Cancer Patients Who Suffer From Stress And Depression don't Survive a long time

In cancer patients stress can affect a tumor's ability to grow and spread. However, the biological mechanisms that underlie such associations are not well understood. Now, researchers at Fox Chase Cancer Center find that poor psychosocial functioning is associated with greater vascular endothelial growth factor (VEGF) expression - a signaling protein that not only stimulates tumor growth, but is also associated with shorter disease-free survival in head and neck cancer patients.
"There is research showing that high VEGF expression in other cancers, such as ovarian, is associated with psychosocial factors," says Carolyn Fang, Ph.D., Co-Leader of the Cancer Prevention and Control Program at Fox Chase, who presented the study at the 32nd Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine on Thursday, April 28th. "This information coupled with what we already know about VEGF promoting tumor aggressiveness and poorer prognosis in head and neck cancer patients, certainly gave us a reason to look at this biomarker."
VEGF not only plays a pivotal role in angiogenesis, but it is also regulated by stress hormones and key cytokines - a category of signaling molecules used extensively in intercellular communication.
In the current study, Fang and colleagues looked at 37 newly diagnosed, pre-surgical head and neck cancer patients, to see if psychosocial functioning, such as perceived stress and depressive factors, was associated with VEGF, a biological pathway relating to patient outcomes. The patients were predominantly male (70.3%), and approximately 57-years-old, with primary tumor sites of the oral cavity (65.9%), larynx (19.9%), and oropharynx (13.5%). Over 40% of them were classified as having early-stage disease.
Each patient was given a psychosocial questionnaire to complete prior to treatment, which required them to answer questions about social support, depression, and perceived stress. In addition, VEGF expression in tumor tissue obtained during surgery was evaluated using immunohistochemistry - a process that helps detect the presence of specific proteins in cells or tissues.
"Our analysis indicated that higher levels of perceived stress and depressive symptoms were associated with greater VEGF expression in the tumor tissue of these patients" says Fang. Greater VEGF expression was, in turn, associated with shorter disease-free survival among patients.
The associations between psychosocial functioning and VEGF were strong among early-stage patients, but were less apparent among late-stage patients.
"It's possible that in early stage disease, psychosocial stress makes patients more susceptible to cancer-related death, while in patients with advanced disease, other factors become more important in determining outcome," says Miriam N. Lango, M.D., Medical Director of Speech Pathology Service and Attending Surgeon in Head and Neck Oncology at Fox Chase. "In patients with advanced cancers, psychosocial interventions may have less of an impact since these cancers are inherently more aggressive."

Major depression can cause Genetic Risk

A new research, published by Cell Press in the April 28 issue of the journal Neuron, suggests a previously unrecognized mechanism for major depression and may guide future therapeutic strategies for this debilitating mood disorder.

Major depression is a psychiatric disorder that is responsible for a substantial loss in work productivity and can even lead to suicide in some individuals. "Current treatments for major depression are indispensible but their clinical efficacy is still unsatisfactory, as reflected by high rates of treatment resistance and side effects," explains study author Dr. Martin A. Kohli from the Max Planck Institute of Psychiatry in Munich, Germany. "Identification of mechanisms causing depression is pertinent for discovery of better antidepressants."  

While is likely that a combination of genetic and environmental risk factors contribute to major depression, identification of risk-conferring genes has been challenging due to the complexity of the genetics and the considerable environmental factors associated with the disease. Dr. Kohli and colleagues performed a stringent genome-wide association study of patients diagnosed with major depression and matched control subjects with no history of psychiatric illness. They identified SLC6A15, a gene that codes for a neuronal amino acid transporter protein, as a novel susceptibility gene for major depression. The finding was confirmed in an expanded study examining over 15,000 individuals. 

The researchers examined the functional relevance of the genetic association between SLC6A15 and major depression. Already nondepressed subjects carrying the risk-conferring genetic variants showed lower expression of SLC6A15 in the hippocampus, a brain region implicated in major depression. Moreover, using human brain imaging, risk variant carriers with a positive life history of major depression showed smaller hippocampi. Finally, in a mouse model, lower hippocampal SLC6A15 expression was linked to the effects of chronic social stress, a proven risk factor for depression.

The authors suggest that reduced SLC6A15 expression might lead to perturbation of neuronal circuits related to susceptibility for major depression. "Our results support the notion that lower SLC6A15 expression, especially in the hippocampus, could increase an individual's stress susceptibility by altering neuronal integrity and excitatory neurotransmission in this key brain region," says senior author Dr. Elisabeth B. Binder. "Because SLC6A15 appears amenable to drug targeting, our results may incite the discovery of a novel class of antidepressant drugs."

Source:
Elisabeth Lyons
Cell Press

Link Between Antidepressants and Heart Trouble

Men taking antidepressants may be at risk for atherosclerosis, which can increase the risk of a heart attack or stroke, a small, preliminary study suggests.

Antidepressants were associated with about a 5% increase in the thickness of the large artery in the neck called the carotid artery, which carries blood to the brain, the researchers from Emory University found.

Yet experts not involved with the study noted that it did not prove a cause-and-effect relationship between antidepressant use and heart trouble, and added that depression itself can increase the risk of cardiovascular problems.

"Antidepressant medications may decrease cardiovascular risk by treating depression," said Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles.

Since the new findings are very preliminary, Fonarow said, "Patients should not be concerned or stop taking antidepressant medications on the basis of this study."

Results of the research were scheduled to be presented Saturday at the American College of Cardiology's annual scientific session, in New Orleans. Experts note that studies presented at medical conferences do not undergo the same vetting as research published in peer-reviewed journals. The study was funded by the U.S. National Institutes of Health.

For the study, a team led by Dr. Amit Shah, a cardiology fellow at Emory, collected data on 513 middle-aged male twins who were part of the Vietnam Era Twin Registry. Sixteen percent of the men were taking antidepressants, and of these, 60% were taking selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Lexapro and Zoloft. The others were taking older antidepressants.

To try to isolate the effect of antidepressants on blood vessels, the researchers measured the thickness of the carotid artery -- called carotid intima-media thickness. The study authors found that a twin taking an antidepressant had a greater intima-media thickness than a brother not taking the drugs.

The finding held true, regardless of the antidepressant taken, the researchers said.

"There is a clear association between increased intima-media thickness and taking an antidepressant, and this trend is even stronger when we look at people who are on these medications and are more depressed," Shah said in a news release from the American College of Cardiology.

"Because we didn't see an association between depression itself and a thickening of the carotid artery, it strengthens the argument that it is more likely the antidepressants than the actual depression that could be behind the association," he added.

The findings also held true after compensating for such factors as age, diabetes, blood pressure, current or previous smoking, cholesterol and weight. Other factors weighed included depressive symptoms, history of major depression and heart disease, alcohol and coffee use, statin use, physical activity, education and employment, the researchers said.

Since each additional year of life is associated with a small increase in intima-media thickness, a brother taking antidepressants is physically 4 years older than the brother not taking antidepressants, Shah's team contended. They also said that even a small increase in intima-media thickness can increase the risk of a heart attack or stroke by 1.8%.

It's not clear why there might be an association between antidepressant use and heart disease, the study authors noted. These drugs increase levels of the brain chemicals serotonin and norepinephrine, which are often low in depressed individuals.

