| * Please note that most treatment modalities listed below are based on conventional medicine. PreventDisease.com does not advocate the use of any pharmaceutical drug treatments. Long-term drug therapy is very detrimental to human health. All drug information is for your reference only and readers are strongly encouraged to research healthier alternatives to any drug therapies listed.
some unhappiness, often as a result of a change, either in the form
of a setback or a loss, or simply, as Freud said, "everyday misery."
The painful feelings that accompany these events are usually appropriate,
necessary, and transitory, and can even present an opportunity for
personal growth. However, when depression persists and impairs daily
life, it may be an indication of a depressive disorder. Severity,
duration, and the presence of other symptoms are the factors that
distinguish normal sadness from a depressive disorder.
Depression has been alluded to by a variety of names in both medical
and popular literature for thousands of years. Early English texts
refer to "melancholia," which was for centuries the generic term
for all emotional disorders. Depression is now referred to as a
mood disorder, and the primary subtypes are major depression, dysthymia
(chronic and usually milder depression), and atypical depression.
Other important forms of depression are premenstrual dysphoric disorder
(PDD, also called PMDD) and seasonal affective disorder (SAD).
(The other major mood disorder, not discussed in this report, is
bipolar disorder, or manic-depressive illness, which is characterized
by periods of depression alternating with episodes of excessive
energy and activity. [
In major, or
acute, depression, at least five of the symptoms listed below must
occur for a period of at least two weeks, and they must represent
a change from previous behavior or mood. Depressed mood or loss
of interest must be present.
1. Depressed mood on most days for most of each day. (Irritability
may be prominent in children and adolescents.)
2. Total or very noticeable loss of pleasure most of the time.
3. Significant increases or decreases in appetite, weight, or both.
4. Sleep disorders, either insomnia or excessive sleepiness, nearly
5. Feelings of agitation or a sense of intense slowness.
6. Loss of energy and a daily sense of tiredness.
7. Sense of guilt or worthlessness nearly all the time.
8. Inability to concentrate occurring nearly every day.
9. Recurrent thoughts of death or suicide.
In addition, other criteria must be met:
A long-term study
conducted in 1997 found that episodes of major depression usually
last about twenty weeks. Between 30% and 40% of depressed patients
experience sudden attacks of anger that they describe as uncharacteristic
- The symptoms
listed above should not follow or accompany manic episodes (such
as in bipolar or other disorders).
- They should
impair important normal functions (such as work or personal
- They are
not caused by drugs, alcohol, or other substances.
- They are
not caused by normal grief. [For definition see below. ]
Symptoms of depression in children may differ from those in adults.
They may include:
- An inability
to enjoy favorite activities.
of physical problems, such as headaches and stomach aches.
- Poor performance
- Low energy.
- Poor concentration.
in eating or sleeping patterns or both.
- A greater
tendency to bully others. (Anxious children are more often bullied).
chronic depression, afflicts 3% to 6% of the general population,
and is characterized by many of the same symptoms that occur in
major depression; symptoms of dysthymia are less intense and last
much longer, at least two years. The symptoms of dysthymia have
been described as a "veil of sadness" that covers most activities.
Possibly because of the duration of the symptoms, patients who suffer
from chronic minor depression do not exhibit marked changes in mood
or in daily functioning, although they have low energy, a general
negativity, and a sense of dissatisfaction and hopelessness.
Double Depression. Often, symptoms become more severe over
time. In one long-term study, nearly all patients with dysthymia
suffered at least one episode of major depression superimposed on
chronic depression (sometimes called double depression) at some
time in their life. Some experts believe that such double depression
should be considered as part of the natural course of dysthymic
disorder. Women may be more susceptible to double depression. In
one study, more than one-third of those who recovered from dysthymia
relapsed within five years.
People with atypical
depression generally overeat, oversleep, have a feeling of being
weighed down, and have strong feelings of rejection.
disorder (SAD) is characterized by annual episodes of depression
during fall or winter that remit in the spring or summer and which
may be replaced by a manic phase. Other symptoms include fatigue,
a tendency to overeat (particularly carbohydrates) and to oversleep
in winter. (A minority of individuals with SAD has the more common
depressive symptoms of under eating and being sleepless.)
SAD tends to last about five months in those who live in the northern
part of America. It should be noted that seasonal changes affect
many people's moods, regardless of gender and whether or not they
have SAD. Simply being mildly depressed during the winter does not
mean that one has SAD. Nor does living in a Northern country with
long winter nights guarantee a higher risk for depression.
of severe depression, irritability, and tension before menstruation
is known as premenstrual dysphoric disorder (PDD or PMDD) (also
called late-luteal dysphoric disorder). It affects an estimated
3% to 8% of women in their reproductive years. A diagnosis of PDD
depends on having five or more standard symptoms of major depression
[ see above ] that occur during most menstrual cycles, with
symptoms worsening a week or so before the menstrual period and
The symptoms of grief (bereavement) and depression have much in
common; indeed, it may be difficult to separate the two. Grief,
however, is considered to be a healthy and important emotional response
for dealing with loss, and it generally follows a characteristic
If the grief
is still severe after this period, however, it may affect a person's
health or increase the risk for on-going depression. Some experts
suggest that such a severe persistent grieving state be categorized
as a separate psychologic diagnosis, termed complicated grief disorder,
which would be related to post-traumatic stress syndrome and require
normally has a limited duration. In people without any co-existing
emotional disorder, bereavement usually lasts between three
and six months.
- The grieving
person typically endures a succession of emotions that include
shock and denial, loneliness, despair, social alienation, and
- The recovery
period following this process, during which the individual becomes
re-involved with life, takes about the same amount of time as
the bereavement cycle.
Loneliness. Like grief, loneliness is a condition that may
often be mistaken for depression. In fact, while loneliness and
depression often go hand in hand, some researchers believe that
some people with loneliness may be effectively treated for depression.
Of course, every person feels loneliness now and then; debilitating
loneliness, however, is often characterized by misery, a feeling
of hollowness, unrealistic expectations for one's life, and feeling
removed from others. Shy people may be more prone to loneliness.
Psychotherapy of various kinds may help people address and allay
The causes of
depression are not fully known. Most likely a combination of genetic,
biologic, and environmental factors are at work.
Because depression runs in families, and has a strong genetic component,
there is compelling evidence that it is a biologic phenomenon. Data
from family, twin, adoption, and genetic studies have confirmed
this. There is stronger risk of other family members getting depression
with early recurrent forms of depression. Studies have found that
first-degree relatives of patients with depression are two to six
times more likely to develop the problem than individuals without
a family history.
The basic biologic
causes of depression are strongly linked to abnormalities in the
delivery of certain key neurotransmitters (chemical messengers in
the brain), most importantly the following:
The degree to
which these chemical messengers are disturbed is determined by other
factors, such as light, structural abnormalities in the brain, sleep
disorders, or genetic susceptibility. For example, researchers have
identified a defect in the gene known as SERT, which regulates serotonin,
which has been linked to depression.
a group of neurotransmitters that consists of dopamine, norepinephrine,
and epinephrine, also called adrenaline.
Hormones. In women, the female hormones estrogen and progesterone
most likely play a role in depression. [ See Box Specific
Causes of Depression in Women.] Abnormal levels of certain stress
and growth hormones may also play some role in depression.
Stress Hormones. Corticotropin-releasing factor (CRF), which
is believed to be a stress hormone and a neurotransmitter, is also
thought to be involved in depression. Increased CRF concentrations
have been found in the cerebrospinal fluid of depressed patients.
Other observations of CRF in depressed patients have supported this
theory. CRF activity is also associated with sleep and appetite
disruptions and with decreased libido.
Alterations in Brain Structure and Function
Patients with major depressive disorder have been found to have
smaller hippocampi and amygdalas. (The hippocampus stores memory
and activity in the amygdala has been correlated with activation
of important emotional states, including anxiety and depression.)
There is also evidence to suggest that the activity of certain pathways
in the brain, responsible for regulating mood and associated behaviors
and thoughts, is altered in depression.
A 2000 study supported previous evidence that in some older people
with depression, atherosclerosis, or narrowing of the arteries in
the brain, caused depression, rather than chemical or emotional
as Adaptive Strategy
theorize that low mood is an adaptive response to situations in
which expectations fail to match achievements and active efforts
produce no benefit (such as with an unrequited love affair, career
failure, or a challenge of authority). In its healthy state, the
pain this response causes provides both an incentive to disengage
and a passive, withdrawn state that allows a period of thoughtful
time before changing direction. Depression as a disorder (characterized
by pervasive pessimism, low self-esteem and total lack of initiative)
may develop if there are constant unachievable objects or goals
and there are no positive relationships to help a person change
direction. (Such cases could certainly occur in highly competitive
societies that lack strong social support and where the media holds
up unattainable images as desirable.) Such a theory does not, however,
rule out biologic or other factors that can contribute to depressive
Specific Causes of Depression in Women
regardless of nationality or socioeconomic level, have significantly
higher rates of depression than men. The causes of such higher
rates appear to be a mix of biologic and cultural factors.
are at risk for emotional swings when they experience extreme
hormonal shifts. The role of hormones in depression is not
clear, but female hormones undoubtedly play some role in premenstrual
dysphoria, postpartum depression, and SAD. These forms of
depression recede or stop after menopause. Evidence for hormonal
causes of depression is mostly based on observations of depression
during specific stages in female development.
Early Puberty. Girls who go through puberty early
(reaching the midpoint at 11 years or younger) are more likely
to experience depression during adolescence than girls who
Premenopause. Premenopausal women (between the ages
of 20 and 45) were most susceptible to depression, with 22%
of this age group reporting symptoms of major depression.
