Treatments for Depression

The good news about depression is that you have a number of excellent treatments to choose from. More than 80% of people who get treatment for depression say that it helps them feel better.
Here's a rundown of some of the most common approaches. Many people use a mix. For instance, you might try medicine and therapy at the same time. Some studies show that using both together is better than using either one alone.

Talk Therapy for Depression

Talking with a trained therapist is one of the best treatments for depression. Many studies show that it helps. Some people choose to be in therapy for several months to work on a few key issues. Other people prefer to stay in therapy for years, gradually working through larger problems. The choice is up to you. Here are some common types of therapy.

• Cognitive behavioral therapy helps you see how behaviors -- and the way you think about things -- play a role in your depression. Your therapist will help you change some of these unhealthy patterns.
• Interpersonal therapy focuses on your relationships with other people and how they affect you. Your therapist will also help you identify and change unhealthy behaviors.
• Problem solving therapy focuses on the specific problems you currently face, and on helping you find solutions to those problems.

Antidepressant Medicines

Medicines are the other key treatment for depression. If one antidepressant doesn't work well, you might try another drug of the same class or a different class of depression medicines. Your doctor might also try changing the dose. In some cases, your doctor might recommend taking more than one medication for your depression. There are now dozens of antidepressants that your health care provider can choose from. They include:

• Selective serotonin reuptake inhibitors (SSRIs). These common medicines include Celexa (citalopram), Lexapro (escitalopram), Paxil (paroxetine), Prozac (fluoxetine), and Zoloft (sertraline). Side effects are generally mild. They include stomach upset, sexual problems, insomnia, dizziness, weight change, and headaches.
• Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a newer type of antidepressant. This class includes Cymbalta (duloxetine), Effexor (venlafaxine), and Pristiq (desvenlafaxine). Side effects include upset stomach, insomnia, sexual problems, anxiety, dizziness, and fatigue.
• Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) were some of the first medicines used to treat depression. TCAs include amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil). Side effects of include stomach upset, dizziness, dry mouth, changes in blood pressure, changes in blood sugar levels, and nausea. MAOIs can cause serious interactions with other medications and certain foods. While they work well, these drugs aren't typically used for initial treatment.
• Other medications: Bupropion (Wellbutrin, Aplenzin) is different than other antidepressants and only weakly affects the brain chemicals that other antidepressants influence. Side effects are usually mild, includi All antidepressants carry a boxed warning about increased risks of suicidal thinking and behavior in children, adolescents, and young adults 18-24 years old. Depression and other psychiatric problems are also linked to increased risk of suicide. All patients started on antidepressant medication should be monitored closely.
  Other medicines may be prescribed in addition to antidepressants, particularly in treatment resistant depression. Here are examples of medicines that may be used to augment as an add-on to antidepressant treatment.
  
• Antipsychotic medications like Abilify and Seroquel can be used as an add-on to antidepressant treatment. Symbyax, a combination of the antipsychotic drug Zyprexa and an SSRI (fluoxetine), is approved for treatment-resistant depression.
• Your doctor may recommend or prescribe other medications or supplements not FDA approved for use in depression.

Working with your doctor, you can weigh the risks and benefits of treatment and optimize the use of medication that best relieves your symptoms.

ECT (Electroconvulsive Therapy) for Depression

This is a safe and effective treatment for people with depression that is resistant to medication. It's typically used on people who haven't been helped by medicines or therapy.
In ECT, your doctor will use electric charges to create a controlled seizure. These seizures seem to affect the chemical balance and functioning of the brain. It may sound scary. But during the procedure, you receive anesthesia and a muscle relaxant, so you won't feel anything.
ECT tends to work very quickly. It also works well -- about 80%-90% of people who receive it show improvement. The most common side effect is temporary memory loss.
You might have up to 12 sessions over a few weeks. Some people get "maintenance" therapy with ECT to prevent depression from returning.

Vagus Nerve Stimulation (VNS) for Depression

Vagus Nerve Stimulation (VNS) is a new option for people with severe, treatment-resistant depression. Approved by the FDA in 2005, it's used only on people who haven't been helped by at least four antidepressants.
VNS involves implanting a small electrical generator in your chest, like a pacemaker. The device is attached with wires to the vagus nerve, which runs from the neck into the brain. Once implanted, the device sends electrical pulses to the vagus nerve every few seconds. The pulses are then delivered via the vagus nerve to the area of the brain thought to regulate mood. The electrical charges may change the balance of chemicals in your brain and relieve depression.
The device must be implanted by a surgeon, but patients can usually go home the same day.

• ng upset stomach, headache, insomnia, and anxiety. Bupropion may be less likely to cause sexual side effects than other antidepressants. Mirtazapine (Remeron) is usually taken at bedtime. Side effects are usually mild and include sleepiness, weight gain, elevated triglycerides, and dizziness. Trazodone (Desyrel) is usually taken with food to reduce chance for stomach upset. Other side effects include drowsiness, dizziness, constipation, dry mouth, and blurry vision.

ranscranial magnetic stimulation is a new nondrug approach that's been approved for treatment-resistant depression. Unlike VNS and ECT, it uses a magnetic field to induce a much smaller electric current in a specific part of the brain without causing a seizure or loss of consciousness.  TMS is used to treat milder depression and works best in patients who have failed to benefit from one, but not two or more, antidepressant treatments. Also, unlike ECT, TMS does not require sedation and is administered on an outpatient basis.
Patients undergoing TMS must be treated four or five times a week for four weeks.

Alternative Treatments for Depression

Some people use herbs, supplements, and other alternative therapies for depression. However, none of these approaches has been proven to work. Herbs and supplements -- like St. John's wort -- can have side effects and cause interactions with other medicines. Never start taking an herb or supplement without talking to your doctor first.
Other alternative treatments -- like acupuncture, hypnosis, and meditation -- may help some people with their symptoms. Since they have few risks, you might want to try them, provided that your health care provider says it's OK.

Depression At A Glance

• A depressive disorder is a syndrome (group of symptoms) that reflects a sad, blue mood exceeding normal sadness or grief.
• Depressive disorders are characterized not only by negative thoughts, moods, and behaviors but also by specific changes in bodily functions (for example, eating, sleeping, and sexual activity).
• One in 10 people will have a depressive disorder in their lifetime, and in one of 10 cases, the depression is a fatal disease as a result of suicide.
• Some types of depression, especially bipolar depression, run in families.
• While there are many social, psychological, and environmental risk factors for developing depression, some are particularly prevalent in one gender or the other, or in particular age or ethnic groups.
• There can be some differences in symptoms of depression depending on age, gender, and ethnicity.
• Depression is diagnosed only clinically in that there is no laboratory test or X-ray for depression. Therefore, it is crucial to see a health practitioner as soon as you notice symptoms of depression in yourself, your friends, or family.
• The first step in getting appropriate treatment is a complete physical and psychological evaluation to determine whether the person, in fact, has a depressive disorder.
• Depression is not a weakness but a serious illness with biological, psychological, and social aspects to its cause, symptoms, and treatment. A person cannot will it away. Untreated, it will worsen. Undertreated, it will return.
• There are many safe and effective medications, particularly the SSRIs, that can be of great help in depression.
• For full recovery from a mood disorder, regardless of whether there is a precipitating factor or it seems to come out of the blue, treatments with medications and/or electroconvulsive therapy (ECT) and psychotherapy are necessary./li>
• In the future, through depression research and education, we will continue to improve our treatments, decrease society's burden, and hopefully improve prevention of this illness.