Shah said increased levels of these chemicals may cause blood vessels to tighten, and this may lead to reduced blood flow to organs and higher blood pressure, which is a risk factor for atherosclerosis.

Commenting on the study, Dr. Dominique L. Musselman, an associate professor of clinical psychiatry at the University of Miami Miller School of Medicine, underscored that the findings show an association between antidepressant use and atherosclerosis, but not a cause-and-effect relationship.

"This finding is somewhat counterintuitive since it is well known that SSRIs enhance a tendency to bleed," she said, adding that more rigorous studies are needed to see if a cause-and-effect relationship exists.

Musselman also strongly advises patients not to stop taking antidepressants based on this study. Not treating depression can have serious consequences for quality of life, survival after a heart attack or other cardiovascular events, she said.

"This is an important finding that needs to be replicated," she added.

Anti-inflammatory medications make SSRI antidepressants less effective

anti-inflammatory drugs make SSRI antidepressants less effective, examples of SSRIs (selective serotonin reuptake inhibitors) include: 

• citalopram (Celexa, Cipramil, Cipram, Dalsan, Recital, Emocal, Sepram, Seropram, Citox, Cital)
• dapoxetine (Priligy)
• escitalopram (Lexapro, Cipralex, Seroplex, Esertia)
• fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Ladose, Motivest,Flutop, Fluctin (EUR), Fluox (NZ), Depress (UZB), Lovan (AUS))
• fluvoxamine (Luvox, Fevarin, Faverin, Dumyrox, Favoxil, Movox)
• paroxetine (Paxil, Seroxat, Sereupin, Aropax, Deroxat, Divarius, Rexetin, Xetanor, Paroxat, Loxamine, Deparoc)

• sertraline (Zoloft, Lustral, Serlain, Asentra)

some patients on SSRIs do not appear to derive any benefits. this lack of efficacy may be preventable if patients stayed off anti-inflammatory medications.

Scientists treated mice with SSRIs and gave some of them anti-inflammatory drugs, while others were given SSRIs without anti-inflammatories. They observed the animals' behavior when given tasks which are sensitive to antidepressant treatment. They found that those on anti-inflammatory drugs showed inhibited behavioral responses.

They also found that human patients with depression who were on both SSRIs and anti-inflammatory drugs had a significantly lower chance of experiencing relief of symptoms typically offered by antidepressants compared to similar patients who did not take anti-inflammatory medications.
They found that:

• Only 40% of patients on antidepressants and anti-inflammatory drugs responded to their SSRI medication
• 54% of patients on SSRIs and not on anti-inflammatory medications responded to their SSRI drug

The researchers explain that a significant number patients with Alzheimer's disease, for example, suffer from depression, which needs to be treated effectively to prevent more severe Alzheimer's symptoms. They add that depression among elderly individuals also raises the risk of developing Alzheimer's. If depression can be treated effectively, most likely the chances of developing Alzheimer's would be reduced.

                                                         

Are You Experiencing Clinical Depression Or Are You Just Sad?

As is pointed out in The "How To Transform Your Life" E-Workshop, understanding is necessary for successful coping. When a problem is understood, it is much easier to change.

It is hard to win a war when you don't know the enemy. And depression can be a strong enemy indeed--An enemy that defeats many men, women, and children.

Have you been struggling with the enemy depression? If so you are not alone.

In fact, as Richard O'Connor tells us in his book, Undoing Depression: What Therapy Doesn't Teach You and Medication Can't Give You , Twenty percent of the population experiences depression at one time or another.. Twenty million Americans -- or one in ten -- experience at lease one episode of major depression.

The rate of clinical depression is increasing all over the world. Depressive disorders affect all ages, races and religions

According to Paul A. Wider, author of Overcoming Depression And Manic Depression (Bipolar Depression): The Non-Drug Approach , several of the great men of history struggled with depression. These included Saint Francis of Assisi, Abraham Lincoln, Albert Einstein, Theodore Roosevelt, and Winston Churchill.

Depression is described as an implacable, unpredictable Beast by Tracy Thompson. Ms. Thompson has suffered with depression since childhood. Often her depression was so severe that she, in her own words, "thought how nice it would be to kill myself." ( The Beast: A Journey Through Depression).

For years she didn't understand the disease of depression. She writes in her book that it was only after she came to terms with the disease that she was able to develop a new and better life -- a life described as one of "work, love, and ordinary happiness." (back cover)

There Is Hope For You

You too can develop a new and better life. But to do so you need to understand depression. You also need to know if you are experiencng clinical depression or just sadness.

Sadness Verses Clinical Depression

So what is the difference between clinical depression and sadness?

Clinical depression is more than sadness. It is a disease. Francis Mark Mondimore, author of Depression: The Mood Disease , points out that sadness is reactive...depression is not.

Sadness happens when your circumstances are sad. The sadness that you experience is in proportion to the situation. You can understand why you are feeling depressed.

With sadness, as your situation gets better, so does your mood. You become more happy.

But with clinical depression the sadness takes on a life of its own. It is unpredictable. It comes on for apparently no reason, whether your situation is good or bad.

At times a stressful circumstance will trigger clinical depression. At other times it seems to come out of the blue.

Andrew Solomon states in his book, The Noonday Demon: An Atlas of Depression , "Perhaps depression can best be described as emotional pain that forces itself on us against our will, and then breaks free of its externals." 

Take Action

How can I know if I am clinically depressed or just sad?

Begin to keep a daily log or journal of your mood. Rate how depressed you feel each day on a scale of 0 (= no depression) to 10 (= very severe depression).

Also write about what is happening when you become depressed. Can you explain the depression in light of your situations or circumstances? Or does it seem to occur regardless of what your situations or circumstances are like?

By keeping this log, you may gain insight into problems that you need to address. Such insights may be helpful as you work on self help for your clinical depression.

Coping With Sadness

At times sadness is a symptom of clinical depression...Other times it is a normal, reactive mood.

Either way, feelings of sadness indicate that you need to make changes in your life. Sadness, like any painful emotion, is an alarm.

Alarms warn you that you have a problem. It may be a serious problem or a minor problem. Which ever it is, you need to try and understand what the feeling is warning you about. And you need to take steps to correct the problem.

Now, I realize understanding problems and coping with those problems is often easier said than done. Nevertheless, you can learn to cope. You just need to know how.

To help you learn how to cope, The "How To Transform Your Life" E-Workshop has been developed. This e-workshop takes you step-by-step through the process of changing your life for the better.

As you...

• recognize your clinical depression
• and actively make changes in your life

...you will find yourself experiencing a more satisfying and less depressing life.

In short, clinical depression is a disease that affects many men, women, and children of all races and religions.

Sadness is a reactive mood. Depression is more than a sad mood, it is a disease.

Nevertheless, with both sadness and clinical depression you can help by coping well with problems and stressors. It is important to develop good coping skills.