Premenstrual dysphoric disorder (severe depression before
a period) specifically affects an estimated 3% to 8% of women
in their reproductive years. [ See ,
Report # 79, Premenstrual Syndrome. ]
Postpartum Depression. Nearly every new mother experiences
a short period of mild depression following childbirth (known
as the "baby blues"). It is not considered postpartum depression,
however, unless it persists beyond a week or two and is very
severe. Studies have reported that between 8% and 20% of women
have diagnosable postpartum depression within three months
of delivery, with 5% in one study having suicidal thoughts.
One study strongly suggested that the fluctuating levels of
estrogen and progesterone accompanying childbirth may play
a major role in postpartum depression, at least in women who
are sensitive to such changes. Different studies have suggested
that the following women may be at higher risk for postpartum
depression are the following conditions:
be noted that many male partners of new mothers also suffer
from depression surrounding the birth of a child.
A history of prior depressive episodes.
Being a new mother and having an infant with medical problems.
Psychological distress during or after the pregnancy.
Lacking social support or feeling as if it is lacking.
Having two or more children.
Depression During Pregnancy. A 2001 study found that depression
during pregnancy was more common than depression after pregnancy,
with the highest depression scores occurring in week 32. The
authors commented that depression during pregnancy is a neglected
area, and that the effects of depression on the fetus are
Miscarriage. Miscarriage poses a very high risk for
depression, particularly in the first month after the loss.
Older women with no previous successful pregnancies and those
with a history of depression are at particular risk during
Perimenopause. Depression often occurs around menopause
(the perimenopausal period), when, in addition to hormonal
changes, other factors (cultural pressures favoring young
women, sudden recognition of aging, and sleeplessness) are
involved. In one study, over half of perimenopausal women
were diagnosed with major depression. (Women taking hormone
replacement therapy during this period were just as likely
to become depressed as those not on hormonal therapy, but
the depression tended to be less severe.)
Postmenopause. One study suggests that average depression
scores in women who were past menopause were nearly as low
as those in premenopausal women. In fact, many women report
that after menopause, previous bouts of depression, particularly
when caused by seasonal changes or premenopausal syndrome
recede or stop completely.
Affiliate Behaviors and Oxytocin
of studies report that depression in women is more likely
to be due to interpersonal problems, while in men depression
tends to be attributed to stressful life events. One theory
about the higher risk of depression in women concerns affiliate
behaviors, which are those that involve activities surrounding
relationships, and a peptide called oxytocin (OT).
Oxytocin, which is found in mammals, stimulates certain functions
such as milk release during nursing and uterine contraction
at labor. Under primitive conditions, the release of OT after
puberty also coincided with early mating and breeding. Evidence
suggests then that it may also play a role in affiliate behaviors
such as maternal caregiving and sexual bonding after puberty.
In certain cultures, however, there is a longer delay between
puberty and marriage and childbirth. The release of OT, then,
and the subsequent inability to mate may create feelings of
loss and separation.
This theory is backed up by some research. Some studies suggest
that young women most vulnerable to depression are those with
risk factors that intensify feelings of separation. Such risk
factors include the following:
would also help explain why the rates of depression in men
and women are fairly equal after menopause.
Insecure attachments with parents
Shyness that limits interactions with others
Not having resources other than people to cope with separation.
ARE THE RISK FACTORS FOR DEPRESSION?
second only to high blood pressure as a chronic condition encountered
by primary care physicians. It is estimated that 10% of people who
visit their physician suffer from major depression, although it
in most cases it goes unrecognized or inadequately treated. Depression
is an illness that can afflict anyone, regardless of age, race,
class, or gender, and it is sometimes referred to as the common
cold of mental illness. Although some evidence suggests the depression
has increased over recent decades, one 40-year analysis found the
overall rate to be holding steady, although the burden of depression
may be shifting to women younger than 45.
At any given
time, five to nine percent of women are depressed, compared to two
to three percent of men. In one study, nearly half of all women
surveyed had experienced depression at some point in their lives
and over half of those who suffered from it had sought treatment.
Women are also more apt to have multiple types of depression (dysthymia
and major depression). [ See Box Specific
Causes of Depression in Women.]
not rare in men. In fact, prepubescent boys are more likely than
girls of the same age group to be depressed. One interesting report
suggested that men are more apt than women to mask their depression
by using alcohol, which may result in a lower reported (but not
actual) incidence of depression in men. Studies of Amish and Orthodox
Jewish communities, in which alcohol is not used, report an equal
incidence of depression in men and women.
in Children and the Elderly
that 2% of children and between 4% and 8% of teenagers suffer from
depression. The highest incidence occurs in girls after puberty,
although depression before puberty is more likely to occur in boys.
Symptoms for depression in children may differ from those in adults
and may be evident only from reports of problems in school. Studies
suggest that when children or adolescents are treated, up to 80%
will recover. Still, between 25% and 50% of such young people have
a recurrence of depression within two years of the first episode.
in the Elderly
suggested that, in general, a third of the elderly population is
depressed. (According to one study, however, only 10% get treatment.)
The aging process itself, however, is unlikely to be the cause in
all cases. As with depression in young mothers, studies are not
- An Italian
study indicated that the very old (people who lived beyond 90
years of age) were no more likely to be depressed than younger
adults. (The rate was 10% in both groups.)
- The severity
of depression in elderly patients is strongly associated with
poor health and less ability to function. In one study of older
adults undergoing rehabilitation, nearly half were depressed,
but as their function improved so did their mood.
one study suggested that the more pessimistic an elderly person
is, the less likely he or she is to experience depression. Such
individuals may be more able to accept the negative experiences
that come with age than those with an optimistic personality.
who experiences cumulative negative life events, physical illness,
the death of a loved one, impaired functioning, or loss of independence
can become deeply depressed. The elderly are at highest risk
for such events.
Status and Economic Considerations
and Economic Groups. Being in a low socioeconomic group is
a major risk factor for depression. Money, of course, allows greater
access to good medical care, but this factor does not fully explain
the higher rates of depression in impoverished people. People at
any income level are likely to be depressed if they have poor health
and are socially isolated. Some studies suggest that Western cultural
attitudes that hinge income to social status may play a significant
role in the connection between poverty and depression:
and Economic Risk Factors in Women. The role that work, marriage,
and children play in a woman's depression is complex. Many women
feel that they must be everything to everyone and at the same time
feel as if they are no one at all. Such a self-image is common and
should be strongly considered as a major contributor to depression
in many women, particularly those who work and have small children.
The following are results of studies suggesting the difficulty of
assessing the relationship between a woman's social status and depression,
- In one
British study, actual poverty or unemployment increased the
duration of any existing depression, but it did not appear to
play any important causal role. Feelings of financial
insecurity, however, both caused and prolonged depression.
study reported that Mexican adults living in California who
immigrated to America had half the psychiatric illnesses as
native-born Mexican-Americans regardless of their income. But,
the longer the immigrants lived in the US, the greater their
risk for psychiatric problems. Traditional Mexican cultural
influences and social ties, then, appeared to protect newly
arrived immigrants from mental illness, even when they were
poor. Eventually, however, the consequences of Americanization
added to poverty and led to feelings of alienation and inferiority.
- In a report
issued by the World Health Organization in 1996 on women worldwide,
married women with children had a higher risk for depression
than did married childless women, single women, or single or
- A survey
of women in the Boston area reported, however, that women between
the ages of 36 and 44 who had children were significantly less
likely to be depressed than childless women. And the more children
they had, the less depressed they tended to be. This study targeted
older premenopausal women. The difference between this study
and others may be due to the presence of older children, who
might add a supportive emotional network, rather than dependent
- The perceived
low status and isolation accompanying the role of housewife
may play a role in a young mother's depression. A European study
reported that depression increased in men and fell in women
between 1980 and 1995, a period coinciding with more women entering
the work force. (Work outside the home that fails to provide
social support, however, will not necessarily help protect against
studies in the US have reported that grandmothers who care for
their grandchildren and mothers of toddlers, regardless of whether
they worked or not, have a very high risk for depression.
have had serious bouts of depression usually cite a stressful life
event as the precipitating factor for their illness. Recent loss
of a loved one is the most frequently reported precipitant of acute
depression, but all major (and even minor) losses cause grief. Losing
a spouse through divorce or death is a major risk factor for depression
in anyone anywhere. Traumatic events, such as abuse or even natural
events such as earthquakes, can cause severe immediate or delayed
depression from which recovery takes a long time. Most people are
able to cope with the emotional pain and eventually move beyond
it without becoming chronically depressed. People who develop acute
or chronic depression after a loss may have predisposing factors,
including genetic or biologic ones, that make them more vulnerable.
The existence or absence of a strong social network of family, friends,
or both also has a major positive or negative effect, respectively,
Chronic Medical Conditions. Any chronic or serious illness
that is life threatening or out of a person's control can lead to
Thyroid Disease. Thyroid disease can cause depression; it
may even be misdiagnosed as depression and go undetected.
Headaches. One study reported that nearly half of people
with chronic tension headaches met criteria for either anxiety or
depression. It wasn't clear whether the psychiatric disorder preceded
or followed the onset of headaches. Two further studies found that
people who had migraines were far more likely to be depressed (and
vice versa) than those who did not have migraines. In fact, a 2000
study showed that 47% of migraine sufferers experienced depression.
Some experts believe that a syndrome of migraine headaches, anxiety,
and depression, which occurs in some people, is caused by common
factors, such as abnormalities in certain chemical messengers, particularly
dopamine or serotonin.
Stroke. Having a stroke increases the risk of developing
A number of drugs
taken for chronic problems cause depression. Among them are pain
relievers for arthritis, cholesterol-lowering drugs, medications
for high blood pressure and heart problems, and bronchodilators
used for asthma and other lung disorders.
