Depression

with Ashwini Gundelly, M.D., Internal Medicine, Advanced Healthcare

Posted: June 1, 2004

It is estimated that 25 percent of women and 12 percent of men will experience at least one episode of major depression during their lifetimes. Primary risk factors are female gender; a history of depression in a parent, sibling or child; and a previous episode of major depression.

Other risk factors include a history of depression in a more distant relative, lack of social support, significant stressful life events and alcohol or substance abuse. Grief, a normal reaction to loss, is not classified as depression. A grieving person can, however, slide into depression. It’s up to the diagnostician to determine whether the grieving process has escalated into an episode of depression.

Ashwini Gundelly, M.D., Internist with Advanced Healthcare "Goals of treatment for depression include addressing the symptoms; addressing family, environmental and social issues that may play a role in depression; and enabling the depressed person to understand what brought about the depression and what changes are necessary to resolve symptoms and prevent a relapse."

“Up to 50 percent of primary care visits in an average clinic day have been estimated to involve some component of emotional distress that raises the possibility of a psychiatric condition,” said Dr. Ashwini Gundelly, an internist with Advanced Healthcare. “Depression itself is one of the top five diagnostic entities that occur in primary care settings.”

Most of her patients with depression don’t come in complaining of the condition. Instead, she said, they tell her they’re having a problem with insomnia or persistent fatigue, or sudden weight gain or loss. But all are physical symptoms of depression, a medical condition Dr. Gundelly said is characterized by a wide variety of symptoms, both psychological and physical.

The exact cause isn’t known, but researchers believe that chemicals in the brain, particularly serotonin, norephinephrine and dopamine, play a role. These neurochemicals play essential roles in all brain functions, including movement, sensation, memory and emotion.

Dr. Gundelly said everyone gets sad or depressed from time to time. The difference between someone who is feeling down and someone who needs treatment for depression is the duration of the bleak spell. If symptoms persist for two weeks or more with no letup and interfere with your daily activities, she said, you should see a doctor.

Signs of depression
Symptoms of depression, according to the DSM-IV, a diagnostic manual used by medical professionals, are: sadness most of the day, particularly in the morning; markedly diminished pleasure or interest in daily activities; significant weight loss or weight gain; insomnia or excessive sleep; agitated movements or very slow movements; fatigue or loss of energy; feelings of worthlessness or guilt; impaired concentration and indecisiveness; and recurring thoughts of death or suicide.

Patients with five or more of the symptoms are considered to have major depression. Those with between two and four suffer from atypical or minor depression.

Dysthmia is a particularly insidious form of the disease. A low-grade depression whose most prominent symptoms include absence of pleasure or interest in activities, low self-esteem and low energy, dysthmia can persist for two years or more.

Seasonal Affective Disorder is also a form of major depression. It differs from the others in that it is predictable, occurring at a particular time of year and recurring at regular, predictable intervals. The diagnosis is made if a patient experiences at least two major episodes of depression within a two-year period that meet the seasonal criteria.

Treatment
While there is no definitive test for the condition, blood tests are often done to rule out other medical conditions that could be causing the symptoms. Dr. Gundelly cited hypothyroidism as one example of a medical condition whose symptoms mirror those of depression. The causes and treatment, however, are completely different.

“Goals of treatment for depression include addressing the symptoms; addressing family, environmental and social issues that may play a role in depression; and enabling the depressed person to understand what brought about the depression and what changes are necessary to resolve symptoms and prevent a relapse,” she said.

While some patients are reluctant to accept a diagnosis of depression, she said, those who do end up recovering more quickly and are less likely to suffer a relapse in the future.

Treatment options may include psychotherapy, which involves a referral to a qualified therapist, drug treatment or a combination of both.

“Therapy with antidepressant drugs helps re-establish the normal balance of neurochemicals in the brain,” Dr. Gundelly said. Several classes of antidepressants have been developed (see below); clinicians rely on several factors in determining which drug is the best for a particular patient.

Medications for Depression
Neurochemicals play a role in depression. For that reason, several classes of drugs that work to regulate the production of serotonin, norepinephrine and dopamine, have been developed to treat the condition.

It takes about two to six weeks for antidepressants to work, and about 50 percent of people treated with these drugs respond positively. For those who do not respond within the eight-week period, different drugs are tried. For those on antidepressants, the medication should be continued for six to nine months after the symptoms subside if the depression was a first episode.

There are four main classes of antidepressant drugs, each with their own particular advantages and drawbacks. Doctors take several factors into account when initially prescribing an antidepressant, the most important of which is making sure any other drugs the patient is taking won’t cause a potentially dangerous interaction.

The most common first-line drugs prescribed for depression are the selective seratonin reuptake inhibitors (SSRI). They have the fewest side effects, and there is less danger of overdosing on these drugs. They work by increasing serotonin levels in the brain. Trade names include Prozac, Zoloft, Paxil, Celexa and Lexapro. The main side effects of these drugs include jitteriness, restlessness, headaches, sexual side effects, nausea and insomnia.

The tricyclic antidepressants alter levels of several different neurochemicals in the brain. Trade names include Tofrinel, Elavil, Norpramin and Pamelor. Because of numerous side effects and since the development of SSRIs, they are less commonly used as first-line antidepressants. Side effects include dry mouth, blurred vision, constipation, weight gain, sexual problems and rapid heartbeat. Some people with heart disease cannot take these drugs, as they can cause arrhythmias.

Monoamine Oxidase Inhibitors (MAOI) have been proven to be especially effective in treating atypical depression and were the first class of drugs used to successfully treat depression. They are not, however, the first choice of many doctors because of the possibility of potentially toxic interactions with tyramine, a chemical common in a variety of foods and beverages. People who take MAOIs must avoid grapefruit, fermented cheeses, imported beer, avocados, champagne, soy sauces, bananas, any fermented smoked or aged fish or meat. Trade names include Parnate and Nardil.

The heterocyclic class of antidepressants includes Wellbutrin, which has been especially effective in people who have symptoms of fatigue and poor concentration. Although it has few side effects, it has been associated with seizures when treating people with eating disorders. Unlike other antidepressants, it doesn’t have sexual side effects.

Drugs that fall into other classes include Effexor, which is effective in people who have responded poorly to other treatments. Common side effects include insomnia, dizziness, nausea, sedation and constipation. Patients on Effexor need to have their blood pressure monitored, as the drug can cause it to rise. Serzone also has fewer sexual side effects, its other side effects are dry mouth, constipation, nausea, sedation and dizziness. The most common side effect of Trazodone is sedation, in rare cases it can cause irregular heartbeat or priapism. Remeron, one of the newer antidepressants, is particularly effective in patients who also suffer from anxiety and insomnia. Its most common side effect is sedation.

We Have Answers Do you have medical questions or need help finding a doctor? The experts at Columbia St. Mary's and Advanced Healthcare can help. Click here.