depression, that help might be counseling, medications, both, or another approach.

If you take medications for depression, take them as prescribed. They will not work as well otherwise. If you do not like their effects, talk with your prescriber. Often there is a way to make things better.

Counseling works best if you keep your appointments, speak openly about your goals and concerns, and think about what you have discussed. Some therapists assign homework. It is important to practice your new skills.

Treatment can help, but it is not the whole story. You can take other steps to help recovery. Here are some suggestions:

Deal with stresses. If your depression partly feeds on real troubles in your life such as a bad job or relationship, no pill will get you well unless you also deal with the stressful situations. With help from therapy or otherwise, one way or another you may need to make some changes in your life.

Do not neglect yourself. Many of us get depressed because of stressful caregiving duties. If you spend all your time tending to a sick relative, for example, you must find a way to give yourself a break occasionally. Even if you cannot find a good reason for feeling depressed, make time to care for yourself. Keep your home clean and neat. Take care of your body, appearance, diet, activity, and sleep. These are important parts of your recovery.

Be sure to eat. Keep in mind that your body and brain need the right fuel, and the right amount of it, in order to run well. Eat enough, but avoid the temptation to use food for comfort. It can be tempting to lift your mood with alcohol or recreational drugs, but this is a bad idea. It may work for a while, but there is no free lunch. The payback is tough.

Stay active. Depression can make you feel like you do not want to leave your bed, but keeping active is a great idea. Even if you need to push yourself, exercise is a good way to lift your spirits. Studies have shown exercise to be a good antidepressant. Some people benefit from doing yoga or meditation.

Do not isolate yourself. Find a way to be around people who make you feel good about yourself and about the future. A connection with others is very healing.

Consider practicing spirituality. A spiritual practice may be very meaningful and life affirming for some. It can sustain hope and help you keep your eye on the light at the end of the tunnel. If you’ve lost touch with your previous religious or spiritual activity, it may be very helpful to reconnect.

If despite your best efforts, your depression is not lifting, seek referral to a specialist. See your physician and request referral to a psychiatrist or other expert mental health practitioner about your condition. The diagnosis of depression can be complex. It sometimes requires physical examinations and tests to investigate possibility of bipolar disorder or physical causes. For example, low thyroid, vitamin deficiency, or more serious conditions. It can also increase risk of development of cardiovascular illness and cancer, so it’s wise to seek medical attention if your depression is worsening. Severe depression can lead to various kinds of self-harm.

The good news is that depression is treatable.

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: www.helpguide.org/mental/depression_tips.htm; www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.html

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

SAD is a mood disorder related to the season or time of the year.

People with seasonal affective disorder (SAD) have mood issues linked to a season or time of year. Most people with SAD have symptoms in late fall or early winter, but some have them in late spring or early summer.

Causes

SAD has to do with the effect of seasonal light change. Over the course of a year, the patterns and amount of available sunlight changes. This causes changes in people’s circadian rhythms, or “biological clocks.”

Melatonin has been linked to SAD. Melatonin is a hormone secreted in the brain that may be linked to low mood. More melatonin is made the more a person spends time in the dark.

Symptoms

• Decreased hunger, or more of a taste for sweets, carbs, or starches
• Weight loss or weight gain not due to other health reasons
• Sleeping more or sleeping less
• Feeling tired most of the day
• A drop in energy level
• A change in activity level
• Trouble thinking, focusing, or making choices
• Feelings of worthlessness or guilt
• Thoughts of suicide or suicide attempts

Treatment

• Light therapy
• Medications
• Counseling

By Chris E. Stout, Psy.D., M.B.A.

©2001-2021 Carelon Behavioral Health

Summary

• If you have chronic depression, you need to recognize it before you can get it treated.
• Positive lifestyle changes can help you conquer it.

Chronic depression is clinically significant depression that has lasted at least two years. It is more serious than short-lived depression. It takes the fun out of life. Relationships and work tend to suffer and you may care less and less about how you look. You may even neglect your health and medical issues. It is important to seek help if some of these symptoms sound familiar.

How do I know if I have chronic depression?

Before you can get help, you need to be seen by your doctor or someone with mental health training. Learning about depression will help you to avoid blaming yourself and feeling like a failure. A doctor will help you take stock of the problem and think about the next steps toward recovery. Don’t put this off, because your chances for wellness and recovery are better if you seek help earlier. Try not to let hopeless, negative thoughts keep you from getting help.

