Depression

Depression is a common response to certain events and circumstances. Feeling “blue” from time to time is a part of everyday life and does not require treatment. Depression only becomes a problem when it interferes with normal social, occupational, or academic functioning.

This second kind of depression is estimated to affect over thirty million Americans. In most cases, depression can be easily recognized and cured. Openly discussing your feelings and symptoms with your physician is the first—and perhaps the most important—step you can take toward eventual recovery.

Types of Depression

The American Psychiatric Association has defined depression, in part, as a “loss of interest or pleasure in all or almost all usual activities and pastimes.” There are, however, many different types of depression, each having its own unique characteristics and method treatment.

Reactive depression.

Depression that results from a difficult or stressful life circumstance—such as the loss of a loved one or a job or a prolonged illness—is referred to as reactive depression. Grief is a common type of reactive depression.

Physically based depression.

Some types of depression are associated with or believed to be caused by physical or biochemical changes in the brain. A shortage of certain brain chemicals or changes in brain receptors may be responsible for depression in some individuals. Because depression tends to run in families, some people may even have a genetic tendency to develop it. Depression may occur as a reaction—probably biochemical—to such infectious diseases as hepatitis, mononucleosis, and tuberculosis. In addition, a number of drugs, particularly central nervous system depressants (“downers”) such as alcohol and barbiturates, may cause feelings of depression.

Manic depression.

Also known as bi-polar disorder, the third major type of depression is characterized by periods of intense excitement and creativity alternating with bouts of severe despair. These seemingly inexplicable mood swings also appear to have a biochemical basis and can be brought under control through medical treatment.

Outward signs

Depressive illness makes itself known in a variety of ways. One of the most common is some kind of physical ailment, such as a digestive problem, frequent headaches, or other pains, fatigue, or nervousness. Indeed, such complaints are often the reason why people with depression initially visit a doctor. But by probing deeper, a doctor may uncover certain other things that have been happening recently, such as:

• difficulty in falling or staying asleep or feeling excessively sleepy
• frequent or unexplainable crying spells
• inability to concentrate or remember recent events
• feeling of worthlessness, guilt, or self-blame
• loss of appetite or compulsion to overeat, with noticeable weight change
• periods of intense activity or severe slowing of physical movement
• loss of interest or pleasure in usual activities or decrease in sexual drive
• decrease in energy or increased fatigue
• recurrent thoughts of death or suicide or attempted suicide

Of course, any one of these symptoms, by itself, is just a normal part of daily living. But when they occur in combination and persist for at least a couple of weeks, the chances are that the cause is actually depression. Recognizing these symptoms and discussing them with your doctor is important, not only to establish the need for specific treatment but also to gauge the effect of the treatment prescribed for you.

Treatment

Depression can be treated successfully in a variety of ways, both medical and non-medical. Discussing your feelings of depression with your physician is an important first step. Keep the channels of communication open by accurately reporting your symptoms to your doctor. The course of treatment chosen will depend largely on your participation.

There are ways you can deal with depression on your own. Moderate exercise can be of great benefit to you in overcoming your depression. It may be difficult to get started initially, but regular exercise (daily if possible) can help you sleep better and lift your mood. Involve yourself in projects you enjoy in spite of the temptation to withdraw from activities, friends, and family. Keeping active is important during a bout with depression, but do not overdo it. You may want to balance physical and social activity with periods of relaxation or meditation. Talking over your feelings with a family member or a close friend will help you “air things out” and feel less alone. Avoid napping, which may worsen insomnia, and consuming alcohol or taking un-prescribed (illicit) drugs, which are only a temporary escape from your real problems and may make you feel worse in the long run.

Formal treatment of depression usually involves psychotherapy or the use of prescription medications, and sometimes both. Psychotherapy involves talking over your problems with a trained professional—a clinical psychologist, psychiatrist, or psychiatric social worker—who will encourage you to examine your current situation and help you identify the sources of your conflicts, frustrations, and unhappiness. Once discovered, efforts can be made to change the negative patterns and habits that may be contributing to your depressed mood.

If taking medication is part of your treatment, remember to take it only as directed by your physician. There are many drugs available for use in depression. The type your doctor chooses will depend on the nature of your depression and the symptoms you may be experiencing along with it. It may take one to several weeks to feel the full beneficial effects, so do not get discouraged. As with any medication, there may be side effects: report them to your doctor. In some cases, the side effects will disappear with continued use of the medication. In other cases, the dosage may need to be altered. If you drive, it may be wise to determine how you react to the drug prescribed to you before operating a vehicle. Do not drink wine, beer, or any other alcoholic beverage while taking an anti-depressant drug. Certain anti-depressants also require a change in diet; if your doctor has mentioned specific foods to be avoided, follow his or her instructions completely.