A 2001 study showed that smokers with a history of depression who
stop smoking are seven times more likely to have another episode
of depression than those who don't quit. This risk remains high
for at least 6 months. Smokers with a history of depression are
not encouraged to continue smoking, but rather to keep a close watch
on recurrence of depressive symptoms if they do stop smoking. The
antidepressant bupropion (Zyban, Wellbutrin), which is approved
for helping people quit smoking, may be particularly useful in smokers
who suffer from depression.
is a frequent companion to anxiety disorders. In one study, up to
96% of patients with depressive disorders experienced concurrent
anxiety. More than two-thirds of people with obsessive-compulsive
disorder, a common anxiety disorder, also suffer from depression.
Characteristics and Disorders
suggests that certain personality styles, which include an intense
need for close relationships and concern for disapproval or need
for control, pose a high risk for depression, particularly after
an adverse life event. In line with these findings, the following
specific personality disorders have been associated not
only to a first episode of depression, but to relapses:
disorders, as opposed to emotional disorders, are those with abnormal
behavioral patterns rather than abnormal emotions.)
- A person
with borderline personality disorde r acts impulsively
and has a poor self-image and unstable relationships. In one
study, those with borderline personality disorder and major
depression were more likely than those with either condition
alone to plan and attempt suicide.
- An avoidant
personality avoids strangers and unfamiliar situations.
are an integral part of depressive disorders, with more than 90%
of depressed patients experiencing insomnia. A study of male medical
students found that young men who experience insomnia are twice
as likely to suffer from depression at middle age. Genetic factors
may play a role in the association between sleep disorders and depression.
In one study of patients diagnosed with depression, family members
with certain sleep abnormalities were found to be at greater risk
for depression than those with normal sleep patterns. Abnormal sleep
patterns often preceded the first episode of depression. Individuals
with normal sleep patterns who were from families with abnormal
sleep habits also appeared to have an increased risk for mood disorders.
A family history
of mental illness, especially mood disorders, such as bipolar disorder,
major depression, and chronic depression, appears to predispose
a patient to the development of depression. Children of depressed
parents are at high risk for depression and other emotional disorders.
Factors for Seasonal Affective Disorder
disorder (SAD) affects about one in 20 adults. About 80% of those
who suffer from SAD are women. Obviously, people who live in the
North are more apt to experience SAD than are Southerners.
SERIOUS IS DEPRESSION?
Depression is often chronic, with episodes of recurrence and
improvement. Approximately one-third of patients with a single episode
of major depression will have another episode within one year after
discontinuing treatment, and more than 50% will have a recurrence
at some point in their lives. Depression is more likely to recur
if the first episode was more severe, prolonged, or if there have
Dysthymic Disorder. In a study of dysthymic disorder, slightly
more than half the patients recovered in a five-year period. In
the same study, more than three-quarters suffered a major depressive
episode. More than 90% recovered, but their risk for another episode
was actually higher that patients who suffered just from major depression.
Although an early
study reported a risk of suicide in 15% of people with depression,
a 2000 study gave strong evidence that the risk is much lower, between
2% to 9%, with the highest risk in patients who are hospitalized
for depression. Some studies indicate that dysthymia may even pose
a higher risk than episodic major depressive disorder. Some studies
report the following for specific groups:
Gender. Depressed men are more likely to commit suicide than depressed
women, although suicidal preoccupation or threats of suicide should
always be treated seriously, especially in anyone known to be depressed.
Adolescents. In a 2001 study of adolescents, feeling connected with
parents and family was protective for young people of both genders
and all major ethnic groups. Risk factors included a previous suicide
attempt, exposure to violence, either as victim or perpetrator,
alcohol or drug use, and school problems. In one study, depression
was the major factor in overdose among adolescents. (Impulsivity
was the other major contributor to self-poisoning.) A parent should
seek help as soon as possible for any child who exhibits signs of
severe depression or when suicidal thoughts are expressed.
Elderly. Suicide in the elderly is the third-leading cause of death
related to injury; men account for 81% of these suicides, with divorced
or widowed men at highest risk.
on Physical Health
in the elderly or in people with serious illness seems to reduce
their survival rates, even independently of any accompanying illness.
In one study, even minor depression was associated with a higher
risk for a shorter life in men (although not in women). A 2000 study
indicated that even mild depressive symptoms in people aged 65 and
above are associated with a higher risk of becoming disabled and
having a lower chance of recovery.
Decreased physical activity and social involvement certainly play
a role in the association between depression and illness severity.
Some research also suggests, however, that depression produces biologic
factors, such as low serotonin levels, which trigger stress-related
responses in the body that cause blood clotting problems, inflammation,
and damage to organs and cells.
Heart Disease and Heart Attacks. Many studies have now reported
strong associations between depression and an increase in the incidence
and severity of heart attacks and death after a heart attack. Depression
may even impair a patient's response to medication for heart disease.
Although people with heart disease may certainly become depressed,
this does not explain entirely the link between the two problems.
The data are now suggesting that depression itself may be a true
risk factor for heart disease as well as its increased severity.
A number of studies have suggested that depression has biologic
effects on the heart, including blood clotting and heart rate. A
study in 2001, for example, reported an association between depression
and a greater risk for death from heart problems even in people
without a history of heart disease. Another 2001 study was the first
to relate depression to risk of heart failure in people with hypertension.
(On the other hand, studies also suggest that hardening of the arteries
in the brain may cause depression, so depression may simply be a
marker of severe or emerging heart disease.)
The more severe the depression, the more dangerous to the health,
although even mild depression, including feelings of hopelessness,
experienced over many years, may harm the heart, even in people
with no early signs of heart disease.
Stroke. Depression also appears to increase the risk for
stroke in both women and men, particularly among African Americans.
One study, for example, reported that young African American adults
with depressive symptoms were at high risk for developing hypertension,
an important cause of stroke (Young Caucasian adults with depression
were at risk for hypertensive incidents but not hypertension itself.)
Another study, published in 2001, confirmed that self-reported mood
symptoms correlated with increased mortality 12 and 24 months after
a stroke. Researchers speculate that depression and stroke might
have common patterns of development.
Neurologic Decline. Depression in the elderly is associated
with a decline in mental functioning, regardless of the presence
of dementia. Brain scans in the elderly, for example, have reported
greater atrophy in the brains of depressed individuals than in those
of nondepressed ones.
Osteoporosis. Some studies have linked past and current major
depression with bone-density loss in women. One explanation for
this association is that depressed women have higher levels of the
stress hormone cortisol, which may contribute to bone density loss.
!Obesity!. One study reported that it was associated with
Increasing Sensations of Pain. Depression coincides with
high pain scores in people with chronic diseases, such as rheumatoid
Breast Cancer. A 2000 study found a link between prior depression
and increased rates of breast cancer. Depression and breast cancer
are each associated with estrogen levels, which may help explain
the association. Other studies have found no link between breast
cancer and emotional disorders.
the Health of Offspring. One study has found that children
of depressed parents are at greater risk for many medical conditions
(eg, urinary and genital disorders, headaches, lung problems) and
hospitalizations. But depressed children whose parents did not suffer
from mood disorders were at no higher risk for medical disorders.
Increased Risk for Addictions. Severely depressed people
are at high risk for alcoholism, smoking, and other forms of addiction.
Pregnant women who drink may be increasing their child's risk for
a future mental illness, as well as increasing their risk for delivering
children with birth defects.
Effects on Marriage. In one survey, nearly half of people
who suffered from psychiatric disorders before or during their first
marriage were divorced, compared to a divorce rate of 36% in those
who never suffered from emotional disorders.
Job Bias. In one British study, 60% of personnel directors
said that they would never hire anyone for an executive position
who had been previously diagnosed with depression. About a quarter
of these professionals felt that formerly depressed people couldn't
even handle clerical or manual jobs. (As a comparison, only 3% of
personnel directors said that they thought diabetes would impair
anyone's performance.) This strong bias against psychiatric disorders
may be higher in England than in some other countries, but it is
still indicative of the prejudices present in many cultures that
inaccurately and unfairly separate psychiatric from physical conditions
when assessing capability.
Drug Abuse. It is estimated that 25% of people with alcohol
or drug abuse problems also have major depression. In one 2000 study,
women with a history of depression were 2.6 times more likely to
drink heavily than were women with no such history.
Smoking. Depression is a well-known risk factor for smoking
and increases the danger of starting young. Indeed, nicotine may
stimulate receptors in the brain that improve mood in certain people
with genetically induced depression.
IS DEPRESSION DIAGNOSED?
on Family Physicians
Most people who
are depressed do not seek psychiatric help and must rely on their
family doctor. Unfortunately, there are a number of obstacles associated
with this approach:
all patients who visit their physician should be screened for depression,
certain individuals, such as the following, may be at higher risk
and so warrant a screening test:
suggest that although at least 10% of patients who visit a physician
are suffering from major depression, most cases are unrecognized
or inadequately treated. One study, in fact, reported that only
25% of family physicians accurately diagnose depression.
themselves may be unable to sense or admit to their own depression.
In one study, although 21% of patients who visited their family
physicians were depressed, only one percent described their
problem as depression.
- To compound
the problem, half the physicians in one study admitted to deliberately
diagnosing a different problem, such as fatigue, anxiety, insomnia,
or headache, in some of their patients who had depression. Reasons
for doing this included uncertainty about the diagnosis, a concern
that insurers wouldn't reimburse the patient for a diagnosis
of depression, or because of the stigma attached to such a diagnosis.
can be confused with other medical illnesses. Weight loss and
fatigue, for example, accompany many conditions, some serious,
but they can also occur with depression.
