What is Depression?
Major depressive disorder, often referred to as depression, is a common illness that can affect anyone. For the average American, it estimated that about 20% of people will experience depression at one point in their lives. It is estimated that over 19 million Americans will experience some form of depression each year. Depression affects twice as many women as men. Recognizing the signs and symptoms of depression can greatly help to improve one’s life, relationships, and overall health. Depression is not just “feeling blue.” It is more than being sad or feeling grief after a loss. Depression is a medical disorder, just like diabetes or thyroid disease. Depression affects your thoughts, feelings, behaviors, relationships and physical health. Depression can even influence your sensitivity to pain. Depression is a common and highly treatable condition. Asking for and accepting help is not an admission of weakness or laziness, but is the first step toward regaining your health and overall well-being.
People with major depressive disorder have a number of symptoms nearly every day for at least 2 weeks. These symptoms include at least one of the following:
- Loss of interest in things you used to do
- Feeling sad, blue, or down in the dumps
You may also have at least 3 of the following:
- Feeling slowed down or restless and unable to sit still
- Increase or decrease in appetite or weight
- Thoughts of death or suicide
- Problems concentrating, thinking, remembering, or making decisions.
- Trouble sleeping or sleeping too much
- Loss of energy or feeling tired all of the time
- Feeling guilty or a sense of worthlessness.
Symptoms of depression can occur in several mood disorders other than major depressive disorder. These include:
Bipolar disorder, also known as manic-depressive disorder, is a common mood disorder in which people have periods of extreme mood swings that can range from manic highs to severe depression. Bipolar disorder affects at least one in 70 people. In the United States, approximately 6 million adults have bipolar disorder. Overall, the disorder affects both men and women equally. Bipolar disorder can occur anytime, but the usual age of onset is before age 25. However, the disorder can be difficult to diagnose, because many people with bipolar disorder experience depression more frequently than mania, which results in a delay in proper diagnosis.
Dysthymia, sometimes referred to as chronic depression, is a less severe form of depression. Symptoms of dysthymia can linger for a long period of time, perhaps two years or longer. Those who suffer from dysthymia are usually able to function adequately but might seem consistently unhappy. While not disabling like major depression, dysthymia can keep you from feeling your best and functioning optimally. Dysthymia can begin in childhood or in adulthood and seems to be more common in women.
Pregnant and postpartum women go through many life changes that can be stressful, even overwhelming. Postpartum depression is observed in approximately 10% of women who have recently given birth. Unlike the “baby blues,” which is an extremely common reaction following delivery, postpartum depression does not go away quickly. Researchers think that changes in hormone levels during and after pregnancy may lead to postpartum depression. Postpartum depression can make a new mom feel restless, anxious, fatigued and worthless. She may experience mood changes that interfere with her ability to carry out everyday tasks. She may worry that she might hurt herself or her baby. She may withdraw from friends or family or have difficulty attaching to the baby. Women with postpartum depression often believe that having a baby should be the happiest time of their lives and their depression makes them think that they are not good mothers. Treatments for postpartum depression include medications, hormones, and psychotherapy.
Seasonal affective disorder (also called SAD) is a type of depression that is triggered by the seasons. The most common type of SAD is called winter-onset depression. As many as half a million people in the United States may have winter-onset depression. Symptoms usually begin in late fall or early winter and go away by summer. A much less common type of SAD, known as summer-onset depression, usually begins in the late spring or early summer and goes away by winter. SAD may be related to changes in the amount of daylight during different times of the year. Treatments for SAD include light therapy, medications, psychotherapy, dietary changes and exercise.
Treatment Options
At the Depression Center we offer “evidence-based treatments” for depression and other problems. We have a team of experts knowledgeable about treatments that have been scientifically demonstrated to be effective. Our research team and affiliates are at the forefront of research efforts to further our understanding of biological and psychotherapeutic interventions for mood disorders. Our clinical team works closely with our researchers to make sure our patients receive the latest, state-of-the-art treatments. While there is much yet to be learned, scientific investigations have clearly shown that there are excellent medication, biological and psychotherapy options for depression and other mood disorders. There are several evidence-based psychotherapies for depression. Some of the most widely used and studied are Cognitive Therapy (CT), Interpersonal Therapy (IPT), and Behavioral Activation (BA). At the Depression Center, we tailor the psychotherapy to meet the needs for every individual patient. The term “Cognitive-Behavioral Therapy” or CBT is commonly used to describe evidence-based psychotherapies that focus on a person’s thoughts, behaviors, emotions, and relationships.
