Some herbs do have mildly calming effects. These include chamomile, passionflower, kava, valerian, lavender, lemon balm, and skullcap. They are available in many formats, including teas, oils, pills, tinctures, and sprays.

There is some evidence that these herbs can have calming effects, but the evidence is not conclusive, and the effects may be pretty mild. Certainly they’re not strong enough to, say, stop a panic attack in its tracks or treat an anxiety disorder. Such herbs are most useful when taken before bed to help you calm down and fall asleep. If you take them during the day, you may find they make you drowsy.

Herbal Remedy Regulation Issues

If you decide to try herbal remedies for anxiety, be aware that they’re not as well regulated as drugs. This means that what’s on the bottle’s label may not match what’s inside.

Now that looks relaxing—chamomile tea. It may not have the same effect on all of us, but it’s nevertheless a popular home remedy for leveling off stress.

In most cases, long-term studies demonstrating efficacy and safety are lacking. Remaining questions about the safety of kava (also written as “kava kava” or kavakava”) are particularly concerning, and some countries have banned it because of the risk of liver damage. Kava may also cause headache, nausea, and dizziness. Some people may experience allergic reactions to herbal remedies. Don’t combine or replace prescribed medication for anxiety with an herbal remedy without first speaking with your health care provider.

Vitamins and Minerals for Anxiety and Stress

There are several vitamin and mineral preparations that are marketed as stress-busters. Typically, the rationale behind this claim is that these products replenish the vitamins and minerals that are likely to be diminished in times of stress. Alternatively, they rely on the fact that a lack of a certain vitamin or mineral may produce anxiety as a symptom, so vitamin and mineral manufacturers claim supplementation can help with this.

The truth is, unless you have a known deficiency, there is no evidence vitamin and mineral supplements will help with your anxiety or stress. If you think you might have a deficiency, your doctor can perform blood tests to find out for sure.

Using Over-the-Counter Medications to Treat Anxiety

Even though there are currently no approved over-the-counter anxiety medications. That doesn’t stop some people from relying on the side effects of OTC medications meant for other purposes to calm their anxiety.

Many over-the-counter drugs produce sedation or drowsiness. These include antihistamines, cough syrups, cold medicines, muscle relaxants, painkillers, and sleep medications. It can be tempting to try to alleviate anxiety with one of these medications, but it’s not safe. None of these drugs are meant to be taken long-term, and it’s more than likely you’ll need to keep increasing the dose in order to maintain the same level of sedation. You can quickly overdose yourself without even realizing it. In addition, once you stop taking these medications, the rebound effect can make you feel even worse.

If your stress or anxiety is severe enough for you to be scanning pharmacy shelves looking for relief, it’s likely you need some professional help. Talk to your health care professional about effective therapies such as psychotherapy, biofeedback, meditation, and prescription medication.

RECOMMENDED FOR YOU

• Anxiety Medication: Drug Treatment Options for Managing Anxiety Disorders
• Anxiety Medication and Antidepressants: Do They Make a Difference?
• Serotonin Supplements to Treat Depression, Anxiety, and Insomnia Yourself
• Finding the Best Antidepressants for Anxiety 

Originally published in 2016, this post is regularly updated.

The post Do Over-the-Counter Anxiety Medications and Supplements Work? appeared first on University Health News.

The truth is that, for better or worse, most people are able to tolerate the drudgery of feeling “pretty awful” for a long period of time without there being any real danger of losing control, doing something “crazy,” “going mad,” or “breaking down.” In fact, the feeling that you might be going crazy or are about to lose control is actually a common symptom of anxiety or depression. So, be assured that there are millions of people out there who, like you, feel as if their brains might just melt out of their ears one day.

That said, there are warning signs that can suggest you’re headed for a mental breakdown.

What Is a Mental Breakdown? Symptoms Tell the Story

Keep in mind that the phrase “mental breakdown” is not a medical term or official diagnosis. It has no clear-cut diagnostic criteria. There are no tests or checklists that can determine conclusively whether you’re experiencing one. The expression simply means that you’re suffering or struggling enough that you feel as if you’re getting closer and closer to a point where you cannot go on.

In extreme cases, mental breakdown symptoms might mean you’re feeling suicidal. It might be that you’re getting angrier and angrier, and perhaps afraid you might actually hurt someone. You could be losing touch with reality. You might feel that the responsibilities of daily living—getting up, getting dressed, eating, and going to work or taking care of your children or family members—are simply not possible anymore. You also might be dealing with stresses such as an illness (or an illness in a loved one) that you simply cannot face anymore. Under such circumstances, it’s time to seek help.

15 Mental Breakdown Symptoms

Here are 15 signs that you might be close to the edge:

1. Someone has expressed concern that you’re behaving strangely or self-destructively.
2. Your body seems to be no longer able to function properly.
3. You can no longer face basic responsibilities, such as caring for a child or parent who depends on you.
4. You have great difficulty getting out of bed.
5. You’re afraid you won’t be able to control your temper and might do something destructive or dangerous or hurt someone.
6. You feel completely without hope.
7. You feel overwhelmed most or all of the time.
8. You’re having negative feelings—such as loneliness, pain, or anxiety—that begin to feel unbearable.
9. You’re increasingly concerned that people are out to get you.
10. You’re no longer able to maintain a safe place to live or to get enough food to eat.
11. You’re resorting more and more to drugs or alcohol just to get through the day.
12. You’re experiencing frequent mood swings.
13. You frequently feel restless and agitated.
14. You’re starting to hear or see things that are not there.
15. You’re thinking about harming yourself or someone else.

If any of the above apply to you, set up an appointment with your doctor to discuss troubling issues. You can also try talking with a trusted friend or a member of the clergy. If you have any thoughts of suicide or if you feel that you may be a danger to yourself or others, you need help immediately. Go to the emergency room of your local hospital, call 911, or call a suicide hotline such as 800-273-TALK or 800-SUICIDE.

The Breaking Point

It’s important to recognize that having mental breakdown symptoms is not a sign of weakness. The human spirit can take only so much stress, anxiety, and pressure before it falters. Everyone has his or her breaking point; often, we don’t even know what that point is unless we are tested.

For some of us, dropping out of school and losing the support of our parents can be enough to send us over the edge. Others may appear almost superhuman, taking care of children, parents, or other vulnerable people while holding down a full-time job and living with a chronic disease. The point is not to compare. If you feel like you can’t take things the way they are anymore, reach out for help.

RECOMMENDED FOR YOU

• 6 Tips to Conquer Stress, Anxiety, and Depression Symptoms
• How to De-Stress: 4 Proven Tactics
• How to Deal with Stress
• Symptoms of a Nervous Breakdown 

See also this page from the U.S. National Library of Medicine, this one from the Centers for Disease Control and Prevention, and this resource from the National Alliance on Mental Illness.

Originally published in 2017.

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It is important not to be your own worst enemy in this regard. If you feel miserable, get help. Don’t worry about whether your misery is severe enough to “deserve” professional attention. Even if you don’t believe that treatment can help, rather than stay depressed, give treatment the benefit of the doubt.

When getting help is simply a matter of logistics, new technologies for delivering care may provide a solution. There are many telephone- and online-based treatments available. These include programs called MoodGYM and BluePages. Most of them are based on the model of cognitive behavioral therapy (CBT), but online therapist matching services such as BetterHelp.com let you choose what kind of therapist to connect with and how you want to interact (e.g., by phone, chat, or video chat).

There are even smartphone apps that can help you, such as one called Mobilyze. This clever app detects signs of depression based on your location, activity level, social interactions (phone calls, emails, and texts), and mood, and then makes suggestions to help bring you out of your funk, such as calling or visiting a friend.

Several online forums and support groups also are available for depression sufferers, such as MoodNetwork.org. Many of these are free of charge to join.

Internet-Based CBT An Effective Treatment

Online therapy has great potential to help people who, for any number of reasons, are not able to regularly attend face-to-face sessions with a therapist. But does it work just as well? Several studies have looked at the impact of self-guided internet-based psychotherapy. In one promising analysis of the available research out of Indiana University in Bloomington, investigators reviewed 21 studies looking at how effective internet apps that use self-guided CBT-based approaches to treat depression are. The data suggest that not only is this strategy effective, it is even helpful for people with severe depression. Many experts had assumed that CBT-based apps might only be helpful for those with milder forms of the condition. In general, internet-based CBT was about as effective as face-to-face CBT and antidepressants.

For more information about depression symptoms and treatment, purchase Overcoming Depression from University Health News.

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American Academy of Child and Adolescent Psychiatry
www.aacap.org
202-966-7300
3615 Wisconsin Ave., NW
Washington, D.C. 20016-3007

American Foundation for Suicide Prevention
www.afsp.org
info@afsp.org
888-333-AFSP (2377)
120 Wall St., 29th Floor
New York, NY 10005

American Psychiatric Association
www.psych.org
apa@psych.org
202-559-3900
800 Maine Ave., SW, Suite 900
Washington, DC 20024

American Psychological Association
www.apa.org
800-374-2721
750 First St., NE
Washington, D.C. 20002-4242

American Society for Adolescent Psychiatry
www.adolescent-psychiatry.org
ASAPadolpsych@gmail.com
703-746-8900
5903 Mount Eagle Dr., Suite 917
Alexandria, VA 22303

Anxiety and Depression Association of America
www.adaa.org
information@adaa.org
240-485-1001
8701 George Ave., Suite 412
Silver Spring, MD 20910

Depression and Bipolar Support Alliance
www.dbsalliance.org
800-826-3632
55 E. Jackson Blvd., Suite 490
Chicago, IL 60604

Gay and Lesbian Medical Association
www.glma.org
info@glma.org
202-600-8037
1133 19th St., NW, Suite 302
Washington, DC 20036

Massachusetts General Hospital Clay Center for Young Healthy Minds
www.mghclaycenter.org
contact@mghclaycenter.org
617-643-1590
One Bowdoin Sq., Suite 900
Boston, MA 02114

Massachusetts General Hospital Center for Women’s Mental Health
www.womensmentalhealth.org
(617) 724-7792
admin@womensmentalhealth.org
Simches Research Bldg.
185 Cambridge St., Suite 2200
Boston, MA 02114

Mental Health America
www.mentalhealthamerica.net
800-969-6642
500 Montgomery St., Suite 820
Alexandria, VA 22314

MoodNetwork
https://moodnetwork.org/
moodnetwork@partners.org
617-643-2076

National Alliance on Mental Illness (NAMI)
www.nami.org
info@nami.org
703-524-7600
Helpline: 800-950-6264 or text NAMI to 741741
3803 N. Fairfax Dr., Suite 100
Arlington, VA 22203

National Council for Behavioral Health
www.thenationalcouncil.org
communications@thenationalcouncil.org
202-684-7457
1400 K St. NW, Suite 400
Washington, D.C. 20005

National Institute of Mental Health
www.nimh.nih.gov
nimhinfo@nih.gov
866-615-6464
6001 Executive Blvd.,
Rm 6200, MSC 9663
Bethesda, MD 20892-9663

National Network of Depression Centers
www.nndc.org
734-332-3914
2350 Green Rd., Suite 191
Ann Arbor, MI 48105

National Suicide Prevention Lifeline
www.suicidepreventionlifeline.org
chat online at https://suicidepreventionlifeline.org/chat/
1-800-273-TALK (8255)

Substance Abuse and Mental Health Services Administration (SAMHSA)
www.samhsa.gov
877-SAMHSA-7 (726-4727)
5600 Fishers La.
Rockville, MD 20857

SAMHSA’s Center for Mental Health Services Locator
www.findtreatment.samhsa.gov
1-800-662-HELP (4357)

SAMHSA’s National Mental Health Information Center
www.healthfinder.gov
healthfinder@hhs.gov
1101 Wootton Pkwy.
Rockville, MD 20852

The Trevor Project For LGBTQ youth in crisis
Thetrevorproject.org
(includes online chat)
1-866-488-7386
Text START to 678678
IF IN DISTRESS, CALL: 800-273-TALK (8255) OR Text START to 678678