- Many people
lack insurance that will cover mental health costs. Such people
are also likely to have adverse socioeconomic situations that
increase their risk for depression.
with a family or personal history of depression.
with multiple medical problems.
with physical symptoms that have no clear medical cause.
with chronic pain.
who visit their physician more frequently than expected.
A mental health
specialist, such as a psychiatrist, social worker, or psychologist,
is the best source for a diagnosis of depression. Such health professionals
may administer a screening test, such as the Beck Depression Inventory
or the Hamilton Rating Scale, which consists of about 20 questions
that assess the individual for depression. Studies are finding that
even computerized phone interviews are valuable as screening tools
for depression. It is important to note, however, that these tests
are limited, and mental health professionals generally diagnose
depression based on symptoms and other criteria. [ For diagnostic
criteria, see What Is Depression?.]
Depression in Specific Populations
Depression in the Elderly. Because of the complex relationship
between depression, drug interactions, and serious physical illness
in the elderly, an accurate diagnosis in this group is important
but not always straightforward. The characteristic symptoms of depression
are not always present or readily apparent in older people:
Depression in People from Nonwestern Cultures. People from nonwestern
countries are more apt to report physical symptoms (such as headache,
constipation, weakness, or back pain) related to the depression,
rather than mood-related symptoms.
- Some older
people may be aware of their depression but believe that nothing
can be done about it.
- Many elderly
people who are depressed may report only physical symptoms (aches
and pains) or other mood states (confusion, agitation, anxiety,
and irritability) related to depression rather than depression
they are unable or unwilling to express their feelings or are
even unaware that they are depressed.
symptoms are often ignored or confused with other ailments common
in the elderly, including Parkinson's or Alzheimer's disease,
dementia, thyroid disorders, arthritis, stroke, cancer, heart
disease, and other chronic conditions.
may even be a predictor of Alzheimer's disease or an impending
physical illness before the symptoms of the disease itself become
is also a side effect of many drugs that are commonly prescribed
for the elderly. It is often very difficult, then, to determine
if the patient's depression is a psychologic reaction to the
illness, caused by the disease itself, or completely independent
from the medical condition. Both physical and emotional conditions
should be considered in making a diagnosis in older people.
ARE THE GENERAL GUIDELINES FOR TREATMENT OF DEPRESSION?
the Optimal Therapeutic Choice
depression have a number of options, including psychotherapy, antidepressants,
or both. The majority of people with acute depression respond to
either the first or second trial of therapy. Still, more than two-thirds
of people with depression, particularly the elderly, do not receive
any therapy for it. Lack of health insurance is a major factor in
these low treatment rates.
In general, the treatment choice depends on the degree and type
of depression and other accompanying conditions.
Patients with Major Depression. Several approaches to patients
with major depression are common:
Minor Depression. Patients with minor depression (fewer than
five symptoms that persist for less than two years) may respond
as well to watchful waiting and supportive care as to specific treatments,
although this is unclear. For example, one study found that newer
antidepressants were only modestly helpful in older patients with
mild depression. Supportive care that consists only of brief and
occasional counseling sessions with the family doctor may be as
helpful as antidepressants in some cases.
- A combination
of antidepressants and structured psychotherapy is very effective
for most patients with major depression. One study, for example,
reported a response rate of 73% using cognitive behavioral therapy
and Nefazodone, a newer antidepressant. Other studies also suggest
that benefits persist when cognitive therapy is included in
the treatment regimen. (In fact, some studies estimate that
only 40% of people with chronic depression respond to medications
alone compared to 60% who are given combination treatment.)
- For those
who fail medications and psychotherapy, other techniques, such
as electroconvulsive therapy (ECT), are safe and effective.
- In recent
years, experimental procedures like vagus nerve stimulation
and repetitive transcranial magnetic stimulation have also been
found to be effective in some cases of treatment resistant depression.
Patients with Dysthymia. Patients with dysthymia may respond
Patients with Depression and Other Psychiatric Problems. Other
psychiatric problems often coexist with depression. If patients
also suffer from anxiety, treating the depression first often relieves
both problems. Those with more severe psychiatric problems, such
as bipolar disorder or schizophrenia, require specialized treatments.
Patients with Depression and Medical Conditions. Depression
can worsen many medical conditions and may even increase mortality
rates from some, such as heart attack and stroke. Depression, then,
should be aggressively treated in anyone with a serious medical
Patients with Depression and Substance Abuse Problems. Treating
depression in patients who abuse alcohol or drugs is important and
can sometimes help patients quit.
Most people with
depression can be treated in an office setting by a psychiatrist
or other therapist. Infrequently, the level of dysfunction may be
serious enough to warrant hospitalization in order to provide protection
from further deterioration or self-harm.
Mental Health Professionals. The only health professionals
who can prescribe antidepressants are the following:
mental health professionals cannot prescribe drugs, most therapists
have arrangements with a psychiatrist for providing medications
to their patients. In general, mental health professionals are categorized
by their training:
(These are mental health professionals with MDs.)
- Any medical
physician with an MD.
- Some psychiatric
Tips for Selecting
have a degree in psychiatry, psychology, or social work as well
as several years of training at a psychoanalytic institute.
have graduate-level training, including an internship in a mental
- A clinical
social worker has a master's degree and two years of supervised
experience in mental health and human services.
psychiatric nurses have a master's degree and can provide therapeutic
can locate a mental health professional in their areas by asking
their doctor for a referral or contacting one of the mental
health organizations. [See Where Else Can Help be Obtained for
- The patient
should describe problems briefly but specifically over the phone
to any prospective therapist to get a sense of whether he or
she will suit the patient's needs.
- An advanced
degree does not necessarily guarantee quality therapy. The patient's
belief in his or her health provider may be the most important
component in recovery, as indicated by studies reporting that
placebos relieve depression in about half of patients and in
some cases actually work better than psychotherapy.
should not be shy about considering a change in their therapist
if they lack confidence in their current one.
Treatment Guidelines for Specific Patient Groups
Nursing Women. Studies to date suggest that neither selective
serotonin reuptake inhibitors (SSRIs) nor tricyclic antidepressants
pose a higher than normal risk for birth defects or miscarriage
when pregnant women take them. Studies on the effects on infants
of nursing women taking SSRIs report very low levels of the medications
in blood but no observable negative effects on the babies. Such
continuing evidence suggesting that antidepressants are unlikely
to be harmful during pregnancy and nursing is hopeful news for women
with severe depression who are pregnant or wish to conceive. More
research is needed, however, and most physicians advise women to
avoid, if possible, any medications during pregnancy and nursing.
Children and Adolescents. Treatment choices for children
and adolescents with depression varies according to severity:
are used, tricyclic antidepressants tend to be less useful in adolescents
and children than they do in adults, and they have many side effects.
MAOIs are also not commonly prescribed. Despite the fact that none
of the SSRIs has been approved for use in children and adolescents,
SSRIs are frequently prescribed in this age group. Fluoxetine is
the most extensively studied SSRI in children. Some of the newer,
designer antidepressants, such as nefazodone and venlafaxine, may
also be safe and effective in children.
- Mild to
Moderate Depression. Children and adolescents with mild to moderate
depression should receive psychotherapy before medications are
tried. One study suggested that there was very little difference
in success rates among three major forms of psychotherapy: cognitive-behavioral
therapy, family therapy, or supportive therapy. All achieved
about an 80% recovery, with a 30% recurrent rate an average
of 4 months after recovery. Severe depression and conflicts
with parents made recovery more difficult.
Depression. The American Academy of Child and Adolescent Psychiatry
now recommends the SSRI antidepressants for children and adolescents
with very severe depression that does not respond to psychotherapy.
For best results, these drugs should be combined during the
early acute phase with a mixture of psychotherapies, including
cognitive-behavioral, interpersonal, and psychodynamic therapies.
Initial drug treatments should continue for at least six months,
and a maintenance phase should last another year or longer.
Elderly Adults. Ideally, elderly depressed patients should
be treated with a combination of psychotherapy and antidepressants.
Some experts recommend only psychotherapy or attention intervention
for elderly patients with mild depression. In some older patients,
a regular exercise program may even be sufficient to improve mood.
In many cases, however, psychotherapy is not available to elderly
patients. Tricyclics are less expensive than SSRIs, but choosing
between them may depend on specific conditions in older people:
- Of possible
significance for people with heart disease or stroke is a 2000
study reporting that the SSRI paroxetine (Paxil) may reduce
the risk for blood clotting. (The other antidepressant in the
study was a tricyclic antidepressant and had no such effect.)
This suggests that the SSRIs may be the drugs of choice for
treating patients with depression and a history of heart disease
or stroke. The authors even suggest comparing SSRIs with aspirin
for reducing blood clotting and for preventing heart disease
or strokes in patients without depression. Tricyclic antidepressants,
in any case, pose a higher risk than for adverse effects on
the heart and possibly the lungs. (The older tricyclics e.g.
amitriptyline (Elavil) and imipramine (Tofranil) have other
severe side effects in older adults.)
have fewer side effects than tricyclics.
- It is
commonly believed SSRIs pose a lower risk for falls than the
older tricyclic antidepressants. Recent studies, however, have
found no difference in risk between the two drug classes. (Whether
all of the newer antidepressants pose a risk for falls is not
with Parkinson's may want to avoid SSRIs because they can increase
the risk for tremor and other symptoms of the disease.
ARE THE DRUGS USED FOR DEPRESSION?
of Antidepressants. Antidepressants are very effective. One
study reported that up to 90% of patients with major depression
will improve with good compliance and adequate doses of the right
The primary target of most major antidepressant drug classes is
the transport of the important neurotransmitters serotonin and norepinephrine.