Risk for Depression and Cognitive Deterioration in Older Individuals: The Important Role of Past and Present Environmental Influences

For many Americans, aging can be successful, with maintenance of happy, healthy, active lifestyles into the eighth or ninth decade of life. However, this happy scenario is not true for many elderly individuals for whom aging may be associated with medical morbidity, disability, social isolation, and the development of neuropsychiatric disturbances, including depression or a decline in memory and cognition. These disturbances
are not minor: both depression and cognitive decline increase disability, mortality rates, and risk of institutionalization while lowering one’s quality of life.
When they occur, these neuropsychiatric disorders have devastating outcomes affecting both the individual and the individual’s family. Thus, it is important that we better understand the pathophysiology of how and why these disorders develop, which can potentially guide research toward preventive interventions, wherein we treat the individual before the depression or cognitive decline becomes crippling.
Research examining risk factors for developing depression in later life has provided crucial information about its development and pathogenesis. Unfortunately, much of this literature has limited clinical applicability, as it does not provide information on what factors increase the prospective risk of developing incident depression in a currently nondepressed or mildly depressed older individual. In other words, an astute clinician can identify numerous factors that increase the risk of developing depression, including disability, social isolation, and chronic medical illnesses, but not all individuals with these risk factors will go on to become depressed. Which of these risk factors are the strongest predictors of a new onset of a depressive episode? The answer to this question can inform clinicians and guide intervention studies aimed at developing preventive strategies to reduce rates of incident depression.
In this issue of the Journal, Lyness and colleagues report results from a study examining this very question. The study design involved recruiting over 600 elderly individuals without current major depressive disorder from primary care practices. This population was exceptionally well-characterized across a wide range of clinical and psychosocial variables, and over 400 of them remained in the study for at least 1 year.
Using this approach, the authors found that many previously identified risk factors for the development of depression did not prospectively influence incident new-onset depression.
However, they found that a specific combination of factors, including subsyndromal depressive symptoms, history of previous depressive episodes, and functional impairment, identified a group at high risk for incident depression.
It is not necessarily surprising that this combination of risk factors substantially increases the risk for incident depression, but what is important is the number-needed to-treat statistic. The authors report that five individuals with disability, past major depressive disorder, and current low levels of depressive symptoms would need to be treated effectively to prevent one future major depressive episode. Given the complications of depression in an elderly population, a preventive approach for this at-risk population may be quite important to not only prevent psychological suffering but to also avoid the deleterious effects of depression on comorbid medical illness. Thus, a preventive approach may be cost-effective based on the number-needed-to-treat statistic, may improve other medical outcomes, and may be acceptable to many patients due to the relative tolerability of selective serotonin reuptake inhibitors and low cost of their generic versions. Alternatively, in those situations where antidepressant medications are not an acceptable option, psychotherapy or interventions targeting functional disability may have preventive efficacy.
There are several subtly important findings in this article that are overshadowed by the primary findings. First, depression is often characterized as a stress response to environmental adversity; however, the authors did not find that stressful life events predicted incident depression. Instead, they found a relationship between the risk of incident depression and perceived family criticism, an interesting finding given how genetic differences may influence the perception of social relationships. However, although stressful events did not predict incident depression, stress may be related to memory problems, which are common in late-life depression. The converse of this relationship is also true: depressive symptoms are common in older subjects with mild cognitive impairment. This epidemiological relationship may be particularly salient given how Lyness and colleagues found that almost 75% of their sample exhibited minor or subsyndromal depressive symptoms.
Also in this issue, Peavy and colleagues examine the influence of stress on memory decline. Although others have investigated the relationship between psychosocial stress and memory performance, this study reports on longitudinal assessments of stress, cortisol, and memory in distinct cohorts of older subjects who were either cognitively intact or who showed deficits consistent with mild cognitive impairment. Interestingly, the authors did not find a relationship between measures of salivary cortisol and stressful life events but did find independent effects of each of these measures on cognition. The authors report that stressful life events over 3 years were associated with accelerated cognitive decline, but only in those subjects with mild cognitive impairment. However, the authors also found that increased cortisol levels were associated with a decreased rate of cognitive decline in mildly impaired subjects over the study period. Peavy and colleagues discuss this unexpected finding and propose that the pathophysiological processes underlying mild cognitive impairment may alter cortisol’s effect on hippocampal and memory function, although higher cortisol may ultimately be associated with memory impairment should this population progress from mild impairment to a diagnosis of Alzheimer’s disease.
As the authors observe, the association between stress and cortisol is complex. This relationship may depend on numerous environmental and biological factors, including differences in the type or duration of stressors, support systems, individual coping mechanisms and reactivity to environmental stimuli, and genetic differences. This relationship becomes even more complex when examined in an older population, who are at risk of exhibiting memory impairment and cognitive changes but also exhibit age-related changes in hypothalamic-pituitary-adrenal axis activity. Importantly, when examining these relationships in any adult population, elderly or not, it is becoming evident that it needs to be considered in the context of childhood life events.
Childhood adversity is associated with altered adult hypothalamic-pituitary-adrenal axis reactivity, persistent changes in cognitive function through adolescence and into adulthood, and increased risk for psychiatric disturbances in adulthood, including depression. Interestingly, both the relationship between early-life stress and hypothalamic-pituitary-adrenal axis reactivity and between early-life stress and depression may be moderated by genetic differences. Although much of the work examining the relationship between childhood adversity, psychopathology, and genetic differences has been conducted in younger adult populations, there may be comparable relationships in elderly cohorts, where childhood adversity is associated with poorer psychosocial adjustment and risk of depression .
The studies by Lyness and colleagues and Peavy and colleagues utilized longitudinal approaches to better understand the development of depression and cognitive dysfunction in older populations. These methodological approaches are particularly crucial in studies of older individuals, who are characterized by ongoing aging effects on the brain and increased risk for dementia and cognitive impairment with advanced age. As demonstrated in this issue, such approaches have strong utility to inform about potential avenues for preventive interventions and also to inform about differences in biological mechanisms contributing to neuropsychiatric disease. Both types of methodological approaches will be crucial as we develop new interventions to improve mental health in later life.

My Mental Health Diagnoses -- What Types of Clinical Depressions Do I Have?

There are many types of clinical depressive disorders, with different mental health diagnoses.

Each type of clinical depression has its own diagnosis or name. Sometimes it can be confusing when you read about or talk with someone concerning depression.

Recently, a patient in my office told me, "My psychiatrist said I have clinical depression. I know that is more severe than major depression."

This statement reflects the confusion concerning all the different names of depression. Actually major depression is just one type of clinical depression.

Clinical depression is a term for all the depressive disorders. Major depression is a specific type of depressive disorder.

It is important for you to know about the types of clinical depressions and the mental health diagnoses used for each. Otherwise, you may become confused as you gather information about depression.

This article will help you become familiar with the mental health diagnoses used to classify clinical depressions.

Accurately diagnosing the types of depression that you are experiencing is important.

Notice that I said it is important to accurately diagnose the types --plural -- of depression.

You can experience more than one type of clinical depression at the same time.

You may be experiencing...

• major depressive disorder
• bipolar disorder
• dysthymic disorder
• cyclothymic disorder
• adjustment disorder with depressed mood
• seasonal affective disorder
• substance-induced mood disorder
• mood disorder due to a general medical condition
• premenstrual dysphoric disorder
• postpartum depression
  

By reading about each of these mental health diagnoses you can get a good idea of the types of depressions you are experiencing. But to accurately clarify the mental health diagnoses of the types of clinical depressions that you are experiencing, you will need to be evaluated by a qualified psychologist or psychiatrist.

The psychologist or psychiatrist will consider your symptoms, your medical history, your family history, and your social history. Based on this information, he or she will determine what mental health diagnoses fit the types of clinical depressions you are experiencing.