Summing up

Depression can be a serious illness that interferes with the ability to function and cope with daily life. Fortunately, a number of effective treatments for depression have been developed, and most people now recognize that telling a depressed person to cheer up is not likely to do much good. Most cases of depression improve with treatment. You or any individual suffering from depression can learn how to avoid unnecessary stressful situations and achieve a greater sense of balance through a specifically prescribed combination of self-awareness, suitable mediation, and, where indicated, a program of counseling, psycho-therapy, or other forms of treatment. Depression, no matter what its cause, is nothing to be ashamed of. Getting it out in the open is the best way to overcome it.

Questions and Answers about Depression

Q. What is depression?

Being clinically depressed is very different from the down type of feeling that all people experience from time to time. Occasional feelings of sadness are a normal part of life, and it is that such feelings are often colloquially referred to as "depression." In clinical depression, such feelings are out of proportion to any external causes. There are things in everyone's life that are possible causes of sadness, but people who are not depressed manage to cope with these things without becoming incapacitated.

As one might expect, depression can present itself as feeling sad or "having the blues". However, sadness may not always be the dominant feeling of a depressed person. Depression can also be experienced as a numb or empty feeling, or perhaps no awareness of feeling at all. A depressed person may experience a noticeable loss in their ability to feel pleasure about anything. Depression, as viewed by psychiatrists, is an illness in which a person experiences a marked change in their mood and in the way they view themselves and the world. Depression as a significant depressive disorder ranges from short in duration and mild to long term and very severe, even life threatening.

Depressive disorders come in different forms, just like other illnesses such as heart disease. The three most prevalent forms are major depression, Dysthymia, and bipolar disorder.

Q. What is major depression?

Major depression is manifested by a combination of symptoms (see symptom list below) that interfere with the ability to work, sleep, eat; and enjoy once-pleasurable activities. These disabling episodes of depression can occur once, twice, or several times in a lifetime.

Q. What is Dysthymia?

A less severe type of depression, Dysthymia, involves long-term, chronic symptoms that do not disable, but keep you from functioning at "full steam" or from feeling good. Sometimes people with Dysthymia also experience major depressive episodes.

Q. What is bipolar depression (manic-depressive illness)?

Another type of depressive disorder is manic-depressive illness, also called bipolar depression. Not nearly as prevalent as other forms of depressive disorders, manic depressive illness involves cycles of depression and elation or mania. Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, you can have any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all symptoms listed under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, unwise business or financial decisions may be made when in a manic phase.

Q. What is Seasonal Affective Disorder (SAD)?

SAD is a pattern of depressive illness in which symptoms recur every winter. This form of depressive illness often is accompanied by such symptoms as marked decrease in energy, increased need for sleep, and carbohydrate craving. Phototherapy - morning exposure to bright, full spectrum light - can often be dramatically helpful.

Q. What is Post Partum Depression?

Mild moodiness and "blues" are very common after having a baby, but when symptoms are more than mild or last more than a few days, help should be sought. Post partum depression can be extremely serious for both mother and baby.

Q. How is bereavement different from depression?

A full depressive syndrome frequently is a normal reaction to the death of a loved one (bereavement), with feelings of depression and such associated symptoms as poor appetite, weight loss, and insomnia. However, morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation are uncommon and suggest that the bereavement is complicated by the development of a Major Depression. The duration of "normal" bereavement varies considerably among different cultural groups.

Q. What is Endogenous Depression?

A depression is said to be endogenous if it occurs without a particular bad event, stressful situation or other definite, outside cause being present in the person's life. Endogenous depression usually responds well to medication. Some authorities do not consider this to be a useful diagnostic category.

Q. What is atypical depression?

"Atypical depression" is not an official diagnostic category, but it is often discussed informally. A person suffering from atypical depression generally has increased appetite and sleeps more than usual. An atypical depressive may also be able to enjoy pleasurable circumstances despite being unable to seek out such circumstances. This contrasts with the "typical" depressive, who generally has reduced appetite and insomnia, and who is often unable to find pleasure in anything. Despite its name, atypical depression may in fact be more common than the other kind.

Symptoms

Q. What are the typical symptoms of depression?

A depressive disorder is a "whole-body" illness, involving your body, mood, and thoughts. It affects the way you eat and sleep, the way you feel about yourself, and the way you think about things. A depressive disorder is not a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help over 80% of those who suffer from depression. Bipolar depression includes periods of high or mania. Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Also, severity of symptoms varies with individuals.