There are many different treatments that improve symptoms of depression including psychotherapy, medications, or a combination of medications and psychotherapy. Research shows that, for many patients, the combination of medication and psychotherapy is most effective.
Neurotransmitters are chemicals in the brain that regulate moods, emotions, thoughts and behaviors. In states of depression, researchers have shown that there are “imbalances” in key neurotransmitters impacting mood. Imbalances in neurotransmitters may be genetic, may be triggered by psychological or life stressors, or may result from a combination of genetic factors and life stressors.
Anti-depressants work by changing levels of key neurotransmitters involved in brain circuits that regulate mood. By increasing these levels of neurotransmitters, circuits that regulate moods in the brain are “re-balanced,” resulting in an improvement in symptoms. Although the response to anti-depressants is not immediate, most people experience improvement in symptoms within one to four weeks. However, symptoms may continue to improve for up to 12 weeks after starting an anti-depressant. One half of patients will respond to an initial trial of anti-depressants. Seventy five to 80% of patients will eventually respond if the first medication trial is not effective. Once a response is achieved, it is important to remain on medication for a minimum of six months. For more severe cases of depression or for depression that recurs, it may be necessary to remain on medication indefinitely.
The most commonly prescribed anti-depressants are serotonin reuptake inhibitors (SRRIs), medications which increase levels of serotonin in the brain. Other anti-depressant medications work by increasing other neurotransmitters such as norepinephrine or dopamine. As medications affect neurotransmitters in different ways, if a full response is not obtained with an initial medication trial, selecting another anti-depressant, using a combination of anti-depressants, adding a medication that boosts the effectiveness of an anti-depressant, or the addition of psychotherapy may be necessary.
At the depression center, we collaborate with patients to explore state-of-the-art options for medication interventions to improve symptoms of depression and quality of life.
Therapy
Aaron Beck, M.D. at the University of Pennsylvania developed a type of therapy for depression called Cognitive Therapy, which is often referred to as Cognitive-behavioral Therapy or CBT. He noted that people with depression have consistent patterns of negative thinking. For example, a person who had dinner plans with a friend who cancelled might think, “my friend doesn’t like me anymore.” This negative thinking creates a spiral that leads to negative emotions and behaviors such as withdrawal or avoidance. CBT helps people by helping them to identify their negative views of themselves, others and their future. In the example above, the therapist might help the person to find alternatives to their automatic assumption that their friend doesn’t like them anymore. They would search together to find other, more balanced explanations, such as “maybe she had to work late or was sick.”
CBT is an active, collaborative approach that often involves the use of homework or experimenting with new activities, communication patterns, alternative thinking, and problem-solving for difficult life problems. Typically, the therapy lasts from 8 to 20 sessions, although it may last longer depending on the individual needs of the patient. Learning to consistently think in newer, more adaptive, and helpful ways can help to reduce symptoms of depression. Many people report that these changes lead to increased meaning, satisfaction, and happiness in their lives and relationships. There is strong evidence from research that CBT helps to prevent the relapse of depression by helping people learn new coping, problem-solving, and thinking strategies.