This is an important step in getting depression help. One reason this is so important is that different types of clinical depression require different treatments. You need to know what types of depessions you are experiencing so that you can pursue the most effective treatment to help your depressions.

Donald F. Klein, MD, wrote in his book, Understanding Depression: A Complete Guide to Its Diagnosis and Treatment , "Correct medical diagnosis should lead to a treatment that in most instances is effective, moderately fast, and inexpensive."

Labels Verses Diagnoses

A word of caution is in order here, however. Don't label yourself. And don't accept a label that someone else places on you.

You are more than whatever disorders you have. You may have clinical depressions -- But you are not clinical depressions.

You can't accurately say, "I am clinical depression."

You can accurately say, "I have clinical depression."

Even though you want to avoid labeling yourself, it is important to seek accurate mental health diagnoses of any clinical depressions that you are experiencing.

See the difference...Don't label yourself. Do accept mental health diagnoses of the conditions.

In other words, label the condition, not yourself. If you label yourself as clinical depression, you will increase guilt and shame. If you label the condition, your self-esteem can remain intact and you can then address the disorder by trying to help your depression.

Paul Wider wrote in his book, Overcoming Depression and Manic Depression (Bipolar Disorder): A Whole-Person Approach , "Beware of labels. Don't accept a label! Labels are hard to get rid of. Do accept a diagnosis from a competent person (doctor or therapist) if they say that healing is needed."

Take Action

Regardless of your mental health diagnoses and the types of clinical depressions that you are experiencing, you will need to take action to help your depression. You can first take action by calling and scheduling an appointment with a qualified psychologist or psychiatrist.

You can also help your depression by developing coping skills. Coping skills are the tools that you need to change your life from one that is less satisfying to one that is more satisfying. Coping skills are also the tools that you need to overcome problems that get in your way as you work on changing your life -- problems that block your progress toward a better life.

The "How To Transform Your Life" E-Workshop can help you acquire and develop the skills needed to change your life.

As you receive treatment for your mental health diagnoses -- including clinical depressions -- The "How To Transform Your Life" E-Workshop may help you make faster, more complete, and more lasting progress.

To learn more about the E-Workshop, click here.
In summary, there are many different mental health diagnoses for the different types of clinical depressions.

You may be experiencing one or more of these types of depressions.

To accurately diagnose your depressions you need to be evaluated by a psychologist or psychiatrist.

Once the types of clinical depressions that you are experiencing have been identified, effective treatment can begin. The "How to Transform Your Life" E-Workshop can help you develop the coping skill needed to help your depression.

There are several older terms used for types of depression. Although these terms are not used currently you may come across them as you read older books and articles about depression.

Cognitive Therapy for Depression

Almost everyone has dark thoughts when his or her mood is bad. With depression, though, the thoughts can be extremely negative. They can also take over and distort your view of reality.

Cognitive therapy can be an effective way to defuse those thoughts. When used for depression, cognitive therapy provides a mental tool kit that can be used to challenge negative thoughts. Over the long term, cognitive therapy for depression can change the way a depressed person sees the world.

Studies have shown that cognitive therapy works at least as well as antidepressants in helping people with mild to moderate depression. Treatment with medication and/or psychotherapy can shorten depression's course and can help reduce symptoms such as fatigue and poor self-esteem that accompany depression. Read on to see how cognitive therapy or talk therapy might help you start thinking and feeling better if you are depressed.

Cognitive Therapy for Depression: A Thinking Problem

Cognitive therapy was developed in the 1960s as an alternative way to treat depression, says Judith S. Beck, PhD. Beck is director of the Beck Institute for Cognitive Therapy and Research located just outside Philadelphia. She tells WebMD that the principle underlying cognitive therapy is "thoughts influence moods."

According to cognitive therapists, depression is maintained by constant negative thoughts. These thoughts are known as automatic thoughts. That means they occur without a conscious effort. For example, a depressed person might have automatic thoughts like these:

• "I always fail at everything."
• "I'm the world's worst mother."
• "I am doomed to be unhappy."

Beck says automatic thoughts "may have a grain of truth. But," she adds, "the depressed person distorts or exaggerates the reality of the situation." This negative distortion helps fuel the depression.

With cognitive therapy, a person learns to recognize and correct negative automatic thoughts.  Over time, the depressed person will be able to discover and correct deeply held but false beliefs that contribute to the depression.

"It's not the power of positive thinking," Beck says. "It's the power of realistic thinking. People find that when they think more realistically, they usually feel better."

Cognitive Therapy for Depression: How It Works

Cognitive therapy posits that most problems have several parts. Those parts include:

• the problem as the person sees it
• the person's thoughts about the problem
• the person's emotions surrounding the problem
• the person's physical feelings at the time
• the person's actions before, during, and after the problem occurs

The way cognitive therapy works is a patient learns to "disassemble" problems into these various parts. Once a person does that, problems that seemed overwhelming become manageable.

During regular cognitive therapy sessions, a trained therapist teaches the tools of cognitive therapy. Then between sessions, the patient often does homework. That homework helps the person learn how to apply the tools to solve specific life problems.

"They make small changes in their thinking and behavior every day," Beck says. "Then over time, these small changes lead to lasting improvement in mood and outlook."

Cognitive Therapy for Depression: Evidence It's Effective

How well does cognitive therapy for depression work? And how well does it stack up when compared to other treatments for depression?

Robert DeRubeis, PhD, is professor of psychology and associate dean for the social sciences at the University of Pennsylvania. He tells WebMD, "The evidence is consistent and convincing that cognitive therapy is an effective treatment for depression. And," he adds, "[that means] not just the milder forms of depression."

Large, well-designed studies that include hundreds of subjects have shown the following:

1. Cognitive therapy works as well as antidepressant medicines alone to improve mild to moderate depression.

"When conducted well, cognitive therapy works as quickly and as thoroughly as antidepressant medications," says DeRubeis, who has led several large studies of cognitive therapy for depression. "Used consistently, cognitive therapy may work better than antidepressants in the long run," he adds.

2. Cognitive therapy works as well as antidepressant medicines at preventing depression relapses.

DeRubeis tells WebMD that when a person continues using the skills he learned with cognitive therapy, those skills help prevent relapses, a common problem with depression. "Cognitive therapy appears to prevent the return of symptoms as well as taking medication," he says. "And it does it without medication."

3. Cognitive therapy reduces residual symptoms of depression.

After a "successful" treatment for depression, many people continue to have mild depressive symptoms. Adding cognitive therapy to the treatment plan helps reduce these residual symptoms.

Cognitive Therapy for Depression: With or Without Antidepressants?

Cognitive therapy has become the standard "talk therapy" used to treat depression. In addition to its high rate of success, it is also cost-effective. The benefits from cognitive therapy often come in weeks rather than months or years, as may be the case with other treatments. 

But can cognitive therapy replace antidepressant medications? For some people, says DeRubeis, the answer is yes.

"The data show that, when conducted well, cognitive therapy is a reasonable alternative to medications even for more severe forms of depression," DeRubeis says. This assumes a patient is able to participate in a cognitive therapy program.

But it doesn't have to be an "either-or" decision. In some studies, cognitive therapy for depression worked even better when combined with antidepressants.

Because everyone's situation is unique, the decision about how to use cognitive therapy should always be made by the patient and the mental health provider together.