Such drug classes are the following:
A great deal
of leeway exists in choosing an appropriate antidepressant. Overall,
they seem to be equally effective, although cost, individual responses,
and side effects vary widely. Some examples of possible differences
among drug classes include the following:
serotonin-reuptake inhibitors (SSRIs).
oxidase inhibitors (MAOIs), including newer MAOIs called selective
- A new
group of drugs generally referred to as designer-antidepressants
are similar to SSRIs, but have been developed to specifically
target specific neurotransmitters (brain chemicals) other than,
or in addition to, serotonin.
- The herbal
remedy St. John's Wort is included as a separate category, since
it is unregulated and its chemical classification has not yet
Duration of Initial Treatment. The guidelines for the duration
of an initial antidepressant regimen is as follows:
- In one
study, SSRIs, St. John's Wort, and moclobemide (a European selective
MAOI) were better tolerated and had lower dropout rates than
and some of the newer antidepressants may be beneficial in treating
anxiety and certain subtypes of depressive disorders unresponsive
to previous agents, including premenstrual dysphoric disorder
and seasonal affective disorder, atypical depression, and recurrent
- MAOI inhibitors
are the most effective antidepressants for atypical depression,
but have some severe side effects and restrictive dietary rules.
to one 2000 study, SSRIs may be more effective in women and
tricyclics in men.
Recurrence of depression is very common. About a third of patients
will relapse after a first episode within a year of ending treatment,
and more than half will experience a recurring bout of depression
at some point during their lives. Among those at highest risk for
early relapse and who may require on-going antidepressants are the
should start at a low dose, which is increased over a period
of five to ten days.
- Some experts
recommend that the patients see their physician every one to
two weeks until substantial improvement occurs. It is important
to note, however, that it may take four to six weeks before
a patient experiences the effects of any antidepressant.
- Side effects
usually diminish within one to four weeks. (Exceptions may be
weight gain and sexual dysfunction.)
- If no
improvement occurs within three to four weeks, however, and
the patient is not overly distressed by side effects, an alternative
agent may be tried. More than 80% of patients respond to some
antidepressant, although specific agents are helpful for only
about half of patients. This suggests that if one medication
fails, another has a good chance of being helpful. Newer agents
with different mechanisms are being developed all the time that
are improving response rates.
- In general,
patients should stay on antidepressants for at least six months
after symptom relief to help prevent relapse. (Patients who
improve within two weeks of taking medications may not require
then, may need maintenance therapy for at least two years. Experts
disagree, however, on the optimal length of maintenance therapy
or the appropriate dosage. Once the patient and physician agree
on withdrawal, it should be gradual, over two to three months, with
with at least two major episodes of depression for two years
or longer before initial treatment.
who continue to have low-level depression for seven months after
starting antidepressant treatments.
It should be noted that there is no risk for addiction with current
antidepressants, and many of the common antidepressants, including
most standard SSRIs, have been proven safe when taken for a number
Common Side Effects. No matter how well a drug treats depression,
the ability of the patient to tolerate its side effects strongly
influences his or her compliance with therapy. Lack of compliance
is probably the major barrier to success. According to one study,
as many as 70% of elderly depressed patients did not adhere to antidepressant
drug regimens. Side effects can be avoided or moderated if any regimen
is started at low doses and built up over time. Although specific
side effects are discussed under individual drugs, there are a few
that are common to many of them:
dysfunction is a common side effect of nearly all the standard
antidepressants and some of the newer drugs. These side effects
can be particularly distressing for patients on maintenance
treatment who otherwise feel well. Some of the newer antidepressants,
such as mirtazapine, bupropion, or nefazodone, may be effective
alternatives. Sildenafil (Viagra), used for erectile dysfunction
in men, may help reverse sexual dysfunction from antidepressants
in both men and women. More research is in progress. One small
study reported that the herbal remedy ginkgo biloba was associated
with improved sexual function in patients taking antidepressants.
- An increased
risk of oral health problems caused by dry mouth is associated
with long-term use of most antidepressants. The risks appear
to be highest with some of the new designer antidepressants,
with multiple drug use, and with the presence of oral infections.
Patients can increase salivation by chewing gum, taking vitamin
C tablets, using saliva substitutes, and rinsing the mouth frequently.
all antidepressants have complicated interactions with other
drugs, some are very serious. A few are mentioned in the individual
drug discussions below, but many are not, and patients should
inform the physician of any drugs they are taking, including
all antidepressants are metabolized in the liver, so anyone
with liver abnormalities should use them with caution.
withdrawal from many antidepressants can produce severe side
effects; no antidepressant should be stopped abruptly without
consultation with a physician.
study has helped lay to rest very early reports of an association
between Prozac and an increased risk for suicidal thoughts
and behavior. In this study, there was actually an insignificant
reduction in suicidal risk.
Paradoxically, there is some evidence to suggest that antidepressants
might revitalize suicidal attempts in patients who were
too despondent before treatment to make the effort. Experts
warn that caregivers and physicians should be very vigilant
for any signs of suicidal intent during the early acute
phases of treatment. Patients themselves should be aware
of any suicidal thoughts during initial recovery and seek
inhibitors (SSRIs) are now the first-line treatment of major depression.
They work by increasing levels of serotonin in the brain. SSRIs
include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),
fluvoxamine (Luvox), and citalopram (Celexa, Cipramil). Because
they act on serotonin specifically, SSRIs have fewer side effects
than the older antidepressants, which have more widespread effects
in the body. Patients taking SSRIs report not only relief of depressive
symptoms but also a higher level of efficiency, more energy, and
better relationships with other people.
Candidates for SSRIs. SSRIs appear to help people with the
SSRIs interact with numerous drugs, and caution should be taken
that the physician is well informed of any other medications the
patient is taking. Of particular note is sibutramine (Meridia),
which is used for weight loss, and which also affects serotonin
- Mild to
moderately severe major depression.
premenstrual syndrome and premenstrual dysphoric disorder (PMDD).
A repackaged form of fluoxetine (Sarafem) is the first SSRI
specifically FDA-approved for PMDD. Other SSRIs and newer antidepressants,
however, are also proving to be effective.
nondepressive disorders, including obsessive-compulsive disorder,
panic disorder, and bulimia.
and aggressive behaviors in psychiatric patients and in people
with no mental health problems.
and heart disease. There is some evidence that SSRIs may have
benefits for the heart as well as the brain.
- of Effectiveness
and Use. SSRIs take, on average, two to four weeks to be
effective in most adults. They may take even longer, up to 12
weeks, in the elderly and in those with dysthymia. By 14 weeks,
depression should be in remission in everyone who responds to
the drugs. Unfortunately, recurrence is common once the drugs
are stopped. Some patients may need to be on maintenance indefinitely.
Studies to date have indicated that the standard SSRIs are probably
safe, although it is unclear what the duration of treatment
Side Effects of SSRIs. Side effects include the following:
of SSRI-Induced Side Effects
and gastrointestinal problems. These effects usually wear off
insomnia, mild tremor, and impulsivity occur in 10% and 20%
of people who take SSRIs, these symptoms may be particularly
problematic in patients who also suffer from anxiety, sleeplessness,
or both. Such side effects may persist. On the other hand, about
20% of SSRI-treated patients experience drowsiness, which may
be counteracted by taking the medication at bedtime.
- Dry mouth
is common and can increase the risk for cavities and mouth sores.
- Lack of
motivation, fatigue, and mental dullness.
Gain. Some weight loss during the first few weeks of treatment
may occur, but over time patients on maintenance treatment typically
return to their pretreatment weight or gain weight. Weight gain
varies depending on the SSRI. For example in one study patients
who took paroxetine (Paxil) experienced five times the weight
gain as those who took citalopram (Celexa). Patients should
be encouraged to maintain a low-calorie diet and to exercise.
They should be aware that some of the weight-loss medications,
notably sibutramine (Meridia), can have serious interactions
dysfunction, including delayed or loss of orgasm and low sexual
drive, is now a well-known side effect of SSRIs. It should be
noted however that in one 2001 study, sexual desire increased
in 20% of women and 27% of men taking the SSRI. In patients
with normal sexual function, only about 15% of patients experienced
greater sexual dysfunction, which was generally mild to moderate
and mostly took the form of less sexual interest. Taking a supervised
drug "holiday" on the weekend may improve sexual function during
that time. (Withdrawal symptoms may develop and include return
of depression, sleep problems, exhaustion, and dizziness. Prozac,
with its longer duration of action, appears to be associated
with a lower risk for withdrawal symptoms than shorter-lasting
SSRIs, but a weekend off this drug may not be long enough to
restore sexual function.) The physician may recommend other
strategies to circumvent sexual dysfunction, including reducing
the antidepressant dosage, switching antidepressants, or adding
medication to curtail the side effect. Some of the newer, so-called
designer antidepressants may have less severe impairment of
have been some reports of worsened glaucoma in patients taking
SSRIs. This is a very rare complication and it isn't clear that
there is a causal relationship. Patients with glaucoma who take
SSRIs should have their eyes examined regularly.
symptoms. Dizziness, muscle weakness or pain, odd sensations
in the limbs, nausea, loose stools, visual disturbances, irritability,
insomnia, mood worsening, and headaches have been known to occur
with sudden discontinuation of SSRIs. The symptoms are more
likely to occur with antidepressants with shorter half-lives
as compared with fluoxetine, which has a long half-life. Reducing
the dose of the antidepressant before stopping it is recommended.
people taking these drugs should take the lowest dose possible,
and those with heart problems should be monitored closely. Over
the years, some patients taking SSRIs have reported a group
of side effects, known as extrapyramidal symptoms, which are
similar to those in Parkinson's disease and affect the nerves
and muscles controlling movement and coordination. They are
uncommon, and when they develop they tend to occur within the
first month of treatment.
