Sunday, December 6, 2009

DEPRESSION: Are you more than just sad or down?

I was up late on the computer, organizing years of digital photos. While watching TV, I was intrigued by a commercial I saw. It was along the lines of, 'How do you know if your depression is as bad as you think it is? The voices pointed viewers in the direction of an online self-assessment that will determine the severity of depression, if any, and direct you to some help. It only took about 15 minutes to complete the WebMD Depression Health Check.

I found this particularly timely. If you've read this blog before, you might have picked up on my internal battle with depression: do I have it? Why can't I be grateful? How can I help people here if I'm down? etc, etc, etc. My depression symptoms from Cushing's went haywire with post-partum depression and even post-op pituitary surgery.

While taking the assessment, it asks if you are taking medication. I said, yes to taking a sertraline/zoloft generic for over a year without much improvement. It asks if you have any conditions that may worsen depression, AND CUSHING'S WAS LISTED. I couldn't believe my eyes! Somewhere in the medical community, SOMEONE IS MENTIONING AND EVEN RECOGNIZING CUSHING'S! I feel a little validated... even though I bet this is only one way for BigPharma to sink their teeth into us and not let us go. Regardless, I will take any help I can get. I feel completely at a loss as to what to do next to help myself, so I am interested to see what they suggest. In fact, to be helpful, I thought I would share what the final assessment showed, in a report for my doctor and me :)

Date: December 6,2009
Patient Name:

Dear Doctor,

Your patient recently completed the online Depression Health Check Health Check at WebMD. This tool is designed to help your patients become better informed about their conditions and compliant with your prescribed therapy. Full clinical references are provided at the end of this document

Dx major depressive disorder (MDD)
30-39yo female dx MDD >6 mo ago. Currently treating with Rx. Sx STB |||| with Tx.

* Zoloft (sertraline)

ROS positive

* Depressed mood (DSM major)
* Anhedonia (DSM major)
* Anxiety (DSM minor)
* Difficulty sleeping (DSM minor)
* Difficulty concentrating (DSM minor)
* Feelings of worthlessness or guilt (DSM minor)
* Increased fatigue or loss of energy (DSM minor)
* Weight change (DSM minor)
* Recurrent thoughts of death or suicide (DSM minor)

WebMD Healthcheck

You've been living with depression for some time, now. Unfortunately you haven't found a treatment regimen that works well for you. Perhaps it's time to talk to your doctor.

Ask About Treatment-Resistant Depression
If you have been on at least two different medications over the past six months or longer and you have taken the medication exactly as prescribed, it is possible that your depression could be "treatment resistant." If you think that might be the case for you, talk to your doctor, because treatment-resistant depression requires a different tactic. Sometimes what is thought to be treatment-resistant depression turns out to be bipolar disorder or another medical illness that has gone undiagnosed. Your doctor can help determine whether you need a different treatment plan or further evaluation.

Don't Get Discouraged

There are many options that can help you control your symptoms and take back your life. Trying different combinations of medication, talk therapy, and lifestyle changes may increase the likelihood that you'll achieve remission, which is the ultimate goal.

Give each combination a thorough try before deciding that it's not working for you. Long-term treatment for two years or more may be necessary. Keep a journal to track your symptoms and responses to medications and other therapies, so you can see your progress over time.

Be a Patient Patient

Medications that treat depression do not work overnight. When first started, many of these medications take at least two weeks to build up in your bloodstream to levels at which an effect may be noticed. If your medication is not working after two weeks, your doctor may increase the dosage, add or change to another medication, or do both to help control your symptoms. Talk therapy often is recommended, too.

Do Be Compliant

To make sure your medication is as effective as it can be in as few courses as possible, it's important that you be diligent about following your doctor's instructions. Take the medication in the amount prescribed and at the same time(s) every day. If you have questions about whether you are taking your medication(s) correctly, your doctor or pharmacist can review your treatment instructions with you and make any necessary adjustments that may make it easier for you.
If you work with your doctor and find a successful treatment plan, it is important to stay on that treatment plan for six to 12 months, even if you start to feel better after one month of treatment. Not following your doctors instructions can increase your risk of relapse. Relapse can be common once drug therapy is stopped or if symptoms persist. And two or more episodes of major depression increase the risks of another episode of depression. Talk with your doctor to determine how long you should stay on treatment.