Interpersonal therapy (IPT) is a focused, short-term psychotherapy developed specifically for depression. People play a large part in most of our lives, even when we tend to think that we face life alone. Although the causes of depression are unknown, its onset is frequently associated with problems in personal relationships, including dealings with one’s spouse, children, family, or colleagues. Problems in relating to others or the loss of loved ones may bring on depression in some people, while for others the symptoms of depression prevent them from dealing with other people as successfully as they usually do. Depression is often triggered by interpersonal stressors such as unresolved grief, interpersonal role disputes with significant others, role transitions such as leaving a job, divorce or relocating, or interpersonal deficits such as loneliness or isolation. IPT focuses on reducing depressive symptoms and dealing with the social and interpersonal problems associated with the onset of the symptoms. The patient and therapist work together to understand the onset of the depressive symptoms and to identify the specific interpersonal stressor that needs to be focused on in therapy. For example, a woman struggling with depression during a divorce might need to focus on the loss of the marriage (grief), and adjusting to being single (role transition).
Behavioral activation (BA) can be used in conjunction with cognitive-behavioral therapy or alone. The aim of BA is to change a person’s mood by enhancing their activities and behaviors. With depression, people often get into a vicious cycle where they withdraw or avoid activities they used to find pleasurable or got a sense of accomplishment from. The more a person withdraws the more they feel their life is not rewarding, and they may sink lower into a depression. This in turn may lead to more and more withdrawal and the pattern continues. In BA, the therapist develops a strategy to activate people to help them get out of this vicious cycle. The goal to is enhance a person’s daily activities, mood, pleasure and sense of accomplishment. For example, a person with depression may start to avoid going out to lunch with friends. While there may be some initial relief in not going, eventually their life becomes less rewarding. As they focus in therapy to experience greater contact with rewarding activities their depression begins to lift.
What is Bipolar Disorder?
Bipolar disorder, also known as manic-depressive disorder, is a common mood disorder in which people have periods of extreme mood swings that can range from manic highs to severe depression. Bipolar disorder affects at least one in 70 people. In the United States, approximately 6 million adults have bipolar disorder. Overall, the disorder affects both men and women equally. Bipolar disorder can occur anytime, but the usual age of onset is before age 25. However, the disorder can be difficult to diagnose, because many people with bipolar disorder experience depression more frequently than mania, which results in a delay in proper diagnosis.
Like Depression, bipolar disorder is a medical disorder, just like diabetes or thyroid disease. Asking for and accepting help is not an admission of weakness or a character flaw. Rather, it is the first step toward managing this complex condition. With appropriate treatment, people with bipolar disorder can live fulfilling and productive lives.
Common symptoms of mania include a distinct period of:
- Either elevated, euphoric, or irritable, angry mood
- Racing thoughts and flight of ideas
- Increased activity
- Impulsive behaviors, such as spending sprees or sexual indiscretions
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Being more talkative than usual
- Distractibility
- Engaging in risky behavior.
Subtypes of Bipolar Disorder
The classic form of bipolar disorder is called bipolar I disorder. It is characterized by a person having one or more manic episodes. Most people also experience depressive episodes in addition to manic episodes. Severe episodes of bipolar disorder may lead to periods of psychosis, which may include hallucinations (seeing or hearing things that aren’t there), or delusions (false but strongly held beliefs).
Bipolar II is a type of bipolar disorder in which people have had at least one hypomanic episode in addition to a depressive episode. A hypomanic episode is a period of elevated, expansive, or irritable mood that lasts for a shorter period of time and causes fewer problems in functioning than a manic episode.
Cyclothymia is a chronic, fluctuating mood disturbance characterized by periods of hypomania and periods of depression. Although the person experiences some of the symptoms of depression, the depressive symptoms are not fully characteristic of a major depressive episode.
Other Variations
Some people with Bipolar I or II disorders have rapid cycling. Rapid cycling is currently defined as having 4 or more mood episodes within 12 months. The person might cycle rapidly through different mood states, such as depression, mania, mixed or hypomania.
A mixed episode is characterized by a period of time lasting at least one week, in which symptoms of mania and depression occur at the same time.
Treatment Options
Medications are considered an essential part of treatment of bipolar disorder. Medications allow people with bipolar disorder to remain well longer, have fewer recurrences of their illness and remain more in control of their lives. Most often, bipolar medications include mood stabilizing agents and antipsychotic agents. Working with your doctor to learn about a medication’s benefits and side effects is also an essential part of medication treatment. A collaborative working relationship between a patient and his or her psychiatrist is necessary to find the medication or combination of medications that work best. Mood stabilizers are used to reduce the highs and lows of bipolar disorder. The main mood stabilizers in use today include lithium carbonate (Lithonate, Eskalith CR, among others), divalproex sodium (Depakote, Depakote ER, Depakene, valproic acid), lamotrigine (Lamictal) and carbamazepine (Tegretol, Carbetrol).