Other conditions can look like chronic depression. Your doctor will help you think about what is causing your symptoms. Identify the stressful events in your life. Follow up on health issues if they are present. Pay attention to psychiatric conditions other than depression and to the harmful effects of medicine, alcohol and recreational drugs. Any of these might need special attention if present.

How is it treated?

If chronic depression is present, you can help yourself by making changes in your lifestyle and by starting treatment. These approaches work together to help you get better faster and to stay healthier.

Think about your lifestyle. Do you stick to a healthy diet? You can get depressed when your diet is missing things that your body needs. Abusing alcohol or using recreational drugs can worsen symptoms of depression and make it harder to find relief.

What about your activity? Physical exercise is good not only for your body but also for your mind and your mood. Aerobic exercise and weight training both help you stay healthy, happy and fit.

Are you making enough time for fun? You will enjoy life more if you make time to do things that bring you joy. Go dancing, or to a movie or sports event. It may be more fun than you expect.

Are you keeping involved with people? Social interactions are a very important part of a healthy lifestyle. When you’re depressed, you probably don’t want to see anyone or do more than you need to do. But pushing yourself to do these things will help you recover better and more quickly. You may find it helpful to go to a support group. Check out the Depression and Bipolar Support Alliance, listed below, for a list of groups in your area.

Although making these kinds of lifestyle changes can be hard, there are many supports available to help you. Weight-loss groups and exercising with a buddy are some examples to consider.

If you have chronic depression, you should also get professional help, though fewer than half of people with it actually do. The help consists of talk therapy or psychotherapy, antidepressant medications, or the combination of both of these.

Studies have shown that antidepressants help many people with chronic depression. The newer pills, those that increase brain serotonin levels, are often successful in reducing the symptoms. They have mild side effects for most people. They may take time to work, or you may need to try more than one type to find the best one for you.

A few psychotherapies have been shown very effective in treating chronic depression. Cognitive-behavioral therapy (CBT) focuses on identifying and changing the self-defeating, negative thoughts that increase depression. A special form of CBT, the cognitive-behavioral analysis system of psychotherapy (CBASP), focuses on understanding the effects that behavior has on other people and teaches skills for changing those effects. Interpersonal therapy (IPT) targets problems related to interpersonal conflict, social role transitions, social skills deficits, and grief.

The combination of psychotherapy and medicine is fastest and most effective for many individuals. Psychotherapy is especially important for those chronically depressed people whose history included traumatic events. Try to find a therapist with specific experience treating chronic depression.

With lifestyle changes and treatment, chronic depression is likely to get better. It takes time, though, for improvement to occur. Hopelessness and thoughts of failure can get in the way of recovery. With the right kind of help and enough time, improvement is likely. Know that there is help and life can be much more rewarding and enjoyable after depression improves.

Resources

Depression and Bipolar Support Alliance

National Alliance on Mental Illness

By James M. Ellison, M.D., M.P.H.

©2012-2019 Carelon Behavioral Health

Source: Gelenberg AJ, Kocsis JH, McCullough JP et al. The state of knowledge of chronic depression. J Clin Psychiatry 2006;67(2):179-184; Torpey DC, Klein DN. Chronic depression: Update on classification and treatment. Current Psychiatry Reports 2008;10:458-464.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options

Summary

• Depression that lasts at least two years is called chronic.
• Chronic depression is serious but treatable.

Many of us wake each morning feeling happy and good. We look forward to being with other people, working, eating, exercising or having fun. We may be starting a busy and stressful day, but there will be moments that bring us joy. There may also be times when we are feeling sad or down. These periods may be brief lasting only a day or two.

However, for some of us, the day begins differently. Imagine waking up tired. You slept poorly and are in a bad mood. Your body aches. You don’t have much energy. Getting out of bed is almost too difficult. The day ahead looks hard. Nothing seems fun, but you have got to keep going. If this is how you feel most of the day, and if you have been feeling this way for several weeks, you may have depression. Chronic depression is repeated long-lasting bouts that come and go.

Understanding major depressive disorder

Depression is a complicated word. You might say you are depressed when you’re just feeling lousy for the moment. Major depressive disorder, though, is the disease of depression. That means having a low mood for more than two weeks, along with other problems such as changes in sleep, appetite, focus and interest. You might feel guilty, restless or have very low energy. You might even be thinking about ending your life. Major depressive disorder is diagnosed when a lot of these problems are present, but depression even with fewer symptoms can be very bad.