Symptoms of Depression:

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that you once enjoyed, including sex
• Insomnia, early-morning awakening, or oversleeping.
• Appetite and/or weight loss or overeating and weight gain
• Decreased energy, fatigue, feeling "slowed down"
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Difficulty concentrating, remembering, making decisions
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Symptoms of Mania:

• Inappropriate elation
• Inappropriate irritability
• Severe insomnia
• Grandiose notions
• Increased talking
• Disconnected and racing thoughts
• Increased sexual desire
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

Q. What are the diagnostic criteria for depression?

Depression comes in many forms and in many degrees. Below, you will find some of the most common depressive types, along with some of the diagnostic criteria from the DSM-IV (the official diagnostic and statistical manual for psychiatric illnesses).

*Major Depression is the most serious type of depression. Many people with a major depression can not continue to function normally. The treatments for this are medication, psychotherapy and, in extreme cases, electroconvulsive therapy (ECT).

Diagnostic criteria: A. At least five of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood, or (2) loss of interest or pleasure. (Do not include symptoms that are clearly due to a physical condition, mood incongruent delusions or hallucinations, incoherence, or marked loosening of associations.)

1. depressed mood most of the day, nearly every day, as indicated either by subjective account or observation by others
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation by others of apathy most of the time)
3. significant weight loss or weight gain when not dieting (e.g. more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness nearly every day (either by subjective account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Causes

Q. What causes depression?

The groups of symptoms which doctors and therapists use to diagnose depression ("depressive symptoms"), which includes the important provision that the symptoms have manifested for more than a few weeks and that they are interfering with normal life, are the result of an alteration in brain chemistry. This alteration is similar to temporary, normal variations in brain chemistry which can be triggered by illness, stress, frustration, or grief, but it differs in that it is self-sustaining and does not resolve itself upon removal of such triggering events (if any such trigger can be found at all, which is not always the case.)

Instead, the alteration continues, producing depressive symptoms and through those symptoms, enormous new stresses on the person: unhappiness, sleep disorders, lack of concentration, difficulty in doing one's job, inability to care for one's physical and emotional needs, strain on existing relationships with friends and family. These new stresses may be sufficient to act as triggers for continuing brain chemistry alteration, or they may simply prevent the resolution of the difficulties which may have triggered the initial alteration, or both.

The depressive brain chemistry alteration seems to be self-limiting in most cases: after one to three years, a more normal chemistry reappears, even without medical treatment. However, if the alteration is profound enough to cause suicidal impulses, a majority of untreated depressed people will in fact attempt suicide, and as many as 17% will eventually succeed. Therefore, depression must be thought of as a potentially fatal illness. Friends and relatives may be deceived by the casual way that profoundly depressed people speak of suicide or self-mutilation. They are not casual because they "don't really mean it"; they are casual because these things seem no worse than the mental pain they are already suffering. Any comment such as, "You'd be better off if I were gone," or "I wish I could just jump out a window," is the equivalent of a sudden high fever; the depressed person must be taken to a professional who can monitor their danger. A formulated plan, such as, "I'm going to jump in front of the next car that comes by," is the equivalent of sudden unconsciousness: an immediate medical emergency which may require hospitalization.

Depression can shut down the survival instinct or temporarily suppress it. Therefore, depressed suicidal thinking is not the same as the suicidal thinking of normal people who have reached a crisis point in their lives. Depressive suicides give less warning, need less time to plan, and are willing to attempt more painful and immediate means, such as jumping out of a moving car. He or she may also fight the impulse to suicide by compromising on self-injury - cutting themselves with knives, for example, in an attempt to distract his or herself from severe mental pain. Again, relatives and friends are likely to be astonished by how quickly such an impulse can appear and be acted upon.

Q. What initiates the alteration in brain chemistry?

It can be either a psychological or a physical event. On the physical side, a hormonal change may provide the initial trigger: some women dip into depression briefly each month during their premenstrual phase; some find that the hormone balance created by oral contraceptives disposes them to depression; pregnancy, the end of pregnancy, and menopause have also been cited. Men's hormone levels fluctuate as deeply but less obviously.

It is well known that certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, and Parkinsonism. This seems to be the result of a chemical effect rather than a purely psychological one, since other, equally traumatic and serious illnesses don't show the same high risk of depression.