How Others Are Responding to Treatment

Response to depression treatment can be very personal, but sometimes you just need to know you're not alone. See how your treatment response compares with others, like you, who have been diagnosed with depression, are currently treating their depression, and have recently taken this same WebMD Depression Health Check.

You reported that since starting your treatment that your depression symptoms are
slightly worse.

What Others On Prescription Treatment Are Reporting
Much improved (16%)
Slightly improved (40%)
No change (23%)
Slightly worse (13%)
Much worse (8%)

Be Careful With Supplements

Several types of dietary supplements are touted as mood enhancers, including St. John's wort, valerian, lavender, B vitamins, and omega-3 fatty acids, but there is mixed or little evidence about their effectiveness. In some cases, supplements can cause dangerous interactions with prescription medications. Be cautious, and be smart: Tell your doctor about everything that you are taking, even vitamins! Ask your doctor or pharmacist about any supplements.

Pain and Mood

A common occurrence with depression can be chronic pain (pain that persists over a long period of time). Research presented by Harvard Medical School showed that depressed patients have three times the average risk of developing chronic pain. But chronic pain also leads to depression, as the same research also showed that people with chronic pain have three times the average risk of developing anxiety disorders and depression.

Depression and pain are closely connected. One of the reasons researchers believe this connection exists is because two chemicals in the brain -- serotonin and norepinephrine, which brain cells use to communicate -- affect areas of the brain linked to both pain and mood. Just as being depressed may make people feel more intense pain, being in pain all the time may lead to mood swings, immobility, and isolation, further compounding the feelings of depression.
Depression may contribute to the discomfort associated with back pain, chest pain, constipation, diarrhea, dizziness, exhaustion, headaches, joint pain, lightheadedness, muscle pain, nausea, and stomach problems. Because those symptoms occur with many conditions, specifically linking them to depression is a difficult task for doctors.

If pain or depression symptoms persist, you should see your doctor. After a thorough evaluation, your doctor can diagnose the problem and offer treatment, such as prescription medications, physical therapy and/or talk therapy. A study recently published in the Journal of the American Medical Association shows that people with both depression and chronic pain (of the lower back, hip, or knee) significantly decreased their depression, pain severity, and disability if their treatment included 12 weeks of antidepressant therapy, six weeks of a pain self-management program, and six months of continued therapy.

Medical Illness and Depression

Sadness can be a state of mood, and that state could be normal for a person or abnormal, and therefore part of an illness. As an illness, depression is a collection of symptoms and signs that interferes with your normal day-to-day activities. Depression also can occur as part of an underlying bipolar disorder, or secondary to substance use or abuse, certain medications, dementia, or other medical conditions.

Sometimes it is difficult to determine if depression is the result of an existing medical condition -- or the cause of symptoms. A recent paper in the American Journal of Medicine states that depression is increased in most major chronic medical conditions, and explains that treatments for those conditions may increase the risk for depression, too.

Diabetes, Depression, and More

A review of more than a dozen studies reveals that although type 2 diabetes may increase the risk for depression, depression is a much stronger risk factor for type 2 diabetes. Another recent study shows that treating depression improved insulin resistance, which occurs when the body doesn't respond as well to insulin and increases the risks for type 2 diabetes. One link between the two conditions could be cortisol, a hormone related to stress, which is a known risk factor for depression. When stress increases, cortisol is released, and cortisol affects blood sugar metabolism.

Alzheimer's disease also is more likely to develop in people with memory problems who are depressed than it is in people with memory problems who are not depressed, according to a new study published in the journal Neurology.
Other conditions linked to depression, whether by hormones or direct effects on the brain or major body systems, include:

Autoimmune disorders, such as Addison's disease, lupus, and rheumatoid arthritis
Coronary heart disease
Fibromyalgia, osteoarthritis and other musculoskeletal conditions
Head injuries
Infections, such as pneumonia, Epstein-Barr virus, HIV, the flu (influenza), and tuberculosis (TB)
Metabolic and hormonal disorders, such as anemia, Cushing's disease, low potassium, low sodium, and thyroid or parathyroid disorders
Neurologic disorders, such as multiple sclerosis or stroke