Drugs to Treat Depression

There are several types of depression medications (antidepressants) used to treat depression and conditions that have depression as a component of the disease, such as bipolar disorder. These drugs improve symptoms of depression by increasing the availability of certain brain chemicals called neurotransmitters. It is believed that these brain chemicals can help improve emotions.

• Tricyclic antidepressants (TCAs) are some of the first antidepressants used to treat depression. They primarily affect the levels of two chemical messengers (neurotransmitters), norepinephrine and serotonin, in the brain. Although these drugs are effective in treating depression, they have more side effects, so they usually aren't the first drugs used.
• Monoamine oxidase inhibitors (MAOIs) are another early form of antidepressant. These drugs are most effective in people with depression who do not respond to other treatments. They are also effective for other mental illnesses. Substances in certain foods, like cheese, beverages like wine, and medications can interact with an MAOI, so these people taking this medication must adhere to strict dietary restrictions (see below). For this reason these antidepressants also aren't usually the first drugs used.
• Selective serotonin reuptake inhibitors (SSRIs) are a newer form of antidepressant. These drugs work by altering the amount of a chemical in the brain called serotonin.

• Serotonin and norepinephrine reuptake inhibitors (SNRIs)are another newer form of antidepressant medicine. They treat depression by increasing availability of the brain chemicals serotonin and norepinephrine.                   

 *When taking an MAOI, you must avoid taking certain medications (including some over the counter medicines like Sudafed) and eating certain foods such as aged cheese, wine and beer, avocados, bananas, canned meats, yogurt, soy sauce, packaged soups and sour cream.
It is important to note that you should not drink alcoholic beverages while taking antidepressant medicines, since alcohol can seriously interfere with their beneficial effects.
In October 2004, the FDA determined that antidepressant medications may increase the risk of suicidal thinking and behavior in children and adolescents with depression and other psychiatric disorders. If you have questions or concerns, discuss them with your health care provider.

What is in the future for depression?

The future is very bright for the treatment of depression. In response to the customs and practices of their patients from a variety of cultures, physicians are becoming more sensitized to and knowledgeable about natural remedies. Vitamins and other nutritional supplements like vitamin D, folate, and vitamin B12 may be useful in alleviating depression, either alone or in combination with an antidepressant medication. Another intervention from alternative medicine is St. John's wort (Hypericum perforatum). This herbal remedy has been found to be helpful for some individuals who suffer from mild to moderate depression. However, St. John's wort being an herbal remedy is no guarantee against developing complications. For example, its chemical similarity to many antidepressants disqualifies it from being given to people who are taking those medications. We are close to having genetic markers for bipolar disorder. Soon after, we hope to also have them for major depression. That way, we can know of a child's vulnerability to depression from birth and try to create preventive strategies. For example, we can teach parents early warning signs so that they can get treatment for their children, if necessary, to ward off future problems.

The new world of pharmacogenetics holds the promise of actually keeping the genes responsible for depression turned off so as to avoid the illnesses completely. Also, by studying genes, we are learning more about the matching of patients with treatment. This kind of information will be able to tell us which patients do well on which types of drugs and psychotherapy regimens.

We are learning more about the interactions of the neurochemicals, the chemical messengers in the brain, and their influence on depression. Moreover, new categories of neurochemicals, such as neuropeptides and substance P, are being studied. As a result, we will soon be able to develop new drugs that should be more effective with fewer side effects. We are also learning startling things about how maternal stress early in pregnancy can profoundly affect the developing fetus. For example, we now know that maternal stress can greatly increase the risk for the fetus to develop depression as an adult.

Further information is also being discerned about how to most effectively make treatment of depression available and acceptable to all who need it. This is particularly important for children and adolescents, minorities, individuals who are economically disadvantaged or live in rural areas, the elderly and for people with developmental disabilities, who are known to suffer from lack of adequate access to mental-health treatment that is knowledgeable and respectful of what may be their unique needs and preferences. While sadness will always be part of the human condition, hopefully we will be able to lessen or eradicate the more severe mood disorders from the world to the benefit of all of us.

Where can one seek help for depression?

A complete physical and psychological diagnostic evaluation by professionals will help the depressed person decide the type of treatment that might be best for him or her. However, if the situation is urgent because a suicide seems possible, taking the patient to the emergency room is the appropriate course of action. If the patient makes a suicide gesture or attempt, a 911 call is warranted. The patient might not realize how much help he or she needs. In fact, he or she might feel undeserving of help because of the negativity and helplessness that is a part of depressive illness.

Listed below are the types of people and places that will make a referral or provide diagnostic and treatment services. Check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "hospitals," or "physicians" for phone numbers and addresses.

• Family doctors
• Mental-health specialists, such as psychiatrists, psychologists, social workers, pastoral or mental-health counselors
• Health-maintenance organizations
• Community mental-health centers
• Hospital psychiatry departments and outpatient clinics
• Community support groups, often hospital-affiliated
• University or medical school-affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

How can someone help a person who is depressed?

Family and friends can help! Since depression can make the affected person feel exhausted and helpless, he or she will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effects. Although unintentional, friends and loved ones may unknowingly say and do things that may be hurtful to the depressed person. It may help to share the information in this article with those you most care about so they can better understand and help you.

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This help may involve encouraging the individual to stay with treatment until symptoms begin to go away (usually 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 for several months after symptoms have improved. Always report a worsening depression to the patient's physician or therapist.

The second most important way to help is to offer emotional support. This support 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 depressed person's therapist.

Invite the depressed person for walks, outings, and to the movies and other activities. Be gently insistent if your invitation is refused. Encourage participation in activities that once gave pleasure, such as hobbies, sports, or religious or cultural activities. However, do not push the depressed person to undertake too much too soon. The depressed person needs company and diversion, but too many demands can increase feelings of failure.

Do not accuse the depressed person of faking illness or of laziness. Do not expect him or her "to snap out of it." Eventually, with treatment, most depressed people do get better. Keep that in mind. Moreover, keep reassuring the depressed person that, with time and help, he or she will feel better.

What about discontinuing antidepressants?

Antidepressants should be gradually tapered and should not be abruptly discontinued. Abruptly stopping an antidepressant in some patients can cause discontinuation syndrome.

