Diagnosing depression

Depression is a medical condition that causes psychological and physical symptoms. The most pronounced symptom is extreme sadness. Depression is distinguished from grief or ‘occasional blues’ in that it is persistent for more than weeks and affects daily activities and relationships. Depressed people may no longer enjoy or care about things they used to like doing. They may have feelings of sadness, guilt, hopelessness, helplessness or worthlessness. They may gain or lose weight, feel tired/have no energy, sleep too much or too little and occasional think about death or suicide.

Depression is common and the risk of suffering from depression in a person’s lifetime is up to 12 per cent in men and 25 per cent in women¹. Depression is a treatable condition with counselling, drug therapy and other treatments to help get depressed people back on tract.

Your genetics² and early life stress such as childhood trauma probably contributes to vulnerability toward depression throughout life³. This, combined with additional social factors such as isolation, relationship and work stress, criticism from family members and depression in one's friends and neighbours may lead to depression onset or perpetuate depressive episodes⁴.

Treatments for depression

• Take medications. Antidepressants help re-establish the normal chemical balance in the brain. Some people may start to feel better within two weeks, but the medication may not have its full effect until four to six weeks or longer. If there has been no improvement, an alternate medication will be recommended.
• Psychotherapy is a process where you can speak with a psychologist, psychiatrist or social worker, discuss your feelings worries, and relationships and together will discuss other ways to think and deal with situations which will improve social skills, increase your confidence & cope with depressive symptoms. The benefit starts within a few weeks, but may take up to eight weeks to get the full benefit.
• Both. A large study has found a higher response rate in patients receiving both medication and psychotherapy5

Secondary depression

Depression can occur secondary to many other medical illnesses⁶. The doctor will request test to exclude the following conditions:

• Cardiac - ischemic heart disease, heart failure, cardiomyopathy
• Endocrine and metabolic disorders — hypothyroidism, diabetes mellitus, vitamin deficiencies, parathyroid disorders, polycystic ovarian syndrome, premenstrual tension, premenstrual dysmorphic disorder, pregnancy
• Neurological - epilepsies, Parkinson's disease, multiple sclerosis, Alzheimer's disease, cerebrovascular disease, traumatic brain injury
• Infectious disorders - neurosyphilis, HIV/AIDS
• Inflammatory disorders - collagen-vascular diseases, irritable bowel syndrome, chronic liver disorders
• Neoplastic disorders - central nervous system tumours, paraneoplastic syndromes

If you are feeling down, please speak to your doctor.

Pregnancy & Postpartum Depression

It is unclear why pregnancy represents a vulnerable time for onset of depression in some women. Possible factors that may interact with each other include hormonal shifts, neuroendocrine changes, and psychosocial adjustments. Postpartum affects ten per cent of women, which is the same rate as non-pregnant women.

The symptoms of depression during pregnancy may be misattributed to normal pregnancy-related changes in maternal physiology and temperament. It is important to know that feeling sad, blue, hopeless or helpless mood and suicidal ideation are distinguishing features of depression.

The risk factors for developing depression during pregnancy⁷ are:

• Life stress, including adverse life events
• Lack of social support
• Domestic violence

There is no single hormone that is the causative agent. Postpartum depression can affect the mother-child relationship marital relationship, child development and mental health of the partner. Treatment is usually psychotherapy first and then the addition of pharmacotherapy. Selective Serotonin Reuptake Inhibitors (SSRIs) are usually the first choice because of milder side effects⁸.

Premenstrual Syndrome (PMT) & Premenstrual Dysphoric Disorder (PMDD)

Both these disorders affect women with both physical (bloating fatigue breast tenderness) and behavioural symptoms (labile or depressed mood, irritability, increased appetite, difficulty concentrating) in the latter two weeks of the menstrual cycle and disrupts the woman’s life. PMDD is a more severe form of PMT where the predominant symptoms are irritability, anger and tension⁹.

PMS is common, affecting up to 75 per cent of women with regular menstrual cycles, while true PMDD affects only five per cent of women in this group¹⁰.

It is not clear why some people develop PMS and PMDD and others do not. It is thought that those that do are more sensitive to the fluctuating hormone levels of oestrogen and progesterone that influences their serotonin levels¹¹. Serotonin is many involved with irritability and anger but also has a role in the depressive symptoms and food cravings reported with PMDD¹².