The post Resources appeared first on University Health News.

anhedonia: The inability to feel pleasure; a common symptom of depression.

antidepressants: Medications that improve mood and functioning in people with depression by regulating the levels of neurotransmitters in the brain. Some antidepressants are used to treat other conditions such as anxiety, pain syndromes, and obsessive compulsive disorder.

antipsychotics: Drugs used to treat symptoms of psychosis, such as hallucinations and delusions; they also can play a role in the treatment of depression and bipolar disorder.

anxiety: This response to stress causes feelings such as nervousness, fear, or apprehension. It can range from mild and unsettling to debilitating.

anxiolytics: Drugs used to treat anxiety; sometimes used for depression that has an anxiety component.

atypical depression: Depression that includes symptoms of overeating, oversleeping, and sensitivity to rejection or criticism, but also the ability to temporarily respond with improved mood to happy or positive events.

bipolar disorder: A mental disorder in which the person experiences mood swings from mania to depression.

borderline personality disorder: A psychiatric condition typically characterized by profound feelings of emptiness, unstable interpersonal relationships, self-destructive behaviors, and suicidal tendencies.

clinical depression: Another term for major depression as well as levels of depression that may not meet full criteria for major depression but are causing meaningful levels of distress and impairment.

delusion: A symptom of psychosis in which a person has a fixed belief, sometimes bizarre, which has no basis in reality.

dementia: Umbrella term for a wide range of conditions associated with a progressive decline in cognition that affects a person’s ability to conduct everyday activities. The most common form of dementia is Alzheimer’s disease. Other forms include Lewy Body Dementia, Frontotemporal Dementia and Dementia in Parkinson’s Disease.

endorphins: Naturally occurring molecules that attach to receptors in the brain and spinal cord to stop pain messages and elevate mood.

hypothyroidism: A condition in which the thyroid gland becomes underactive. Hypothyroidism sometimes causes symptoms that mimic depression, such as low energy, weight gain, or difficulty thinking or remembering.

major depression: A condition characterized by depressed or irritable mood, low interest, feelings of worthlessness or guilt, fatigue, difficulty concentrating, suicidal thoughts, and/or changes in sleep, appetite, and/or weight that last for more than two weeks and are significant enough to interfere with a person’s life.

mania: A mental state characterized by inflated self-esteem, increased activity, decreased need for sleep, irritability, impulsiveness, racing thoughts, rapid speech, and sometimes, hallucinations and delusions; manic episodes occur in people who have bipolar (manic-depressive) disorder.

mixed episode: A period in which individuals with mood disorders experience symptoms of both mania and depression at the same time, such as intense sadness combined with rapid thoughts and increased energy.

monoamine oxidase inhibitors (MAOIs): A class of antidepressant drugs that work by preventing the enzyme monoamine oxidase from breaking down the neurotransmitters serotonin, norepinephrine, and dopamine in the brain. MAOIs are associated with special precautions regarding diet and drug interactions.

mood stabilizer: A class of drugs that helps regulate the pattern of extremely high and low moods experienced by people with bipolar disorder.

neuromodulation: Different ways of using technology to stimulate nerves and the brain such as electroconvulsive therapy, deep brain stimulation or transcranial magnetic stimulation.

norepinephrine: A neurotransmitter and hormone that is involved in the body’s “fight-or-flight” arousal response, as well as in regulating mood.

persistent depressive disorder: A condition in which depressed mood and at least two other symptoms of depression last for two years or more.

postpartum depression: Depressed mood that occurs in the mother after the birth of a baby and lasts for more than two weeks after delivery.

postpartum psychosis: Confusion, loss of reality, and severe depression that can occur in the mother after childbirth. This is a medical emergency, due to extreme confusion interfering with function and because the mother may have thoughts of harming herself or her baby.

premenstrual dysmorphic disorder (PDD): A type of short-lived but recurrent depression that occurs during the premenstrual period and then diminishes or disappears as menses begin.

prepartum depression: Depression that occurs during pregnancy (also known as antepartum depression).

psychiatrist: A medical doctor who treats depression and other mental disorders. Psychiatrists can prescribe medications and order laboratory tests, such as blood tests or brain imaging.

psychodynamic therapy: A form of treatment for depression that seeks to help patients identify and understand how their past experiences and unconscious feelings have contributed to their current thoughts and behaviors.

psychologist: A mental health professional who can diagnose and treat depression. In most states, psychologists are not licensed to prescribe medications. Instead, they specialize in providing talk therapy (psychotherapy).

psychotherapy: A treatment in which a therapist helps the patient talk through and try to find solutions to the issues that are causing depression.

psychotic depression: A form of depression in which a person hallucinates, has false beliefs, and loses touch with reality.

remission: The full return of normal moods and functioning following an episode of depression. Remission may also refer to return to full health after other challenges such as anxiety or substance use disorders.

seasonal affective disorder (SAD): Symptoms of depression that regularly occur with the change in seasons, and persist through the season, typically, winter when there is less light.

selective serotonin reuptake inhibitors (SSRIs): A class of antidepressants that treat depression and other conditions including anxiety by blocking the reuptake of serotonin, making more of the neurotransmitter available to the brain.

serotonin: A chemical messenger in the brain, known as a neurotransmitter, that helps to regulate mood, sleep, and other functions.

serotonin and norepinephrine reuptake inhibitors (SNRIs): A class of antidepressants that treat depression and other conditions including anxiety by blocking the reuptake of both serotonin and norepinephrine, making more of these neurotransmitters available to the brain.

social worker: A clinician with a graduate degree and license in social work who may provide individual or group psychotherapy or may provide case management within a treatment team.

substance-induced depression: A type of depression brought on by taking medications or other drugs.

treatment-resistant depression: Depression that does not respond to one or more courses of treatment (which most often involves taking a full dose of an antidepressant for at least eight to 12 weeks or engaging in evidence-based psychotherapy for 12–16 weeks).

tricyclic antidepressants: An older class of antidepressant that improves mood by increasing levels of serotonin and norepinephrine in the brain and working on other brain receptors. They also may relieve pain as well as anxiety.

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Getting Needed Care

About half of depressed people do not receive the care they need. Barriers to receiving care include not believing your symptoms are severe enough to merit treatment, lack of hope that treatment will help, inability to identify or physically get to the centers where care is available, cost of treatment, and the stigma or discomfort associated with being treated for a mental disorder.

It is important not to be your own worst enemy in this regard. If you feel miserable, get help. Don’t worry about whether your misery is severe enough to “deserve” professional attention. Even if you don’t believe that treatment can help, rather than stay depressed, give treatment the benefit of the doubt. There are ways of finding the help you need, even if it is not always found where you first expect it. If you have a primary care doctor, that is often a good place to start. It is likely your doctor has worked with trusted mental health professionals in your area. Your health insurance company is required to maintain an updated list of mental health providers who accept your insurance and should provide assistance in finding them. In addition, many of the organizations listed at the end of this report contain information about finding help.

Online Assistance

When getting help is simply a matter of logistics, new technologies for delivering care may provide a solution. There are many telephone- and online-based treatments available. These include programs called MoodGYM and BluePages. Most of them are based on the model of CBT, but online therapist matching services such as BetterHelp.com let you choose what kind of therapist to connect with and how you want to interact (e.g., by phone, chat, or video chat).

There are even smartphone apps that can help you, such as one called Mobilyze. This clever app detects signs of depression based on your location, activity level, social interactions (phone calls, emails, and texts), and mood, and then makes suggestions to help bring you out of your funk, such as calling or visiting a friend.

Several online forums and support groups also are available for depression sufferers, such as MoodNetwork.org. Many of these are free of charge to join.

Finding Support

Often, overcoming depression is not just about getting the right treatment. It’s about finding the support you need in the community. Things like regular coffee dates with a close friend, family member, or trusted member of the clergy can do a world of good. Support and self-help groups, either in person or online, also can provide the support you need. A list of resources at the end of this book can help you find such groups.

While virtual support groups can provide easily accessible, crucially important support while you build up a real-life social network, don’t neglect your efforts to make face-to-face contact with others. It is best not to spend too much time alone when you are depressed, even though you might crave solitude much of the time.

In addition, while spending time on social media might seem like a good way to connect with others, it can backfire for some vulnerable people. Research suggests that too much time spent on social media actually can contribute to depression, especially if you use it to make comparisons between your life and the lives of others. Remember, most people post a pretty glorified version of their lives online. Don’t feel you need to live up to someone else’s highlight reel.

When to Seek Emergency Services

Sometimes people sink so deeply into depression that they can no longer see any hope. To them, the only possible future is one that doesn’t include them. These people begin to contemplate taking their own life.

Depression is one of the biggest risk factors for suicide. Any thoughts of hurting yourself are very serious. Get help right away by calling a friend, your doctor, 911, or the National Suicide Prevention Hotline at: 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255).

If you see any of the warning signs for suicide in someone you care about, encourage the person to get help. If you think a suicide attempt is imminent, call 911 or get other emergency assistance right away.

Recurrence and Relapse

One of the most important, yet most neglected, aspects of depression treatment is preventing depression from returning. Relapse refers to the return of depression after a period of weeks or months of doing well. The term “recurrence” sometimes refers to a relapse that occurs much later, such as after many months or years of mood stability.

Most research has been directed at the initial treatment for depression rather than on maintaining health once the depression has resolved. Similarly, most doctors and patients are focused so intently on the goal of recovering from depression that the idea of preventing a relapse is almost an afterthought. Nevertheless, the statistics speak for themselves. Anyone who has had one episode of major depression has at least a 50 percent chance of experiencing another episode at some point in his or her life. Anyone who has had two or more episodes of depression, periods of depression that have lasted for years, been hospitalized for depression, or not fully recovered from a current episode of depression, has an extremely high likelihood of relapse, even over the next 12 months. This means that for many people, depression is not simply an “episode,” but a long-term disorder—like high blood pressure or diabetes—that requires long-term management.

Identify Warning Signs

For most people, identifying the warning signs that their depression is returning (such as becoming more isolated or not responding to emails and phone calls) can help nip a relapse in the bud. Identifying triggers of past depression, such as a loss, move, disappointment, or work stress also can help you develop a treatment plan with your health-care provider that reduces the likelihood of a full-blown relapse in the future.

Managing Expectations

For many people, depression is not a “one-off” episode but a long-term condition. You need to go into treatment with the expectation that you may have periods of improvement and periods in which your symptoms get worse. It is essential that you learn to manage your condition just as you would with diabetes or heart disease and discuss relapse prevention with your doctor or mental health professional.

Do not stop taking your medication just because you feel better, as this can trigger quite significant withdrawal effects and may result in your depression returning with a vengeance. This doesn’t mean you can never stop taking medication for depression. Just plan it out carefully with your doctor beforehand.

Some people need to stay on medication for life while others can remain well without medication, or with a lower dose. If you are one of those individuals who require medications not only to heal from depression but to stay healthy in the long term, it is important to recognize that medications are not a crutch or something you should feel ashamed of. Rather, antidepressants are part of the long-term management of your illness along with other measures that may help keep you well, such as psychotherapy, healthy lifestyle habits, and a good support network.

Promoting Recovery

The good news is that there is a lot you can do to promote your recovery from depression. The most important and most obvious is to listen to your doctor and stick to your treatment plan.

Take the Long View

Keep your long-term goals in mind. It usually takes two to three weeks before you begin to feel better, and it can take as long as six to 12 weeks to know whether a medication will be fully effective for you. Stopping and starting medications prematurely will not give your body enough time to respond to the recommended treatment, and it won’t allow your doctor to determine whether the medication is right for you.

Practice Self-Compassion

Take it easy on yourself. Depressed people often lack self-compassion, and this actually can contribute to the depression. It’s easy to blame yourself for the way you feel, or to think you deserve to feel the way you do. Many people feel they should be able to “pull themselves together” and get on with life. You might even have had some people tell you this. Such feelings or comments stem from a fundamental misunderstanding of depression. Just as you can’t “decide” one day not to have diabetes, you can’t wake up one morning and choose not to be depressed. What you can choose to do is to get the help you need to feel better.