Cognitive Therapy for Depression: Think Well, Feel Better

Depression demonstrates how closely linked the mind and body are. People who are depressed, frequently feel bad physically, not just sad or "down." Besides helping to improve a person's mood, cognitive therapy can also improve the physical symptoms of depression. It does this by:

• improving a person's overall energy level
• increasing the quality and duration of sleep
• improving appetite and restoring the pleasure of eating
• heightening a person's sex drive

Cognitive therapy can also relieve chronic pain. Many people with chronic pain also have depression. According to Beverly E. Thorn, PhD, cognitive therapy treats both at once." Thorn is professor of psychology at the University of Alabama and author of Cognitive Therapy for Chronic Pain. She says that after a course of cognitive therapy for chronic pain, "patients' symptoms related to depression are reduced as well."

The effects of cognitive therapy are often longer lasting than pain medicines. "Pain medications have all kinds of side effects and can actually add to depression," Thorn says. With cognitive therapy, patients learn coping skills and how to apply them. When they do, there is less need for pain medications.

Cognitive Therapy for Depression: 5 Questions to Ask Your Provider

Here are questions to ask your provider if you are considering cognitive therapy for depression:

1.       Should I take antidepressants if I'm trying cognitive therapy?

2.       How do I find a therapist who practices cognitive therapy?

3.       Will my health insurance cover cognitive therapy?

4.       When can I expect to start feeling better?

5.       How will I know cognitive therapy is working for me?

Chronic Pain and Depression: Managing Pain When You're Depressed

Living with chronic pain should be enough of a burden for anybody. But pile on depression -- one of the most common problems faced by people with chronic pain -- and that burden gets even heavier.

Depression can magnify pain, and make it harder to cope. The good news is that chronic pain and depression aren't inseparable. Effective treatments can relieve depression and make chronic pain more tolerable.

Chronic Pain and Depression: A Terrible Twosome

If you have chronic pain and depression, you've got plenty of company. That's because chronic pain and depression are common problems that often overlap. Depression is one of the most common psychological issues facing people who suffer from chronic pain, and it often complicates the patient's conditions and treatment. Consider these statistics:

• According to the American Pain Foundation, about 32 million people in the U.S. report pain lasting longer than one year. 
• From one-quarter to more than half of patients who complain of pain to their physicians are depressed. 
• On average, 65% of depressed people also complain of pain. 
• People whose pain limits their independence are especially likely to get depressed.

Because depression in patients with chronic pain frequently goes undiagnosed, it often goes untreated. Pain symptoms and complaints take center stage on most doctors' visits. The result is depression, along with sleep disturbances, loss of appetite, lack of energy, and decreased physical activity which may make pain much worse.

"Chronic pain and depression go hand in hand," says Steven Feinberg, MD, adjunct associate clinical professor at Stanford University School of Medicine. "You almost have to assume a person with chronic pain is depressed and begin there."

Chronic Pain and Depression: A Vicious Cycle

Pain provokes an emotional response in everyone. Anxiety, irritability, and agitation -- all these are normal feelings when we're hurting. Normally, as pain subsides, so does the stressful response.

But what if the pain doesn't go away? Over time, the constantly activated stress response can cause multiple problems associated with depression. Those problems can include:

• chronic anxiety
• confused thinking
• fatigue
• irritability
• sleep disturbances
• weight gain or loss

Some of the overlap between depression and chronic pain can be explained by biology. Depression and chronic pain share some of the same neurotransmitters -- the chemical messengers traveling between nerves.  They also share some of the same nerve pathways.

The impact of chronic pain on a person's life overall also contributes to depression.

"The real pain comes from the losses" caused by chronic pain, according to Feinberg. "Losing a job, losing respect as a functional person, loss of sexual relations, all these make people depressed."

Once depression sets in, it magnifies the pain that is already there. "Depression adds a double whammy to chronic pain by reducing the ability to cope," says Beverly E. Thorn, professor of psychology at the University of Alabama and author of the book Cognitive Therapy for Chronic Pain.

Research has compared people with chronic pain and depression to those who only suffer chronic pain. Those with chronic pain and depression: 

• report more intense pain
• feel less control of their lives
• use more unhealthy coping strategies

Because chronic pain and depression are so intertwined, depression and chronic pain are often treated together. In fact, some treatments can improve both chronic pain and depression.

Treating Chronic Pain and Depression: A "Whole-Life" Approach

Chronic pain and depression can affect a person's entire life. Consequently, an ideal treatment approach addresses all the areas of one's life affected by chronic pain and depression.

Because of the connection between chronic pain and depression, it makes sense that their treatments overlap.

Antidepressants

The fact that chronic pain and depression involve the same nerves and neurotransmitters means that antidepressants can be used to improve both chronic pain and depression.

"People hate to hear, 'it's all in your head.' But the reality is, the experience of pain is in your head," says Feinberg. "Antidepressants work on the brain to reduce the perception of pain."

Tricyclic antidepressants have abundant evidence of effectiveness. However, because of side effects their use is often limited. Some newer antidepressants are prescribed by doctors to treat certain painful chronic syndromes and seem to work well with fewer side effects.

Physical Activity

Many people with chronic pain avoid exercise. "They can't differentiate chronic pain from the 'good hurt' of exercise," says Feinberg. But, the less you do, the more out of shape you become. That means you have a higher risk of injury and worsened pain.

The key is to break this cycle. "We now know that gentle, regular physical activity is a crucial part of managing chronic pain," says Thorn. Everyone with chronic pain can and should do some kind of exercise. Consult with a physician to design an exercise plan that's safe and effective for you.

Exercise is also proven to help depression. "Physical activity releases the same kind of brain chemicals that antidepressant medications release -- [it's] a natural antidepressant," says Thorn.

Mental and Spiritual Health

Chronic pain affects your ability to live, work, and play the way you're used to. This can change how you see yourself -- sometimes for the worse.

"When somebody begins to take on the identity of a 'disabled chronic pain patient,' there is a real concern that they have sunk into the pain and become a victim," says Thorn.

Fighting this process is a critical aspect of treatment. "People with chronic pain end up sitting around," which leads to feeling passive, says Feinberg. "The best thing is for people to get busy, take control."

Working with a health care provider who refuses to see you as a helpless victim is part of the formula for success. The goal is to replace the victim identity with one of a "well person with pain," according to Thorn.

Treating Chronic Pain and Depression: Cognitive Therapy for Chronic Pain

Is there such a thing as "mind over matter"? Can you "think" your way out of feeling pain?

It may be hard to believe, but research clearly shows that for ordinary people, certain kinds of mental training truly improve chronic pain.

One approach is cognitive therapy. In cognitive therapy, a person learns to notice the negative "automatic thoughts" that surround the experience of chronic pain. These thoughts are often distortions of reality. Cognitive therapy can teach a person how to change these thought patterns and improve the experience of pain.

"The whole idea is that your thoughts and emotions have a profound impact on how you cope" with chronic pain, says Thorn. "There's very good evidence that cognitive therapy can reduce the overall experience of pain."

Cognitive therapy is also a proven treatment for depression. According to Thorn, cognitive therapy "reduces symptoms of depression and anxiety" in chronic pain patients.

In one study Thorn conducted, at the end of a 10-week cognitive therapy program, "95% of patients felt their lives were improved, and 50% said they had less pain." She also says, "Many participants also reduced their need for medications."