- High doses
or interactions with other drugs may cause hallucinations, confusion,
changes in blood pressure, stiffness, and irregular heart beats.
Serious interactions can occur with other antidepressants, such
as tricyclics and, of particular note, MAOIs [see below]. Other
serious interactions have occurred with meperidine (Demerol)
and illegal substances (such as LSD, cocaine, or "ecstasy").
who take SSRIs may drink alcohol in moderation, although the
combination may compound any drowsiness experienced with SSRIs,
and some SSRIs increase the effects of alcohol.
from overdose is extremely rare.
A number of drugs
have now been developed that target other neurotransmitters, such
as norepinephrine, alone or in addition to serotonin. In general,
the advantages of the new designer antidepressants are as follows:
They do share
some side effects, including dizziness and dry mouth, with other
- They may
be more tolerable than the older tricyclic compounds and even
some SSRIs, although long-term side effects are not fully known
in this group.
- Most of
these drugs have fewer adverse effects on sexual function than
SSRIs, and some people have even reported enhanced sexuality
with some of them.
- They may
be more effective for severely depressed patients than the SSRIs.
such as mirtazapine and nefazodone, may also provide relief
from insomnia and anxiety, that are common in many depressed
patients. (SSRIs and antidepressants that increase uptake of
both serotonin and norepinephrine generally pose a higher risk
Bupropion. Bupropion (Wellbutrin, Zyban) is particularly
effective for a number of conditions and is also used for smoking
cessation. It causes less sexual dysfunction than SSRIs. Side effects
include restlessness, agitation, sleeplessness, headache, rashes,
stomach problems, and in rare cases, hallucinations and bizarre
thinking. Initial weight loss occurs in about 25% of patients. High
doses may cause seizures; this side effect is uncommon and tends
to occur in patients with eating disorders (anorexia or bulimia)
or those with risk factors for seizures.
Venlafaxine. Venlafaxine (Effexor) is another designer antidepressant
known as a serotonin-noradrenaline reuptake inhibitor. It is similar
to fluoxetine (Prozac) in effectiveness and tolerability for most
patients. In a group who required higher doses of an antidepressant
in order to obtain a response, venlafaxine was slightly more effective
than Prozac. After several studies found it to be effective at preventing
depression recurrence, it was approved by the FDA in 2001 for this
purpose. In a 2001 study, in fact, it was more effective in preventing
relapse than SSRIs.
As with the SSRIs, and unlike other newer antidepressants, venlafaxine
impairs sexual function. Although clinical trials have shown that
the drug is safe and effective in most people, of concern are recent
reports of changes in blood pressure and heart conduction abnormalities,
which may cause serious problems in elderly patients. Some patients
report severe withdrawal symptoms, including dizziness and nausea.
Nefazodone. Nefazodone (Serzone) is more rapidly effective
and has fewer distressing side effects, including sexual dysfunction,
than SSRIs. The drug can also be combined with SSRIs or psychotherapies
for improved response. Nefazodone is one of the only antidepressants
that has a positive effect on sleep efficiency. In a 2000 study
of patients with dysthymia, those who received a combination of
nefazodone and cognitive therapy and completed treatment experienced
85% response rate. The response rates were slightly over 50% with
either treatment alone. The drug may cause an abrupt drop in blood
pressure after standing up suddenly. Of concern are rare cases of
liver failure in patients taking nefazodone.
Mirtazapine. Mirtazapine (Remeron) is a unique antidepressant
known as a 5-HT2 blocker. It affects both serotonin and norepinephrine
(also called noradrenaline). In addition to taking it orally, mirtazapine
is now available as a tablet that dissolves on the tongue. Compared
to some common SSRIs, studies are indicating that it becomes effective
more rapidly and has stronger early actions against anxiety in patients
who suffer both disorders. A 2001 study suggested that it is an
effective alternative for patients who do not respond to SSRIs;
furthermore, patients may be able to safely switch directly from
an SSRI to mirtazapine without a withdrawal. It causes less sexual
dysfunction than other drugs as well. Mirtazapine interacts with
histamine, a chemical involved in allergic responses; these actions
can cause drowsiness, which may make it a useful drug for depressed
patients who suffer from insomnia. It also causes blurred vision.
The drug has been associated with weight gain, although in one study
it was not significant. It does not appear to have the adverse acute
effects on the heart that other newer antidepressants have, although
it may elevate cholesterol and triglyceride levels slightly.
Reboxetine. Reboxetine (Edronax) is yet another promising
unique antidepressant, known as a selective noradrenaline reuptake
inhibitor. Early studies reported that it was more effective than
Prozac in reducing depression and improving social functioning,
although in one study more patients taking reboxetine dropped out
(12% versus 7% for Prozac) because of side effects. It is available
worldwide but the FDA has not approved marketing it in the US.
Before the introduction
of SSRIs, tricyclics had been the standard treatment for depression.
They are sometimes referred to as belonging to one of two categories:
tertiary or secondary amines:
used or investigative tricyclics include doxepin (Sinequan), amoxapine
(Asendin), maprotiline (Ludiomill), protriptyline (Vivactil), trimipramine
(Surmontil), mianserin (Bolvidon), and dothiepin (Prothiaden).
amines include amitriptyline (Elavil, Endep) and imipramine
amines include desipramine (Norpramin) and nortriptyline (Pamelor,
Aventyl). Secondary amines may have fewer side effects than
tertiary amines, but they are as toxic in high amounts.
Candidates for Tricyclics. Tricyclics are as effective as
SSRIs for most forms of depression and may even offer benefits for
many people with dysthymia, who generally do not respond to SSRIs.
In one clinical trial, men responded far better to the tricyclic
imipramine (Tofranil) than they did to the SSRI sertraline (Zoloft).
Side Effects of Tricyclics. Side effects are fairly common
with these medications. In fact, in an analysis of studies, more
tricyclic users discontinued their drugs due to side effects than
did SSRI or MAOI users. Those most often reported include the following:
have serious, although rare, side effects:
- Dry mouth.
Blood pressure may drop suddenly when sitting up or standing.
and their severity may vary among the tricyclics. Examples are the
- They tend
to cause disturbances in heart rhythm, which can pose a danger
for some patients with certain heart diseases. One study comparing
nortriptyline with paroxetine, an SSRI, reported nine times
more adverse cardiac events with the use of the tricyclic than
with the SSRI.
- Also of
concern is a study reporting that tricyclics, particularly imipramine,
may be responsible for 10% of cases of a lung disease called
idiopathic pulmonary fibrosis (IPF), which can cause lung inflammation
and scarring. Initial symptoms are breathlessness and dry cough.
The two newer tricyclics, mianserin and dothiepin, also increased
can be fatal with an overdose.
- Of concern
is a 2000 study showing a small increased risk for non-Hodgkin's
- In one
study, mianserin, a newer tricyclic, improved sexual dysfunction
caused by SSRIs.
can cause sun sensitivity, and people who take this should take
precautions against sunlight when they go outdoors.
Oxidase Inhibitors (MAOIs)
inhibitors (MAOIs) block the enzyme monoamine oxidase, which has
negative effects on many of the neurotransmitters that are important
for well being. MAOIs include phenelzine (Nardil), isocarboxazid
(Marplan), and tranylcypromine (Parnate). Because these agents can
have very severe side effects, they are usually indicated only when
other antidepressants prove ineffective. Newer MAOIs, such as moclobemide
(Aurorix, Manerix), target only one form of the MAOI enzyme, and
it may be effective without the significant side effects of the
older MAOIs for patients with dysthymia. At this time moclobemide
is not available in the US.
Candidates for MAOIs. They may be effective for the following
MAOIs commonly cause the following side effects:
hypotension (a sudden drop in blood pressure upon standing).
dysfunction. (Of note, however, in one 2000 study, only 1.9%
of patients taking the newer European MAOI moclobemide reported
sexual dysfunction related to their antidepressant compared
to 21.6% of patients taking SSRIs.)
- The most
serious side effect is severe hypertension, which can be brought
on by eating certain foods having a high tyramine content. Such
foods include aged cheeses, most red wines, sauerkraut, vermouth,
chicken livers, dried meats and fish, canned figs, fava beans,
and concentrated yeast products.
may also cause birth defects and should not be taken by pregnant
- Very dangerous
side effects can occur from interactions with other antidepressants,
including SSRIs. There should be at least a two to five-week
break between taking MAOIs and other antidepressants. MAOIs
can have serious interactions with other drugs as well, including
some common over-the-counter cough medications, psychostimulants
(such as Ritalin), and decongestants.
St. John's Wort
( Hypericum perforatum ) is an herbal remedy that is helping
mild to moderate depression in many patients. Small early studies
report that it was similar in effectiveness to and had fewer side
effects than tricyclic antidepressants. Unfortunately, a 2001 study
showed that it is no more effective than placebo for treating major
depression. The authors of this study commented that previous studies
have had methodological flaws. The National Institutes of Health
is funding another longer term study, which may clarify the effectiveness
of St. John's Wort in treating depression.
General Guidelines. This herbal substance is not regulated
and there is no guarantee of quality in any brands currently available.
At this time, the following guidelines are recommended:
Side effects include nausea, dry mouth, allergic reactions,
and fatigue, although, in general, side effects are quite uncommon.
In one study, only 1.1% of patients discontinued the agent because
of side effects. Some people have reported temporary nerve damage
after sun exposure, specifically pain and tingling on sun-exposed
areas. However, a 2001 study in healthy volunteers indicated that
St. John's Wort does not influence skin sensitivity to ultraviolet
radiation, visible light, or solar-simulated radiation. People taking
this drug should avoid sunlight or cover up when going outdoors.