You’re experiencing a medical condition that needs to be treated. Excessive feelings of guilt or self-blame are symptoms of your disease, not evidence of your poor character. Focus on the positive and cultivate gratitude, which has been shown to go hand-in-hand with good mental health.

Healthy Lifestyle Choices

If you are going to treat your depression successfully and keep it under control for many years, your treatment must be part of an overall healthy lifestyle. There is no guarantee that depression won’t come back. Even when you are doing everything right, depression can relapse. But by doing all the right things, you are more likely to bring your depression under control so you can get back to your life sooner and greatly reduce your chances of relapsing.

Exercise Regularly

Research has found that exercising for as little as 30 minutes a day can be just as effective at relieving the symptoms of major depression as drug therapy. For many individuals with major depression, exercise also can play a useful part along with medications and psychotherapy. A longitudinal review of exercise research over a 26-year span suggests that even fairly low levels of exercise, such as walking or gardening for 20 to 30 minutes a day, can help ward off depression in individuals of all ages. So, just taking a short walk in the fresh air will do you good.

Release Happiness Hormones

It is believed that exercise helps relieve depression, at least in part, because it stimulates the body to produce endorphins. These are hormones your body releases in response to situations that trigger pain and inflammation. For instance, exercising, being injured, or picking up an infection all will trigger endorphin production. There also is evidence that the body releases endorphins in response to massage, acupuncture, and eating chocolate or spicy foods. Endorphins are chemically similar to pain-relieving opiate drugs, such as morphine and codeine, and they actually affect similar receptors in the brain.

Unfortunately, an endorphin high is temporary. That’s why engaging regularly in physical activity is so important for people with depression. You need to trigger those “happiness hormones” routinely to obtain the full benefit. Regular exercise has been shown to help relieve symptoms of depression and anxiety, reduce stress, improve sleep, boost self-esteem, and help people manage chronic pain.

Endorphins are not released the minute you start getting your body going. You have to exercise for several minutes at least before you can enjoy the benefit of endorphins. How long and how intensely you need to exercise to produce endorphins actually varies quite a bit from person to person. So, while it’s a great idea to find a buddy to exercise with, don’t get discouraged if your companion starts to feel happy and relaxed while all you feel is sweaty and exhausted. Just keep going. Start out small if you need to and work your way up. Tell yourself that exercise is good for you no matter what, so time spent exercising is never wasted time.

Exercise and Neurogenesis

Beyond endorphins, exercise has other benefits that contribute to its effectiveness for depression. One of these is a boost in the production of new nerve cells, called neurogenesis, in the hippocampus. The psychological impact of feeling empowered by exercising is undoubtedly another important component of its helpfulness in combatting depression.

Get Moving and Stick with it

Depression can make it hard to get going, stick with things that you find difficult, or cause you to believe nothing can help you. Feelings such as these can make it difficult for you to start an exercise program. Don’t let that stop you from benefitting from exercise. Start slowly. Just go for a walk down the street or around the block. Anything is better than nothing.

Mind-Body Benefits of Yoga

Yoga is a form of exercise that can be particularly beneficial for people with depression because it can include elements of spirituality, relaxation, and meditation, all of which can help balance your mood.

There is increasing evidence that all types of yoga can help people with depression feel better, or help vulnerable people avoid becoming depressed. Research has been done on the many types of yoga and, so far, none has been shown to be more effective for depression than another. So, try several different styles to find which you enjoy most and build a regular habit by attending classes several times week. Yoga classes are offered in many places, including hospitals, dedicated studios, community centers, and YMCAs.

Maintain a Healthy Diet

Several research studies have shown that diet can have a profound impact on mood. Many have linked a diet high in fast foods, such as pizza, hamburgers, and hot dogs, as well as high in trans fats, an unhealthy type of fat found in many packaged and processed foods, can substantially increase the risk of depression. Conversely, eating healthy polyunsaturated fats (found in fish and vegetable oils) as well as fruits, vegetables, and whole grains is associated with feeling happier and having a lower risk for depression.

Given the known link between heart disease and depression (see Chapter 3), it comes as no surprise that research is now showing a link between a heart-healthy diet and a reduced risk of depression.

Limit your intake of unhealthy fats and sugars and instead eat plenty of fruits, vegetables, fish, and whole grains. Avoid alcohol and drugs. Depression treatments don’t work as well with even moderate use of alcohol or recreational drugs. If you cannot simply taper off alcohol and drug use, get treated for alcohol/drug problems while you are being treated for depression.

Sleep Well

Depression and poor sleep are closely linked. Understandably, people who are depressed can have trouble getting to sleep or staying asleep because of the persistent worries that plague them. When you don’t sleep well, you feel worse during the day. You have less energy to go out with friends or to exercise. The link between poor sleep and depression appears to be biological, too. Some people with depression sleep too much and never seem to feel rested. Too much or too little sleep exacerbates the depression you’re already experiencing. Between seven and nine hours of sleep a night is considered optimal, but everyone is different. You may need more or less sleep than this to be at your best.

Some people have sleep disorders such as obstructive sleep apnea or restless legs syndrome, which can worsen depression and hinder treatment. If you have been told you snore excessively or move constantly throughout the night, if you feel tired all the time, or if you just know you are not sleeping well at night or waking frequently, that’s a sign you should talk to your doctor about getting a formal sleep evaluation.

If you are in the process of choosing an antidepressant with your doctor and you also have trouble sleeping, be sure to mention this. Some antidepressants are better at helping with sleep than others.

Manage Stress

Stress is a big player in depression. Control it before it controls you. Great stress-busting techniques include exercise, yoga, meditation, progressive relaxation, and guided imagery. Whenever you feel that your stress is getting out of control, take a step back. Take a vacation from work, leave your kids with a babysitter, or get help taking care of an ailing spouse or relative—whatever you need to do to regroup.

Massage

If you have ever had a massage, you know how relaxed it can make you feel. A review of studies found that massage might help relieve the symptoms of depression. The studies included in the review found that massage therapy had “potentially significant effects” on the symptoms of depression, possibly through its ability to reduce stress and induce a state of relaxation.

Relaxation and Meditation

Guided imagery, in which a recording or a live instructor guides you to focus on a particular image or experience in great detail, can be a good way to teach your body how to relax. In deep relaxation, you learn to completely release the tension from your body, starting with one body part and then moving on to the next.

Meditation usually involves sitting quietly for a period of time and focusing on something, such as your breath. Recently, mindfulness meditation, a form of meditation adapted from Buddhist practice in which you learn to be “in the moment” and accepting of your immediate thoughts, feelings, and sensations in a non-judgmental manner, has been shown to be particularly effective for mental health issues.

An analysis of studies showed moderately good evidence for the benefits of mindfulness meditation to help manage both depression and anxiety. The analysis also showed that the right kind of mindfulness meditation can be about as effective as taking antidepressants, and that it seems to work better than many other forms of relaxation or meditation for the treatment of depression. Other recent studies have shown that mindfulness-based practices can be effective for almost anyone, regardless of age, gender, race, or religion, and that it may help prevent relapses of depression.

Formal talk therapies (psychotherapies) have adapted elements of mindfulness based meditation into their treatments.

There are a variety of apps and online tools that can help you discover the world of meditation and deep relaxation. Many are free of charge. For instance, The Honest Guys provide literally hundreds of relaxation and meditation videos on their YouTube channel.

Find Pleasure

If you are depressed, you may seriously doubt your ability to ever experience pleasure again, but that is your illness talking, and it lies. Allow yourself to do the things you used to enjoy before your depression took root. Go see a movie. Call a friend. Go out for a great meal. Don’t expect to fully enjoy these moments until your depression is treated, but by continuing to give yourself opportunities to experience pleasure, you will contribute to your recovery.

Release Your Emotions

When you’re feeling stressed out or sad, let it out. Bottled-up grief and anger can ferment until it finally explodes. Talk about your feelings to family members, friends, or a therapist. Write your thoughts in a journal. When in doubt, a good cry can be very therapeutic. Also be sure to communicate. Don’t assume that your family or friends can read your mind. Let them know if you are struggling and you need their help. Give them constructive feedback if things they say or do make you feel worse rather than better. Suggest some other ways they can support you.

Providing Support

It can be difficult to be a good friend to someone who is depressed. They may be no fun at all. They may be unreliable or so totally wrapped up in their own problems they barely notice you are there. Remind yourself that these are symptoms of an underlying illness, and if you can guide them toward the help they need, you may be able to get your old friend back.

It’s not uncommon for people suffering from depression to not even realize that they are depressed. Particularly if the depression is longstanding, they may think that the way they feel is just part of normal life and that there is nothing they can do about it. As a result, they may refuse to even try to get better. Alternatively, they may be well aware that they are depressed but feel so hopeless about life that they don’t think there is any point in trying to make things better.

Whether they are in denial or despair, stoic, or self-destructive, people with depression who are not ready to face the reality of their condition can be hard to help. In fact, it may be that they are impossible to help, at least for a time. You can’t talk someone out of depression. You can’t make them feel better by pointing out the positives in their life. You cannot cure anyone or force them to get the help they need. You can only let them know you are concerned about them and gently guide them in the right direction to get help. Ultimately, except in an emergency situation where you are concerned about their immediate risk of suicide, it is up to them to decide whether or not to take the journey. However, you can help them in practical ways such as helping them set up a doctor’s appointment or identify mental health professionals in their area.

Depression Is Not Contagious

While it may not be healthy to spend all your time with people who “bring you down,” research shows that positive emotions spread more easily among people than negative ones. Always take care of your own mental health and maintain healthy boundaries, but also be aware that supporting another person who is going through a rough time can make a world of difference, and their low mood is not going to rub off on you permanently.

Break the Ice

The very first thing you can do for someone with depression is mention that you have noticed something is wrong. Suggest that depression may be the cause. Be prepared for the fact that the person may take offense. Explain that your intentions are good. Offer your help and support but realize that you cannot “cure” that person no matter how hard you try. All you can do is help them recognize that there is a problem, let them know you care, and suggest professional help.

Don’t shy away from asking someone directly about his or her depression. Even trained health-care professionals sometimes don’t recognize the signs and symptoms in themselves. Feedback from a concerned friend or family member is often a helpful “wake-up call” to someone who is depressed, whether or not that person decides to act on it right away.

Suggest Resources

When you first approach a friend or a loved one about depression, bring a few recommendations for available local services, such as the names and phone numbers of therapists or support groups. Your doctor, insurance company, local hospital, or local support groups, such as the Depression and Bipolar Support Alliance, can all help you identify services available in your area. The Substance Abuse and Mental Health Services Organization, American Psychological Association, Psychology Today, and Anxiety and Depression Association of America, also offer therapist locator services on their websites.

Gently keep track of whether your loved one seeks treatment and follows up on whatever care is proposed, such as seeing a therapist or taking medication as prescribed. Those first few weeks can be the most difficult, when facing the truth is painful and medication may be causing side effects. Offer your encouragement along the way.

Signs of Trouble

With anyone who is depressed, it is always important to be on the lookout for signs of suicidal tendencies. Some of the warning signs include:

• being obsessed with death, talking about it all the time
• putting their affairs in order, such as finalizing a last will and testament or giving away treasured objects or pets
• engaging in risky behaviors, like drinking and driving
• saying things like, “everyone will be better off when I’m gone”
• calling people to say goodbye
• talking or writing or posting on social media sites about committing suicide.

If you see any of these warning signs, call a mental health professional, a suicide hotline (such as 1-800-SUICIDE or 1-800-273-TALK), or 911 right away.

Don’t hesitate to ask whether a close friend or family member has had any thoughts of self-harm or not wanting to live. Asking about suicide does not make it more likely. On the contrary, it can give people the opportunity they need to share their burden and get the help they need. Suicidal thoughts are often part of being depressed. They do not necessarily require hospitalization, but they do need to be taken seriously, and they always require urgent evaluation.