For example, abruptly stopping an SSRI such as paroxetine can cause dizziness, nausea, flu-like symptoms, body aches, anxiety, irritability, fatigue, and vivid dreams. These symptoms typically occur within days of abrupt cessation, and can last one to two weeks (up to 21 days). Among the SSRIs, paroxetine and fluvoxamine cause more pronounced discontinuation symptoms than fluoxetine, sertraline, and citalopram. Some patients experience discontinuation symptoms despite gradual tapering of the SSRI. Abrupt cessation of venlafaxine, duloxetine, or desvenlafaxine can cause discontinuation symptoms similar to those of SSRIs.

Abruptly stopping MAOIs can lead to irritability, agitation, and delirium. Similarly, abruptly stopping a TCA can cause agitation, irritability, and abnormal heart rhythms.

What about self-help?

Depressive disorders make those afflicted feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual situation. It should be remembered that negative thinking fades as treatment begins to take effect. In the meantime, the following are helpful tips for coping with depression:

• Eat healthy foods. Many may find that folate food supplements help improve their mood.
• Make time to get enough rest to physically promote improvement in your mood.
• Express your feelings, either to friends, in a journal, or using art to help release some negative feelings.
• Do not set difficult goals for yourself or take on a great deal of responsibility.
• Break large tasks into small ones, set some priorities, and do what you can when you can.
• Do not expect too much from yourself too soon as this will only increase feelings of failure.
• Try to be with other people, which is usually better than being alone.
• Participate in activities that may make you feel better.
• You might try exercising mildly, going to a movie or a ball game, or participating in religious or social activities.
• Don't rush or overdo it. Don't get upset if your mood is not greatly improved right away. Feeling better takes time.
• Do not make major life decisions, such as changing jobs or getting married or divorced without consulting others who know you well. These people often can have a more objective view of your situation. In any case, it is advisable to postpone important decisions until your depression has lifted.
• Do not expect to "snap out" of your depression. People rarely do. Help yourself as much as you can, and do not blame yourself for not being up to par.
• Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.
• Plan how you would get help for yourself in an emergency, like calling friends, family, your physical or mental-health professional or a local emergency room if you were to develop thoughts of harming yourself or someone else.
• Limit your access to things that could be used to hurt yourself or others (for example, do not keep excess medication of any kind, firearms, or other weapons in the home).

Common Causes of Depression

If you're depressed, it might not be easy to figure out why. In most cases, depression doesn't have a single cause. Instead, it results from a mix of things -- your genes, events in your past, your current circumstances, and other risk factors.

Here are a few of the things that can play a role in depression.

• Biology. We still don't know exactly what happens in the brain when people become depressed. But studies show that certain parts of the brain don't seem to be working normally. Depression might also be affected by changes in the levels of certain chemicals in the brain, called neurotransmitters.
• Genetics. Researchers know that if depression runs in your family, you have a higher chance of becoming depressed.
• Gender. Studies show that women are about twice as likely as men to become depressed. No one's sure why. The hormonal changes that women go through at different times of their lives may be a factor.
• Age. People who are elderly are at higher risk of depression. That can be compounded by other factors -- living alone and having a lack of social support. 
• Health conditions. Conditions such as cancer, heart disease, thyroid problems, chronic pain, and many others increase your risk of becoming depressed.
• Trauma and grief. Trauma, such as violence or physical or emotional abuse -- whether it's early in life or more recent -- can trigger depression. So can grief after the death of a friend or loved one.
• Changes and stressful events. It's not surprising that people might become depressed during stressful times -- such as during a divorce or while caring for a sick relative. Yet even positive changes -- like getting married or starting a new job -- can sometimes trigger depression.
• Medications and substances. Many prescription drugs can cause symptoms of depression. Alcohol or substance abuse is common in depressed people. It often makes their condition worse.

Some people have a clear sense of why they become depressed. Others don't. The most important thing to remember is that depression is not your fault. It's not a flaw in your character. It's a disease that can affect anyone -- and regardless of the cause, there are many good ways to treat it.

What about sexual dysfunction related to antidepressants?

The SSRI antidepressants can cause sexual dysfunction. SSRIs have been reported to decrease sex drive (libido) in both men and women. SSRIs have been reported to cause inability to achieve orgasm or delay in achieving orgasm (anorgasmia) in women and difficulty with ejaculation (delay in ejaculating or loss of ability to ejaculate) in men. Sexual dysfunction with SSRIs is common though the exact incidence is not clearly known. Furthermore, sexual side effects have also been reported with the use of other antidepressant classes such a MAOIs, TCAs, and dual-action antidepressants.

Management of sexual dysfunction due to SSRIs includes the following options:

• Decrease the SSRI dose. This option may be appropriate if the patient is on high doses of an SSRI. Reducing the SSRI dose may also diminish the antidepressant effect. Remember, patients should never change medications and medication doses on their own without permission and monitoring by his/her doctor.
• Trial of sildenafil (Viagra) or other sexual-enhancement medication. Studies in men whose depression has responded to SSRI but have developed sexual dysfunction showed improvement in sexual function with Viagra. Men taking Viagra reported significant improvements in arousal, erection, ejaculation, and orgasm as compared to men who were taking placebo, although Viagra generally does not increase one's libido.
• For men who do not respond to Viagra (and for women with sexual dysfunction due to SSRI), switching from SSRI to another class of antidepressants may be helpful. For example, bupropion, mirtazapine, and duloxetine may have no sexual side effects or significantly less sexual side effects than SSRIs.
• For patients who are unable to switch from SSRIs to another class of antidepressants either because of lack of tolerance or lack of therapeutic response to the other antidepressants, the doctor may consider adding another medication to the SSRI. For example, some doctors have reported success by adding bupropion to SSRI to improve sexual function. However, more clinical trials are needed to determine whether this strategy really works.
• Some doctors also may use buspirone to improve sexual function in patients treated with SSRI. More clinical studies are needed to determine whether this strategy works.

What is the general approach to treating depression?

In general, the severe depressive illnesses, particularly those that are recurrent, will require antidepressant medications (or ECT in severe cases) along with psychotherapy for the best outcome. If a person suffers one major depressive episode, he or she has a 50% chance of a second episode. If the individual suffers two major depressive episodes, the chance of a third episode is 75%-80%. If the person suffers three episodes, the likelihood of a fourth episode is 90%-95%. Therefore, after a first depressive episode, it might make sense for the patient to gradually come off medication. However, after a second and certainly after a third episode, most clinicians will have a patient remain on a maintenance dosage of the medication for an extended period of years, if not permanently.

Patience is required because the treatment of depression takes time. Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for the patient. Sometimes, the dosage must be increased to be effective.