Q. Is a tendency to depression inherited?

It seems there are some people whose brain chemistry is predisposed to the depressive response, and others who are at much lower risk of depression even if exposed to the same physical or psychological triggers. The genetic relations of manic-depressives are at a higher risk for unipolar depression than the population at large or their adopted/by marriage relations. There seems to be a link between high creativity and the gene for manic-depression: artists and writers often are not manic-depressive themselves, but have a family member who is. Studies of families in which members of each generation develop manic-depressive illness found that those with the illness have a somewhat different genetic make-up than those who do not get ill. However, the reverse is not true: not everybody with the genetic make-up that causes vulnerability to manic-depressive illness has the disorder. Apparently additional factors, possibly a stressful environment, are involved in its onset.

Major depression also seems to occur in some families generation after generation. However, depression can occur in people with no family history of any form of mental illness. Similarly, there is no evidence of individuals who are entirely immune to depression under all possible conditions.

Psychological triggers: many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to astonishingly virulent and inappropriate guilt and self-hatred.

The (genuine) life events that most often appear in connection with depression are various, but there is one distinguishing feature that appears in many cases, over and over: loss of self-determination, of empowerment, of self-confidence. More profoundly: a loss of self, of the abilities or activities that a person identifies with herself. Stereotypically: a man loses the job that had defined him to himself and others, whether that definition was "executive" or "breadwinner"; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. It could be, in general, any life change, often caused by events beyond one's control, which damages the structure that gave life meaning.

The ability of a person to respond to such an event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors which may best be explored in talk therapy: why is the person's self-esteem so bound up in the position or state that has been lost? Can she find a new source of self-esteem? Therapy can be immensely helpful here.

Obviously, not everyone to whom this sort of event happens becomes depressed, and not every person who becomes depressed has had this sort of catastrophe befall them. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious trigger, psychological or physical.

Some depressions may well be caused by a spontaneous aberration in brain chemistry, with no trigger that we can currently identify, just as a seizure or migraine may have an obvious trigger or be apparently spontaneous.

However, once the depressive state has set in, both physical and psychological problems will be generated in abundance. What faster way to lose a job or a spouse than to be too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically promoted, pathological self-hatred? And what can be worse for self-esteem than watching one's appearance and household disintegrate as one loses the motivation to shower, straighten up, wash dishes or laundry, or choose presentable clothes? Health deteriorates as well: some depressed people can't sleep or eat, others sleep constantly (a real help on the job!) and eat incessantly, sometimes in order to stay awake, sometimes because it's the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, so there may be an element of self-medication here); almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression.

The question, "Is depression mostly physical or psychological," is rather beside the point. Depression may be triggered by either physical or psychological events. Most commonly, both seem to be involved, though it is often difficult to separate the two when one is talking about psychology and neurochemistry. But however it begins, depression quickly develops into a set of physical and psychological problems which feed on each other and grow. This is why a combination of physical and psychological intervention has been shown to give the best results for most patients, regardless of any classifications that doctors may have tried to impose on their depression and its cause.

Treatment

Q. What sorts of psychotherapy are effective for depression?

Two effective methods of psychotherapy for people with depressions are cognitive therapy and interpersonal therapy.

Both psychoanalysis and insight oriented psychotherapy have not been shown to be effective treatments for people with a depressive disorder.

Q. Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?

There are very few kinds of depression for which there are specific antidepressant treatments. When it comes to people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause depressed bipolar people not just to come out of their depressions, but to develop manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed bipolar patients are on a mood stabilizer such as lithium, Tegretol, or Depakote when they are started on an antidepressant.

Q. How do you tell when a treatment is not working? How do you know when to switch treatments?

Antidepressant treatment is clearly not working when the individual receiving the treatment remains depressed or becomes depressed again. When a recently started antidepressant fails to cause improvement, the depressed individual often asks that the medication be stopped, and a new one started. It generally does not make sense to change antidepressants until 8-weeks at the maximum tolerated dose have elapsed. With some tricyclic antidepressants, it is important to check the blood level of the antidepressant before it is stopped. The blood test can tell if the amount in the blood has been adequate. Only after an adequate trial of one antidepressant should another be tried. To have been on four antidepressants in an 8-week period means that one has not had an adequate trial on any of them.

Q. How do antidepressants relieve depression?

There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain's concentration of molecules, receptors, to which these transmitters bind. In some unknown way it is the changes in the receptors that are thought responsible for improvement.

Q. Are Antidepressants just "happy pills?"

No matter what their exact mode of action may be, it is clear that antidepressants are not "happy pills." There is no street-market in antidepressants, for, unlike "speed" which will improve the mood of almost everybody, antidepressants only improve the mood of depressed people. Also unlike the almost instant effects of speed, the mood-improving effects of antidepressants develop slowly over a number of weeks. "Speed" induces a highly artificial state, while antidepressants cause the brain to slowly increase its production of naturally occurring neurotransmitters.