Conclusion

We hope that after reading this report, you have a much better understanding of depression—its causes, symptoms, prevalence, and most importantly, how to get help when you or someone you know is experiencing persistent dark moods.

To better understand your own mental health status, take the PHQ-9 Questionnaire on the following page.The questionnaire will provide you with insights, but not a true diagnosis.  Use what you learn about yourself to have an open and honest conversation with your primary care doctor or a mental health professional.

There are many treatments for depression, and they do work. Medications, therapy, and neuromodulation approaches have helped people climb out of their depression, often permanently. Researchers around the world are working hard to learn more about depression and its causes. Their discoveries are opening doors to newer and potentially even ­better treatments ahead.

The post 7. Living with Depression and Providing Support to Others appeared first on University Health News.

This chapter describes what depression typically looks like in children and older adults and how best to manage it.

Depression in Children

All children get sad from time to time. Often, they seem to respond dramatically to the slightest frustration, like losing a toy or having to turn the TV off. Yet for some children, low or disrupted mood is an everyday occurrence. About five percent of children and adolescents are depressed at any given time, according to the American Academy of Child & Adolescent Psychiatry.

Research suggests that the biological underpinnings of depression can start in the first years of life. Using fMRI to look at brain function among preschoolers with and without depression, investigators from Washington University demonstrated that depressed preschoolers have excessive activity in the amygdala of their brains, an important region for processing emotion. These findings suggest that depressed preschoolers have exaggerated emotional responses, which could be the biological underpinnings of lifelong vulnerability to mental illness.

Up to around age 10, depression occurs about equally in boys and girls. During adolescence, however, the condition becomes increasingly prevalent in girls, especially after the hormonal changes that occur around the time of their first menstrual period. Brain imaging studies also are starting to uncover how depression affects boys and girls differently.

Causes of Depression in Children

Just as in adults, depression in children stems from a combination of factors:

• Brain chemistry. Neurotransmitter imbalances can affect mood in children, just as they do in adults, and some children may be born with imbalances in brain activity affecting regions that regulate mood.
• Environment. Although depression can arise in children with a loving family and a secure upbringing, experiencing unstable or abusive relationships and other forms of stress increase the odds of depression at an early age.
• Genetics. Children of depressed parents are more likely to become depressed themselves.
• Personal history. Kids who have behavioral or anxiety disorders are more likely to be depressed. Physical illness also can predispose children to depression, as it does in adults.

Symptoms in Children

Children—especially young children—may have great difficulty articulating that they are upset. If depression is all they know, they may not even realize that they have a problem that can be helped. Their symptoms often do not follow the typical pattern of adult depression. For example, a child might seem bored or angry rather than sad. Depressed kids also tend to complain of physical ailments, such as stomachaches or headaches, because they can’t express their emotions accurately.

Impact on Sleep. Depression and sleep problems go hand-in-hand for people of all ages, but sleep is particularly likely to be disrupted among children and adolescents with depression and other mental health problems. It remains unclear, however, whether poor sleep habits contribute to mental illness or whether mental illness has a biological effect that makes sleep more difficult for some children. Probably both are correct to some extent, depending on the individual child.

A study published in the journal Sleep demonstrated that adolescents who went to bed at midnight or later had an increased risk for depression and suicidal thoughts compared with those who maintained a bedtime of 10 p.m. or earlier. The authors say a lack of sleep could contribute to depression by making it difficult for kids to deal with daily life stresses. In some adolescents, an altered sleep-wake cycle may be a sign of depression rather than its cause, so have a talk with your child if you notice unusual or unhealthy sleep patterns.

Sleep hygiene is a term used to describe habits and environments that promote slumber. Reserve the bedroom solely for sleep (no TV and no digital devices), and keep the room cool, dark, and quiet. Also, avoid caffeine, and heavy meals at least three hours before bedtime. Sleep-enhancing habits include a warm bath or shower, reading a book, drinking herbal tea, and gentle stretching.

Social Problems. Most people who experienced bullying or rejection as children remember the pain of that time acutely, even decades after it is past. It is becoming increasingly clear that social problems in childhood can have a significant impact on mental health, and this can persist for a lifetime.

In children and adolescents, problems with depression frequently go hand-in-hand with problems in social relationships. For instance, a study published in the journal Child Development revealed that children who were depressed in fourth grade were at increased risk of being victimized by peers the following year, and this in turn predicted the likelihood that they would have difficulty being accepted by peers in sixth grade. These findings call into question the assumption that there is a one-way association between lack of peer acceptance and depression. In fact, either one can lead to the other. This is why it is important to address both social problems and signs of depression in children as early as possible. Early intervention can help prevent the problem from compounding over time.

Diagnosing Children

Most research into the diagnosis and treatment of depression has focused on adults. As a result, the problem often is overlooked or improperly handled when it occurs in children and adolescents, who are not just little adults. Experts in child and adolescent health are trying to address this by offering official guidelines and recommendations for diagnosing and treating depression in young people.

The stakes are high. Adolescents who aren’t treated for depression tend to do poorly in school and have difficulties with social relationships. They complain more often of physical illness, and they are more likely to abuse drugs, have an unwanted pregnancy, or commit suicide. For these reasons, the U.S. Preventive Services Task Force recommends that primary care physicians routinely screen all of their teenage patients for major depression.

Although the Task Force says there isn’t enough evidence currently to recommend the same screening for children under age 12, parents of young children should be on the lookout for the symptoms of depression and should contact their child’s pediatrician if they are seeing these symptoms on a regular basis.

The Evaluation Process. Diagnosing depression in children starts with a detailed medical, developmental, and mental health history. The doctor will ask when the child’s symptoms started, how long they have lasted, how often they occur, and how intense they are. The doctor also might request tests to rule out medical conditions with symptoms similar to those of depression.

In young children (ages six to 12), parents may be asked to fill out a 35-item Pediatric Symptom Checklist to assess how well their child is functioning psychologically and socially. Older children may be asked to fill out the same questionnaires used to diagnose depression in adults, such as the Beck Depression Inventory or the nine item Patient Health Questionnaire (PHQ-9).

Part of the evaluation may include an interview with a child psychologist or psychiatrist. With very young children, this interview can involve having the child play, or the psychiatrist might observe the child and parents interact. School-age children or teens might be interviewed one-on-one.

For some children, a teacher or another professional who is familiar with how they function at school may be asked to complete some questionnaires. This is because children often behave very differently at home than they do at school. Such evaluations also can help rule out other conditions that may need to be addressed, such as a learning disability or attention deficit/hyperactivity disorder (ADHD).

A Diagnosis Just for Children. Some children’s expressions of depression can be so different from that of adults that experts have proposed a new subtype of depression that more closely fits what is commonly seen in youngsters. This is known as disruptive mood regulation disorder. It is characterized by a mood that is persistently angry or irritable, combined with regular outbursts of temper.

This condition is believed to appear for the first time among children ages six to 18. Some experts suspect that many children diagnosed with bipolar disorder may be more accurately described as having disruptive mood regulation disorder, at least until they get older and the true source of their troubles becomes clearer.

Treating Depression in Children

As with most medical conditions, treatment for depression has been almost exclusively designed for adults. As depression among children and adolescents is being increasingly recognized as a significant problem, treatments that suit this unique and vulnerable population are being more closely studied. Below is a rundown of how depression is usually treated in youngsters.

Medication and Children. Children can be treated with antidepressants, but doctors need to be cautious when prescribing medication to their younger patients. Drug therapy for any medical condition is rarely studied in children. Depression is no exception. Because their nervous systems are growing and their metabolic systems are still developing, it is not necessarily appropriate to think of children as small adults and simply give them a lower dose of what an adult receives.

Concerns over the use of antidepressants in children and adolescents arose after a study suggested that certain antidepressants cause or worsen suicidal thoughts in this age group. Although the risk was still relatively small (4 percent having these thoughts in the antidepressant group, compared with 2 percent in children taking a placebo), in October 2004, the FDA began requiring manufacturers to label all antidepressants with a strong “black box” warning about the risk of suicidal thoughts and behaviors in children. Since then, other studies have called into question whether antidepressants work as well in children and teens as they do in adults.

After reading this, you might be hesitant to let your child take antidepressant therapy, but keep in mind that untreated or incompletely treated depression also carries significant risks. A study published in the British Medical Journal demonstrated that the decreased prescribing of antidepressants to children and adolescents in the U.S. that followed the “black box” warning was associated with an increase in suicide attempts, presumably due to less adequate treatment of depression in this vulnerable young population.

If your child is depressed or suicidal, don’t just reject antidepressants. Follow your doctor’s advice about treatment. A careful assessment of risks and benefits is needed whenever considering antidepressants for children and adolescents, and careful monitoring is needed after antidepressants are started.

Currently, the only antidepressant drug approved by the FDA for use in children is fluoxetine (Prozac), but it is possible your child will be prescribed a different drug if fluoxetine does not produce the desired results, or if your child’s specific symptoms or history suggest another one might be a better choice.

Psychotherapy for Children. Most forms of psychotherapy are developed with adults in mind and then adapted to young people. This can work better with some forms of psychotherapy than others, and there are frequently recommended minimum ages at which certain forms of psychotherapy should first be attempted.

So, what can be done for young children suffering from depression? Researchers from the University of Miami have developed a form of psychotherapy just for children known as Emotion Detectives Treatment Protocol, or EDTP. Designed to treat both anxiety and depression in children, the therapy helps educate youngsters about their emotions and how to manage them. It also provides training in problem-solving skills and teaches strategies for assessing situations. The program includes a component that trains parents to participate in their children’s recovery.

Research also shows that, when it comes to therapy, IPT (see Chapter 5) may be particularly helpful for children with depression when it is performed in a family therapy setting. Investigators from the University of Pittsburgh School of Medicine compared family-based IPT with another form of therapy that focuses on the child alone, called child-centered therapy or CCT. Remission rates from depression were more than twice as high among the youngsters who received the family-based IPT.

Online and app-based forms of psychotherapy, which are becoming more and more common, are often very appealing to children, particularly adolescents. And they work. For instance, research published in the British Medical Journal shows that a specially designed 3-D fantasy video game works just as well as standard care for the treatment of depression among adolescents. The game, which is based on the principles of CBT, is called SPARX. It involves solving challenges to restore balance to a fantasy world that is dominated by Gloomy Negative Automatic Thoughts, or GNATs. In addition to its effectiveness, it also has proven to be far more appealing to teenagers than talking to a therapist about their problems. Of course, in addition to using online or app-based approaches, any child or adolescent with significant depression should be under the care of a professional as well.

Lifestyle Upgrades. Because giving medication designed for adults is not always the best option for children, lifestyle factors may play an even greater role for youngsters than it does for adults.

All children can benefit from a consistent routine, supportive environment, plenty of sleep, a healthful diet, and regular exercise, but these are particularly important for children with or at risk for mental illnesses such as depression.

In fact, a recent study from Norway highlights the importance of exercise in particular. It showed that children who were the most physically active at ages six to eight were less likely to become depressed later in childhood than their less active peers.

Another lifestyle factor that is increasingly important among young people is use of screens. Whether they are watching TV, playing video games, or using social media, excessive screen time may contribute to depression by pulling children away from physical activities and by emitting blue light directly into their eyes, which can disrupt sleep. Some experts are particularly concerned that social media may be contributing to depression by reducing the amount of time children spend in face-to-face contact with each other or by promoting a competitive sort of environment that encourages kids to compare themselves and their lives negatively with the idealized lives that others post online. While all children can benefit from limits on their screen time, this may be particularly important for children who have difficulty regulating their emotions (see “Benefits of Limiting Social Media”).

Depression in Older Adults

According to Mental Health America, more than 2 million of the 34 million Americans aged 65 or older suffer from some sort of depression. This is also the group that stigmatizes depression the most, making them less likely to ask for help. Reportedly, only 38 percent of Americans in this age group consider depression to be a “health” problem, and only 42 percent would seek the help of a professional for it, rather than “handle it themselves.”