Atypical antipsychotics have been found to be very useful in the treatment of bipolar disorder, even if a person does not experience psychosis. All of the atypical antipsychotic agents are useful in treating mania, and include risperdone (Risperidal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). In addition, two of the atypicals have been approved to treat bipolar depression: quetiapine and olanzapine/fluoxetine (Symbyax).
The use of antidepressants in treating bipolar disorder is controversial, as there is little medical evidence that they provide benefits in bipolar depression and may worsen the course of the illness over time. While many patients with bipolar disorder still take antidepressants, speaking to one’s doctor about their use, risks, and potential benefits is the best way to proceed.
For a long time, mental health professionals believed that medication was the only effective treatment for bipolar disorder. However, recent research has demonstrated the value of psychotherapy as an addition to medications. People with bipolar disorder may be particularly vulnerable to stress, changes in schedule, sleep patterns, interpersonal difficulties, and negative thinking. These vulnerabilities may lead to changes in mood, such as a manias or depressions. Psychotherapy helps the person and their family to understand the disorder, identify triggers that are associated with mood changes, make changes to their daily structure and schedule, and thinking patterns that may help shorten mood episodes or prevent mood episodes. In addition, psychotherapies can help patients and their families and friends develop effective ways of communicating during a mood episode that can help minimize symptoms. The psychotherapies that have been studied and found effective for bipolar disorder include Cognitive-Behavioral Therapy (CBT), Family Focused Therapy (FFT), and Interpersonal and Social Rhythm Therapy (IPSRT). Psychotherapy also provides people with a safe, understanding environment where they can explore their feelings about being bipolar, and work toward acceptance and effective management of the disorder.
Developed by Aaron Beck, MD, CBT is a structured, goal-oriented form of psychotherapy that aims to help a person recognize negative thoughts and behavioral patterns and to modify them. The CBT model for bipolar disorder proposes that people with this condition often hold problematic beliefs about themselves (e.g. “I must be flawed, guilty or a failure”) which, when activated by life stressors, can trigger symptoms of bipolar disorder. Cognitive-behavioral therapy typically includes helping the person with bipolar disorder to: (1) identify and change strong thoughts or beliefs about themselves or others that may trigger mood shifts, like elation or depression, (2) identify early signs of mania or depression so that prompt action can be taken to prevent a full manic or depressive episode from occurring, (3) monitor and grade mood, physical activity and sleep, and (4) learn problem solving strategies for handling interpersonal problems and stressors.
Family focused therapy (FFT) was developed by David Miklowitz, Ph.D. and Michael Goldstein, Ph.D. at the University of Colorado and UCLA. FFT was developed to help patients and their families to identify stressors that might precipitate a bipolar episode. The goals of FFT are (1) to provide psychoeducation to the patient and their family about bipolar disorder, (2) to enhance communication within the family, and (2) to develop problem solving skills for life stressors, such as relationship or work problems.
Interpersonal and Social Rhythm Therapy (IPSRT), developed by Ellen Frank, Ph.D., is based on the observation that bipolar disorder is in part a problem of altered body rhythms (e.g. sleep patterns, seasonal rhythms, eating, and exercise rhythms), that are often disrupted by interpersonal changes or stressors. Interpersonal problems (e.g., family disputes) and disruptions in daily routines or social rhythms may make people with bipolar disorder more susceptible to new manic or depressive episodes. IPSRT focuses on minimizing these potential triggers. Body rhythm disturbances such as sleep disturbances, can be managed by helping patients to set up and stick to healthy routines. For example, establishing set bedtime and wake times can help stabilize mood and reduce relapses of the illness.