Q. What percentage of depressed people will respond to antidepressants?

Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken have an excellent chance of responding to another.

Q. What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?

The most common description of the effects of antidepressants is that of feeling the depression gradually lift, and for the person to feel normal again. People who have responded to antidepressants are not euphoric. They are not unfeeling automatons. They are still able to feel sad when bad things happen, and they are able to feel very happy in response to happy events. The sadness they feel with disappointments is not depression but is the sadness anyone feels when disappointed or when having experienced a loss. Antidepressants do not bring about happiness, they just relieve depression. Happiness is not something that can be had from a pill.

Q. What are the major categories of antidepressants?

There are many classes of antidepressants. Two kinds of antidepressants have been around for over 40 years. These are the tricyclic antidepressants and the monoamine oxidase inhibitors. While there are newer antidepressants, many with fewer side-effects, none of the newer antidepressants has been shown to be more effective than these two classes of drugs. In fact, many people who have not responded to newer antidepressants have been successfully treated with one of these classes of drugs.

The tricyclic antidepressants (TCAs) include such drugs as imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor).

The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and selegiline (Emsam) which is the first transdermal antidepressant patch introduced in the market.

One of the popular new classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft) and paroxetine (Paxil) soon followed.  Citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro) are newer additions to this class.  The newest SSRI in the market right now is vilazodone (Viibryd), introduced in 2011.

Another class of antidepressants that is gaining popularity is the serotonin-norepinephrine reuptake inhibitor (SNRI).  This class was first introduced in 1994 with the production of venlafaxine (Effexor).  Soon after, other SNRI’s were added, such as duloxetine (Cymbalta) and desvenlafaxine (Pristiq).

Bupropion (Wellbutrin) is the only drug in its class, as is Trazodone (Desyrel).

Q. What are the side-effects of some of the commonly used antidepressants?

Below is a list of some of the more frequently prescribed antidepressants, and their most common side effects. The figure following each side effect is the percentage of people taking the medication who experience that side effect.

Aventyl (nortriptyline): Dry mouth; Constipation; Weakness-fatigue; Tremor.

Effexor (Venlafaxine) Nausea; Headache; Sleepiness; Dry mouth; Insomnia; Constipation

Elavil (amitriptyline): Dry mouth; Drowsiness; Weight gain; Constipation; Sweating.

Nardil (phenelzine): dry mouth; insomnia; increased heart rate; Lowered blood pressure; Sedation; Over stimulation;

Norpramin (desipramine): dry mouth; increased pulse; constipation; reduced blood pressure.

Pamelor - see Aventyl

Parnate (tranylcypromine) Dry mouth; Insomnia; Increased pulse rate; Lowered blood pressure; Over stimulation; Sedation.

Paxil (paroxetine): decreased sexual interest and/or problems achieving orgasm; nausea; sedation; dizziness; insomnia.

Pristiq (desvenlafaxine): headache; dry mouth; nausea; diarrhea; fatigue; constipation; palpitations.

Prozac (fluoxetine): decreased sexual interest and/or problems achieving orgasm; nausea; headache; nervousness; insomnia; diarrhea.

Sinequan (doxepin): dry mouth; sedation; weight gain; lowered blood pressure; constipation; sweating.

Tofranil (imipramine): dry mouth; reduced blood pressure; constipation; difficulty with urination.

Viibryd (vilazodone): diarrhea; vomiting; insomnia

Wellbutrin (bupropion): agitation; weight loss; dizziness; decreased appetite;

Zoloft (sertraline): nausea; headache; diarrhea; insomnia; dry mouth; sedation.

Q. What are some techniques that can be used by people taking antidepressants to make side effects more tolerable?

Listed below are some frequent side effects of antidepressants, and some techniques to reduce their severity:

Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask your dentist to suggest a fluoride rinse to prevent cavities, visit the dentist more often than usual for tooth and gum hygiene

Constipation: Drink at least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about taking a bulk producing agent such as Metamucil, also ask about taking a stool softener such as Colace, be sure to avoid laxatives such as Ex-Lax.

Bladder problems: The effects of some antidepressants, especially the tricyclic medications may make it difficult for you to start the stream of urine. There may be some hesitation between the time you try to urinate and the time your urine starts to flow. If it takes you over 5-minutes to start urinating, call your doctor.