In choosing an antidepressant, the doctor will take into account the patient's age, his/her other medical conditions, and medication side effects. Doctors often use one of the SSRIs initially because of their lower severity of side effects compared to the other classes of antidepressants. Side effects of SSRI medications can be further minimized by starting them at low doses and gradually increasing the doses to achieve full therapeutic effects. For those patients who do not respond after taking a SSRI at full doses for six to eight weeks, doctors generally switch to a different SSRI or another class of antidepressants. For patients whose depression failed to respond to full doses of one or two SSRIs or whom could not tolerate those medications, doctors will then try medications from another class of antidepressants. Some doctors believe that antidepressants with dual action (action on both serotonin and norepinephrine), such as duloxetine (Cymbalta), (Cymbalta), mirtazapine (Remeron), venlafaxine (Effexor), and desvenlafaxine (Pristiq), may be effective in treating patients with severe depression that is treatment resistant. Other options include bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban), which has action on dopamine (another neurotransmitter). Sometimes doctors may use a combination of antidepressants from different classes. Also, new types of antidepressants are constantly being developed, and one of these may be the best for a particular patient.

If the depressed person is taking more than one medication for depression or medications for any other medical problem, each of the patient's doctors should be made aware of the other prescriptions. Many of these medications are cleared from the body (metabolized) in the liver. This means that the multiple treatments can interact competitively with the liver's biochemical clearing systems. Therefore, the actual blood levels of the medications may be higher or lower than would be expected from the dosage. This information is especially important if the patient is taking anticoagulants (blood thinners), anticonvulsants (seizure medications), or heart medications, such as digitalis (Crystodigin). Although multiple medications do not necessarily pose a problem, all of the patient's doctors may need to be in close contact to adjust dosages accordingly.

Patients often are tempted to stop their medication too soon, especially when they begin feeling better. It is important to keep taking medication therapy until the doctor says to stop, even if the patient feels better beforehand. Doctors often will continue the antidepressant medications for at least six to 12 months because the risk of depression quickly returning when treatment is stopped decreases after that period of time in those people experiencing their first depressive episode. Some medications must be stopped gradually to give the body time to adjust (see discontinuation of antidepressants below). For individuals with bipolar disorder or chronic major depression, medication may have to become a part of everyday life for an extended period of years in order to avoid disabling symptoms.

Antidepressant medications are not habit-forming, so there need not be concern about that. However, as is the case with any type of medication prescribed for more than a few days, antidepressants must be carefully monitored to ensure that the patient is getting the correct dosage. The doctor will want to check the dosage and its effectiveness regularly.

If the patient is taking MAOIs, certain aged, fermented, or pickled foods must be avoided, like many wines, processed meats, and cheeses. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. Remember that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.

People should never mix medications of any kind (prescribed, over the counter, or borrowed) without consulting their doctor. The dentist or any other medical specialist who prescribes a drug should be informed that the patient is taking antidepressants. Some drugs that are harmless when taken alone can cause severe and dangerous side effects when taken with other drugs. This may also be the case for individuals taking supplements or herbal remedies. Some drugs, such as alcohol (including wine, beer, and hard liquor), tranquilizers, narcotics or marijuana, reduce the effectiveness of antidepressants and should be avoided. These and other drugs can also be dangerous when the person's body is either intoxicated with or withdrawing from their effects due to increasing the risk of seizure in combination with antidepressants medications.

Antianxiety drugs such as diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan) are not antidepressants, but they are occasionally prescribed alone or with antidepressants for a brief period of anxiety. However, they should not be taken alone for depressive disorder. Furthermore, the antianxiety drugs should be phased out as soon as the antidepressant and antianxiety effects of the antidepressant medications begin to work, which is usually in four to six weeks.

Finally, the doctor should be consulted concerning any questions about a medication or problem that the patient believes is medication-related.

Coping with Chronic Illness and Depression

Living with a chronic illness is a tremendous challenge. Periods of grief and sadness are to be expected as you come to grips with your condition and its implications. But if you find that your depression persists, it is important to seek help. While you get treatment, experts offer these lifestyle tips:

1. Try not to isolate yourself. Reach out to family and friends.
2. Learn as much as you can about your condition. Knowledge is power when it comes to getting the best treatment available, and maintaining a sense of control.
3. Make sure that you have medical support from experts you trust, and can talk to openly about your concerns.
4. If you suspect that your medication is causing you to be depressed, consult your doctor about alternative treatments.
5. If you are in chronic pain, talk with your physician about alternative pain management.
6. As much as is possible, remain engaged in the activities you enjoy. Stay connected with your community.

What treatments are available for depression?

Regardless of the medication that may be used to treat depression, practitioners have become more aware that different ethnic groups may have different responses and have different risks for side effects than others.

Antidepressant medications

Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. (Remember that brain serotonin levels are often low in depression.) As their name implies, the SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) are connected to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neuron to another.

The SSRIs work by keeping serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. It is thought that this, in turn, helps arouse (activate) cells that have been deactivated by depression, thereby relieving the depressed person's symptoms.

SSRIs have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), which are discussed below. SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs, and therefore do not require the dietary restrictions of the MAOIs. Also, SSRIs do not cause orthostatic hypotension (sudden drop in blood pressure when sitting up or standing) and heart-rhythm disturbances, like the TCAs do. Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), and escitalopram (Lexapro).

SSRIs are generally well tolerated, and side effects are usually mild. The most common side effects are nausea, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Some patients experience tremors with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs. It is characterized by high fevers, seizures, and heart-rhythm disturbances. This condition is very rare and has been reported only in very ill psychiatric patients taking multiple psychiatric medications.

All patients are unique biochemically. Therefore, the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean that another medication in this group will not be beneficial. However, if someone in the patient's family has had a positive response to a particular drug, that drug may be the preferable one to try first.

Dual-action antidepressants: The biochemical reality is that all classes of medications that treat depression (MAOIs, SSRIs, TCAs, and atypical antidepressants) have some effect on both norepinephrine and serotonin, as well as on other neurotransmitters. However, the various medications affect the different neurotransmitters in varying degrees.

Some of the newer antidepressant drugs, however, appear to have particularly robust effects on both the norepinephrine and serotonin systems. These medications seem to be very promising, especially for the more severe and chronic cases of depression. (Psychiatrists, rather than family practitioners, see such cases most frequently.) Venlafaxine (Effexor), duloxetine (Cymbalta) and desvenlafaxine (Pristiq) are three of these dual-action compounds. Effexor is a serotonin reuptake inhibitor that, at lower doses, shares many of the safety and low side-effect characteristics of the SSRIs. At higher doses, this drug appears to block the reuptake of norepinephrine. Thus, venlafaxine can be considered an SNRI, a serotonin and norepinephrine reuptake inhibitor. Cymbalta and Pristiq tend to act as equally powerful serotonin reuptake inhibitors and norepinephrine reuptake inhibitors regardless of the dose. They are, therefore, also considered SNRIs.

