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alt.support.depression FAQ - part 2
Causes (continued)
- What initiates the alteration in brain chemistry?
-
It can be either a psychological or a physical event. On the physical
side, a hormonal change may provide the initial trigger: some women
dip into depression briefly each month during their premenstrual
phase; some find that the hormone balance created by oral
contraceptives disposes them to depression; pregnancy, the end of
pregnancy, and menopause have also been cited. Men's hormone levels
fluctuate as deeply but less obviously.
It is well known that certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, and Parkinsonism. This seems to be the result of a chemical effect rather than a purely psychological one, since other, equally traumatic and serious illnesses don't show the same high risk of depression.
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- Is a tendency to depression inherited?
-
It seems there are some people whose brain chemistry is predisposed
to the depressive response, and others who are at much lower risk of
depression even if exposed to the same physical or psychological
triggers. The genetic relations of manic-depressives are at a higher
risk for unipolar depression than the population at large or their
adopted / by marriage relations. There seems to be a link between high
creativity and the gene for manic-depression: artists and writers
often are not manic-depressive themselves, but have a family member
who is. Studies of families in which members of each generation
develop manic-depressive illness found that those with the illness
have a somewhat different genetic make-up than those who do not get
ill. However, the reverse is not true: not everybody with the genetic
make-up that causes vulnerability to manic-depressive illness has the
disorder. Apparently additional factors, possibly a stressful
environment, are involved in its onset.
Major depression also seems to occur, generation after generation, in some families. However, depression can occur in people with no family history of any form of mental illness. And I would be reluctant to suggest that there is any human who is entirely immune to depression under all possible conditions.
Psychological triggers: many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to astonishingly virulent and inappropriate guilt and self-hatred.
The (genuine) life events that most often appear in connection with depression are various, but there is one distinguishing feature that appears in many cases, over and over: loss of self-determination, of empowerment, of self-confidence. More profoundly: a loss of self, of the abilities or activities that a person identifies with herself. Stereotypically: a man loses the job that had defined him to himself and others, whether that definition was "executive" or "breadwinner"; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. In general, any life change, often caused by events beyond one's control, which damages the structure that gave life meaning.
The ability of a person to respond to such an event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors which may best be explored in talk therapy: why is the person's self-esteem so bound up in the position or state that has been lost? Can she find a new source of self-esteem? Therapy can be immensely helpful here.
Obviously, not everyone to whom this sort of event happens becomes depressed, and not every person who becomes depressed has had this sort of catastrophe befall them. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious trigger, psychological or physical.
Some depressions may well be caused by a spontaneous aberration in brain chemistry, with no trigger that we can currently identify, just as a seizure or migraine may have an obvious trigger or be apparently spontaneous.
However, once the depressive state has set in, both physical and psychological problems will be generated in abundance. What faster way to lose a job or a spouse than to be too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically promoted, pathological self-hatred? And what can be worse for self-esteem than watching one's appearance and household disintegrate as one loses the motivation to shower, straighten up, wash dishes or laundry, or choose attractive clothes? Health deteriorates as well: some depressed people can't sleep or eat, others sleep constantly (a real help on the job!) and eat incessantly, sometimes in order to stay awake, sometimes because it's the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, so there may be an element of self-medication here); almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression.
The question, "Is depression mostly physical or psychological," is rather beside the point. Depression may be triggered by either physical or psychological events. Most commonly, both seem to be involved, though it is often difficult to separate the two when one is talking about psychology and neurochemistry. But however it begins, depression quickly develops into a set of physical and psychological problems which feed on each other and grow. This is why a combination of physical and psychological intervention has been shown to give the best results for most patients, regardless of any classifications that doctors may have tried to impose on their depression and its cause.
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Treatment
- What sorts of psychotherapy are effective for depression?
-
Two effective methods of psychotherapy for people with depressions
are cognitive therapy and interpersonal therapy. Both psychoanalysis,
and insight oriented psychotherapy have not been shown to be
effective treatments for people with a depressive disorder. Cognitive
(and cognitive-behavioral) therapists can be found in most major
cities.
For a referral to a properly trained cognitive therapist practicing close to your location, contact:
While many therapists call themselves cognitive therapists and interpersonal therapists, only a few have had proper training. To find an interpersonal therapist with the best training, contact:
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Medication
- Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?