Causes in Older Adults

In our youth-obsessed culture, it is no surprise that growing old is difficult for many. It can introduce several new stresses in life, such as watching children grow independent and move away, watching a spouse or close friend become sick and die, or losing independence.

More often than in younger people, depression may be caused by an underlying biological disease process (or its treatment) in older adults. With age comes an increased risk of medical conditions that affect brain functioning, such as stroke and cognitive decline (see “Depression Linked with Cognitive Decline”).

In fact, cognitive decline, dementia, and depression are intimately intertwined in older people. The symptoms of each can be difficult to tease apart, and one condition frequently aggravates the other. Recent research reveals that depression experienced in mid- and late-life is linked with an increased risk of developing dementia in older age, and depression in older age is associated with the presence of both mild cognitive impairment and dementia.

Symptoms in Older Adults

As with children, depression may not reveal itself in older adults the same way it does in younger adults. Among older adults, depression often manifests as:

• confusion
• difficulty sleeping
• hallucinations or delusions
• loss of appetite and weight loss
• memory problems
• social isolation
• vague physical complaints.

Diagnosing Older Adults

The notion that low mood is a normal part of aging is a misperception that leads to many missed opportunities for diagnosis and effective treatment. If you or someone you know is feeling depressed, seek assistance. Mental-health experts are available to help, and some specialize in specific age groups, such as teens and older adults.

Older people are more likely to suffer from neurological and other health changes that occur with age, such as stroke, that can act as biological causes of depression. As a result, an evaluation of depression in older people may include tests of physical health, particularly neurological health. A neurological examination assesses motor and sensory skills, the functioning of one or more cranial nerves, hearing and speech, vision, coordination and balance, mental status, and changes in mood or behavior, among other abilities.

Another important component of diagnosing depression in older adults is to assess medications. Researchers say that 39 percent of Americans ages 65 and older take at least five prescription drugs per day and any one of them may have depression-related side effects. Sometimes, a simple medication adjustment is all that is needed to reverse the effects.

Treating Older Adults

The implications of depression on seniors are especially profound because depression can hasten cognitive decline, hinder self-care, and exacerbate illness. It also can increase the risk for suicide among older adults. Older white men face the highest suicide rate of any group in the United States. As a result, it is important to get treatment right.

Older people can be treated for depression in a similar manner as younger adults, but one must be careful with medication. “Start low and go slow” is the typical mantra in this sensitive population. Older people do not metabolize drugs as well as they once did, so they often require lower doses. They also are more susceptible to side effects, and they may be taking other medications that can interact with drugs for depression. The presence of a potential drug-drug interaction does not always mean that a particular drug cannot be taken at all; it means one must be careful with it and look closely for undesirable effects.

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Researchers are constantly searching for new treatment strategies. This chapter offers up the most commonly available approaches.

Medications

Medications that are most often used to treat depression are thought to improve symptoms largely by adjusting levels of neurotransmitters that contribute to mood, although some of the newer or more experimental drugs have different effects. Below is a description of the medications, how they are believed to work, and how to identify and address any problems that may arise.

Antidepressants

Antidepressants are usually the first drugs prescribed for depression. The exception is bipolar disorder, where mood stabilizers are the first-line medications because antidepressants may trigger mania. Antidepressants help lift the mood of people whose mood is abnormally low. Mood stabilizers, on the other hand, help prevent mood from going too low or too high.

Many antidepressants are available, and it’s common that several are tried before the one that works for you is found. To feel the results, these medications commonly need to be your system for several weeks. The following dimensions figure into the decision-making process clinicians use for prescribing antidepressants:

• the type of depression you have and your specific symptoms
• the presense of other medical conditions and any medications you may be taking
• your past response to anti­depressants
• the side-effect profile of different medications (e.g., weight gain, drowsiness, insomnia) and which are most important for you given your other medical conditions and your preferences
• your insurance coverage (including whether it covers generic or brand name drugs)
• your doctor’s personal experience with specific anti­depressants
• Although the response of family members may not predict which antidepressants you will respond best to, knowing that someone close to you did well (or poorly) on a given antidepressant may influence your level of comfort to try it

In recent years, the FDA has approved commercial pharmacogenomics tests to guide antidepressant prescribing. This involves obtaining a cheek swab sent to a laboratory for genetic testing. Although these tests show promise, because knowledge of the genes involved in response to antidepressants is still at an early stage, the value of the tests currently available over and above expert clinical judgment remains uncertain. Although pharmacogenomic testing is not yet part of standard care in selecting an antidepressant, with continued research and further improvement in the tests, they may someday become routine.

Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs revolutionized the treatment of depression when the first drug from this class, known as fluoxetine (Prozac), came to market in 1987. Since then, many other SSRI antidepressants have been developed, such as sertraline (Zoloft), citalopram (Celexa), and paroxetine (Paxil). This class remains the first-line of treatment for many individuals with depression.

SSRIs block the return (reuptake) of serotonin to the neuron’s axons, leaving higher levels of the neurotransmitter available to stimulate brain receptors. They may have other effects on the brain as well. For instance, some research suggests they may have anti-inflammatory effects on the brain and even fundamentally alter how brain regions communicate with each other. SSRIs also can be effective at relieving anxiety and are now routinely used to treat anxiety conditions, such as panic disorder and social anxiety disorder.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). Another common class of antidepressants, called SNRIs, work by altering levels of both serotonin and norepinephrine in the brain. Examples include duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). Some of the SNRIs also are approved for treatment of pain associated with conditions such as fibromyalgia. Therefore, SNRIs may be prescribed as first-line antidepressants for individuals with both pain and depression.

Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs). NDRIs increase the levels of both norepinephrine and dopamine in the brain. The only drug in this class is bupropion (Wellbutrin), but it is available in several different formulations, including slow-release (Wellbutrin SR) and an extended-release (Wellbutrin XL) version. Bupropion is less likely to cause the sexual problems, weight gain, and drowsiness often associated with SSRIs and SNRIs and can be helpful for people also trying to quit smoking, but it can slightly increase the risk for seizures. Thus, it is generally not recommended for people with seizure disorders or an increased risk for seizures, such as people with eating disorders or brain tumors.

Reuptake Inhibitors, Receptor Blockers. Reuptake inhibitors and receptor blockers work by preventing the return of neurotransmitters to their receptors (i.e., reuptake) by blocking those receptors, thus making more of these neurotransmitters available in the brain to help boost mood. Two drugs in this class are approved by the FDA to treat depression: trazodone (Desyrel), which acts on serotonin and its receptors, and nefazodone (Serzone), which blocks both serotonin and norepinephrine and their respective receptors.

Like bupropion, trazodone and nefazodone are less likely to cause sexual dysfunction than the SSRIs or SNRIs. They also often help with insomnia. However, trazodone can cause an uncommon but well-documented side effect in men called priapism, or sustained erection, that requires immediate treatment if it lasts four or more hours. Nefazodone is rarely prescribed because of its association with rare but serious liver problems. In fact, the brand name version, Serzone, is no longer available in the U.S.

Tricyclic Antidepressants (TCAs). TCAs are among the oldest antidepressants prescribed. Drugs in this class include imipramine (Tofranil), nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline (Elavil), and clomipramine (Anafranil).

TCAs have been in use since the 1950s, but they’re not the first choice for treating depression today because of their long list of side effects, which includes weight gain, constipation, dry mouth, dizziness, and heart conduction problems. TCAs may exacerbate pre-existing conditions, such as narrow-angle glaucoma or an enlarged prostate. Because TCAs have effects on electrical conduction through the heart, prescribing clinicians must use caution when prescribing the drug to patients with a family history of sudden death, abnormal heart rhythms, or heart conduction disturbances. Typically patients under 18, over 50, or individuals with a family history or personal history of heart disease will have an ECG (electrocardiogram) prior to starting a TCA to determine whether they may be at increased risk for cardiac side effects.

Because of their side effects, doctors usually don’t prescribe TCAs unless other medications have not been effective. But for some people who don’t respond to newer antidepressants, these drugs can be lifesaving, and they continue to be prescribed under special circumstances.

Monoamine Oxidase Inhibitors (MAOIs). Another older class of antidepressants, MAOIs, work by preventing the enzyme monoamine oxidase from breaking down norepinephrine, serotonin, and dopamine, leaving more of these neurotransmitters available in the brain. MAOIs include tranylcypromine (Parnate), phenelzine (Nardil), isocarboxazid (Marplan), and selegiline (Emsam, which comes in a skin patch formulation).

MAOIs can interact with certain aged and fermented foods, like aged cheeses, aged/smoked meats (including pepperoni), yeast extracts (such as Marmite), and certain alcoholic beverages, such as ales and wine. As a result, they are usually prescribed only to people who have not responded to other treatments and are willing and able to stick with these dietary restrictions. Eating these foods while taking an MAOI can lead to a sudden rise in blood pressure (hypertensive crisis), which requires emergency treatment.

A large number of medications also interact adversely with MAOIs to the point of being life-threatening, including all the other antidepressants, many painkillers, and medications that affect levels of serotonin in the brain (such as a class of migraine drugs known as “triptans”). Nevertheless, MAOIs can be an important avenue of treatment for people who do not respond to other antidepressants.

Other Novel Antidepressants. Mirtazapine (Remeron) is an antidepressant that works by increasing the activity of norepinephrine and serotonin in the brain, though in a different way than SSRIs and SNRIs. Because mirtazapine tends to cause drowsiness and enhances appetite, it is sometimes considered an appealing option for people who are struggling with insomnia or weight loss related to depression.

The drug vilazodone (Viibryd) also blocks serotonin reuptake and works on serotonin receptors. It may have fewer sexual side effects than some of the other antidepressants.

Vortioxetine (Trintellix) is one of a new class of antidepressants called “serotonin modulators and stimulators.” It blocks reuptake of serotonin and selectively blocks or stimulates certain specific serotonin receptor subtypes.

New Rapid-Acting Antidepressants. After years of study showing promising results, a ketamine-based treatment for depression has finally been approved by the FDA. Ketamine falls under the class of drugs known as NMDA receptor antagonists and has been used for many years as an anesthetic.

The approved drug is actually a subtype of ketamine known as esketamine, and it is available under the brand name Spravato. This new fast-acting treatment is meant to be taken in conjunction with standard antidepressant therapy for people whose depression does not respond adequately to antidepressants alone. The drug is taken in nasal spray form, where it is rapidly absorbed by the body via the tissues in the nasal cavity. One of its key benefits is that its fast onset of action may provide more rapid relief than standard antidepressants for people suffering from suicidal thoughts.

Esketamine modulates a neurotransmitter known as glutamate, which is produced by neurons and other brain cells called glia. It is involved in most aspects of normal brain function including cognition, memory, and learning. Too much glutamate, however, can have toxic effects on brain cells. This is the first antidepressant to primarily target glutamate.

Experts remain concerned about potential side effects of esketamine which may include agitation, dissociative (out-of-body) experiences, and elevated blood pressure, as well as the risk of abuse (ketamine is occasionally sold as a street drug under the name Special K). As a result, its use remains strictly monitored and can only be taken in a medical office under the watchful eye of a healthcare professional.

It is important to recognize that esketamine treatment is very new. That means there is not as much information available on its effects as for other treatments for depression. Some experts are still quite concerned about its safety. It was approved based on the results of four clinical trials, three of short duration and one of longer duration. Only the longer-duration trial showed benefits, and the results were not encouraging in those over the age of 65.

Another major barrier to this new treatment is cost. You may have to pay up to $900 per treatment, and usually, several treatments are needed before you find relief. Health insurance may only cover some (if any) of this cost. For all these reasons, esketamine therapy is currently reserved only for those who are very sick, often at high risk of suicide, and who have not found relief from multiple other treatments.

In addition to approving esketamine in 2019, the FDA also approved another rapidly acting antidepressant brexanolone (Zulresso). Brexanolone is in a new class of antidepressants called neurosteroids that modulate the activity of a subtype of GABA receptors (GABA-A receptors) in the brain. At this time, brexanolone is approved only for one type of depression, postpartum depression, though similar neurosteroids are under study for other forms of severe depression. An advantage of brexanolone, like that of esketamine, is that when it works, it often works within several days rather than many weeks. A disadvantage is that it needs to be administered intravenously over several days, typically involving monitoring in a hospital setting. Sedation, dizziness, occasional fainting or loss of consciousness, and hot flashes are among the side effects of brexanolone.