Mirtazapine (Remeron), another antidepressant, is a tetracyclic compound (four-ring chemical structure). It works at somewhat different biochemical sites and in different ways than the other drugs. It affects serotonin, but at a postsynaptic site (after the connection between nerve cells). It also increases histamine levels, which can cause drowsiness. For this reason, mirtazapine is given at bedtime and is often prescribed for people who have trouble falling asleep. Like the SNRIs, it also works by increasing levels in the norepinephrine system. Other than causing sedation, this medication has side effects that are similar to those of the SSRIs but to a lesser degree in many cases.

Atypical antidepressants are so named because they work in a variety of ways. Thus, atypical antidepressants are not TCAs, SSRIs, or SNRIs, but they are effective in treating depression for many people nonetheless. More specifically, they increase the level of certain neurochemicals in the brain synapses (where nerves communicate with each other). Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin). The United States Food and Drug Administration (FDA) has also approved bupropion for use in weaning from addiction to cigarettes. This drug is also being studied for treating attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). These problems affect many children and adults and restrict their ability to manage their impulses and activity level, focus, or concentrate on one thing at a time.

Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote), carbamazepine (Epitol, Tegretol), and lamotrigine (Lamictal) are mood stabilizers and anticonvulsants. They have been used to treat bipolar depression. Certain antipsychotic medications, such as ziprasidone (Geodon), risperidone (Risperdal), quetiapine (Seroquel),  aripiprazole (Abilify), asenapine (Saphris), and paliperidone (Invega), may treat psychotic depression. They have also been found to be effective mood stabilizers and are therefore sometimes been used to treat bipolar depression, usually in combination with other antidepressants.

Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants. Examples of MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). MAOIs elevate the levels of neurochemicals in the brain synapses by inhibiting monoamine oxidase. Monoamine oxidase is the main enzyme that breaks down neurochemicals, such as norepinephrine. When monoamine oxidase is inhibited, the norepinephrine is not broken down and, therefore, the amount of norepinephrine in the brain is increased.

MAOIs also impair the ability to break down tyramine, a substance found in aged cheese, wines, most nuts, chocolate, and some other foods. Tyramine, like norepinephrine, can elevate blood pressure. Therefore, the consumption of tyramine-containing foods by a patient taking an MAOI drug can cause elevated blood levels of tyramine and dangerously high blood pressure. In addition, MAOIs can interact with over-the-counter cold and cough medications to cause dangerously high blood pressure. The reason for this is that these cold and cough medications often contain drugs that likewise can increase blood pressure. Because of these potentially serious drug and food interactions, MAOIs are usually only prescribed after other treatment options have failed.

Tricyclic antidepressants (TCAs) were developed in the 1950s and '60s to treat depression. They are called tricyclic antidepressants because their chemical structures consist of three chemical rings. TCAs work mainly by increasing the level of norepinephrine in the brain synapses, although they also may affect serotonin levels. Doctors often use TCAs to treat moderate to severe depression. Examples of tricyclic antidepressants are amitriptyline (Elavil), protriptyline (Vivactil), desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), imipramine (Tofranil), trimipramine (Surmontil), and perphenazine (Triavil).

Tetracyclic antidepressants are similar in action to tricyclics, but their structure has four chemical rings. Examples of tetracyclics include maprotiline (Ludiomil) and mirtazapine (Remeron), a drug that was discussed above under dual-action antidepressants.

TCAs are safe and generally well tolerated when properly prescribed and administered. However, if taken in overdose, TCAs can cause life-threatening heart-rhythm disturbances. Some TCAs can also have anticholinergic side effects, which are due to the blocking of the activity of the nerves that are responsible for control of the heart rate, gut motion, visual focus, and saliva production. Thus, some TCAs can produce dry mouth, blurred vision, constipation, and dizziness upon standing. The dizziness results from low blood pressure that occurs upon standing (orthostatic hypotension). Anticholinergic side effects can also aggravate narrow-angle glaucoma, urinary obstruction due to benign prostate hypertrophy, and cause delirium in the elderly. TCAs should also be avoided in patients with seizure disorders or a history of strokes.

Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine) are used primarily for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, antipsychotics, or even thyroid hormone. They are sometimes used alone but rarely. The reason they are usually used sparingly and with other medications for depression is that unlike the other medications, they may induce an emotional rush and a high in both depressed and nondepressed people. Therefore, the stimulants are potentially addictive drugs.

Electroconvulsive therapy (ECT)

In the ECT procedure, an electric current is passed through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. ECT often is effective in cases where trials of a number of antidepressant medications do not provide sufficient relief of symptoms. This procedure probably works, as previously mentioned, by a massive neurochemical release in the brain due to the controlled seizure. Often highly effective, ECT relieves depression within one to two weeks after beginning treatments in many people. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications or have a combination of both treatments.

Over the years, the technique of ECT has been much improved. The treatment is given in the hospital under anesthesia so that people receiving ECT do not hurt themselves or feel pain. Most patients undergo six to 10 treatments. An electrical current is passed through the brain to cause a controlled seizure, which typically lasts for 20 to 90 seconds. The patient is awake in five to 10 minutes. The most common side effect is short-term memory loss, which resolves quickly. ECT can usually be safely done as an outpatient procedure.

Psychotherapies

Many forms of psychotherapy are effectively used to help depressed individuals, including some short-term (10 to 20 weeks) therapies. Talking therapies (psychotherapies) help patients gain insight into their problems and resolve them through verbal give-and-take with the therapist. Behavioral therapists help patients learn how to obtain more satisfaction and rewards through their own actions. These therapists also help patients to unlearn the behavioral patterns that may contribute to their depression.

Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with depression.

Psychodynamic therapies are sometimes used to treat depression. They focus on resolving the patient's internal psychological conflicts that are typically thought to be rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) in negative or self-injurious behavior

How is depression diagnosed?

People who wonder if they should talk to their health professional about whether or not they have depression may consider taking a depression self-test, which asks questions about depressive symptoms. In thinking about when to seek medical advice about depression, the sufferer can benefit from considering if the sadness lasts more than two weeks or so or if the way they are feeling significantly interferes with their ability to function at home, school, or work and in their relationships with others. The first step to obtaining appropriate treatment is accurate diagnosis, which requires a complete physical and psychological evaluation to determine whether the person may have a depressive illness, and if so, what type. As previously mentioned, certain medications, as well as some medical conditions, can cause symptoms of depression. Therefore, the examining physician should rule out (exclude) these possibilities through an interview, physical examination, and laboratory tests. Many primary-care doctors use screening tools, symptoms tests, for depression, which are usually questionnaires that help identify people who have symptoms of depression and may need to receive a full mental-health evaluation.

A thorough diagnostic evaluation includes a complete history of the patient's symptoms:

1. When did the symptoms start? 2. How long have they lasted? 3. How severe are they? 4. Have the symptoms occurred before, and if so, were they treated and what treatment was received?

The doctor usually asks about alcohol and drug use and whether the patient has had thoughts about death or suicide. Further, the history often includes questions about whether other family members have had a depressive illness, and if treated, what treatments they received and which were effective.