-
There are very few kinds of depression for which there are specific
antidepressant treatments. When it comes to people with Bipolar
Disorder who are depressed there are some major problems. Most
importantly, with any antidepressant, there is a possibility that the
antidepressant treatment will cause depressed bipolar people not just
to come out of their depressions, but to develop manic episodes. The
possibility of an antidepressant causing mania is least when the
antidepressant is bupropion (Wellbutrin). The possibility of mania is
greatly reduced if depressed bipolar folks are on a mood stabilizer
such as lithium, Tegretol or Depakote when they are started on an
antidepressant.
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- How do you tell when a treatment is not working? How do you know when to switch treatments?
-
Antidepressant treatment is clearly not working when the individual
receiving the treatment remains depressed or becomes depressed again.
When a recently started antidepressant fails to cause improvement,
the depressed individual often asks that the medication be stopped,
and a new one started. It generally does not make sense to change
antidepressants until 8-weeks at the maximum tolerated dose have
elapsed. With some tricyclic antidepressants, it is important to
check the blood level of the antidepressant before it is stopped. The
blood test can tell if the amount in the blood has been adequate.
Only after an adequate trial of one antidepressant should another be
tried. To have been on four antidepressants in an 8-week period means
that one has not had an adequate trial on any of them.
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- How do antidepressants relieve depression?
-
There are several classes of antidepressants, all of which seem to
work by increasing levels of certain neurotransmitters (most commonly
serotonin, norepinephrine, and dopamine) in the brain. It is not
entirely clear why increasing neurotransmitter levels should reduce
the severity of a depression. One theory holds that the increased
concentration of neurotransmitters causes changes in the brain's
concentration of molecules, receptors, to which these transmitters
bind. In some unknown way it is the changes in the receptors that are
thought responsible for improvement.
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- Are Antidepressants just "happy pills?"
-
No matter what their exact mode of action may be, it is clear that
antidepressants are not "happy pills." There is no street-market in
antidepressants, for unlike "speed" which will improve the mood of
almost everybody, antidepressants only improve the mood of depressed
people. Also unlike the almost instant effects of speed, the
mood-improving effects of antidepressants develop slowly over a
number of weeks. "Speed" induces a highly artificial state,
antidepressants cause the brain to slowly increase its production of
naturally occurring neurotransmitters.
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- What percentage of depressed people will respond to antidepressants?
-
Generally, about 2/3 of depressed people will
respond to any given
antidepressant. People who do not respond to the first antidepressant
they have taken, have an excellent chance of responding to another.
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- What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?
-
The most common description of the effects of antidepressants is that
of feeling the depression gradually lift, and for the person to feel
normal again. People who have responded to antidepressants are not
euphoric. They are not unfeeling automatons. The are still able to
feel sad when bad things happen, and they are able to feel very happy
in response to happy events. The sadness they feel with
disappointments is not depression, but is the sadness anyone feels
when disappointed or when having experienced a loss. Antidepressants
do not bring about happiness, they just relieve depression. Happiness
is not something that can be had from a pill.
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- What are the major categories of anti-depressants?
-
There are many classes of antidepressants. Two kinds of
antidepressants have been around for over 30 years. These are the
tricyclic antidepressants and the monoamine oxidase inhibitors. While
there are newer antidepressants, many with fewer side-effects, none
of the newer antidepressants has been shown to be more effective than
these two classes of drugs. In fact, many people who have not
responded to newer antidepressants have been successfully treated
with one of these classes of drugs.
The tricyclic antidepressants (TCAs) include such drugs as imipramine (Tofranil), amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor).
The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has recently been taken off the market in the U.S.A. for marketing rather than safety or efficacy reasons.
One of the popular new classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in late 1994, or early 1995.
Bupropion (Wellbutrin) is the only drug in its class, as is trazodone (Desyrel). The most recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug in yet another class of drugs.
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- What are the side-effects of some of the commonly used antidepressants?
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Below is a list of some of the more frequently prescribed
antidepressants, and their most common side effects. The figure
following each side effect is the percentage of people taking the
medication who experience that side effect.
Aventyl (nortriptyline): Dry mouth (15); Constipation (15); Weakness-fatigue (10); Tremor (10).
