March 11th

Ok so, here I am back again. I am going to bore you all today with some of the stuff I have to deal with on my course. Last week I had to give a presentation on depression. This was a paticularly brave choice. It is not easy giving a presentation on something you suffer from, especially as the expectations on me were huge. This is some of the information I used.

• In any given 1-year period, 9.5 percent of the population, or about 121 million adults, suffer from a depressive illness.
• Depression is among the leading causes of disability worldwide.
• Depression can be reliably diagnosed and treated in primary care.
• Depression affects people of any race, gender or age.
• Fewer than 25% of those affected have access to effective treatments.

This figures are astounding and when you consider that the WHO (World Helath Organisation) says this about it you begin to see the seriousness of this problem:

"Depression is the leading cause of disability as measured by YLDs (years lived with disabilities) and the 4th leading contributor to the global burden of disease (DALYs. Disability Adjusted Life Years. The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability) in 2000.
By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calculated for all ages, both sexes.
Today, depression is already the 2nd cause of DALYs in the age category 15-44 years for both sexes combined."

So what is depression? The Dictionary defines it as this:

Psychology. A psychiatric disorder characterized by an inability to concentrate, insomnia, loss of appetite, anhedonia, feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death. Also called clinical depression.

It doesnt really tell us a lot. Basically depression is lots of things to lots of different people. I have compiled a list of the most common symptoms:

1. Persistent sad, anxious, or "empty" mood
2. Feelings of hopelessness, pessimism
3. Feelings of guilt, worthlessness, helplessness
4. Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
5. Decreased energy, fatigue, being "slowed down"
6. Difficulty concentrating, remembering, making decisions
7. Insomnia, early-morning awakening, or oversleeping
8. Appetite and/or weight loss or overeating and weight gain
9. Thoughts of death or suicide; suicide attempts
10. Thoughts of self harming
11. Delusions and/or hallucinations
12. Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.

So now we know the definition of it, and the symptoms, so how de we treat it? well there are numerous theories and treatments:

Medication-SSRI’s, Tricyclics, MAOI’s, SNRI’s
Herbal Therapies-St Johns Wort
Psychotherapies-“Talking”, behavioural ECT-Electroconvulsive therapy

Medication

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications chiefly the selective serotonin reuptake inhibitors (SSRIs) the tricyclics, and the monoamine oxidase inhibitors (MAOIs). The SSRIs and other newer medications that affect neurotransmitters such as dopamine or norepinephrine generally have fewer side effects than tricyclics.
Sometimes the doctor will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, anti-depressant medications must be taken regularly for 3 to 4 weeks (in some cases, as many as 8 weeks) before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for at least 4 to 9 months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust. Never stop taking an antidepressant without consulting the doctor for instructions on how to safely discontinue the medication. For individuals with bipolar disorder or chronic major depression, medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly. For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions. Some drugs, although safe when taken alone can, if taken with others, cause severe and dangerous side effects. Some drugs, like alcohol or street drugs may reduce the effectiveness of antidepressants and should be avoided. This includes wine, beer, and hard liquor. Some people who have not had a problem with alcohol use may be permitted by their doctor to use a modest amount of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants. They are sometimes prescribed along with antidepressants; however, they are not effective when taken alone for a depressive disorder.
Stimulants, such as amphetamines, are not effective antidepressants, but they are used occasionally under close supervision in medically ill depressed patients. Questions about any antidepressant prescribed, or problems that may be related to the medication should be discussed with the doctor.
Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has pre-existing thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol®) and valproate (Depakote®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal®) and gabapentin (Neurontin®): their role in the treatment hierarchy of bipolar disorder remains under study.
Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Herbal Therapies

In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John's wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John's wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses. Because of the widespread interest in St. John's wort, the National Institutes of Health (NIH) conducted a 3-year study, sponsored by three NIH components the National Institute of Mental Health, the National Centre for Complementary and
Alternative Medicine and the Office of Dietary Supplements. The study was designed to include 336 patients with major depression of moderate severity, randomly assigned to an 8-week trial with one-third of patients receiving a uniform dose of St. John's wort, another third sertraline, a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression, and the final third a placebo (a pill that looks exactly like the SSRI and the St. John's wort, but has no active ingredients). The study participants who respond positively were followed for an additional 18 weeks. At the end of the first phase of the study, participants were measured on two scales, one for depression and one for overall functioning.
There was no significant difference in rate of response for depression, but the scale for overall functioning was better for the antidepressant than for either St. John’s wort or placebo. While this study did not support the use of St. John’s wort in the treatment of major depression, ongoing NIH-supported research is examining a possible role for St. John’s wort in the treatment of milder forms of depression.
The Food and Drug Administration issued a Public Health Advisory on February 10, 2000. It stated that St. John’s wort appears to affect an important metabolic pathway that is used by many drugs prescribed to treat conditions such as AIDS, heart disease, depression, seizures, certain cancers, and rejection of transplants. Therefore, health care providers should alert their patients about these potential drug interactions.
Some other herbal supplements frequently used that have not been evaluated in large-scale clinical trials are ephedra, gingko biloba, Echinacea, and ginseng. Any herbal supplement should be taken only after consultation with the doctor or other health care provider.

Psychotherapies

Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with “homework” assignments between sessions. “Behavioural" therapist’s help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioural patterns that contribute to or result from their depression.
Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioural therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive/behavioural therapists help patients change the negative styles of thinking and behaving often associated with depression.
Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

How to help Yourself if you are depressed

Depressive disorders make one 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 circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Set realistic goals in light of the depression and assume a reasonable amount of responsibility
• Break large tasks into small ones, set some priorities, and do what you can as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Mild exercise, going to a movie, a ballgame, or participating in religious, social, or other activities may help.
• Expect your mood to improve gradually, not immediately. Feeling better takes time.
• It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition change jobs, get married or divorced discuss it with others who know you well and have a more objective view of your situation.
• People rarely "snap out of" a depression. But they can feel a little better day-by-day
• Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression responds to treatment.
• Let your family and friends help you.

How Family and friends can help

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication. The depressed person should be encouraged to obey the doctor's orders about the use of alcoholic products while on medication. The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's therapist. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure. Do not accuse the depressed person of faking illness or of laziness, or expect him or her “to snap out of it.” Eventually, with treatment, most people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

So there ya go, that was a brief summary of the lecture I gave on depression, it is very clinical and misses out lots of stuff. If you want full details and places to go for further help please dont hesitate to contact me.

So after all that how am I feeling? Lost I guess. Down, needy (did I really just admit that?) a lot of emotions. All jumbled up inside with no release. Still soon the release will come.