A diagnostic evaluation also includes a mental-status examination to determine if the patient's speech, thought pattern, or memory has been affected, as often happens in the case of a depressive or manic-depressive illness. As of today, there is no laboratory test, blood test, or X-ray that can diagnose a mental disorder. Even the powerful CT, MRI, SPECT, and PET scans, which can help diagnose other neurological disorders such as stroke or brain tumors, cannot detect the subtle and complex brain changes in psychiatric illness. However, these techniques are currently useful in research on mental health and perhaps in the future they will be useful for diagnosis as well.

Crisis, Loss and Depression

Losing a job can be every bit as devastating as undergoing a divorce or suffering the death of a loved one. Such traumatic, life-altering events can promote feelings of anger, denial and deep sadness.
Doctors recommend people seek help quickly after a major loss. The pain of profound loss may never go away completely. But successful treatment can help shift your focus away from what is lost to what is left.
Look for warning signs of depression, such as:

1. Despondency
2. Changes in appetite
3. Problems concentrating or sleeping

Postpartum depression

Postpartum depression (PPD) is a condition that describes a range of physical and emotional changes that many mothers can have after having a baby. PPD can be treated with medication and counseling. Talk with your health-care practitioner right away if you think you have PPD.

There are three types of PPD women can have after giving birth:

1. The so-called "baby blues" happen in many women in the days right after childbirth. A new mother can have sudden mood swings, such as feeling very happy and then feeling very sad or angry. She may cry for no reason and can feel impatient, irritable, restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long as one to two weeks after delivery. The baby blues do not always require treatment from a health-care provider. Often, joining a support group of new moms or talking with other moms helps.
2. Postpartum depression (PPD) can happen a few days or even months after childbirth. PPD can happen after the birth of any child, not just the first child. A woman can have feelings similar to the baby blues -- sadness, despair, anxiety, irritability -- but she feels them much more strongly than she would with the baby blues. PPD often keeps a woman from doing the things she needs to do every day. When a woman's ability to function is affected, this is a sure sign that she needs to see her health-care provider right away. If a woman does not get treatment for PPD, symptoms can get worse and last for as long as one year. While PPD is a serious condition, it can be treated with medication and counseling.
3. Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first three months after childbirth. Women can experience psychotic depression, in that the depression causes them to lose touch with reality, have auditory hallucinations (hearing things that aren't actually happening, like a person talking), and delusions (seeing things differently from what they are in reality). Visual hallucinations (seeing things that aren't there) are less common. Other symptoms include insomnia (not being able to sleep), feeling agitated (unsettled) and angry, strange feelings and behaviors, as well as having suicidal or homicidal thoughts. Women who have postpartum psychosis need treatment right away and almost always need medication. Sometimes women are put into the hospital because they are at risk for hurting themselves or someone else, including their baby.

Depression: Coping With Anxiety Symptoms

Depression and anxiety often go together.

Depression and anxiety might seem like opposites, but they often go together. More than half of the people diagnosed with depression also have anxiety.

Either condition can be disabling on its own. Together, depression and anxiety can be especially hard to live with, hard to diagnose, and hard to treat.

“When you’re in the grip of depression and anxiety, it can feel like the misery will never end, that you’ll never recover,” says Dean F. MacKinnon, MD, an associate professor at the Johns Hopkins Hospital in Baltimore. “But people do recover. You just need to find the right treatment.”

The Symptoms of Depression and Anxiety

Depression can make feel people profoundly discouraged, helpless, and hopeless. Anxiety can make them agitated and overwhelmed by physical symptoms -- a pounding heart, tightness in the chest, and difficulty breathing.

People diagnosed with both depression and anxiety tend to have

• More severe symptoms
• More impairment in their day-to-day lives
• More trouble finding the right treatment
• A higher risk of suicide

Tips for Depression and Anxiety Treatment

Depression and anxiety can be harder to treat than either condition on its own. Getting control might take more intensive treatment and closer monitoring, says Ian A. Cook, MD, the director of the Depression Research Program at UCLA. Here are some tips.

1. Give medicine time to work. Many antidepressants also help with anxiety. You might need other medicines as well. It could take time for the drugs to work -- and time for your doctor to find the ideal medicines for you. In the meantime, stick with your treatment and take your medication as prescribed.
2. Put effort into therapy. Although many types of talk therapy might help, cognitive behavioral therapy has the best evidence for treating anxiety and depression. It helps people identify and then change the thought and behavior patterns that add to their distress. Try to do your part: the benefit you’ll get from therapy is directly related to the work you put into it.
3. Make some lifestyle changes. As your treatment takes effect, you can do a lot on your own to reinforce it. Breathing exercises, muscle relaxation, and yoga can help. So can the basics, like eating well, getting enough sleep, and exercising. The key is to figure out ways of integrating better habits into your life -- something that you can work on with your therapist.
4. Get a second opinion. When they're combined, depression and anxiety can be hard to diagnose. It's easy for a doctor to miss some of your symptoms -- and as a result, you could wind up with the wrong treatment. If you have any doubts about your care, it's smart to check in with another expert.
5. Focus on small steps. If you’re grappling with depression and anxiety, making it through the day is hard enough. Anything beyond that might seem impossible.  “Changing your behavior can seem overwhelming,” Cook says. “I encourage people to make small, manageable steps in the right direction.” Over time, small changes can give you the confidence to make bigger ones.
6. Be an active partner in your treatment. There are many good ways to treat depression and anxiety. But they all hinge on one thing: a good relationship with your healthcare providers. Whether you see a GP, psychiatrist, psychologist, or social worker -- or a combination -- you need to trust one another and work as a team.

Depression: Recognizing the Emotional Symptoms

Common symptoms of depression can make work and daily life almost impossible. Depression can skew your view of the world, making everything seem hopeless. Depression can make you feel utterly alone.

But you're not. Major depression affects about 14 million American adults, or about 6.7% of the population 18 or older in any given year. This guide will help you recognize some of the symptoms of depression.

You may already know some of the emotional and psychological effects of depression. They include:

• Feeling sad, empty, hopeless, or numb. These feelings are with you most of the day, every day.
• Loss of interest in things you used to enjoy. You might no longer bother with hobbies that you used to love. You might not like being around friends. You might lose interest in sex.
• Irritability or anxiety. You might be short-tempered and find it hard to relax.
• Trouble making decisions. Depression can make it hard to think clearly or concentrate. Making a simple choice can seem overwhelming.
• Feeling guilty or worthless. These feelings are often exaggerated or inappropriate to the situation. You might feel guilty for things that aren't your fault or that you have no control over. Or you may feel intense guilt for minor mistakes.
• Thoughts of death and suicide. The types of thoughts vary. Some people wish that they were dead, feeling that the world would be better off without them. Others make very explicit plans to hurt themselves. One of the best ways to prevent suicide in someone that is depressed is to recognize the warning signs of suicide. Take these signs seriously.