Effexor (venlafaxine): Nausea (35); Headache (25); Sleepiness (25); Dry mouth (20); Insomnia (20); Constipation (15).
Elavil (amitriptyline): Dry mouth (40); Drowsiness (30); Weight gain (30); Constipation (25); Sweating (20).
Nardil (phenelzine): dry mouth (30); insomnia (25); Increased heart rate (25); Lowered blood pressure (20); Sedation (15); Over stimulation (10);
Norpramin (desipramine): dry mouth (15); increased pulse (15); constipation (10); reduced blood pressure (10).
Pamelor - see Aventyl
Parnate (tranylcypromine): Dry mouth (20); Insomnia (20); Increased pulse rate (20); Lowered blood pressure (15); Over stimulation (15); Sedation (15).
Paxil (paroxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (25); Sedation (25); Dizziness (15); Insomnia (15).
Prozac (fluoxetine): Decreased sexual interest and/or problems achieving orgasm (30); Nausea (20); Headache (20); Nervousness (15); Insomnia (15); Diarrhea (15).
Sinequan (doxepin): Dry mouth (40); Sedation (40); Weight gain (30); Lowered blood pressure (25); Constipation (25); Sweating (20).
Tofranil (imipramine): Dry mouth (30), Reduced blood pressure (30), Constipation (20), Difficulty with urination (15).
Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness (20); Decreased appetite (20);
Zoloft (sertraline): Decreased sexual interest and/or problems achieving orgasm (30);Nausea (25); Headache (20); Diarrhea (20); Insomnia 15); Dry mouth (15); Sedation (15).
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- What are some techniques that can be used by people taking antidepressants to make side effects more tolerable?
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Listed below are some frequent side effects of antidepressants, and
some techniques to reduce their severity:
Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask the dentist to suggest a fluoride rinse to prevent cavities, visit the dentist more often than usual for tooth and gum hygiene.
Constipation: Drink at least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about taking a bulk producing agent such as Metamucil, also ask about taking a stool softener such as Colace, be sure to avoid laxatives such as Ex-Lax.
Bladder problems: The effects of some antidepressants, especially the tricyclic medications may make it difficult for you to start the stream of urine. There may be some hesitation between the time you try to urinate and the time your urine starts to flow. If it takes you over 5-minutes to start the stream, call your doctor.
Blurred vision: The tricyclic antidepressants may make it difficult for you to read. Distant vision is usually unaffected. If reading is important to you the effects of the antidepressant can be compensated for by a change in glasses. As you may compensate for the change in your vision, try to postpone getting new glasses as long as possible.
Dizziness: Dizziness when getting out of bed or when standing up from a chair, or when climbing stairs may be a problem when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing posture slowly may help prevent this kind of dizziness. Drinking adequate amounts of liquid and eating enough salt each day is important. Be sure to speak to your doctor if this side-effect is severe.
Drowsiness: This side effect often passes as you get used to taking the antidepressant that has been prescribed for you. Ask your doctor if it is safe for you to increase your intake of caffeine, and if so, by how much. If you are drowsy be sure not to drive or operate dangerous machinery.
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- Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?
-
Both lowered sexual desire and difficulties having an orgasm, in both
men and women, are particularly a problem with the selective
serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and
the monoamine oxidase inhibitors (Nardil and Parnate). There is no
treatment for decreased sexual interest except lowering the dose or
switching to a drug that does not have sexual side effects such as
bupropion (Wellbutrin). Difficulty having orgasms may be treated by a
number of medications. Among those medications are: Periactin,
Urecholine, and Symmetrel. None of these are over-the-counter drugs
and they must be prescribed by a physician. Unfortunately, many
psychiatrists are not familiar with using these medications to treat
the sexual side-effects of antidepressants.
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- What should I do if my antidepressant does not work?
- Many people decide that their antidepressant is not working prematurely. When one starts an antidepressant the hope is for rapid relief from depression. What must be remembered is that for an antidepressant to work, you must be on an adequate dose of the drug for an adequate length of time. A fair trial of any antidepressant is at least two months. Prior to a two month trial the only reason to abandon an antidepressant trial is if the medication is causing severe side effects. With many antidepressants the dose has to be increased at intervals far above the starting dose. Unfortunately, the two-month period mentioned above, refers to two months following the most recent increase in the dose, not the time from starting the particular antidepressant.