Some medications that may increase the risk of or symptoms of depression include:

Barbiturates, such as phenobarbital, which is used to treat epilepsy or insomnia
Beta-blockers, such as atenolol or metropolol, used to treat high blood pressure
Chemotherapy agents used for treating cancer
Cholinesterase inhibitors, such as neostigmine or physostigmine, used for treating Alzheimer's disease
Cimetidine (Tagamet), which is used for treating ulcers
Narcotics, such as codeine, hydrocodone, oxycodone, used for treating pain
Steroids, such as prednisone, used for reducing inflammation
Withdrawal from illicit drugs, such as cocaine

Learning More About Depression
You know how depression makes you feel. You've gone through the diagnostic process. You've probably even learned a thing or two about neurotransmitters while dealing with your condition. But you, like many researchers, are probably still curious.

What Causes Depression?
Two neurotransmitters (chemicals that help brain cells communicate) long thought to be involved in mood disorders include serotonin and norepinephrine. A long-standing theory has been that underactive neurotransmissions of these and other brain chemicals cause depression and may be involved in other mood disorders.

Defining Major Depressive Disorder
Since the 1970s, major depressive disorder has been defined by the presence of nine symptoms: sadness, loss of interest or pleasure, feelings of guilt, feelings of worthlessness, trouble concentrating or making decisions, suicidal thoughts, fatigue, abnormal eating patterns, and trouble sleeping.

Depression doesn't have to have such a strong impact on your life. Depression certainly can be a debilitating condition that increases irritability, restlessness, fatigue, and feelings of worthlessness, while decreasing sex drive, energy levels, and sleep. And it can hurt physically by contributing to headaches, back pain, digestive problems, bodily aches, and joint pain. But doctors can help you manage your symptoms. And you can play a large role in managing your condition by staying focused on your lifestyle.

Sometimes treating depression requires you to take a step back and see how far you've come. You won't notice a difference from day to day. If you keep track of your symptoms, such as in a journal or calendar, you'll likely notice improvements month to month. If you do not, please talk to your doctor and make sure you are motivated and willing to give yourself the care you need.

Take Care of Yourself

To reduce your symptoms while following the treatment plan your doctor recommends, be sure to:

1. Reduce Stress.
The emotional effects of stress, such as anxiety, panic attacks, and sleep deprivation, may compound the physical symptoms associated with depression, such as headaches, upset stomach, and sexual dysfunction. And having depression may mean you'll feel more stress. Trying stress-reducing techniques like meditation, cognitive behavioral therapy, or yoga may serve a dual purpose. It may help you reduce the stress you feel, and it may reduce the negative effects of stress on your body. If trying to squeeze in a yoga class only increases your stress level, simply sitting comfortably in a quiet room for 15 minutes with eyes closed may let tension and stress have a chance to melt away.

2. Get Moving.
We understand that depression may keep you from feeling like exercising. But if you can motivate yourself to do whatever activity you are able, the movement can start to make you feel better. Moving your body triggers the release of endorphins into the body, which are mood-boosting chemicals.
Getting exercise on a regular basis strengthens the heart and muscles, which may help reduce physical symptoms associated with depression, such as pain. Exercise also reduces stress, improves sleep, and wards off anxiety. A win-win all around. And remember, physical activity doesn't have to mean running. Walking, gardening, and playing outside with the kids count as physical activity. Remember to talk to your doctor before beginning an exercise program.

3. Eat Well.
The foods you eat may affect your mood. Too much sugar may alter the balance of chemicals in the brain, contributing to mood swings and symptoms of depression. And one recent study potentially links a low level of omega-3 fatty acids with both depression and coronary heart disease. And depression is known to be a risk factor for coronary heart disease in those who do not have heart disease, and it is known to worsen outcomes in those who do have heart disease.
Maintaining a healthy diet may help lower your risks for other health problems. Choose fresh fruits and vegetables, whole grains, low-fat dairy, and poultry or fish, and make sure you eat them in proper portions. Limit highly processed foods, red meats, high-fat dairy products, and sweets. Avoid alcohol and foods containing trans fats.