Understanding chronic depression

Most people with major depression feel better over time. With treatment such as medications or psychotherapy, many get better faster. But at least one in every five people with significant depression keeps on feeling that way for months. Once it has lasted at least two years, it is called a chronic depression.

Chronic depression comes in a few different forms. Some people have persistent depressive disorder (or dysthymia), a condition in which a person’s mood is depressed most of the day, more days than not, for at least two years. At least two of the following problems are also present during this time: appetite that is too low or too high, too much or too little sleep, low energy, low self-esteem, poor concentration or feelings of hopelessness. During this time, there is no break in the low mood and other problems that last longer than two months at a time. The mood problems can’t be blamed on drugs or medical conditions or other problems. The low mood gets in the way of working or getting along with other people. If someone with dysthymia gets depressed enough to fit the description for major depression, they are said to have double depression.

Chronic depression also can refer to an episode of major depression that has lasted at least two years or improved only partly.

Depression that begins earlier in life is more likely to become chronic. Chronic depression also can begin in later years. Having a family member with it can increase the risk of experiencing depression.

A depression that is chronic is more serious in some ways, because it is less likely to get better even with treatment. Chronic depression is often found in people with lower social support. It is linked, too, with a greater risk for having other issues such as alcohol or other drug problems. People with chronic depression are more likely to think about or complete suicide. They experience a sense of poorer health and a greater level of disability.

The good news

Chronic depression is serious and common, but it is a treatable condition. Treatment may be needed for a long time, since the risk for getting depressed again is high, but newer antidepressants and specially designed approaches to psychotherapy offer hope to many. With good treatment, there can be relief from depression and much greater happiness in life!

By James M. Ellison, M.D., M.P.H.

©2012-2021 Carelon Behavioral Health

Source: Gelenberg AJ, Kocsis JH, McCullough JP et al. The state of knowledge of chronic depression. J Clin Psychiatry 2006;67(2):179-184; H￶lzel L, H￤rter M, Reese C, et al. Risk factors for chronic depressionﾗa systematic review. J Affect Disord 2011;129(1-3):1-13; Klein DN, Shankman SA, Rose S. Ten-year prospective follow-up study of the naturalistic course of dysthymic disorder and double depression. Am J Psychiatry. 2006;163(5):872-80.

When someone has clinical depression, that person’s spouse or partner is affected as well. Depression can interfere with all aspects of a person’s life: work, sleeping and eating habits, and relationships.

If you or your partner is depressed, you may have noticed the following strains on your relationship.

The partner with depression may:

• Become distant, irritable, angry or sad
• Contribute less to the relationship and running of the household
• Lose interest in sex
• No longer enjoy going out as a couple or doing activities you used to do together

The partner who does not have depression may:

• Start to feel the other’s sadness, despair and hopelessness
• Become resentful and exhausted from taking on more of the parenting, chores and financial responsibilities
• Mourn the change in activities and social outings

It takes more work to keep your relationship strong when one of you has depression. Fortunately, depression is usually temporary when it’s treated. Both you and your partner have a role to play in treating the depression and helping one another through this difficult period.

If you have depression

Depression is treatable. You may feel like you will never be happy again, but by taking action, you should see your symptoms improve.

• Seek professional help. Your health care provider can help you find the right treatment for your depression, such as therapy, medications and lifestyle changes.
• Talk with your partner about what it is like to have depression. Your partner may believe they caused your unhappiness. Reassure them that’s not the case.
• Tell your partner how they can support you. Try to be specific about what you want and need. Your partner won’t know unless you tell them. 
• Focus on what you love about your partner rather than what annoys you. Depression can keep you from noticing the positive things in life. You may have to remind yourself to look for qualities you admire in your mate.
• Do something fun or physically active with your partner every day. Even if it’s just a 20-minute walk, it gets you both outside for fresh air and allows you to reconnect.

If your partner is depressed

It’s natural to feel confused and upset when the person you love becomes depressed. You may wonder if you caused it. At times, you may blame your partner for their behavior. Depression is a complex condition with many causes — it’s not either person’s fault. 

• Learn everything you can about the disease. Depression can take different forms, so ask your partner to describe how it affects them. This will help you understand what they are going through. It will also reassure both of you that no one is to blame for it.  
• Try to be patient with your partner. Depression is an illness. It’s unrealistic to expect them to “just cheer up.”  
• Find ways to keep your spirits up. Living with a person with major depression can sap your energy and bring your mood down. Do things you find uplifting; spend time with people whose company you enjoy.
• Try not to take things too personally. Depression may cause your loved one to be negative and critical. They may find fault with you or with something you did. Look for ways to get past the criticism so you don’t end up arguing.
• Understand that you can’t “fix” your partner’s depression. However, you can support their efforts to help themself.