Mood Stabilizers

As the name implies, mood stabilizers are drugs that are given to help smooth out your moods and prevent extreme fluctuations from occurring. Most often, they are given to people with bipolar disorder because they help prevent their mood from getting too high (mania/hypomania) or too low (depression). Antidepressant drugs can trigger an episode of mania or hypomania in people with bipolar disorder, making mood stabilizers a much safer choice. Once on a mood stabilizer, some individuals with bipolar disorder can safely take an antidepressant, though mania due to antidepressants is always a risk that needs to be closely monitored for. For a more complete description of bipolar disorder, see Chapter 2.

But mood stabilizers occasionally are given to people with other types of depression as well, particularly when antidepressant medications have not been found to be effective. In some of these people, it is possible that they have bipolar disorder, but so far have only experienced significant lows without significant highs, which can delay making a correct diagnosis. However, even individuals with unipolar depression may experience a boost to their antidepressants when combined with certain mood stabilizers.

Lithium. Lithium (Eskalith, Lithobid, and Lithonate), a naturally occurring compound, was the first approved mood stabilizer. It is still a very popular option today because it is so effective, but it’s not an easy drug to take. It has a narrow therapeutic window, meaning there is a very small difference between the dose that is effective and the dose that is toxic. To keep people at the correct dose, it is often important to do regular blood tests to determine exactly how much of the drug is circulating within the body. Signs that your dose of lithium may be too high include confusion, nausea, vomiting, diarrhea, tremor, and unsteadiness (almost like being drunk). Be sure to tell your doctor if you are taking lithium and experience any of these symptoms.

Anticonvulsants. Initially developed to help prevent epileptic seizures, some anticonvulsants also have been found to help people with depression or bipolar disorder. Anticonvulsants used in this manner are sometimes referred to as “anticonvulsant mood stabilizers.” Some of the anticonvulsants most commonly used as mood stabilizers include valproic acid (Depakote), lamotrigine (Lamictal), carbamazepine (Tegretol), and oxcarbazepine (Trileptal).

While they don’t share the same side effects associated with lithium, anticonvulsants still can produce troublesome effects, such as elevated liver function enzymes with valproic acid or a serious skin rash with lamotrigine. If you are prescribed an anticonvulsant for its mood-stabilizing effect, be sure to talk with your doctor if you experience any bothersome side effects.

New treatments using these medications remain an active area of research. One possibility for future use is the anticon­vulsant drug ezogabine (see “Anti­convulsant Reduces Symptoms”).

Antipsychotics. Initially developed for treatment of psychosis, such as hallucinations and delusions, a number of antipsychotic medications have proven helpful in the treatment of either hard-to-treat depression or bipolar disorder. Most often, newer antipsychotics known as atypical antipsychotics are chosen for these conditions. They include drugs like quetiapine (Seroquel), risperidone (Risperdal), and aripiprazole (Abilify).

Don’t worry if your doctor prescribes an antipsychotic drug to help with your depression. Some people think this means their doctor believes they are “crazy” or simply sicker than they are letting on, but this is not true. Some of the new antipsychotics are becoming quite common treatments for depression.

Like other drugs, antipsychotics can have side effects. Many antipsychotic medications are associated with metabolic side effects such as weight gain or elevated blood sugar. They may also cause muscle or motor symptoms including muscle stiffness, muscle restlessness (akathisia), tremor, or a delayed but often persistent side effect called tardive dyskinesia (TD) that involves involuntary movements, often of the lips, tongue, or face but sometimes of the trunk or extremities. Be sure to speak with your doctor if you experience any side effects that trouble you.

Anti-Anxiety Medications

Anxiety and depression are conditions that are very frequently seen together. As a result, many patients with depression may receive anti-anxiety medications, also known as anxiolytics. The most commonly prescribed anti-anxiety drugs are benzodiazepines; they include lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax).

Often, anti-anxiety medications such as these are prescribed only for a short time, usually a few days or weeks. This is because they have some addiction potential. In addition, it is possible to build up a tolerance to these drugs, meaning you require more and more to get the same effect. As a result, individuals with both depression and anxiety often are given an antidepressant drug that also is known to have an anti-anxiety effect, such as the SSRIs or SNRIs described earlier, rather than an anti-anxiety drug to use long-term. Nevertheless, some individuals with chronic anxiety benefit from longer-term treatment with anti-anxiety drugs with regular monitoring to ensure their safety.

Finding the Right Medication

It is important to know that only about one-third of people with depression improve completely with the first medication they try. For others, it takes some thoughtful trial and error. Try not to be discouraged if you are one of these people. It is quite normal to change the dose or type of medication over several weeks or months until you find what works best for you. In some cases, two or more drugs may be necessary to give you the best possible relief.

Side Effects

Currently available antidepressants can take weeks or months to reach their full effects. In the meantime, this is the same period when side effects are at their worst. As a result, antidepressant treatment may actually make you feel worse before it helps you feel better. It is always important to share side effects with your doctor. Some side effects will merit a switch to another drug, but often, if you are able to get through the first days and weeks of treatment, side effects diminish and the beneficial effects increase.

While side effects vary from one antidepressant to another, some of the most commonly reported are nausea, fatigue, changes in appetite, changes in sexual functioning or desire, and dry mouth.

Some common side effects can be embarrassing to talk about, such as changes in your sex drive or sexual functioning. Remember that your doctor has heard it all before. There is nothing to be ashamed of. Your doctor cannot help you manage your side effects unless you share them. Always report all side effects to your physician, who should document them in your medical record. Side effects often go unreported because many patients neglect to tell their doctors about them.

Since you may temporarily feel worse on antidepressants, it is important to have a plan in place to get through these difficult first few weeks, especially if you feel suicidal.

While it may not be possible to avoid side effects altogether, some specific antidepressants are known to cause certain side effects more than others. For this reason, it is a good idea to tell your doctor if there are certain side effects in particular that you would like to avoid.

Maintenance Drug Therapy

Depression treatment guidelines from the American Psychiatric Association recommend that people with depression  continue antidepressant, for at least four to six months after their depression is fully gone to prevent it from returning. For most individuals, stopping an antidepressant sooner than this means a high chance of relapse. Because it often takes several or more months to get better on an antidepressant and an added four to six months of continued treatment after feeling better, this means that, for most individuals, a full course of antidepressants involves around nine to twelve months of continuous treatment to get well and remain well.

People with a history of serious issues such as suicide attempts, psychotic symptoms, or prolonged work disability may need to be supported by longer-term maintenance drug therapy for several years or more. In some cases, you may try lowering your dose, especially if you are experiencing troublesome side effects, but only with advice and careful follow-up from your doctor.

You should never stop taking medication prescribed for depression on your own. Your symptoms could recur, or you might experience uncomfortable effects associated with rapid withdrawal of the medication, such as nausea, headaches, muscle aches, and more intense depression. Some people experience quite unusual symptoms on sudden discontinuation of their antidepressants such as “zapping” sensations on their scalp. These are not dangerous but can be scary and annoying. If you and your doctor agree that it is time to lower your dose or discontinue treatment, the normal procedure is to reduce the dose gradually.

Risks Versus Benefits

Like all medications, antidepressants are associated with risks, but it is important to consider those risks in the context of their potential to improve symptoms of depression, which can be incapacitating and have an even worse impact on your life.

Another concern when starting antidepressant treatment is how they may interact with other drugs or supplements you are taking. Any medication you take has the potential to react with another drug, whether it is prescribed, taken over-the-counter, or used illicitly. Some medications even can interact with certain types of foods. Your doctor and pharmacist can tell you more about possible interactions among the medications you are taking and how to avoid them. It is good practice to bring an updated list of medications and supplements you are taking to your doctor’s appointments and to alert your doctor to any new medications or supplements you are about to start so that possible interactions can be considered.

Women who are pregnant or are considering becoming pregnant need to be particularly cautious when starting an antidepressant, or indeed any drug therapy. Some recent studies have linked exposure to certain SSRI medications with adverse effects on the development of fetuses. Other studies failed to find these same outcomes, however. The flip side of this coin is that untreated depression during pregnancy and in the months after birth also can have negative effects on a baby’s health. It is therefore especially important to weigh the risks and benefits of medication during this special time with your doctor.

Psychotherapy

Another very important component of treatment for depression is psychotherapy, also known as “talk therapy” or just “therapy.” It means conversing with a trained professional about the issues that may be causing or worsening your symptoms.

Psychotherapy doesn’t simply mean “venting.” It is a tool that can help you identify the problems causing or contributing to your depression so you can begin to work through them. Talk therapy also involves learning problem-solving strategies, developing new ways of thinking, and building specific skills that can reduce depression and help prevent the chances of relapse.

Individual, Family, and Group Counseling

While one person might benefit from one-on-one time with his or her therapist, another might feel more comfortable discussing issues in a supportive group setting. Others benefit from having family members present, if family dynamics are a substantial source of stress (this is often the case for children and adolescents) or if family members would benefit from learning more about how to be supportive. It depends on individual preference and circumstances and the kinds of skills and support that are most needed. Counseling comes in several different forms to accommodate these preferences and needs, including:

• Individual therapy. You meet one-on-one with a therapist. Once-a-week appointments are common as a starting point, although the frequency of visits is often tailored over time to meet individual needs.
• Group therapy. You meet with a therapist and several other patients with similar symptoms; the therapist leads the group. Sometimes the group focuses on a specific issue, such as domestic abuse, substance abuse, or bereavement. The therapist usually introduces topics for discussion and directs the meetings. The benefit of having other people at your therapy session is that you can learn from people who have similar issues in a safe and confidential setting with a professional guiding the discussion. Being with a group helps remind you that you’re not alone. But you also must be willing to share very personal thoughts and experiences in a group setting and know that your issues will not always be the focus of discussion.
• Couples and family therapy. Your spouse, parents, children, and/or other family members will accompany you to the session. During meetings with the therapist, you will work together to improve communication and resolve relationship issues you may be experiencing.
• Web-, app-, or telephone-based therapy. A growing range of remote therapies are becoming available. They are especially useful for people who live in remote regions far away from health services or who are too ill to travel. Many of these use the same principles as in-person therapies. When people are able to stick with them, they appear to benefit. Some health systems blend remote therapies with in-person psychotherapy. Adolescents in particular often favor app-based therapy.

Types of Psychotherapy

Whether it is performed in a group, one-on-one, or in a family or couples setting, there are a wide range of therapies available. Therapists are usually specifically trained in one or more of these types of psychotherapy, so if you have a type of therapy in mind, it is important to ask your therapist if he or she is trained to provide it. Each type is based on a specific understanding of what causes depression and what is most likely to help people overcome the condition. Some of the most common types of psychotherapy are described below.

Cognitive Behavioral Therapy (CBT). To get a sense of CBT, imagine this scenario: You are in charge of your company’s weekly status meeting and get stuck in traffic on your way to work. Everyone will have to wait for you to arrive to start the meeting. This is the second time in a month this has happened. Maybe this is the last straw? Will you be fired? Will your colleagues lose respect for you? Many people have thoughts like this, but for some people, these thoughts spiral. Before they know it, they are convinced their being late is catastrophic; they believe they are incapable of holding down a job. By the time they arrive at work, their steadily mounting panic may, indeed, get in the way of their effectiveness at work, thus becoming a self-fulfilling prophecy.

The concept behind CBT is that your thoughts can have a big impact on your mood. CBT aims to identify and change negative perceptions to create a more positive outlook.

CBT first identifies the negative thoughts you have about yourself (“I am incompetent”), your environment (“traffic makes it impossible to get to work on time”), and your future (“I will be unemployed”). Working closely with your therapist, you begin to understand how certain negative beliefs have no basis in reality or, at the very least, are wildly exaggerated. Then, you reframe those false beliefs and replace them with more realistic ones. So, a CBT therapist might help the person above to recognize that while her colleagues might well be annoyed, this is unlikely to end her career. Also, taking steps to leave earlier every day can help prevent this from happening again.