Because you've been diagnosed with depression, it's especially important to pay close attention to what you eat. Depression may make some people turn to food for comfort and gain weight, whereas others will lose their appetite and lose weight.
If you have excess weight to lose, reducing your body weight could improve your symptoms of depression. A recent study done at the University of Pennsylvania shows that people with symptoms of depression who took part in a 6-month behavioral weight loss program not only lost an average of 8% of their body weight, they also significantly reduced their symptoms of depression. In addition, they improved their glucose and cholesterol levels and reduced their triglyceride level, thereby cutting their risk of heart disease and stroke, and they also significantly reduced their symptoms of depression.

4. Be Aware of Alcohol's Effects. Alcohol dulls symptoms and pain because it depresses the central nervous system. That means it affects chemicals in the brain. For example, alcohol reduces serotonin, which increases symptoms of depression. Alcohol abuse or dependency can be associated with major depressive disorder. Eliminating the intake of alcohol is an important part of your treatment. Avoiding alcohol altogether is best if you are taking prescription medications, as mixing alcohol with medication may result in serious side effects.

5. Find Shoulders to Lean On. Sometimes a good friend with a great ear for listening can help relieve some of the pressure depression brings. Spending time with friends and family members who make you feel good or working one-on-one with a therapist gives you a place to vent.

Beyond family, friends, and your therapist, joining a support group can help you connect with others who are experiencing similar problems. Support groups allow you to share the ups and downs you experience while trying to manage your depression, and may allow you to learn some new coping solutions from others in the group. Check local hospitals as well as state and local chapters of the National Alliance on Mental Health for support groups in your area. Some support groups are online, as well.

The more you know about depression and treatment, the better equipped you'll be to make wise decisions about your health. You answered 10 out of 10 questions correctly, or 100%. HEY, WOW--maybe being smart will make me feel better about myself?! :)

Depression can make you feel pain more intensely, and having chronic pain can make you feel depressed. True or False?
The answer is TRUE.

Depression is not just an emotional condition, it's very much physical, as well. People who are depressed are more likely to experience sleep disturbances, headaches, back pain and continuous dull aches and pain. Although depression can increase a negative response to pain, some of the chemical messengers to the brain for pain and depression are shared, making it possible for the brain to associate depression with pain, and vice versa. In fact, depression and chronic pain have a reciprocal relationship: People with chronic pain experience three times the average risk of developing psychiatric symptoms, including depression, and people living with depression have three times the average risk of developing chronic pain.
A Harvard Medical Center review found chronic pain to be both an emotional and physical condition, resembling depression and affecting mood and behavior and leading to isolation and immobility. Medications are available that alleviate both the mood symptoms and the pain. Eating well, reducing stress, and exercising also help keep pain and other symptoms at bay.

Depression medications may take several weeks to achieve their full effect. True or False?
The answer is TRUE.

Medications prescribed for the treatment of depression do not reduce symptoms overnight. It takes time for the medications to interact with the body, anywhere from four to eight weeks, as the medications increase chemical messengers in the brain. Not all medications interact with individuals the same way: What may work well for one patient may not work well for another. If one medication, taken for eight weeks, does not reduce symptoms of depression, doctors may try increasing dosages or try different medications altogether, again requiring additional weeks before knowing if they work. However, once the right course of treatment is found, depression symptoms can be greatly reduced and depression can go into remission. It's worth the wait.

Depression medication together with talk therapy is usually more effective than either type of treatment alone. True or False?
The answer is TRUE.

The goal of treatment is to put symptoms of depression in remission so that you can do what you enjoy and enjoy what you do. For some people, remission occurs after a course or two of antidepressants. For others, it is achieved with psychotherapy and no medication. For some people who have depression, psychotherapy may be recommended as the initial treatment. An antidepressant medication should be started if psychotherapy doesn't improve symptoms. For those who have severe depressive symptoms when diagnosed, antidepressant medication is recommended as the initial treatment.

At least a dozen studies show that the combination of psychotherapy and antidepressant medication is more effective than either alone, especially for those who have recurring depression or who have had severe depression for more than two years. Regardless of which type of treatment is being used, taking the medication exactly as prescribed and not missing doses is necessary, as are regular follow-up appointments and open, honest communication with the doctor at those appointments.