When you’re in an intimate relationship, you share your life — good and bad — with someone else. As you find ways to stay close and support one another through periods of depression, your bond will become stronger and your relationship will be able to withstand difficult times.

By Sharron Luttrell, Military OneSource

All intimate partnerships have their ups and downs, but mental illness can cause much distress for both the person with the illness and for the partner. If left unchecked, it can strain a relationship to the breaking point.

Although at times it may seem like a hard task, there are steps you can take to help your partner, your relationship and yourself.

Helping your partner

The first step is to help your partner know there is an issue and accept the need for professional help. This can be hard to do, especially if the symptoms of the illness have come on over time. Other ways to help are to:

• Get feedback from people you trust. Talk with your health care provider, clergy or other professionals. They can serve as a sounding board for your concerns and point you to resources for more help.
• Get the right diagnosis and treatment. Know that you alone can’t make your partner better. Ask your doctor for a referral to a mental health expert. Don’t wait for a crisis to get help.
• Learn about your partner’s mental illness. Illnesses such as post-traumatic stress disorder, bipolar disorder, depression, obsessive-compulsive disorder and anxiety disorder each take their toll in unique ways. Know what you and your partner are dealing with by learning about the illness. Join a group devoted to the issue. Read books about it.
• Encourage your partner to follow the treatment plan including taking prescribed medication and going to therapy and other treatment sessions. If family treatment is available, go together.

Helping your relationship

Being in a strong, supportive relationship has a buffering effect on mental illness, while stress in a relationship can make symptoms worse.

• Put yourself in your partner’s shoes. Your loved one did not choose to have a mental health issue. When you find yourself getting mad or blaming them for acting a certain way, try to think about what it’s like to have a mental illness.
• Keep your interactions calm. Finding fault or reacting angrily to their actions may make the symptoms worse.
• Focus on your partner’s positive qualities. Remember what brought you together. The person you fell in love with may often be hidden by the illness, but is still there.
• Don’t treat your partner like a patient. The illness does not define your partner, so hold them to your usual expectations and standards, within reason. 

Helping yourself

Focusing on your partner’s needs while ignoring your own will lead to resentment and burnout. You might lose your temper or slowly pull away, both of which may make their symptoms worse. Here are ways to take care of yourself so you can help your partner get healthy:

• Don’t blame yourself. Mental illness has a biological component; you did not cause it. 
• Do things you enjoy. Boost your physical and emotional energy by making time for friends and hobbies.
• Be open about your partner’s illness. Embarrassment and shame can lead to seclusion at a time when you need more support than ever. Deepen your ties with others by being up front about your partner’s illness.
• Join a support group. Being with people in a similar situation is comforting and will allow you to share tips and advice for coping with your partner’s illness. Find one through your local hospital, community mental health agency or local chapter of the National Alliance on Mental Illness.

Source: Military OneSource

Summary

Factors that influence depression include:

• Stress
• Menopause
• Childbirth

Depression happens more often in women than in men. Reasons for this are due to the differences in women’s bodies, hormones, and their reactions to stress.

Family history

A family history of depression can add to a person’s chances of getting depression. But this is not a certainty in all families. Depression can also happen in women who have no family history of it. Research suggests that a mixture of family traits, where you live, and life events can cause it.

Chemicals and hormones

Brain chemicals play a big role in depression. The parts of the brain in charge of regulating mood, thinking, sleep, hunger, and actions work differently for women who are depressed. The substances that brain cells use to work with others are out of balance.

Studies have shown that hormones change the brain chemicals that control emotions and mood. Certain times during a woman’s life are of note. They include puberty, the time before periods, before, during, and just after having a baby, and right before and during the change of life.

Postpartum depression (PPD)

Having the “baby blues” is widely found in many new mothers. The baby blues is a brief period of mild mood changes. This is not the same as postpartum depression, or PPD. PPD is much more serious. It calls for active care and support for the new mother.

Women are vulnerable to getting PPD after giving birth because of the hormonal and physical changes that happen in a woman’s body after the baby is born. The new and demanding job of caring for a new baby can be hard. This, too, can lead to feelings of sadness. For a few months after giving birth, mothers have a higher chance of getting mental issues, including depression.