The herbal agent appears to reduce the effectiveness of protease
inhibitors, which are used to treat HIV. They may also possibly
interact with oral contraceptives. There has also been evidence
to suggest that St. John's Wort interacts with some medications
to cause toxic reactions.
with severe depression should not take this remedy without a
physician's guidance. Even those with mild depression should
not use St. John's Wort without consulting a physician. Children
and pregnant or nursing women should not take this substance.
should purchase brands only from well-established manufacturers
until regulations have been established for this and other herbal
no dose levels have been established, trials indicate that 300
milligrams taken three times a day may be effective.
- It takes
between two and three weeks for the drug to have an effect.
studies had suggested that the herbal substance might act in
the same way as chemical MAO inhibitors, but the MAO-like activity
of St. John's Wort appear to be minimal. Still, some experts
suggest avoiding large amounts of foods and substances that
have tyramine, such as red wine, meat, and aged cheese.
- It should
not be combined with other antidepressants.
Other Herbal Remedies. Other herbal or natural remedies
being studied for depression are S-adenosylmethionine, valerian,
and kava kava. Some studies have reported some benefits, but in
general they have not proved to be very effective. Research is much
weaker on these agents than on St. John's Wort. [See Box Warnings
for Alternative and So-Called Natural Remedies]
for Alternative and So-Called Natural Remedies
It should be strongly noted that alternative or natural remedies
are not regulated and their quality is not publicly controlled.
In addition, any substance that can affect the body's chemistry
can, like any drug, produce side effects that may be harmful.
There have been a number of reported cases of serious and
even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard
prescription medications. Most problems reported occur in
herbal remedies imported from Asia. Of note for people with
depression, impurities found in L-tryptophan diet supplements
have caused eosinophilia-myalgia syndrome (EMS) in some people.
EMS is a disorder that elevates certain white blood cells
and was fatal in a few cases. The FDA has restricted imported
products containing L-tryptophan. .
Even if studies report positive benefits from herbal remedies,
most, to date, are very small. In addition, the substances
used in such studies are, in most cases, not those being marketed
to the public. The following website is building a database
of natural remedy brands that it tests and rates. Not all
are available yet. https://www.ConsumerLab.com/
Estrogen replacement therapy (ERT) may relieve menopausal and perimenopausal
associated depression and even relieve depression in elderly women
who do not respond to standard antidepressants. Studies have reported
that estrogen given under the tongue (sublingually) or using a patch
has relieved the symptoms of hormone-related depression (postpartum
or perimenopausal depression). ERT has a number of health benefits
and risks, which a physician should discuss with the patient. (Hormone
replacement therapy that contains both progesterone and estrogen
may even cause mild depression.)
strategies generally involve the use of drugs not typically thought
of as antidepressants in combination with a standard antidepressant.
Such strategies are being used for patients who fail standard therapies
or who need to quickly speed up the response of the antidepressant.
Augmentation therapies include use of the following:
- Mood stabilizers
like lithium, carbamazepine, and divalproex sodium.
antipsychotic drugs (such as risperidone).
Standard psychostimulants include dextroamphetamine (Dexedrine)
and methylphenidate (Ritalin). A newer psychostimulant, modafinal,
is also showing promise for augmenting antidepressants. It may
also pose less risk for abuse.
hormones. In one small study, high doses of thyroid hormone
combined with an antidepressant had very mild side effects and
were very effective in half of severely depressed treatment-resistant
patients. Another study reported good results when thyroid hormone
was followed by small doses of lithium.
Pindolol (Visken), a beta-blocker normally used for heart disease,
is proving to be effective in hastening the response of antidepressants
including paroxetine (Paxil), and fluoxetine (Prozac). In one
study, after ten days, nearly half the patients taking the combination
was in remission compared to 25% of patients taking Paxil only.
In the study on Prozac, patients reached a sustained response
within 19 days on the combination compared to 29 days with Prozac
drugs. There is some preliminary evidence to suggest that the
anti-anxiety agent buspirone (BuSpar) may be helpful in treating
resistant depression when added to the SSRIs citalopram or fluoxetine.
More research is needed to confirm the finding. Combinations
with other anxiety agents, including clonazepam (Klonopin) plus
fluoxetine (Prozac), have also produced greater early improvement
than the SSRI alone.
ARE PSYCHOTHERAPEUTIC TECHNIQUES FOR DEPRESSION?
Among the various
psychotherapies, cognitive-behavioral therapy at this time appears
to be the most effective approach for most adult patients. A 2000
study suggested that there was very little difference among major
psychotherapeutic approaches-- cognitive-behavioral therapy, family
therapy, and supportive therapy. There are other effective therapies
as well, such as problem-solving therapy, and interpersonal therapy.
Psychoanalytic or psychodynamic approaches have not been helpful.
(Based on Freudian theory, psychodynamic psychotherapy concentrates
on working through unresolved conflicts from one's childhood. Depression
is viewed as a grieving process for the loss of a parent or other
significant person or for the loss of their love.)
In any case, if psychotherapy is being used along without medications,
benefits should be evident within eight weeks and symptoms should
be fully resolves by 12 weeks. If these conditions are not met,
then the patient should strongly consider antidepressant agents.
In a major analysis
of four randomized comparative studies, cognitive behavior therapy
was as effective as antidepressants in treating severe depression
for many patients. Much of the success of psychologic therapy, in
any case, depends on the skill of the therapist. Many studies suggest
that combining cognitive therapy with antidepressants offer the
greatest benefits for many patients, particularly for dysthymia
(chronic depression). Some studies also report that in these patients
the benefits of cognitive therapy persist for these patients after
treatment has ended, with the risk of relapse reduced by up to 50%.
Best Candidates. Cognitive therapy may be particularly helpful
for the following patients:
does not appear to be as beneficial as antidepressants for most
patients with dysthymia.
with atypical depression.
with mild symptoms of major depression.
with non-psychotic postpartum depression.
- For children
of parents with the disorder. In this case, therapy should involve
the whole family.
Approach. This approach focuses on identification of distorted
perceptions that patients may have of the world and themselves,
changing these perceptions, and discovering new patterns of actions
and behavior. These perceptions, known as schemas, are negative
assumptions developed in childhood that can precipitate and prolong
depression. Cognitive therapy works on the principle that these
schemas can be recognized and altered, thereby changing the response
and eliminating the depression.
Over time, such
exercises help build confidence and eventually alter behavior. Patients
may take either group or individual cognitive therapy. Cognitive
therapy is a time-limited treatment, typically lasting 12 to 14
weeks. Extending this period, however, may help prevent relapse.
In one study, therapy was continued for 10 additional sessions over
the following eight months. This extended treatment significantly
reduced the risk of recurrence. In fact, some experts believe that
short-term therapy is not at all effective for patients with chronic
or relapsing psychiatric disorders.
the patient must learn how to recognize depressive reactions
and thoughts as they occur, usually by keeping a journal of
feelings about and reactions to daily events.
- The patient
is often given "homework" that tests old negative assumptions
against reality and demands different responses.
the patient and therapist examine and challenge these entrenched
and automatic reactions and thoughts.
- As the
patient begins to understand the underlying falseness of the
assumptions that cause depression, he or she can begin substituting
new ways of coping.
Based in part
on psychodynamic theory, interpersonal therapy acknowledges the
childhood roots of depression, but focuses on symptoms and current
issues that may be causing problems. IPT is not as specific as cognitive
or behavioral therapy, and all work is done during the sessions.
The therapist seeks to redirect the patient's attention, which has
been distorted by depression, toward the daily details of social
and family interaction. The goals of this treatment method are improved
communication skills and increased self-esteem within a short period
(three to four months of weekly appointments) of time. Among the
forms of depression best served by IPT are those caused by distorted
or delayed mourning, unexpressed conflicts with people in close
relationships, major life changes, and isolation.
Psychotherapy or Attention Intervention
The intent of
supportive psychotherapy or attention intervention is to provide
the patient with a nonjudgmental environment by offering advice,
attention, and sympathy. Supportive therapy appears to be particularly
helpful for improving compliance with medications by giving reassurance,
especially when setbacks and frustration occur. A 2000 study reported
that it was as effective as other therapies for depressed adolescents.
therapy trains patients to address current problems by breaking
them into smaller manageable parts. They then identify the steps
they should make toward positive change. It involves six individual
sessions, and some evidence suggests it is as effective as medication
in some patients with major depression.
SURGICAL AND OTHER NON PHARMACOLOGIC PROCEDURES ARE AVAILABLE
therapy (ECT), commonly called shock treatment, has received bad
press, in part for its potential memory-depleting effect, since
it was introduced in the 1930s. ECT has been refined over the years
and is now considered to be the most effective treatment for severe
depression. It is effective more than 90% of the time in those with
mood disorders. Continuing ECT may also be effective in preventing
relapse. In one 2000 study, continued use of ECT in responsive patients
plus long-term antidepressant prevented relapse in 73% of patients
after five years compared to 18% in patients on antidepressants
Candidates for ECT. About 40,000 Americans receive ECT each
year, many are elderly women who may be psychiatric inpatients.
Many experts urge that ECT be used earlier in the course of major
depression, although most insurers or HMOs will not pay for early
treatment. ECT may be beneficial for the following patients with
In general, an ECT involves the following:
who cannot, for any reason, take antidepressant drugs.
patients who are psychotic and depressed.
women with severe depression.
with certain heart problems.
patients who fit the adult criteria for ECT.
It should be
noted that this procedure is associated with a great deal of anxiety
and the patient should be reassured. One form of ECT called right
unilateral ECT (RUL ECT) may provide equal therapeutic benefits
to more traditional bilaterally applied forms of the therapy, and
more importantly may have a less potentially deleterious effect
is not necessary for the treatment.