PMS and PMDD should be distinguished from underlying depression as the treatments are different. Symptoms of PMS and PMDD resolve completely as soon as menstruation begins, but those of underlying depression do not.

Treatment for PMS & PMDD

Conservative measures include:

• Exercising four time per week for 30 minutes has a small short-term anti-depressant effect¹³
• Relaxation therapy¹⁴
• A few dietary changes may improve symptoms: Reducing your intake of simple sugar, salt alcohol and caffeine¹⁵
• Ensuring adequate amounts of magnesium 250mg/d¹⁶ Calcium carbonate 1200mg/day¹⁷, Vitamin B6 100mg/day¹⁸ and (according to a small study) Chasteberry 20mg/d¹⁹
• The oral contraceptive pill (OCP) – Response to the OCP varies greatly. Yaz 24/4 has been approved by the US Food and Drug Administration (FDA) for PMDD²⁰
• Selective Serotonin Reuptake Inhibitors (SSRIs) taken during the luteal phase (ovulation to menstruation) are effective^21,22

Perimenopausal Women and Depression

The perimenopause is a time of increased vulnerability to mood disorders²³. The fluctuations in hormones and general decrease in oestrogen production may alter the neuroendocrine system and predispose to the development of depression²⁴.

Treatment for melancholy in the perimenopause patient aims to stabilize the fluctuating hormone levels. Some success has been achieved with low dose OCP, oestradiol and combined hormone replacement therapy^25,26. An antidepressant may also be considered with psychotherapy.

References

1. Weissman et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276(4):293.
2. Kendler et al. A Swedish national twin study of lifetime major depression. Am J Psychiatry. 2006;163(1):109
3. Green et al. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry. 2010;67(2):113
4. Rosenquist et al. Social network determinants of depression. Mol Psychiatry. 2011 Mar;16(3):273-81
5. Combined pharmacotherapy and psychological treatment for depression: a systematic review. Pampallona et al. Arch Gen Psychiatry. 2004;61(7):714
6. Joska, JA & Stein, DJ. Mood disorders. The American Psychiatric Publishing Textbook of Psychiatry (5th Edition), Hales et al. (Ed), American Psychiatric Publishing, Washington DC 2008. p.457
7. Lancaster et al. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol. 2010;202(1):5
8. Qaseem et al. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Clinical Efficacy Assessment Subcommittee of American College of Physicians. Ann Intern Med. 2008;149(10):725
9. Steiner, M & Born, L. Diagnosis and treatment of premenstrual dysphoric disorder: an update. Int Clin Psychopharmacol. 2000;15 Suppl. 3:S5
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11. American College of Obstetricians and Gynecologists. Premenstrual Syndrome: Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Practice Bulletin. 2000;15:1-9
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13. Aganoff, JA & Boyle, GJ. Aerobic exercise, mood states and menstrual cycle symptoms. J Psychosom Res. 1994;38:183-192
14. Girman et al. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol. 2003;188:S56
15. Rossignol, AM & Bonnlander, H. Caffeine-containing beverages, total fluid consumption, and premenstrual syndrome. Am J Public Health. 1990; 80:1106-1110
16. Facchinetti et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol. 1991;78:177-181
17. Thys-Jacobs et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998; 179:444-452
18. Wyatt et al. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ. 1999; 318:1375-1381
19. chellenberg, R. Treatment for the premenstrual syndrome with Agnus castus fruit extract: prospective, randomised, placebo controlled study. BMJ. 2001;322(7279):134
20. Lopez et al. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2009
21. Steiner et al. Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005; 193:352-360
22. Dimmock et al. Efficacy of selective serotonin-reuptake inhibitors in premenstrual syndrome: a systematic review. Lancet. 2000;356(9236):1131
23. Cohen et al. Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles. J Affect Disord. 2002;70:125-132
24. Schmidt, PJ. Depression, the perimenopause, and estrogen therapy. Ann NY Acad Sci. 2005;1052:27-40
25. Schmidt et al. Hormone replacement therapy in menopausal women: past problems and future possibilities. Gynecol Endocrinol. 2006;22:564-577
26. Schmidt, PJ. Mood, depression, and reproductive hormones in the menopausal transition. Am J Med. 2005;118(Suppl. 12B):54-58

Content updated 27 September 2011