Doctor In Your House: Wipe away the tears of depression
BY EVAN L. LIPKIS, MD Special Columnist
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Depression or persistent sadness for more than two weeks affects 20 million Americans. A comprehensive approach is needed. Many people who suffer from depression function at the level of heart failure. Fortunately, more than 90 percent of such patients can improve over time. It is important to note that the recurrence rate is high. There is a 50 percent recurrence rate after one episode and a 90 percent recurrence rate after three episodes. Following a stroke or heart attack, two thirds of patients are affected by depression.
Why am I depressed?
Both genetics and environmental stress play a role in the genesis of this chemical disorder. Both risk factors deplete the brain of neurotransmitters such as serotonin, and this leads to sadness. Many famous people suffer from depression. In the past, Abraham Lincoln tried to treat his depression with mercury that ultimately worsened his condition. Winston Churchill and John Lennon also suffered from this disease.
What can mimic depression?
A full history and physical exam should be performed as other diseases can cause depression. A few mimics include thyroid problems, certain medicines (beta blockers, interferon steroids etc.), a variety of cancers, low testosterone, drug abuse and several brain ailments. Treating such underlying illnesses can improve or cure depression.
Is it all in my head, doctor?
Actually it is! Both genetics and environmental stress can deplete the brain of vital hormones such as dopamine, serotonin and norepinephrine (adrenalin). Depression is a chemical change in the brain just as heart failure is a chemical change in the heart.
Am I bipolar?
Most bipolar patients have chronic depression with bouts of mania. Mania may include pressure of speech, racing thoughts, endless energy, irritability and sometimes hallucinations. It most often starts as a young adult and it is strongly genetic. Treating for just depression can precipitate a manic episode so recognition of bipolar disorder is essential.
What if I have suicidal thoughts?
Seventy percent of depressed patients have suicidal thoughts, which is not unusual. While these individuals are not likely at risk for suicide, a definite plan is a risk factor. Bipolar patients have a significantly higher risk of suicide than depressed patients do.
Are their any non-drug treatments?
A recent Cochrane review showed that exercise has a moderate effect on decreasing depression. Yoga, Tai Chi, acupuncture and meditation may be helpful as well.
Additionally, cognitive behavioral therapy done by a psychotherapist can be useful. This method helps to change the negative self-talk that is often seen in depressed individuals. Hypnosis is an interesting technique to help with negative emotions.
Fish oil, vitamin D, saffron tryptophan, St. John's Wart, SAMe ( S-Adenosyl Methionine) and Deplin ( a prescription form of folic acid called L-methylfolate) may be helpful for depression but has not been well studied.
What standard treatments can be utilized?
All antidepressants have equal response rates. The most common group of agents - SSRIs - increases serotonin in the brain. SNRIs increase both serotonin and norepinepherine. These agents (Cymbalta and venlafaxine) seem to help both depression and chronic pain. Generally, all of these medicines should be increased gradually to achieve a full remission.
Other enhancing medicines can be added if needed. These include lithium, thyroid, Wellbutrin, antipsychotics and stimulants.
Depression is a risk factor for heart disease and dementia so it is important to treat this condition early. Most standard therapies take 2-12 weeks to work.
What about new devices for depression?
Transmagnetic stimulation (TMS) is an expensive but new way to treat depression via magnetic waves. The brain-directed magnetic pulses are the strength of a standard MRI scan. The treatment, which is cleared by the FDA, stimulates neuron activity specifically in the part of the brain that controls mood.
An experimental therapy, known as transcranial direct current stimulation, or tDCS, involves a low-level electrical charge about one-400th of that used in electroshock treatment. Unlike electroshock (also called electroconvulsive therapy or ECT), which is administered for a few seconds to patients under anesthesia, tDCS is given for 20 to 30 minutes continuously while patients are conscious.
Vagal nerve stimulators (VNS) and deep brain stimulators (DBS) are two other devices that can be implanted in the brain to stimulate electrical activity in neurons. This in turn can help treat resistant depression. Finally, multiple general anesthesia inductions with halothane have been helpful.
Doctors Rx: Depression is a common medical disease that has a chemical basis. There is no shame in having this ailment. Fortunately, a primary care physician can utilize effective treatments to affect a cure in more than 90 percent of patients. If you are suffering with depression, see your doctor immediately. For more information, click here.
Evan Lipkis, MD, is a physician, author and lecturer based in Glenview, Illinois. The advice contained in this column is for informational purposes only. Readers should consult with their physician to evaluate any illness or medical condition. Contact Dr. Lipkis through his website at www.drlipkis.com.