Many women who get PPD have had depression in the past. Some women get it while pregnant, but it often goes undetected. It is estimated that 10 percent to 15 percent of women get it after giving birth.

Premenstrual dysphoric disorder (PMDD)

Some women may also have a very bad form of premenstrual syndrome (PMS) called premenstrual dysphoric disorder (PMDD). PMDD is linked to the hormonal changes that typically happen near ovulation and before a woman’s period starts. Signs include feelings of sadness, nervousness, crankiness, and mood swings the week before the start of a period. They are so bad that they get in the way of daily routines.

Women who have debilitating PMDD do not necessarily have unusual hormone shifts. They have many responses to these changes. They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more likely to get menstruation-linked hormone changes.

Perimenopause

Perimenopause can also play a role in getting depression. It can add to stress levels and make hormonal imbalances that change mood and the way the mind works. Many women feel disoriented and confused by what is going on with them. Family history may also play a role.

Signs of later-stage perimenopause can include depression, sleep disruption, and “hot flashes.” Prior harmful events like problems with relationships, work, or social life can add to it. Also, former PPD or sexual abuse and a family history have been found to make depression worse in these women.

Women who have not had children and women who have taken antidepressants have a greater chance of getting depression during this time. Women who have had major depression or relatively mild signs during the menopausal transition tend to feel better with age.

The current thinking is that depressive symptoms during perimenopause are not just about shifting hormone levels. A number of reasons, including past emotional pain, may add to a woman’s vulnerability to depression during these years.

For some women, treating depression during this time may call for not only drugs but also talk therapy. It can help deal with current problems rooted in the past.

Menopause

The transition to the change of life can have many challenges. These can be in the body and relationships.

Hormonal changes increase during the switch from premenopause to menopause. Some women may transition into the change of life without any problems with mood. Others may have a higher chance of getting depression, no matter if they have had it in the past. It seems that depression becomes less widely found after menopause.

Stress

Many women face the added stresses of work and home duties. Or they may be caring for children and aging parents. Trauma, the loss of a loved one, relationships, and financial stress can also add to their chances of getting depression.

It is still not clear, though, why some women who are faced with very large challenges get depression, while others with like challenges do not. Studies have found that women react differently than men to such events, making them more likely to get depressed. It seems that women may react in such a way that draws out their feelings of stress more so than men. That may explain a higher chance of getting depression.

Getting help

Proper diagnosis of depression that leads to proper care can make a good change in a woman’s life. There are many proven therapies that can help.  

Counseling may be the best choice for mild to moderate depression. But this may not be enough. A mixture of medications prescribed by a psychiatrist combined with counseling may be most helpful. This can also lower the chances of the depression coming back.

If you think you have depression, let your doctor know. If you are pregnant, ask for an evaluation both during pregnancy and after giving birth. Depression in pregnancy can have negative effects on the developing child.

Resources

Postpartum Support International
(800) 944-4PPD (4773)
www.postpartum.net

Self-assessment

Wakefield Self-report
The Wakefield Self-Report Questionnaire gauges the severity of depression signs. The test gives point values to answers based on a numerical algorithm.
http://counsellingresource.com/lib/quizzes/depression-testing/wakefield/

By Chris E. Stout, Psy.D., Clinical Professor, Department of Psychiatry, College of Medicine, University of Illinois at Chicago

©2012-2019 Carelon Behavioral Health

Source: Hankin BL, Abramson LY. Development of gender differences in depression: an elaborated cognitive vulnerability-transactional stress theory. Psychological Bulletin. 2001 Nov; 127(6): 773-796. Calvete E, Cardenoso O. Gender differences in cognitive vulnerability to depression and behavior problems in adolescents. Journal of Abnormal Child Psychology. 2005 Apr; 33(2): 179-192. Cyranowski J, Frank E, Young E, Shear K. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry. 2000 Jan; 57(1): 21-27. National Institute of Mental Health; Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush JA. Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine. 2006 Mar 23; 354(12): 1243-1252. Marcus SM, Flynn HA, Blow F, Barry K. A screening study of antidepressant treatments and mood symptoms in pregnancy. Archives of Women’s Mental Health. 2005 May; 8(1): 25-27. Seattle Midlife Womenﾒs Health Study, Menopause, March/April 2008.

Reviewed by Philip Merideth, M.D., J.D., Physician Advisor, Beacon Health Options