CBT is typically meant to be a short-term treatment, usually over two to four months, but some research shows that longer-term CBT may have additional benefits for reducing relapse.

Studies have shown that in many cases, CBT is as effective as antidepressant medications and that combining CBT with medication makes treatment even more effective, particularly for people with major depression or treatment-resistant depression. It also may help prevent depression from returning after it has been treated successfully.

Usually, CBT is conducted one-on-one or in a group with a therapist present, but new technologies make CBT available from your home through a telephone, computer, or smartphone app. These “telehealth” sessions may be covered by insurance.

Acceptance and Commitment Therapy (ACT). The primary goal of ACT is to help individuals accept what is out of their personal control and to commit to actions that can improve and enrich their lives. Unlike CBT, ACT adopts the view that trying to change thoughts and feelings can be counterproductive. A therapist using an ACT approach may use mindfulness techniques, which teach one to recognize and accept thoughts and feelings without judgment and without any attempt to change them. In doing so, negative thoughts and feelings can have less influence on one’s actions and wellbeing. So, in the above example, an ACT therapist might help her patient accept and learn to be comfortable with those feelings of doubt about what her colleagues think of her. That way, they are less likely to cause distress that might lead her to make bad choices, such as showing up to work in a nasty mood. Another component of ACT is to learn to focus on values and activities that bring meaning to one’s life.

ACT has been used primarily to treat individuals with chronic pain as well as anxiety disorders, but some controlled studies have been conducted with depression, and it appears that ACT may be as effective for depression as better-studied approaches, such as CBT.

Interpersonal Therapy (IPT). IPT focuses on identifying any relationship issues that might be driving your depression symptoms. It also helps you improve your communication and conflict resolution skills, so you are better equipped to handle issues that arise with your friends, family members, and coworkers. Frequent issues include unresolved grief, relationship conflicts, transitions to a new role (such as from wife to mother), and social isolation.

Perhaps the person in the original example has lost a job in the past due to tardiness. As a result, she has become so fearful of being fired again that she is overwhelmed with fear every time she makes a minor mistake. An IPT therapist would help this person see how old experiences are creating counterproductive patterns in how she deals with people today and help her to change those patterns.

As with CBT, IPT is used over the short term. Typically, there will be 12 to 16 treatment sessions, which focus on first identifying problems and then teaching you how to resolve them. IPT works well for people with mild-to-moderate depression.

Psychodynamic Therapy. Psychodynamic therapy is typically a longer-term approach to treating depression. You and your therapist will take time exploring how your distant past is affecting your present. You may go back as far as your early childhood, recalling events that you might have consciously forgotten but which are unconsciously driving your dark mood. For example, it might be that your mother was always late for important events in your life, and now you are subconsciously re-creating her chronic lateness because it is a familiar situation for you.

This treatment seeks to identify the roots of your depression by focusing on the behaviors and relationships making you unhappy and then developing new insights about how they affect you. By using techniques such as self-reflection and self-examination, your therapist can help unearth the painful memories and feelings that trouble you and then try to work through them so you can live a healthier, happier life.

Psychodynamic therapy is effective for treating depression as well as anxiety and other co-existing conditions, and the benefits continue even after treatment has ended, according to an analysis of several studies published by the American Psychological Association.

Because psychodynamic therapy tends to be more open-ended and longer-term than CBT or IPT, it may not be as efficient for treating depression in some people. However, shorter-term and more focused versions of psychodynamic therapy also have been developed.

Dialectical Behavior Therapy (DBT). DBT was developed primarily for people who struggle with a condition known as borderline personality disorder, which is usually associated with profound feelings of emptiness, unstable interpersonal relationships, self-destructive behaviors, and suicidal tendencies. DBT emphasizes acceptance and change and is influenced by psychological research and practice as well as by Buddhism.

In recent years, DBT has been used with some success to treat people who do not necessarily have borderline personality disorder but who are dealing with chronic unhappiness and thoughts of suicide. It has been shown to be particularly effective at reducing suicidal thoughts, suicide attempts, and self-injury as well as at helping people tolerate emotional distress.

How to Choose

With all the different forms of psychotherapy available, it can be difficult to choose the one that might be best for you. Ask your health-care provider for suggestions and find out what kinds of treatments are available in your area and covered by your insurance plan. Recent research from the University of Bern in Switzerland suggests that all major forms of psychotherapy are about equally beneficial for depression when delivered by well-trained therapists. So, find a trained therapist you trust in a setting that is comfortable for you.

Neuromodulation

Stimulating the whole brain, certain parts of the brain, or specific major nerves can sometimes produce relief from depression, even when other therapies fail. These kinds of treatments are called neuro­modulation. Different brain and nerve stimulation therapies vary with respect to the area being stimulated, the source of the stimulation, and the invasiveness of the procedure. But in all cases, the goal is to get brain cells firing, new connections forming, or communication networks re-balanced. Of the following neuromodulation treatments, those currently recognized by the FDA for treatment of depression are electroconvulsive therapy, transcranial magnetic stimulation and vagus nerve stimulation, with the others needing more data to support their use in depression.

Electroconvulsive Therapy (ECT)

ECT involves use of an electrical shock to trigger seizures in the brain; the current is well-controlled and delivered while the patient is under anesthesia, so it is painless. This is in stark contrast to typical movie and television representations of the treatment, in which the patient is usually writhing in agony.

ECT is generally used to treat severe depression that has not responded sufficiently to medication and psychotherapy. It is also sometimes used as initial treatment in people with severe and life-threatening symptoms that require a more rapidly acting treatment than medications or psychotherapy.

If your doctor decides you’re a good candidate for ECT, you will have the treatment at a hospital, either as an outpatient or during an inpatient stay. ECT is usually delivered up to two to four times a week, for eight to 12 sessions. Usually both an ECT-trained anesthesiologist and a psychiatrist will supervise your treatment.

No one knows exactly how or why ECT works, but it does. In fact, it is so effective that some experts have found it is an underused option for depression (see “ECT for Treatment-Resistant Depression”). Most patients who respond to ECT receive a follow-up antidepressant to prevent relapse of depression. Some people who do not respond sufficiently well to medications benefit from ongoing “maintenance” ECT, usually consisting of one or two sessions per month, to keep depression at bay.

A significant disadvantage of ECT is its effect on memory. One survey conducted in the United Kingdom found that as many as one-third of patients who underwent ECT had persistent memory loss. While memory side-effects are important to consider, refinements in how ECT is administered have continued to reduce the risk of their occurrence. In addition, ECT requires the use of general anesthesia, and this means the very small but added risk of complications from anesthetic agents. That is why, despite its impressive efficacy, other forms of brain stimulation continue to be investigated.

Deep Brain Stimulation (DBS)

A more invasive technique, called DBS, involves implanting a device in the chest that sends electrical signals into specific brain regions via wires connected to electrodes implanted deep in the brain. These signals stimulate areas in the brain that affect mood and depression. While DBS is usually reserved for epilepsy treatment, research continues to mount on its effectiveness for depression (see “New Insights on Deep Brain Stimulation”).

Risks of DBS include bleeding and infection at the site of the incision, as well as bleeding in the brain, or even a stroke. Some individuals with depression also develop manic symptoms on DBS. These potential risks are serious, but it is important to keep in mind that such events are very unlikely in experienced hands, and DBS has the potential to relieve severe, longstanding depression in people who do not respond to other treatments.

Transcranial Magnetic Stimulation (TMS)

TMS has generated a lot of interest in the medical community because it involves no surgery and few risks, and it is now an FDA-approved treatment for depression. This noninvasive therapy uses an electromagnetic coil placed on the forehead to send pulses to a part of the brain that helps regulate mood. Unlike more invasive brain stimulation techniques, TMS can be delivered right in a doctor’s office, using specialized equipment. Research suggests TMS works by helping to regulate connectivity within certain key regions of the brain.

New data collected outside of a research setting, meaning patients were being treated as part of regular care as opposed to a study, have shown that ­repeated sessions of TMS (known as rTMS) are an effective treatment for r­esistant depression.

An added benefit of TMS is that it does not appear to have any disruptive effects on sleep. Interrupted sleep is a problem commonly seen in depression and can be exacerbated by some forms of depression treatment, including some medications. A relative disadvantage of TMS is that it involves frequent office visits, typically five days a week for four to six weeks.

A more recent version of TMS is called deep TMS because it involves stimulation of deeper regions of the brain. Deep TMS, which is now FDA approved, may prove to be more effective for some individuals than regular TMS, though further research is needed.

Transcranial Direct Current Stimulation (tDCS)

For tDCS, electrodes placed on the scalp run a weak electrical current into the front portion of the brain (an area responsible for intellectual functioning). Research suggests that this approach can help some people who have very resistant depression, and now a new version of this therapy, called transcranial alternating current stimulation (tACS), is also showing promise (see “New Form of Transcranial Stimulation”).

The media has picked up on tDCS in the past couple of years. As a result, tDCS devices, usually referred to as brain stimulation devices, are starting to pop up for sale on the internet. Before you shell out a considerable amount of money to purchase one, keep in mind that the FDA has not officially approved their use for depression. For now, sales of these devices remain unregulated.

Magnetic Seizure Therapy (MST)

Another relatively new form of brain stimulation therapy is known as MST. This treatment provokes seizures in the brain in a manner similar to ECT, but instead of using electrical currents, MST employs magnetic pulses to induce seizures in only one small portion of the brain. (TMS also stimulates the brain with magnetic pulses but does not induce seizure activity.) The biggest benefit of this more focused treatment is that it is less likely to produce the memory problems commonly seen with ECT. Clinical research with MST shows promise among depressed patients who do not respond to conventional therapy.

Other Forms of Brain Stimulation

Experts continue to investigate the potential of different forms of brain stimulation. The more non-invasive the treatment, the more desirable it is, which has led experts from the University of Arizona to explore the use of ultrasound technology to stimulate brain cells. In their research, they applied regular ultrasound wands (like those used to view fetuses in utero) to the heads of 31 patients suffering from chronic pain. The treatment improved mood for up to 40 minutes. It remains to be seen if it can be made to improve mood for longer periods of time.

Another non-invasive form of brain stimulation under investigation is low field magnetic stimulation. This treatment delivers a magnetic field to the brain similar to that experienced during an MRI. It is produced by a magnetic coil attached to a tabletop device. Researchers at McLean Hospital in Belmont, MA, have had some success using this device experimentally to treat depression, though some studies have failed to show benefit.

Nerve Stimulation Therapies

Electrical and magnetic stimulation as a means of relieving depression are not just limited to the brain. Other forms of stimulation target major nerve pathways.

In vagus nerve stimulation (VNS), a surgeon implants a pacemaker-like device called a pulse generator (about the size of a silver dollar) in the chest. The pulse generator sends signals to the vagus nerve in the neck for about 30 seconds once every five minutes. These signals travel up from the vagus nerve to brain centers involved in mood, although doctors still don’t know the exact mechanism by which it works.

VNS has been FDA-approved since the late 1990s for treating epilepsy, and more recently it has been FDA-approved for treatment-resistant depression, but its use for depression is still somewhat limited. Because implanting the pulse generator requires surgery, risks can include infection, bleeding, pain, hoarseness, cough, and damage to the vagus nerve. Even after VNS, many patients need to continue with other depression treatments, such as medication and therapy.

A new and experimental electrical stimulation therapy that shows promise for treating depression is trigeminal nerve stimulation (TNS). TNS involves use of a stimulator about the size of a large cell phone connected by wires to electrodes attached to the forehead. The electrodes send an electrical current to the trigeminal nerve in the face. Stimulating this nerve sends signals deep into the brain in a noninvasive way. One study demonstrated that 80 percent of patients achieved remission with TNS without side effects. Medical trials are ongoing.