- A muscle
relaxant and short-acting anesthetic are administered.
- A small
amount of electric current is sent to the brain, causing a generalized
seizure that lasts for about 40 seconds.
- Most patients
receive six treatments spaced every two to five days. Others
receive up to 15 treatments, followed by six to 12 additional
treatments spaced every other week or longer for another two
to four months.
Side Effects. Side effects of ECT may include temporary
confusion, memory lapses, headache, nausea, muscle soreness, and
heart disturbances. Administering the drug naloxone immediately
before ECT may help reduce its effects on concentration and some
(but not all) forms of memory impairment. Concerns about permanent
memory loss appear to be unfounded. One study that used brain scans
before and after ECT found no evidence of cell damage. In another
small study of teenagers who had undergone ECT for severe mood disorders,
only one of ten reported memory impairment 3-1/2 years after the
is recommended as the first-line treatment for seasonal affective
The Procedure. The procedure is noninvasive and simple:
Some people report
mood improvement as early as two days after treatment. In others
depression may not lift for three or four weeks. (If no improvement
is experienced after that, then the depression is probably caused
by other factors.)
- It is
best performed immediately after waking in the morning.
- The patient
sits a few feet away from a box-like device that emits very
bright fluorescent light (10,000 lux) for about 30 minutes every
Side Effects. Side effects include headache, eye strain,
and irritability, although these symptoms tend to disappear within
a week. Patients taking light-sensitive drugs (eg, those used for
psoriasis), certain antibiotics, or antipsychotic drugs should not
use light therapy. Patients should be examined by an ophthalmologist
before undergoing this treatment.
A surgical technique
called cingulotomy interrupts the cingulate gyrus, a bundle of nerve
fibers in the front of the brain, by applying heat or cold. A recent
variation of this procedure using MRI scans to guide the surgeon
produced long-term improvement in 53% of patients with severe depression.
The procedure is generally safe with few serious complications;
it does not affect either intellect or memory.
magnetic stimulation (TMS) employs high frequency magnetic pulses
that target affected areas of the brain. The intention is similar
to electroconvulsive therapy (ECT) but, unlike ECT it is more precise
and has the potential of having the same benefits as ECT. Studies
are mixed on its benefits. Investigators continue to try various
techniques that might produce consistent improvements.
Vagus Nerve Stimulation
An experimental procedure called vagus nerve stimulation (VNS),
which is currently proving to be effective for patients with epilepsy,
has also shown some success in treating depression. The two vagus
nerves are the longest nerves in the body. They run along each side
of the neck, then down the esophagus to the gastrointestinal tract.
The vagus nerve travels to areas of the brain that control functions
like sleep and mood.
VNS has about a 35% response rate in appropriate candidates with
treatment-resistant depression. (It is not likely to be effective
in patients who have failed to respond to multiple antidepressants.)
The procedure involves the following:
can cause shortness of breath, hoarseness, sore throat, coughing,
ear and throat pain, or nausea and vomiting. These side effects
can be reduced or eliminated by reducing the intensity of stimulation.
Long-term studies on epilepsy patients are reporting no serious
adverse side effects, although the treatment may cause lung function
deterioration in people with existing lung disease.
- A battery-powered
device similar to a pacemaker is implanted under the skin in
the upper left of the chest.
- A lead
is then attached to the left vagus nerve in the lower part of
- The neurologist
programs the device to deliver mild electrical stimulation to
the vagus nerve. (The patient may also pass a magnet over the
device to give it an extra dose if they sense a seizure coming
One small study
reported that acupuncture was effective in relieving depression
in 64% of women, a result comparable to medications or psychotherapy.
Larger studies are required to confirm this result.
Research shows that therapy that involves even one night of sleep
deprivation has an antidepressant benefit in many patients with
depression. Patients that benefit appear to have higher than normal
metabolic rates in parts of their brain that then decline after
LIFESTYLE CHANGES CAN HELP DEPRESSION?
Foods. Some people report relief from depression by eating
foods or diet supplements that boost levels of tryptophan, an amino
acid involved in the production of serotonin. A high-carbohydrate
drink available over the counter called PMS Escape increases tryptophan
levels and may alleviate depression from PMS for about three hours.
Fish Oil. Some evidence suggests that deficiencies in omega-3
polyunsaturated fatty acids, which is found in fish oil, may increase
the risk for depression. Experts then are investigating whether
eating fish or taking omega-3 supplements can reduce depression.
Studies are promising. A 1999 study reported benefits for people
with manic depression who took omega-3 fatty acid pills along
with lithium. And a Scandinavian study found that people who ate
more fish were less likely to be depressed or commit suicide. Larger
scale trials are needed to determine if fish oil is effective in
Caffeine. Studies have found an association between drinking
caffeinated beverages and a lower incidence of suicide, indicating
that coffee or tea might help reduce depression.
and Other Supplements
B Vitamins appear
to be most highly associated with protection against depression.
B3 (niacin) is important in the production of tryptophan and
is produced from processing vitamin B3 (niacin). Dietary sources
of niacin include oily fish (such as salmon or mackerel), pork,
chicken, dried peas and beans, whole grains, seeds, and dried
B12 and calcium supplements may help reduce depression that
occurs before menstruation.
- A 2001
study also suggested that calcium might help prevent postpartum
a vitamin B, may enhance the effectiveness of SSRIs and other
is little strong evidence that exercise can help manage depression,
a number of studies have suggested benefits. The following are some
may be particularly beneficial:
- A 2000
study reported that 30 minutes of brisk exercise three times
a week may be just as effective as medication in relieving the
symptoms of mild to moderate depression and reduces the risk
- A 1999
study on exercise in the elderly reported that after 26 weeks,
exercise was as effective as antidepressants. (Antidepressants
relieved depression earlier, however.)
- One study
found that teenagers who were active in sports have a greater
sense of well being than their sedentary peers; the more vigorously
they exercised, the better their emotional health.
Aerobics. Either brief periods of intense training or prolonged
aerobic workouts can raise chemicals in the brain, such as endorphins,
adrenaline, serotonin, and dopamine, that produce the so-called
runner's high. And, of course, weight loss and increased muscle
tone can boost self-esteem.
Yoga. Yoga practice, which involves rhythmic stretching movements
and breathing have been found to positively affect mood and may
have clinical potential as a technique for improving and stabilizing
mood. One study, in fact, suggested that men actually may have better
results with yoga than with aerobic exercise. In the study men experienced
significantly lower levels of tension, fatigue, and anger after
yoga than after swimming. (Yoga and swimming tended to produce equal
benefits in women.) .
A strong network of social support is both important for prevention
and recovery from depression. Support from family and friends must
be healthy and positive; one study of depressed women showed, however,
that overprotective as well as very distant parenting was associated
with a slow recovery from depression. Studies indicate that people
with strong spiritual faiths have a lower risk for depression. Such
faith does not require an organized religion. People with depression
might find solace from less structured sources, such as those that
teach meditation or other methods for obtaining spiritual self-fulfillment.
ELSE CAN HELP BE OBTAINED FOR DEPRESSION?
for Depressive Illness, P.O. Box 225720, New York, NY 10116.
Call (212-268-4260) or (800-239-1265) or on the Internet (https://www.depression.org/).
National Depressive and Manic-Depressive Association, 730 N. Franklin
St., Suite 501, Chicago, Ill. 60610.
Call (800) 826-3632) on the Internet (https://www.ndmda.org/).
Makes referrals to local support services and offers a free information
National Institute of Mental Health, 5600 Fishers Lane, Parklawn
Building, Rockville, MD 20857.
Call (800-64-PANIC) or on the Internet (https://www.nimh.nih.gov/).
National Alliance for the Mentally Ill (NAMI), 200 N. Glebe Rd.,
Arlington, VA 22203-3754.
Call (800-950-6264) or on the Internet (https://www.nami.org/).
NAMI is a national grass roots organization providing ways for self-help
and support organizations to individuals and families of people
with psychologic disorders.
Society for Light Treatment and Biological Rhythms, 842 Howard Avenue,
New Haven, CT 06519.
Fax: (203-764-4324) or on the Internet (https://www.sltbr.org).
Emotions Anonymous, PO Box 4245, St. Paul, MN 55104.
Call (612-647-9712) or on the Internet (https://www.EmotionsAnonymous.org/).
Offers a 12-step program to help people experiencing emotional difficulties.
Has 1,400 groups worldwide.
National Organization for SAD, PO Box 40133, Washington DC 20016.
This organization supplies the names of light box companies and
other information on seasonal affective disorder.
Health Professional Organizations
for Cognitive Therapy. Call (212-308-2440) or (https://www.cognitivetherapynyc.com/).
Association for the Advancement of Behavior Therapy. Call (212-647-1890)
or (800-685-AABT) or (https://www.aabt.org/).
The American Psychiatric Association. Call (202-682-6000) or (https://www.psych.org).
The American Psychological Association. Call (800-964-2000) or (https://www.psychologicalscience.org/)
The National Association of Social Workers. Call (202-408-8600)
The American Psychiatric Nurses Association. Call (202-857-1133)
American Academy of Child and Adolescent Psychiatry (https://www.aacap.org/).
On the Internet
Mental Health Net (https://mentalhelp.net/).
Information on cognitive therapy (https://www.cognitivetherapy.com/).
Internet Mental Health (https://www.mentalhealth.com/)
is a free encyclopedia of mental health information.
Interesting site assists in finding the right therapist (https://www.1-800-therapist.com/).
Information about virtually all FDA-approved drugs and some herbal
click "drug database").