It doesn't matter if you miss a dose of medication now and then. True or False?
The answer is FALSE.

Antidepressants balance levels of chemicals in the body that regulate mood. There may be a lag before the medications relieve your symptoms. Your doctor's prescribed dosage is meant to work over time to reach the level in your body that will regulate your brain's chemicals. Even if you feel better, do not discontinue your prescribed antidepressant without talking to your doctor. This can result in a relapse of your symptoms or can be associated with symptoms of withdrawal, such as nausea, dizziness, and trouble sleeping. It is important to follow your doctor's medical regimen closely to put depression into remission.

If depression recurs, it is best to treat it with a different medication. True or False?
The answer is FALSE.

If you get your depression symptoms under control, are weaned off the medication by your doctor, and then have a recurrence of depression, many times your doctor may resume the medication that worked previously to manage your symptoms. Of course, the antidepressant you took in the past may have a similar response as you did before; if not, your doctor may consider other treatment options. Because depression tends to run in families, another medication option may be one to which a first-degree relative (mother, father, sister, brother) has had a positive response. Responses to medications often have a genetic component, too.

You can tell if someone is depressed just by looking at them. True or False?
The answer is FALSE.

Many people fear the thought of others knowing that they are depressed, and therefore often do not seek a diagnosis or treatment for their feelings. That is unfortunate because others will not know if you or anyone else is depressed unless you tell them. Although depression is considered to be a medical illness, like arthritis, heart disease, or diabetes, people with depression do not have a physical characteristic that "gives them away." Depression does not make a person have a certain look, nor does it cause any outward signs in the way that, say, arthritis may cause apparent red, swollen joints or a limp.

Once you start feeling better on medication, you can stop taking it. True or False?
The answer is FALSE.

Some patients taking antidepressants may feel so good they assume their depression is in remission and believe they no longer need antidepressants. Patients who abruptly stop taking medications may experience a return of depression symptoms and may also experience symptoms of withdrawal. Researchers examining the effects of abruptly coming off a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) have found that patients felt serious physical and emotional effects, including flu-like symptoms, vomiting, fatigue, and dizziness. It is important to remain on treatment until your doctor recommends slowly weaning you off of medications. Your doctor will lower dosages over time and phase out the medications slowly, so as not to cause withdrawal symptoms or trigger a relapse of depression.

Depression always causes the same symptoms in everyone. True or False?
The answer is FALSE.

Depression is a common medical illness, associated with biologic changes in neurochemistry in the brain. It is associated with both emotional symptoms (mood changes) and physical symptoms, such as fatigue, headache, abdominal pain, and muscle tension, but not everyone who is diagnosed with depression has all of the symptoms. To diagnose major depression, either depressed mood or a loss of interest/pleasure in activities that were once found to be enjoyable must be present most of the day nearly every day for at least two weeks in a row, in addition to changes in sleep, appetite, weight, psychomotor activity, energy level, or ability to concentrate. Thoughts of worthlessness, guilt, death or suicide may also be present.

If the first medication you try doesn't work, no antidepressant will help. True or False?
The answer is FALSE.

Just because one antidepressant doesn't work for you does not mean that another one won't or that your depression can never be treated. If you've been taking a medication exactly as prescribed -- that is, in the proper dosage and not missing any doses -- for at least eight weeks, then tell your doctor that the prescribed medication doesn't seem to be working. Knowing that people can respond differently to the same medication, your doctor will understand. Your doctor may increase your dosage, prescribe a different medication altogether, or suggest that you add talk therapy (one-on-one counseling or support group), which can improve the effectiveness of antidepressant medication. Once you and your doctor find the right course of treatment for you, your symptoms of depression may subside, and your depression may go into remission.

Most people with depression will have it only once in their lifetime. True or False?
The answer is FALSE.

Major depression is a relapsing, remitting illness in most patients. Following a first episode, there is a greater than 40% rate of recurrence over a two-year period; after two episodes, the risk of recurrence within five years is approximately 75%. Ten percent to 30% of patients treated for a major depressive episode will have an incomplete recovery, with persistent symptoms or dysthymia.