Depression

Depression affects approximately 121 million people worldwide.  The total cost of depression for Americans has risen to over 40 billion dollars each year for direct and indirect costs. Direct costs, such as hospitalization, outpatient care, and drug treatment, account for $12.4 billion, while indirect costs incurred by lost productivity, absenteeism, and suicide-related losses in productivity comprise the remainder.

When a person is depressed, it interferes with his or her daily life and routine, such as going to work or school, taking care of children, and relationships with family and friends. The illness causes pain for the person who has it and for those who care about him or her. Loss of a loved one, divorce, bereavement, social isolation, stress and hormonal changes, or traumatic events may trigger depression at any age.

Women are twice as likely to be diagnosed with Major Depressive Disorder as men. It occurs most often between the ages of 25 and 44. At any given time, up to 9 percent of women and 4 percent of men may have the disorder.

The clinical course of major depressive disorder is quite variable. The disorder typically has its onset when the patient is in his or her mid-20s or 30s,  but a later onset is not uncommon.

Most patients who have major depressive disorder will eventually recover, but some patients will never have a remission (two months or more with no symptoms, or one or two symptoms to a mild degree) and others may have many years in which they have no signs and symptoms of depression.

Patients who have had severe depression or who have had an onset at a relatively young age are more likely to have recurrent depression, and depression accompanied with anxiety, personality disorders, or psychotic features has a poor prognosis for remission. Gender and age do not seem to affect the progression of major depressive disorder.

Major depressive disorder is associated with a high mortality risk and most of this risk is from suicide. Major depressive disorder is considered to be a significant risk factor for suicidal behavior, and suicide attempts or threats of suicide are considered to be consistent risk factors for suicide in patients who have major depressive disorder.

Major depressive disorder is a risk factor for the development of chronic diseases (and it negatively influences the progression of these diseases) such as cardiovascular diseases, diabetes, and neurological disorders.

People who have major depressive disorder are more likely to smoke, abuse alcohol and drugs, they report a lower quality of life, and this disorder has a profound effect on the patient’s family life, personal relationships, and professional and social life.

Diagnostic Criteria

The American Psychiatric Association’s diagnostic criteria for major depressive disorder, located in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly attributable to another medical condition.

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Types of Depression

Major Depressive Disorder

MDD is a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person’s lifetime, but more often, it recurs throughout a person’s life.

Dysthymia

Dysthymia, also called Persistent Depressive Disorder, is characterized by long-term (two years or longer), but less severe, symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes. In fact, up to 25 percent of people who develop unipolar depression have been previously diagnosed with dysthymic disorder. Both dysthymic disorder and major depressive disorder can exist at the same time.

Bipolar Disorder

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (e.g., mania or hypomania) to extreme lows (e.g., bipolar depression).

Postpartum Depression

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Seasonal Affective Disorder

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Causes of Depression

Genetic
Depression is to some degree an inherited disease. People who have major depressive disorder are three times more likely to have a first-degree relative (parent or sibling) who has or had depression than people who do not, and twin studies have estimated that the risk of developing depression is approximately 30%-50% associated with genetic variations.

However, despite a consistent body of evidence that indicates people inherit a susceptibility to depression, genome-wide association studies and gene-environment interaction studies have not yet clearly defined the role and contribution of genetics in the development of depression.

Biological
Biological causes of major depressive disorder include abnormal changes in brain structures, impaired and/or abnormal neurotransmitter function, and immune system dysfunction that can cause inflammation and oxidative stress.Whether these changes in structure and function are cause or effect has been difficult to determine, given the heterogeneity of major depressive disorder and the treatments for the disease.

Environmental
Major life stressors are considered to be a strong predictor for the development of major depressive disorder. Chronic diseases such as cancer, chronic obstructive pulmonary disease, diabetes, heart disease also increase the risk for developing depression, as do acute illnesses such as stroke.

Depression also may occur with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease. People who have depression along with another medical illness tend to have more severe symptoms of both mood and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co-existing depression. Treating the depression can also help improve the outcome of treating the co-occurring illness.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety disorder, often accompany depression.

Depression Treatment

Medications and psychotherapy are the primary treatments for major depressive disorder.  When the depression is difficult to treat, Electroconvulsive Treatment (ECT) or Trans-magnetic Stimulation (TMS) can be used.

Antidepressants

Although the SSRIs share the same mechanism of action, therapeutic profiles, and overall side effect profiles, individual patients often react very differently to one SSRI versus another.

Selective Serotonin Re-Uptake Inhibitors (SSRIs)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Vilazodone (Viibryd)

Serotonin-Norepinephrine Re-Uptake Inhibitors (SNRIs)
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Milnacipran (Ixel)
Venlafaxine (Effexor)

Atypical Antidepressants 
Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Nefazadone (Serzone)
Trazodone (Desyrel)
Vilazodone (Viibryd)

Tricyclic and Tetracyclic Anti-Depressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin
Imipramine
Maprotiline
Nortriptyline
Protriptyline
Trimipramine

Monoamine Oxidase Inhibitors (MAOI)
Isocarboxazid
Phenelzine
Selegiline, transdermal
Tranylcypromine

Natural Remedies for Depression

 St. John’s Wort

A well-known botanical product, St. John’s wort has historically been used for management of mental health issues, including depression and anxiety. St. John’s wort comes from the flowering plant Hypericum perforatum.   It is reportedly named as such because the plant tends to bloom on or around June 24th, which is traditionally known as the birthdate of St. John the Baptist.

It contains hypericin and pseudohypericin, both of which may be responsible for its activity, as well as its essential oils and flavenoids, which may also be beneficial.  The specific components of St. John’s wort that make it effective are not entirely known. St. John’s wort has been shown to be effective in the treatment of depression, and some studies have shown it to be as effective as some selective-serotonin reuptake inhibitor antidepressants.

It is possible that St. John’s wort works because it impacts levels of neurotransmitters, including serotonin and dopamine. In addition to management of depression, St. John’s wort may also be effective in the management of other conditions, including symptoms associated with menopause and premenstrual syndrome, seasonal affective disorder, and obsessive-compulsive disorder.

As a precaution, St. John’s wort has been shown to cause some negative side effects in certain patients, particularly when it is taken with other drugs. The FDA has issued warnings about interactions of St. John’s wort with medications. Specifically,  it should not be taken with other antidepressants. St. John’s wort has also caused problems with the effectiveness of some types of drugs, including warfarin, asthma medications, and birth control pills.