Treating Chronic Pain and Depression: How to Get Started

The best way to approach managing chronic pain is to team up with a physician to create a treatment plan. When chronic pain and depression are combined, the need to work with a physician is even greater. Here's how to get started.

• See your primary care physician and tell her you're interested in gaining control over your chronic pain. As you develop a plan, keep in mind that the ideal pain management plan will be multidisciplinary. That means it will address all the areas of your life affected by pain. If your physician is not trained in pain management herself, ask her to refer you to a pain specialist. 
• Empower yourself by tapping into available resources. Several reputable national organizations are devoted to helping people live full lives despite pain. See the list below for their web sites. 
• Find a cognitive therapist near you with experience in the treatment of chronic pain. You can locate one by contacting the national pain organizations or cognitive therapists' professional groups listed below.

Depression Treatment Tips

To get better, you need to take an active role in your treatment. You're not just a patient. You and your doctor have to work as a team.

Of course, right now, you might not feel up to taking an active role in anything. You might have doubts that treatment will help. But push yourself. Depression can make you feel powerless. Taking charge of your treatment is one way to feel in control again.

Here are some tips.

• Stick with it. Treatment won't work right away. Antidepressants may not take effect for four to six weeks. In some cases, a medication may not work and you'll need to try another. Therapy can take awhile, too. But don't despair. If you give them time, these treatments are very likely to help. When a depressed person gets the right medicine, at the right dose, and takes it long enough, treatment succeeds about 70% of the time. But you and your doctor may need to try quite a few treatments before landing on the right therapy for you.
• Take your medicine as prescribed. Get into good habits. Take your medicine at the same time every day. It's easier to remember if you do it along with another activity, like brushing your teeth, eating breakfast, or getting into bed. Get a weekly pillbox, which will make it easy to see if you've missed a dose.
• Never stop taking your medicine without your doctor's OK. If you need to stop taking a medicine for some reason, your doctor may reduce your dose gradually. If you stop suddenly, you may have side effects. Stopping medication abruptly may also cause depression to return.

Don't assume that you can stop taking your medicine when you feel better. Many people need ongoing treatment even when they're feeling well. This can prevent them from getting depressed again. Remember, if you're feeling well now, it might be because your medicine is working. So why stop?

• Make lifestyle changes. There's a lot you can do on your own to supplement your treatment. Eat healthy foods, high in fruits and vegetables and low in sugars and fats. Make sure to get a good night's sleep. Several studies show that physical activity can help with the symptoms of depression. Start slowly. Try taking walks around the neighborhood with a friend. Gradually, work up to exercising on most days of the week.
• Reduce stress at home and at work. Ask for help with some of the stressful things in your life. See if your friends or family will take care of some of the daily hassles, like housework. If your job is stressing you out, figure out ways to scale back some of your duties.
• Be honest. Opening up to a therapist isn't easy. But if you're not truthful, therapy is less likely to help. If you have doubts about therapy or your therapist's approach, don't hide them. Instead, talk about them openly with your therapist. He or she will be happy to have your feedback. Together, you might be able to work out a new approach that works better.
• Be open to new ideas. Your therapist may have suggestions that sound strange. He or she may push you to do things that feel awkward or uncomfortable. But try to stay open. Give new approaches a try. You may find them more helpful than you expected.
• Don't give up. You may feel hopeless right now. You may feel like you're never going to get better. But feeling that way is a symptom of your condition. If you give yourself some time — and allow your treatment to take effect — you will feel better again.

Fears and Facts About Antidepressants

Along with counseling, antidepressants are a common part of treatment for depression. And they are usually effective. Six out of 10 people treated with antidepressants feel better with the first one they try. If the first antidepressant medication doesn't help, the second or third often will. Most people eventually find one that works for them. Yet many people who could benefit from an antidepressant never try one, often because of fears and misconceptions about them, experts say.

Here are eight common fears about antidepressants, as well as facts that can help you decide if an antidepressant might be right for you.

Fear: Antidepressants make you forget your problems rather than deal with them.

Fact: Antidepressants can't make you forget your problems, but they may make it easier for you to deal with them. Being depressed can distort your perception of your problems and sap you of the energy to address difficult issues. Many therapists report that when their patients take antidepressants, it helps them make more progress in counseling.

Fear: Antidepressants change your personality or turn you into a zombie.

Fact: When administered correctly, antidepressants will not change your personality. They will help you feel like yourself again and return to your previous level of functioning. (If a person who isn't depressed takes antidepressants, they do not improve that person's mood or functioning.) Rarely, people experience apathy or loss of emotions while on certain antidepressants. When this happens, switching to a different antidepressant may help.

Fear: Taking an antidepressant will make me gain weight.

Fact: Like all drugs, antidepressants have side effects, and weight gain can be a common one of many of them. Some antidepressants may be more likely than others to cause weight gain; others may actually cause you to lose some weight. If this is a concern, talk with your doctor.

Fear: If I start taking antidepressants, I'll have to take them for the rest of my life.

Fact: Most people who take antidepressants need to take them continuously for six to nine months – not necessarily a lifetime. Once an antidepressant gets depression under control, you should work with your doctor to decide when to stop your medication and then decrease your dose gradually. Discontinuing them suddenly may cause problems such as headaches, dizziness, and nausea.

Fear: Antidepressants will destroy my sex life.

Fact: Antidepressants can have an effect on sexual functioning. The problem is usually an inability to achieve orgasm rather than a lack of desire. But because depression itself decreases libido, a medication that eases depression may improve your sex life. As with other side effects, certain antidepressants may be more likely than others to cause sexual problems.

Fear: Antidepressants are expensive and aren't covered by insurance.

Fact: Antidepressants are usually covered by insurance plans with prescription drug coverage. The cost of antidepressant therapy varies widely, depending on the dosage, the drug you are taking, and whether it is available as a generic. Even without insurance coverage, it is possible to purchase a generic antidepressant for as little as $15 per month.

Fear: Taking an antidepressant is a sign of weakness.

Fact: Like medical conditions such as diabetes or high cholesterol, major depression is a condition that often responds to medication. When depression interferes with your ability to function normally, seeking treatment is not a sign of weakness. It's a sign of good self-care.

Fear: Antidepressants increase the risk of suicide.

Fact: Studies in recent years have raised concerns that antidepressants may raise the risk of suicide among children, adolescents, and young adults. For example, a 2009 review in the British Medical Journal (BMJ) analyzed 372 studies involving nearly 100,000 people who were taking antidepressants. It found that compared to placebo, use of antidepressant drugs was associated with a small increased risk for suicidal thoughts in some children and young adults, have no effect on suicide risk among those 25 to 64, and reduce risk in those 65 and older.

In 2004, the FDA required manufacturers of antidepressants to revise their labels to include a black box warning statement about these risks.

Other studies paint a different picture. A 2006 study published in PLoS Medicine suggests that the use of antidepressants has saved thousands of lives. Data show that the U.S. suicide rate held fairly steady for 15 years prior to the introduction of the widely used antidepressant fluoxetine (Prozac) and then dropped steadily over 14 years while sales of Prozac rose. The research team found the strongest effect among women.

The bottom line: Regardless of your age or sex, it's important to see a doctor immediately if you have suicidal tendencies or witness them in others.

Depression: Finding a Doctor or Therapist

To get better, you need expert help. Many people with depression have a team working with them. This might include your regular health care provider, a psychologist or therapist, and a psychiatrist or psychiatric nurse.