 The good news is that depression is a treatable condition that responds to a variety of treatments.

Depression: Recognizing the Physical Symptoms

Most of us know about the emotional symptoms of depression. But you may not know that depression can be associated with many physical symptoms, too.

In fact, many people with depression suffer from chronic pain or other physical symptoms. These include:

• Headaches. These are fairly common in people with depression. If you already had migraine headaches, they may seem worse if you're depressed.
• Back pain. If you already suffer with back pain, it may be worse if you become depressed.
• Muscle aches and joint pain. Depression can make any kind of chronic pain worse.
• Chest pain. Obviously, it's very important to get chest pain checked out by an expert right away. It can be a sign of serious heart problems. But depression can contribute to the discomfort associated with chest pain.
• Digestive problems. You might feel queasy or nauseous. You might have diarrhea or become chronically constipated.
• Exhaustion and fatigue. No matter how much you sleep, you may still feel tired or worn out. Getting out of the bed in the morning may seem very hard, even impossible.
• Sleeping problems. Many people with depression can't sleep well anymore. They wake up too early or can't fall asleep when they go to bed. Others sleep much more than normal.
• Change in appetite or weight. Some people with depression lose their appetite and lose weight. Others find they crave certain foods -- like carbohydrates -- and weigh more.
• Dizziness or lightheadedness.
  

Because these symptoms occur with many conditions, many depressed people never get help, because they don't know that their physical symptoms might be caused by depression. A lot of doctors miss the symptoms, too.

These physical symptoms aren't "all in your head." Depression can cause real changes in your body. For instance, it can slow down your digestion, which can result in stomach problems.

Depression seems to be related to an imbalance of certain chemicals in your brain. Some of these same chemicals play an important role in how you feel pain. So many experts think that depression can make you feel pain differently than other people.

Treating Physical Symptoms

In some cases, treating your depression -- with therapy or medicine or both -- will resolve your physical symptoms.

But make sure to tell your health care provider about any physical symptoms. Don't assume they'll go away on their own. They may need additional treatment. For instance, your doctor may suggest an antianxiety medicine if you have insomnia. Those drugs help you relax and may allow you to sleep better.

Since pain and depression go together, sometimes easing your pain may help with your depression. Some antidepressants, such as Cymbalta and Effexor, may help with chronic pain, too.

Other treatments can also help with painful symptoms. Certain types of focused therapy -- like cognitive behavioral -- can teach you ways to cope better with the pain.

Craving Carbs: Is It Depression?

Several research studies have uncovered interesting facts about carb cravers.

• Wurtman found that carb cravers can eat 800 or more calories a day than other people. While many carb cravers do become overweight or obese, others control their weight by exercising more, eating less at meals, or turning to low-fat carbs such as popcorn.
• Researchers at Rush University Medical Center in Chicago found that carb cravers who have a mildly depressed mood seem to be self-medicating. They studied women who were overweight and had a history of carb cravings. They gave them a choice between a protein-rich beverage or a carb-rich one. They found that when the women reported being in the worst moods, they picked the carb beverage more often than the protein one. In addition, the carb drink improved their mood better.
• Eating carbohydrates seems to help carb cravers feel better in about 20 minutes, according to Wurtman’s research. When you eat carbs, your body makes more serotonin, the feel-good hormone that is boosted when you are on an antidepressant. Eating the carbs, she says, is an attempt to undo the depressed mood.

Carbohydrate Cravings: Normal or Not?

Step back and analyze your cravings a bit, Wurtman suggests.

Do you crave carbs only when you see someone eating something you like? Then, says Wurtman, you may simply be succumbing to the power of suggestion.

Or do you crave carbs when you face an unpleasant task, like balancing the checkbook, and feel better after you’ve had some? Then you may be “self-medicating.”  Your serotonin is up, and you are doing what you are supposed to, says Wurtman.

Late-afternoon carb cravings are also quite normal, Wurtman says, and don’t necessarily signal depression. "The reason we want to self-medicate with carbs late in the afternoon is not just that life is difficult and filled with frustration, but that it is a normal day-night cycle."

When is a carb craving over the top? If you go to great lengths for a carb-rich food continually, you may want to seek professional help, Wurtman says.

She recalls a woman who was driven to have a brownie from her favorite bakery many times a week. When a ride wasn’t available, she would go to great lengths to get it, even walking several blocks in the dark or bad weather.

That kind of persistent craving may be a sign of depression, not just a funky off mood, and perhaps a clue you should seek mental health care, Wurtman and others say. If your mood stays low and the carbs don't seem to be helping, you should also consider checking in with a health care provider.

Carbohydrate Cravings: Living With Them, Taming Them

If you're a carb craver, you can learn to cope with them -- at minimal or no expense to your health or waistline, experts say.

• Time your eating to accommodate your cravings. The carb cravings typically grow stronger as the day goes on, experts agree. So eat healthfully at breakfast and lunch and focus on protein-rich foods. "In the afternoon, by the time the sun and your mood start sinking, have a carb snack -- popcorn or breakfast cereal -- around 4 p.m.," Wurtman says. Then for dinner, pick pasta, rice or waffles, she suggests.
• Choose sensible carbohydrate-rich foods. Carbs don't have to be gooey and chocolatey every time, Wurtman says. She suggests low-fat crackers, for instance, or pretzels. It keeps the fat low but gives you the carbs you want.
• Don't buy into the guilt. "The current low-carb phase is making people feel guilty," Wurtman says. "There is nothing wrong with having a carb for dinner, or for a snack. You have to have it in a very low-fat form."
• Focus on carbs that are "slow foods."  Think sip, not gobble, when eating these. One of Tribole's favorites: hot chocolate. "You get carbs in the milk and the sweetened chocolate," she says. "It's hard to guzzle hot chocolate, so you are going to savor it."

What are the types of depression, and what are depression symptoms?

Depressive disorders are mood disorders that come in different forms, just as do other illnesses, such as heart disease and diabetes. Three of the most common types of depressive disorders are discussed below. However, remember that within each of these types, there are variations in the number, timing, severity, and persistence of symptoms. There are also differences in how individuals experience depression based on age.

Major depression

Major depression is characterized by a combination of symptoms that last for at least two weeks in a row, including sad and/or irritable mood (see symptom list), that interfere with the ability to work, sleep, eat, and enjoy once-pleasurable activities. Difficulties in sleeping or eating can take the form of excessive or insufficient of either behavior. Disabling episodes of depression can occur once, twice, or several times in a lifetime.

Dysthymia

Dysthymia is a less severe but usually more long-lasting type of depression compared to major depression. It involves long-term (chronic) symptoms that do not disable but yet prevent the affected person from functioning at "full steam" or from feeling good. Sometimes, people with dysthymia also experience episodes of major depression. This combination of the two types of depression is referred to as double-depression.