Anxiety Disorders
Anxiety disorders are the most common of emotional disorders and affect more than 25 million Americans. Anxiety disorders differ from normal feelings of nervousness. Untreated anxiety disorders can push people into avoiding situations that trigger or worsen their symptoms. People with anxiety disorders are likely to suffer from depression, and they also may abuse alcohol and other drugs in an effort to gain relief from their symptoms. Job performance, school work, and personal relationships can also suffer.
- Emotions such as worry, fear and panic.
- Thoughts, usually focused on the future, that negative outcomes will occur such as “I will get sick,” “They won’t like me,” and “I’ll get fired.”
- Behaviors like avoiding places or situations associated with anxiety and/or rituals to decrease their anxiety (like hand-washing or checking).
- Physical symptoms such as racing heart, sweating, dizziness, nausea, headaches and muscle tension.
Generalized anxiety (GAD) is worry about a number of different situations that is difficult to control and lasts for at least 6 months.
Panic Disorder is characterized by intense physical symptoms such as racing heart beat that come on abruptly as well as thoughts such as “I’m dying,” “I’m losing control” or “I’m going crazy.”
Obsessive-Compulsive Disorder (OCD) is characterized by intrusive negative thoughts that the person has difficulty letting go of AND rituals to reduce anxiety such as counting, repeating, ordering, checking and/or excessive hand washing.
Social Phobia is anxiety about social or performance situations and thoughts such as “They won’t like me” or “They’ll think I’m a loser.”
Posttraumatic Stress Disorder (PTSD) occurs in individuals who have survived a severe or terrifying physical or emotional event. People with PTSD may have recurrent nightmares, intrusive memories, or even have flashbacks, where the event seems to be happening all over again. They feel extreme distress when in circumstances that remind them of the trauma, and go to extremes to avoid these situations. Additional symptoms include: Feeling numb or detached, trouble sleeping, feeling jittery or on guard, and irritability.
Simple Phobia is anxiety about and avoidance of a particular thing such as bridges, spiders, or blood.
*People often have more than one anxiety disorder.
What causes anxiety disorders?
Anxiety is thought to be caused by a combination of genetic/ biological predispositions and environmental factors. Some anxiety disorders tend to be more chronic in nature, such as GAD, and others, such as Panic Disorder, are typically triggered by life stressors.
Cognitive-behavioral therapy is an effective form of therapy for anxiety disorders. It is short-term, present-focused and collaborative. Treatment helps clients learn positive strategies to cope with physical symptoms as well as negative thinking patterns. The specific techniques taught depend on the individual client’s symptom presentation and goals and may include:
- Identifying and challenging negative thoughts.
- Mindfulness techniques to remain in the present moment and tolerate negative feelings, thoughts and sensations.
- Relaxation techniques to stay calm and ease tension.
- Exposure to feared situations in real-life and in one’s imagination to reduce anxiety
Medications
Antidepressants were developed to treat depression, but they also help people with anxiety disorders. When treating anxiety disorders, antidepressants generally are started at low doses and increased over time. Antidepressants commonly prescribed to treat depression include Fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa), and venlafaxine (Effexor). Most antidepressants used now are in a class of medications which alter the amount of particular chemicals in the brain. The most common ones used alter seratonin in the brain and are called selective seratonin reuptake inhibitors (SSRIs).
The anti-anxiety medications called benzodiazepines can start working more quickly than antidepressants. These include Clonazepam (Klonopin), Lorazepam (Ativan), and Alprazolam (Xanax).
Bourne, E. J. (2005). Anxiety and Phobia Workbook. (4th ed.). Oakland, CA: New Harbinger Publications.
Hyman, B. M. & Pedrick, C. (2005). The OCD Workbook. Oakland, CA: New Harbinger Publications.
Leahy, R. L. (2009). Anxiety Free: Unravel Your Fears Before They Unravel You. New York: Hay House, Inc.
Leahy, R. L. (2005). The worry cure: Seven steps to stop worry from stopping you. New York, NY: Harmony.
Wilson, R. R. (1996). Don’t Panic: Taking Control of Anxiety Attacks. New York, NY: HarperCollins.
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