In fact, studies show that combination treatment – antidepressants and talk therapy – is the most effective way to treat depression. But getting the right people may seem intimidating. Here are some answers to common questions about finding a doctor and psychologist or therapist. Below these questions, you'll find a list of tips for how to prepare for your first appointment,

• What kind of expert do I need to see? People with depression often see a few different experts. You might see a therapist as well as a doctor or nurse for medicine. You might contact your health insurer first to see what types of care they cover. If you are not covered for psychological therapy, you can look for a therapist who offers a sliding scale based on income.
• Why can't I just see one doctor? Psychiatrists are typically the only doctors who usually prescribe antidepressants and counsel patients in therapy. Often they are expensive. So many people prefer to get their antidepressants from their regular doctor, and have weekly counseling sessions with a therapist. Therapists tend to be psychologists, social workers, or counselors, with lower rates than a psychiatrist.
• How do I find a therapist or a psychiatrist? Ask your regular health care provider for a recommendation. You can also get in touch with organizations such as NAMI, the National Alliance for the Mentally Ill, which can suggest experts in your area. Keep in mind that anyone can call himself or herself a "therapist." Your therapist should be a licensed psychiatrist, psychologist, social worker, psychiatric nurse, or counselor.
• What should I look for? Therapists and psychiatrists use many different approaches. Some focus on practical, here-and-now issues. Others go deeper, probing events from your past that might have played a role in your depression. Many use a mix of styles. Shop around. When you first talk to a potential therapist or psychiatrist, ask about his or her approach. See if it's a good fit. If it's not, find someone else. If you don't click with a person, therapy is less likely to help. You may also want to look for someone who specializes in your particular problem. For instance, if you have a substance abuse problem, find a doctor and therapist who specialize in treating people struggling with addiction.
• What if treatment doesn't help? Once you've settled on a therapist and doctor, you need to give therapy and medication a chance to work. Getting better takes time, often several months. Treatment for depression can be hard at first. Opening up to someone about very personal things in your life isn't easy. But the majority of people do get better with treatment.

Depression Therapy: Preparing for Your First Appointment

It's easy to get flustered when you're first meeting with a doctor and psychologist. So be prepared. Before you first see your doctor or therapist, decide what you'd like to talk about. Think about what you want from treatment. Go in with information and questions.

Here are four key ways to prepare.

1. Write down questions.

Come up with some specific things you want to ask. Don't assume that your doctor will tell you everything you need to know.

For instance, you might ask your doctor:

• Do I need medicine for my depression?
• What kind of medicine will you prescribe?
• What are the side effects and risks?
• How often do I need to take it?
• How quickly will it work?
• Will any of my other medications, herbs, or supplements interact with this medicine?

You could ask your therapist:

• What kind of approach do you use? What will our goals be?
• What will you expect of me? Will you give me specific assignments to do between sessions?
• How often will we meet?
• Will this therapy be short-term or long-term?
• How much does each session cost?

2. Keep a log or journal.

Keeping track of your mood changes in a diary can be helpful to you, your doctor, and your psychologist or therapist. Just jot down a few lines each day. In each entry, include:

• How you're feeling that day
• Your current symptoms
• Any events that might have affected your mood
• How much sleep you got the night before
• The exact doses of any medicines you took

Bring your journal to your first appointment. Show it to your doctor and therapist. If you keep a journal for a few weeks or months, you may start to see patterns to your mood changes that you never noticed before.

3. Don't forget about your physical symptoms.

You might not think that they're relevant, but physical symptoms are often signs of depression. Make sure to tell your health care provider about pain, stomach problems, sleep problems, or any other physical symptoms. In some cases, you may need treatment for these symptoms.

4. Get help from friends or family members.

Ask them about changes they've noticed in your behavior. They may have seen symptoms that you missed. And if you're nervous about your first appointment, ask for a friend or family member to come along.

What's Stopping You from Seeing a Doctor About Depression?

Are you struggling with depression? Are you getting treatment for it? If not, you're not alone. About two-thirds of people with major depression never seek appropriate treatment, and the consequences can be devastating: personal suffering, missed work, broken marriages, health problems and, in the worst cases, death.

The World Health Organization ranks depression as one of the world's most disabling diseases. Yet with treatment, 80% of people with clinical depression improve, usually in a matter of weeks.

So what keeps us from seeking help? "It's hard to find out from folks why they are not coming [for treatment], because if they are not coming, they can't tell us," says Kate Muller, PsyD, director of psychology training and assistant professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine at Montefiore Medical Center in Bronx, N.Y. "But when they do finally get to our offices, they can certainly speak about the things that might have kept them from coming initially," she says.

Major Depression: Reasons Why People Avoid Treatment

Therapists' interviews with people who seek treatment, as well as community surveys, provide some clues as to why people don't get help for depression. If you feel depressed and are trying to deal with it on your own, see if any of these reasons ring true to you. If they do, then follow the experts' advice to get the help you need.

If I give it time, I'll snap out of it. Although a case of the blues passes with time, clinical depression may linger indefinitely if not treated, says Erik Nelson, MD, associate professor of clinical psychiatry at the University of Cincinnati Academic Health Center and staff psychiatrist at the Veterans Administration Medical Center in Cincinnati. People can't just snap out of being depressed. Often, in fact, depression has a biological origin. And like other medical conditions, it often requires treatment to control or heal it.

Waiting for depression to simply pass can be harmful for a number of reasons. For one, depression that goes untreated may become more severe, says Nelson. The longer the delay in treatment, the more difficult it may be to control, and the more likely it is to recur when treatment is stopped. There also is growing evidence that untreated depression can contribute to or worsen other medical problems. "Heart disease is the one that has been most linked to depression, but research also suggests a link between depression and metabolic issues such as obesity, diabetes, and diseases such as Alzheimer's and cancer," says Nelson.

Expert advice: Don't allow depression to linger. Speak to your doctor. If you find it difficult to seek treatment for a mental disorder, remember that depression can have a biological origin and treatment for it may help prevent serious health conditions like heart disease.

I don't want to take antidepressants. "Sometimes I think what keeps people from coming in to see us is that they're afraid they'll have to take a pill," Muller says. "They think, ‘I don't want to take a pill for the rest of my life.'"

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"Cognitive-behavioral therapy is a form of talk therapy that focuses on the here and now -- helping you look at your emotions, thoughts, and behaviors to try to improve your quality of life and reduce your depression," she says. "We know that it may work as well as medications in the short term, but may also last longer."

Expert advice: See a therapist (psychologist, psychiatrist, or social worker) as well as your regular doctor. If you do need a medication, it most likely won't be for life. Learn all you can and don't rely on stories you have heard from others who have taken antidepressants, Muller says. Every person reacts a little differently to them.

I don't feel sad all the time. Why do I need treatment for depression? You don't need to feel sad or cry all day to be clinically depressed. Often people with depression see their primary care physicians for problems such as muscle pain, sleeping difficulties, or fatigue, not knowing those are signs of depression, Nelson says. Sometimes these symptoms accompany sadness; other times they don't.

"There is also so-called ‘masked depression' -- when, for whatever reason, people don't feel in touch with a sense of sadness or abnormal mood," he says. "They may be more likely to report something like apathy, blunted mood, or not feeling like themselves."

In these cases, a doctor may diagnose depression based on other symptoms, particularly decreased interest in or loss of pleasure from favorite activities.