Blurred vision: The tricyclic antidepressants may make it difficult for you to read. Distant vision is usually unaffected. Changing your glasses prescription can usually compensating for any changes in your vision.  As you may compensate for the change in your vision, try to postpone getting new glasses as long as possible.

Dizziness: Dizziness when getting out of bed, when standing up from a chair, or when climbing stairs may be a problem when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing posture slowly may help prevent this kind of dizziness. Drinking adequate amounts of liquid and eating enough salt each day is important. Be sure to speak to your doctor if this side-effect is severe.

Drowsiness: This side effect often passes as you get used to taking the antidepressant that has been prescribed for you. Ask your doctor if it is safe for you to increase your intake of caffeine, and if so, by how much. If you are drowsy be sure not to drive or operate dangerous machinery.

Q. Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?

Both lowered sexual desire and difficulties having an orgasm, in both men and women, are particularly a problem with the selective serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and the monoamine oxidase inhibitors (Nardil and Parnate). There is no treatment for decreased sexual interest except lowering the dose or switching to a drug that does not have sexual side effects such as bupropion (Wellbutrin). Difficulty having orgasms may be treated by a number of medications. Among those medications are: Periactin, Urecholine, and Symmetryl. None of these are over-the-counter drugs and they must be prescribed by a physician. Unfortunately, many psychiatrists are not familiar with using these medications to treat the sexual side-effects of antidepressants.

Q. What should I do if my antidepressant does not work?

Many people decide prematurely that their antidepressant is not working. When one starts an antidepressant the hope is for rapid relief from depression. What must be remembered is that for an antidepressant to work, you must be on an adequate dose of the drug for an adequate length of time. A fair trial of any antidepressant is at least two months (8 weeks).  Before the conclusion of a two month trial the only reason to abandon an antidepressant trial is if the medication is causing severe side effects. With many antidepressants the dose has to be increased at intervals far above the starting dose. Unfortunately, the two-month period mentioned above, refers to two months following the most recent increase in the dose, not the time from starting the particular antidepressant.

Q. If an antidepressant has produced a partial response, but has not fully eliminated depression, what can be done about it?

There are many techniques to help an antidepressant work more completely. The simplest is to increase the dose until relief is experienced or side-effects are too severe. If the dose can not be increased, lithium can be added to any antidepressant to augment its effect. With all antidepressants it is possible to add small doses of stimulants such as pemoline (Cylert), methylphenidate (Ritalin), or dextroamphetamine (Dexedrine) to augment the antidepressant effect. Selective serotonin re-uptake inhibitors often work better when small doses of desipramine (Norpramin) or nortriptyline (Aventyl and Pamelor) are co-administered. Thyroid hormones (Synthroid or Cytomel) may be used to augment any antidepressant. At times combinations of these techniques may be utilized.

Q. What is electroconvulsive therapy (ECT) and when is it used?

ECT is an effective form of treatment for people with depressions and other mood disorders. ECT may be used when a severely depressed patient has not responded to antidepressants, is unable to tolerate the side effects of antidepressants, or must improve rapidly. Some depressed people simply do not respond to antidepressants or mood controlling drugs, and ECT is a way for such people to be effectively treated. ECT is utilized in the treatment of both mania and depression. There are some people who because of severe physical illness are unable to tolerate the side-effects of the medications used to treat mood disorders. Many of these people can successfully be treated with ECT. Pregnant women and people who have recently had heart attacks can be safely treated with ECT. Because of time pressure regarding occupational, social, or family events, some people do not have the time to wait for antidepressants or mood regulating medications to become effective. As ECT quite regularly brings about improvement within two or three weeks, people who are under such time pressure are also excellent candidates for ECT.

Q. Exactly what happens when someone gets ECT?

The physician must fully explain the benefits and dangers of ECT, and the patient give consent, before ECT can be administered. The patient should be encouraged to ask questions about the procedure and should be told that consent for treatments can be withdrawn at any time, and in the event that this happens, the treatments will be stopped. After giving consent, the patient undergoes a complete physical examination, including a chest x-ray, electrocardiogram, and blood and urine tests. A series of ECT usually consists of six to twelve treatments. Treatments can be administered to either in-patients or out-patients. Nothing should be taken by mouth for 8-hours prior to a treatment. An intravenous drip is started and through it medications to induce sleep, relax the muscles of the body, and reduce saliva are given. Once these medications are fully effective, an electrical stimulus is administered through electrodes to the head. The electrical stimulus produces brain wave (EEG) changes that are characteristic of a grand mal seizure. It is believed that this seizure activity leads to the clinical improvement seen after a series of ECT. About 30-minutes after the treatment the patient awakens from sleep. While confused at first, the patient is soon oriented enough to eat breakfast, and return home if the treatments are being done in an outpatient setting.