Bipolar disorder (manic depression)

Another type of depression is bipolar disorder, which encompasses a group of mood disorders that were formerly called manic-depressive illness or manic depression. These conditions show a particular pattern of inheritance. Not nearly as common as the other types of depressive disorders, bipolar disorders involve cycles of mood that include at least one episode of mania or hypomania and may include episodes of depression as well. Bipolar disorders are often chronic and recurring. Sometimes, the mood switches are dramatic and rapid, but most often they are gradual.

When in the depressed cycle, the person can experience any or all of the symptoms of a depressive disorder. When in the manic cycle, any or all of the symptoms listed later in this article under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, indiscriminate or otherwise unsafe sexual practices or unwise business or financial decisions may be made when an individual is in a manic phase.

A significant variant of the bipolar disorders is designated as bipolar II disorder. (The usual form of bipolar disorder is referred to as bipolar I disorder.) Bipolar II disorder is a syndrome in which the affected person has repeated depressive episodes punctuated by what is called hypomania (mini-highs). These euphoric states in bipolar II do not fully meet the criteria for the complete manic episodes that occur in bipolar I.

Symptoms of depression and mania

Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms and some many symptoms. The severity of symptoms also varies with individuals. Less severe symptoms that precede the more debilitating symptoms are called warning signs.

Depression symptoms of major depression or manic depression

• Persistently sad, anxious, angry, irritable, or "empty" mood
• Feelings of hopelessness or pessimism
• Feelings of worthlessness, helplessness, or excessive guilt
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Social isolation, meaning the sufferer avoids interactions with family or friends
  
  
• Insomnia, early-morning awakening, or oversleeping
• Decreased appetite and/or weight loss, or overeating and/or weight gain
• Fatigue, decreased energy, being "slowed down"
• Crying spells
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Difficulty concentrating, remembering, or making decisions
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and/or chronic pain

Mania symptoms of manic depression

• Inappropriate elation
• Inappropriate irritability or anger
• Severe insomnia or decreased need to sleep
• Grandiose notions, like having special powers or importance
• Increased talking speed and/or volume
• Disconnected thoughts or speech
• Racing thoughts
• Severely increased sexual desire and/or activity
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

Craving Carbs: Is It Depression? Many people crave carbohydrates when they feel low.

Does a bad day at the office or a tiff with your spouse send you marching to the cookie jar or the corner bakery?
Or do you find yourself at the vending machine every day precisely at 4 p.m. for some crackers or candy?
If either scenario fits, you're not alone. Many people crave carbohydrates -- especially cookies, candy, or ice cream -- when they feel upset, depressed, or tired.
"Carb craving is part of daily life," says Judith Wurtman, PhD, a former scientist at the Massachusetts Institute of Technology and co-author of The Serotonin Power Diet.  She and her husband, MIT professor Richard J. Wurtman, have long researched carbohydrates and their link to mood and depression.
The Wurtmans published a landmark article about carbs and depression in Scientific American in 1989. They are convinced that the carbohydrate craving is related to decreases in the feel-good hormone serotonin, which is marked by a decline in mood and concentration.
Other experts aren’t so sure. Some wonder if depressed mood and reaching for carbs are both related to an external event -- such as the stock market decline -- or to simply habit.

Carbohydrate Cravings: What's Known? What's Debated?

Carb cravings seem to be related to decreases in serotonin activity, says Wurtman.
"We discovered years and years ago that many people experience the 'universal carbohydrate craving time' between 3:30 p.m. and 5 p.m. every day," she says. "I suspect the tradition of English tea with its carb offering is a ritual developed to fill this need."
"It's a real neurochemical phenomenon," she says.
The Wurtmans’ work, however, has its skeptics.
Edward Abramson, PhD, a psychologist and professor emeritus at California State University, Chico, wrote the book Emotional Eating. He does not think the link is strong and clear-cut.
"You could be down because of loss of money in the stock market," he says. "The depression is triggered by an external event, not by [only] a dip in serotonin. It may be the external event causing the dip in serotonin, not the dip occurring, then the craving, he says.
Another possibility, says Abramson, is that carb craving may be just a habit, learned early. For instance, a woman brought up to believe that anger is not an acceptable emotion may turn to eating treats such as cookies instead -- because that's what she did as a kid and perhaps was encouraged to do by a parent.
Carb cravings can also result from diets, says Evelyn Tribole, RD, a dietitian in Newport Beach, Calif., and author of Healthy Homestyle Cooking.
She sees quite a few dieters who crave carbohydrates, especially if they’re on one of the high-protein, low-carb diets.
"You don't want to kill for a piece of broccoli, but you'd kill for a piece of bread. It's a clear signal,” she says, “that your body needs more carbs. It’s not an abnormal craving.”

What are myths about depression?

The following are myths about depression and its treatment:

• It is a weakness rather than an illness.
• If the sufferer just tries hard enough, it will go away.
• If you ignore depression in yourself or a loved one, it will go away.
• Highly intelligent or highly accomplished people do not get depressed.
• People with developmental disabilities do not get depressed.
• People with depression are "crazy."
• Depression does not really exist.
• Children, teens, the elderly, or men do not get depressed.
• There are ethnic groups for whom depression does not occur.
• Depression cannot look like (present as) irritability.
• People who tell someone they are thinking about committing suicide are only trying to get attention and would never do it, especially if they have talked about it before.
• People with depression cannot have another mental or medical condition at the same time.
• Psychiatric medications are all addicting.
• Psychiatric medications are never necessary to treat depression.
• Medication is the only effective treatment for depression.
• Children and teens should never be given antidepressant medication.

Depression Threatens Independence of Stroke Survivors

Stroke survivors, even if they escape severe mental impairment, are less likely to be independent if they are depressed, older, or have other medical problems, say researchers.

They analyzed data from 367 stroke survivors, average age 62, who had no severe language or thinking skill impairments. Of those patients, 174 were diagnosed with depression one month after their stroke.

The patients' levels of independence were rated using a 0 to 5 scale, with 5 being the most severely disabled and dependent. Three months after their stroke, 20% of the patients scored 3 or higher, meaning they were considered dependent.

Stroke survivors who were severely depressed, older and had other health problems were more likely to be dependent than those who were younger, free of other health problems or not depressed.

The study appears in the March 15 print issue of the journal Neurology.

"Post-stroke depression is a common problem. About 795,000 people in the United States have a stroke each year and one-third of survivors develop depression as a result," study author Arlene Schmid, of the Richard L. Roudebush Veterans Affairs Medical Center and Indiana University in Indianapolis, said in a journal news release.

The researchers did not examine whether improvement in depression helped stroke survivors recover their independence after three months.

"Even if the treatment and improvement of post-stroke depression does not directly influence recovery, it is extremely important for depression to be identified and treated since it is associated with other health and social problems," Schmid said.