Expert advice : If you are experiencing symptoms such as fatigue, muscle pain, or loss of interest in once-loved activities, don't rule out depression as a cause. See your doctor.

I'm embarrassed to talk to my doctor about it. "The shame of having a mental health problem keeps folks from seeking help or even talking about suffering from depression," says Bob Livingstone, a psychotherapist in private practice in the San Francisco area and author of The Body Mind Soul Solution: Healing Emotional Pain through Exercise (Pegasus Books, 2007).But depression is nothing to be ashamed of. It is a medical condition, much like diabetes or high cholesterol, which requires treatment.

It is also a very common condition. Depressive disorders affect nearly 19 million people in the U.S. every year -- regardless of gender, age, race, religion, sexuality, or socioeconomic status. So there's a good chance your doctor won't hear anything from you that she hasn't heard many times before.

Expert advice: Remember that virtually everyone experiences depression at some point, and your doctor will not divulge confidences that you share during an office visit. Still, if speaking to your own doctor is embarrassing, find out if your insurance company has someone you can speak with first by phone. If you don't have insurance coverage for mental health, check out mental health services in your community.

I'm afraid of having to talk about painful subjects in therapy. "Depressed people avoid treatment for fear of having to undergo a probing examination of their psychological pain," says Joe Wegmann, a licensed clinical social worker and board-certified pharmacist in Metairie, La.

"They have a fear of opening it all up – ‘I don't want to go there,'" Muller says. Unfortunately, in some cases, getting into painful discussions is necessary for healing, she says. "But in other cases, it doesn't have to be as deep or scary as you might think. A good therapist understands what is like for someone to open up to a stranger and will guide you through that process. He won't push you to open up too quickly or at a level you are not comfortable with."

Expert advice: Find a therapist you feel comfortable with and ask him as many questions as he asks you, Muller says. Find out what therapy will be like. Although painful discussions may be necessary in time, your therapist cannot force you. What you reveal is up to you.

You Can Start Feeling Better: 8 Important Things to Do About Depression

Sooner or later, everyone gets the blues. Feeling sadness, loneliness, or grief when you go through a difficult life experience is part of being human. And most of the time, you can continue to function. You know that in time you will bounce back, and you do.

But what if you don't bounce back? What if your feelings of sadness linger, are excessive, or interfere with your work, sleep, or recreation? What if you're feeling fatigue or worthlessness, or experiencing weight changes along with your sadness?  You may be experiencing major depression.

Also known as clinical depression, major depressive disorder, or unipolar depression, major depression is a medical condition that exists beyond life's ordinary ups and downs. Almost 18.8 million American adults experience depression each year, and women are nearly twice as likely as men to develop major depression. People with depression cannot simply "pull themselves together" and get better. Treatment -- consisting of counseling or medications, or both -- can be key to recovery.

Major Depression: What Are the Symptoms?

Depression shows itself differently in different people. Common depression symptoms are:

• Depressed mood, sadness, or an "empty" feeling, or appearing sad or tearful to others
• Loss of interest or pleasure in activities you once enjoyed
• Significant weight loss when not dieting, or significant weight gain (for example, more than 5% of body weight in a month)
• Inability to sleep or excessive sleeping
• Restlessness or irritation (irritable mood may be a symptom in children or adolescents too), or feelings of  "dragging"
• Fatigue or loss of energy
• Feelings of worthlessness, or excessive or inappropriate guilt
• Difficulty thinking or concentrating, or indecisiveness
• Recurrent thoughts of death or suicide without a specific plan, or a suicide attempt or specific plan for committing suicide

Depression Treatment: When Should You Get Help?

If you have five or more of these symptoms for most of the day, nearly every day, for at least two weeks, and the symptoms are severe enough to interfere with your daily activities, you may have major depression. It's important to speak to your doctor about treatments to start helping you feel better.

Study Hints at Link Between Antidepressants and Heart Trouble

Men taking antidepressants may be at risk for atherosclerosis, which can increase the risk of a heart attack or stroke, a small, preliminary study suggests.

Antidepressants were associated with about a 5% increase in the thickness of the large artery in the neck called the carotid artery, which carries blood to the brain, the researchers from Emory University found.

Yet experts not involved with the study noted that it did not prove a cause-and-effect relationship between antidepressant use and heart trouble, and added that depression itself can increase the risk of cardiovascular problems.

"Antidepressant medications may decrease cardiovascular risk by treating depression," said Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles.

Since the new findings are very preliminary, Fonarow said, "Patients should not be concerned or stop taking antidepressant medications on the basis of this study."

Results of the research were scheduled to be presented Saturday at the American College of Cardiology's annual scientific session, in New Orleans. Experts note that studies presented at medical conferences do not undergo the same vetting as research published in peer-reviewed journals. The study was funded by the U.S. National Institutes of Health.

For the study, a team led by Dr. Amit Shah, a cardiology fellow at Emory, collected data on 513 middle-aged male twins who were part of the Vietnam Era Twin Registry. Sixteen percent of the men were taking antidepressants, and of these, 60% were taking selective serotonin reuptake inhibitors (SSRIs), such as Prozac, Lexapro and Zoloft. The others were taking older antidepressants.

To try to isolate the effect of antidepressants on blood vessels, the researchers measured the thickness of the carotid artery -- called carotid intima-media thickness. The study authors found that a twin taking an antidepressant had a greater intima-media thickness than a brother not taking the drugs.

The finding held true, regardless of the antidepressant taken, the researchers said.

"There is a clear association between increased intima-media thickness and taking an antidepressant, and this trend is even stronger when we look at people who are on these medications and are more depressed," Shah said in a news release from the American College of Cardiology.

"Because we didn't see an association between depression itself and a thickening of the carotid artery, it strengthens the argument that it is more likely the antidepressants than the actual depression that could be behind the association," he added.

The findings also held true after compensating for such factors as age, diabetes, blood pressure, current or previous smoking, cholesterol and weight. Other factors weighed included depressive symptoms, history of major depression and heart disease, alcohol and coffee use, statin use, physical activity, education and employment, the researchers said.

Since each additional year of life is associated with a small increase in intima-media thickness, a brother taking antidepressants is physically 4 years older than the brother not taking antidepressants, Shah's team contended. They also said that even a small increase in intima-media thickness can increase the risk of a heart attack or stroke by 1.8%.

It's not clear why there might be an association between antidepressant use and heart disease, the study authors noted. These drugs increase levels of the brain chemicals serotonin and norepinephrine, which are often low in depressed individuals.

Shah said increased levels of these chemicals may cause blood vessels to tighten, and this may lead to reduced blood flow to organs and higher blood pressure, which is a risk factor for atherosclerosis.

Commenting on the study, Dr. Dominique L. Musselman, an associate professor of clinical psychiatry at the University of Miami Miller School of Medicine, underscored that the findings show an association between antidepressant use and atherosclerosis, but not a cause-and-effect relationship.

"This finding is somewhat counterintuitive since it is well known that SSRIs enhance a tendency to bleed," she said, adding that more rigorous studies are needed to see if a cause-and-effect relationship exists.

Musselman also strongly advises patients not to stop taking antidepressants based on this study. Not treating depression can have serious consequences for quality of life, survival after a heart attack or other cardiovascular events, she said.

"This is an important finding that needs to be replicated," she added.