Q. How do individuals who have had ECT feel about having had the treatments?

In studies of people treated with ECT it has been found that 80% of such people report that they were helped by the treatments. About 75% say that ECT is no more frightening than going to the dentist.

Q. How long do the beneficial effects of ECT last?

While ECT is a highly successful way of helping people come out of depressions, it has to be followed by antidepressant therapy. If antidepressants are not administered after a series of ECT, there is a 50% relapse rate within 6-months.

Q. Is it true that ECT causes brain damage?

There is no scientific evidence that ECT causes brain damage. A woman who had over 1,000 ECT died of natural causes, and her brain was examined for evidence of ECT-induced brain damage. None was found. ECT does cause memory problems. These memory problems may take a number of months to clear. A small number of people who have received ECT complain of longer lasting memory problems. Such problems do not show up on psychological tests, it is not clear what causes them.

Q. Why is there so much controversy about ECT?

There is little controversy about ECT among psychiatrists. Much of the opposition to ECT seems political in nature and originates in the anti-psychiatry groups that oppose the use of Ritalin for the treatment of children with attention deficit disorder, and who oppose the use of Prozac for the treatment of depressed people.

Substance Abuse

Q. May I drink alcohol while taking antidepressants?

There are a number of problems with the mixture of alcohol and antidepressants. First, antidepressants may make you especially susceptible to the intoxicating effects of alcohol. Second, if you drink more than three or four drinks a week, the effects of alcohol may prevent the antidepressants from working. Reducing or eliminating alcohol intake can cause many people to see an improved benefit from antidepressants.  Third, you may be taking along with the antidepressant a drug such as Clonazepam (Klonopin) with which one should not drink at all.

Q. If I plan to drink alcohol while on medication, what precautions should I take?

There is much misinformation about drinking while on antidepressants. Alcohol can prevent antidepressants from being effective. This is not so much because it interferes with the absorption of antidepressants; it is because of the effects of alcohol upon brain chemistry. Antidepressants can also increase one's susceptibility to the intoxicating effects of alcohol. Also, both alcohol and some antidepressants (especially Wellbutrin) increase the possibility of seizures.

If you are determined to drink despite taking antidepressants you should discuss the matter with your psychiatrist. If you get permission you might want to determine the extent to which the medication has made you more sensitive to the alcohol. You might start by seeing what the effects of half a glass of wine are. You might then experiment with a full glass. Remember, a 4 oz. glass of wine, a 12 oz. bottle of beer, and 1 oz. of hard liquor all contain a relatively similar amount of alcohol.

Q. What's the relationship between depression and recovery from substance abuse?

It is not unusual for people who have recently been withdrawn from alcohol, or other addictive drugs to become depressed. These depressions are often self-limited, and clear in about 8-weeks. If depression has not cleared by the end of that period, anti-depressant therapy should be started.

Q. What does the term "dual-diagnosis" mean?

Dual-diagnosis is a phrase used to indicate the combination of substance abuse and a psychiatric disorder. A path to alcohol or other substance abuse is an attempt to self-medicate uncomfortable symptoms such as depression, anxiety, agitation or feelings of emptiness. The psychiatric disorders that cause such symptoms are often diagnosed in substance abusers.

Q. Is it safe for a person recovering from substance abuse to take drugs?

People recovering from substance abuse can safely take many kinds of psychiatric drugs. Most psychiatric drugs are unable to be abused. The best evidence for this is that there are not street markets for such drugs. On the other hand, The Benzodiazepines (diazepam [Valium], Lorazepam [Ativan], Alprazolam [Xanax], etc.) and the psycho-stimulants (dextroamphetamine [Dexedrine], methamphetamine [Desoxyn], and Ritalin [methylphenidate]) are quite addictive.

For people active in AA please read the pamphlet "The AA Member--Medications & Other Drugs." This outlines AA's official attitude toward medication--that it is necessary for certain illnesses including depression. Too many depressed people who have been talked out of taking antidepressants by members of their AA groups have killed themselves as a result.

Q. How do you know when depression is severe enough that help should be sought?

Professional help is needed when symptoms of depression arise without a clear precipitating cause, when emotional reactions are out of proportion to life events, and especially when symptoms interfere with day-to-day functioning. Professional help should definitely be sought if a person is experiencing suicidal thoughts.

Getting Help

Q. How should family and friends help the depressed person?

The most important things anyone can do for depressed people are to help them get appropriate diagnosis and treatment. This may involve encouraging a depressed individual to stay with treatment until symptoms begin to abate (several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always report them to the doctor. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon.

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

Self-care

Q. How can I help myself get through depression on a day-to-day basis?

Write. Keep a journal. Somehow, writing everything down helps keep the misery from running around in circles.

In general, It is extremely important to try to understand if something you can't seem to accomplish is something you simply CAN'T do because you're depressed (write a computer program, be charming on a date), or whether its something you CAN do, but it's going to be hell (cleaning the house, going for a walk with a friend, getting out of bed). If it turns out to be something you can do, but don't want to, try to do it anyway. You will not always succeed, but try. And when you succeed, it will always amaze you to look back on it afterwards and say "I felt like such shit, but look how well I managed to...!" This last technique, by the way, usually works for body stuff only (cleaning, cooking, etc.). The brain stuff often winds up getting put off until after the depression lifts.

Do not set yourself difficult goals or take on a great deal of responsibility.

Break large tasks into many smaller ones, set some priorities, and do what you can, as you can.

Do not expect too much from yourself. Unrealistic expectations will only increase feelings of failure, as they are impossible to meet. Perfectionism leads to increased depression.

Try to be with other people; it is usually better than being alone.

Participate in activities that may make you feel better. You might try mild exercise, going to a movie, a ball game, or participating in religious or social activities. Don't overdo it or get upset if your mood does not greatly improve right away. Feeling better takes time.

Do not make any major life decisions, such as quitting your job or getting married or separated while depressed. The negative thinking that accompanies depression may lead to horribly wrong decisions.

If pressured to make such a decision, explain that you will make the decision as soon as possible after the depression lifts. Remember you are not seeing yourself, the world, or the future in an objective way when you are depressed.

While people may tell you to "snap out" of your depression, that is not possible. The recovery from depression usually requires antidepressant therapy and/or psychotherapy. You cannot simple make yourself "snap out" of the depression. Asking you to "snap out" of a depression makes as much sense as asking someone to "snap out" of diabetes or an under-active thyroid gland.

Remember: Depression makes you have negative thoughts about yourself, about the world, the people in your life, and about the future. Remember that your negative thoughts are not a rational way to think of things. It is as if you are seeing yourself, the world, and the future through a fog of negativity. Do not accept your negative thinking as being true. It is part of the depression and will disappear as your depression responds to treatment. If your negative (hopeless) view of the future leads you to seriously consider suicide, be sure to tell your doctor about this and ask for help. Suicide would be an irreversible act based on your unrealistically hopeless thoughts.

Remember that the feeling that nothing can make depression better is part of the illness of depression. Things are probably not nearly as hopeless as you think they are.

If you are on medication:

1. Take the medication as directed. Keep taking it as directed for as long as directed.
2. Discuss with the doctor ahead of time what happens in case of unacceptable side-effects.
3. Don't stop taking medication or change dosage without discussing it with your doctor, unless you discussed it ahead of time.
4. Remember to check about mixing other things with medication. Ask the prescribing doctor, and/or the pharmacist and/or look it up in the Physician's Desk Reference. Redundancy is good.
5. Except in emergencies, it is a good idea to check what your insurance covers before receiving treatment.

Do not rely on your doctor or therapist to know everything. Do some reading yourself. Some of what is available to read yourself may be wrong, but much of it will shed light on your disorder.

Talk to your doctor if you think your medication is giving undesirable side-effects.

Do ask them if you think an alternative treatment might be more appropriate for you.

Do tell them anything you think it is important for them to know.

Do feel free to seek out a second opinion from a different, qualified medical professional if you feel that you cannot get what you need from your current one.

Skipping appointments, because you are "too sick to go to the doctor" is generally a bad idea.

If you procrastinate, don't try to get everything done. Start by getting one thing done. Then get the next thing done. Handle one crisis at a time.

If you are trying to remember too many things to do, it is okay to write them down. If you make lists of tasks, work on only one task at a time. Trying to do too many things can be too much. It can be helpful to have a short list of things to do "now" and a longer list of things you have decided not to worry about just yet. When you finish writing the long list, try to forget about it for a while.

If you have a list of things to do, also keep a list of what you have accomplished too, and congratulate yourself each time you get something done. Don't take completed tasks off your to-do list. If you do, you will only have a list of incomplete tasks. It's useful to have the crossed-off items visible so you can see what you have accomplished

In general, drinking alcohol makes depression worse. Many cold remedies contain alcohol. Read the label. Being on medication may change how alcohol affects you.