Experimental Treatments

Researchers are constantly working to fine-tune and add to the available therapies for depression. Here are a few of the exciting new developments you might expect to see in the near future:

Neurogenesis Stimulators

Some drugs are being studied as potential treatments for depression specifically because of their effects on neurogenesis, or the growth of new connections within the brain. These include a group of drugs known as P7C3 compounds, which have been shown to contribute to neurogenesis particularly in the hippocampus.

Several studies already have shown the promise of these compounds in helping to restore function in patients with degenerative conditions affecting the brain, such as Parkinson’s disease. In addition, studies in animals suggest P7C3 compounds might be particularly beneficial for individuals who suffer from depression and other mental health disorders associated with long periods of stress.

Opioid Modulators

Opium and medications derived from opium were among the first known treatments for depression long before the discovery of current antidepressants. Over recent decades, opioid receptors have been discovered in areas of the brain relevant to depression. Nevertheless, the risk of addiction and fatal overdose have prevented these substances from having a significant role as antidepressants. In recent years, however, researchers have begun to develop and test opioid agents or combination agents that may capture some of the apparent antidepressant benefits of older drugs without the same risks of addiction or overdose. In fact, the FDA reviewed data on one promising agent in 2019 but determined that further study was needed.

Psychedelics

Psychedelics are drugs that profoundly distort perception, often producing hallucinations and altered or “expanded” states of consciousness. While some psychedelic drugs have been used in religious and other ceremonies for many years by certain cultures, most psychedelics remain illegal street drugs of abuse in the U.S. Recently, however, their potential as therapeutic agents is being reexamined.

For instance, scientists are investigating the benefits of a compound called psilocybin, which is found in a street drug known as “magic mushrooms” for the treatment of both depression and anxiety. A recent British study found that only two doses given under very controlled circumstances helped treat moderate-to-severe depression that was resistant to other forms of treatment.

Other psychedelic drugs that are in the early stages for the evaluation of depression and other mental illnesses include the street drug LSD and ayahuasca, a hallucinogenic brew made from the Banisteriopsis caapi vine and the Psychotria viridis leaf that is used in traditional ceremonies of certain Amazonian tribes.

Use of psychedelics for mental health has captured the public imagination in recent years, and they have received a lot of press. Keep in mind that it remains unclear how much of a benefit for depression they might have. One thing is for sure, however: In the wrong hands and under the wrong circumstances, they can be quite dangerous. This is an approach best left to the experts for now.

Vitamins and Supplements

Many vitamins and supplements have gained popularity as treatments for depression. While a few of them have some data to back up their use in this way, it is important to remember that none of them are as well-studied for the treatment of depression as standard antidepressant therapy. Some of the most recent data on supplements for mental health are not encouraging (see “No Mental Health Benefits from Supplements”).

Remember that experimenting with vitamins and supplements that are marketed as “natural” and easily available over the counter is not without some risk. The FDA does not regulate supplements in the same way as it does medications. One result of this is that many supplements do not actually contain precisely what is written on the bottle. This means you literally do not know for sure what you are putting in your body. In addition, vitamins and supplements can have side effects, even serious ones, and may interact with medications you may be taking, so always check with your health-care provider before trying anything new.

Omega-3 Fatty Acid Supplements

The omega-3 essential polyunsaturated fatty acids found in fish like salmon, tuna, and halibut, as well as in flaxseed and other plants, are crucial to healthy brain function. A number of studies have found that people with diets high in fish are less likely to be depressed, but results of studies on the effectiveness of omega-3 fatty acid supplements for treating depression, on their own or as adjuncts to standard antidepressants, have been mixed. At this point, the jury is out on whether there is any benefit at all to taking omega-3 supplements, though foods high in omega-3s are known to be healthful.

B and D Vitamins

Some evidence links deficient levels of certain B vitamins, such as vitamin B₁₂ and folate, as well as vitamin D, with depression. B vitamins are important for producing brain chemicals that help regulate mood, and vitamin D is important for proper communication between the nervous system and the rest of the body.

You can ask your doctor for a blood test that will determine whether your B and D vitamin levels are low. If they are, that increases the likelihood that supplementing with B and D vitamins will help your depression.

Vitamin B. Researchers have found that higher intake of some B vitamins may help prevent depression, at least in older people. Seniors are prone to vitamin B deficiency because they are more likely to have medical conditions that interfere with the proper absorption of these nutrients, and they can be neglectful of their diets. A study found that, for each additional 10 milligrams (mg) of vitamin B₆ and 10 micrograms (mcg) of vitamin B₁₂ seniors consumed from both food and supplement sources, the odds of having depression symptoms dropped by 2 percent. Perhaps even more importantly, several studies have shown that adding folate in different forms, including folic acid, L-methylfolate, and folinic acid, to antidepressants that are working only partially or not at all may boost their effectiveness even among individuals with normal folate levels to start with.

Vitamin D. The body obtains vitamin D from certain foods, but it only can produce vitamin D through direct exposure of the skin to sunlight. It comes as no surprise, then, that vitamin D deficiency occurs more frequently among those living in climates with relatively little sunlight and is more likely to occur during winter months.

Recently, vitamin D supplementation among women with known vitamin D deficiency has been shown to be an effective treatment for depression. It is less clear whether vitamin D is helpful for alleviating mood problems when vitamin D deficiency is not present. A recent analysis of the medical literature on the link between depression and vitamin D revealed that most studies to date on this topic have had serious methodological flaws, making it difficult to draw clear conclusions.

S-Adenosylmethionine (SAMe)

S-adenosylmethionine or SAMe (pronounced “sammy”) is a natural substance found in all the body’s cells. It helps produce serotonin and dopamine, and it participates in myriad other natural physiological reactions in the body. Taking SAMe in supplement form is thought to increase the levels of certain neurotransmitters and improve mood. Studies that were conducted in Europe with an injected form of SAMe showed that the supplement was similar in effectiveness to low doses of tricyclic antidepressants. Also, a Harvard study revealed that adding a twice-daily, 800-mg dose of SAMe to SSRI antidepressant therapy boosted both response and remission rates of treatment.

Probiotics

Scientists are increasingly interested in the relationship between our body’s natural bacterial flora, or “microbiome,” and medical conditions that range from inflammatory bowel disease and heart disease to autism and depression. The microbiome appears to play a greater role in health and disease than previously recognized. Probiotics, defined as “good” bacteria necessary for proper bodily functioning, can be taken in supplement form and are believed to help support healthy gut bacteria.

There is increasing evidence that having the correct balance of bacteria in the gut is important for good mental health. Researchers from University College Cork in Ireland have reviewed the available scientific data on the role of probiotics in mental health and found studies that suggest probiotics may help control stress and improve mood. In addition, Canadian researchers have found that mice with a healthier gut biome seem to handle stress better. It is important to recognize, however, that these studies are in their infancy, and experts still are not sure if taking a probiotic supplement will really help people with depression.

How They Work. Experts are not yet certain exactly how probiotics affect mental health, but they do have some strong theories. It is known, for instance, that gut bacteria are involved in the production of many neurotransmitters known to be involved in depression, such as serotonin. Probiotics also may play a role in helping to balance the HPA axis, the body’s stress regulation system. Finally, probiotics may help block chronic inflammation when it stems from the gut, and inflammation has long been known to play a role in depression (see Chapter 1 for more on how the HPA axis works and Chapter 3 for more on the connection between inflammation and depression).

Formulations. Probiotics are available in many different formulations. They are available in the form of pills, powders, drinks, and yogurts. Each contains specific combinations and doses of individual strains of probiotics. It is important to understand that pasteurization can kill these healthy bacteria, so the regular yogurt you buy in the grocery store may not contain appreciable amounts of probiotics. For that reason, it’s a good idea to stick with a product that guarantees the presence of a certain number of live bacterial cultures. Ask your doctor or refer to the product label for appropriate dosing.

Best Probiotic. It is not clear which probiotic supplement is best for preventing or treating depression. The good news is that there is a considerable amount of research going on in this area. In fact, experts have coined a new term to refer to the best probiotics for helping to alleviate psychiatric conditions such as depression: psychobiotic.

Specific bacteria that have the greatest amount of evidence supporting their use as a psychobiotic include strains known as Lactobacillus acidophilus, Lactobacillus casei, and Bifidobacterium bifidum. Taking a supplement containing these three probiotics for eight weeks has been shown to reduce both symptoms of depression and blood markers of inflammation in small studies.

Another probiotic supplement containing Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 has been shown to reduce several measures of psychological distress, including depression, anxiety, and hostility, after only 30 days. This same supplement also has been shown to improve the mood of people suffering from chronic fatigue syndrome.

At present, there are no definitive randomized controlled studies that compare probiotics to established treatments for depression. Any individuals with significant depressive symptoms should consult with their doctors about the use of probiotics, whether considering them as stand-alone treatment for depression or as possible adjunctive treatments in addition to antidepressants and psychotherapy.

Having a healthy mix of bacteria in your gut appears to be important for other aspects of health as well, so it can be tempting to take a probiotic to support both physical and mental health. The problem is, clear evidence that taking a probiotic actually improves the healthy balance of bacteria in your gut is lacking.

The coming years will be an exciting time as we learn how the right balance of bacteria in the gut can help optimize our health and well-being. In the meantime, if you want to try a probiotic for depression, stick with products that list the specific probiotics associated with mental health on their label and talk with your doctor.

St. John’s Wort

This flower extract is one of the most popular, and best studied, alternative remedies for depression. Although a large review of studies conducted by the National Center for Complementary and Integrative Health (NCCIH) showed that the herb wasn’t any better for treating major depression than a placebo, it may be more effective for mild-to-moderate depression. However, there are possible side effects, including fatigue, increased blood pressure, sensitivity to sunlight, and stomach upset. It also can interact with certain medications, including immune-suppressing drugs such as cyclosporine, HIV medications, asthma medications, the heart rhythm drug digoxin, oral contraceptives, and blood thinners. If you are considering using St. John’s wort, discuss the risks carefully with your doctor.

Don’t Give Up

If you feel you’ve tried every medicine and therapy available, and your depression still refuses to go away, you might have treatment-resistant depression. If your depression has been particularly stubborn despite multiple attempts at treatment, this is not a reflection on you but on the challenges of matching individuals with the treatments that will work best for them. Don’t panic and don’t give up. Know that there will be a therapy that eventually will work for you. If standard treatments like medication and therapy are not doing the job, ask your doctor if you might be a candidate for neuromodulation or a clinical trial for a new drug therapy. You may benefit from additional consultation with a psychiatrist who specializes in treatment-resistant depression.

Recent research has shown that most people who are depressed need to try several therapies—or combinations of therapies—before they find the one that works for them. Moreover, people who do find the treatment that works well for them are less likely to have a relapse of their depression. The message here is don’t give up, there is hope and help available.

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Screening Questionnaires

When being evaluated for a diagnosis of depression, you can expect to be asked to describe your symptoms in detail. Some health-care professionals use screening questionnaires to be sure no symptoms are missed and to quantify them more precisely.

Guidelines from the American Psychiatric Association recommend that people with major depressive disorder complete a rating scale—either administered by their doctor or completed on their own—to assess the type, frequency, and severity of their symptoms. Using a rating scale to evaluate symptoms can help doctors and mental health professionals tailor the treatment plan specifically to you. They also can be used later to determine whether treatment is working.

Diagnosing depression as well as determining which treatments individuals with depression are most likely to respond to remain important challenges for physicians and researchers. Although the development of reliable tests is still at an early stage, one hope is that blood, saliva, or other tests may eventually help point us in the right direction (see “Blood Marker for Depression Uncovered”).

Exams and Tests

In addition to having a detailed interview, you may need a physical examination and diagnostic tests to rule out illnesses that cause symptoms of depression, such as a thyroid problem, stroke, central nervous system tumor, head injury, or multiple sclerosis. People with typical signs and symptoms of depression usually do not need to have a detailed physical work-up, but those with complex medical problems, or those whose symptoms do not neatly fit the diagnosis of depression (for example, they have fatigue and weight loss without sadness or loss of interest) should have a physical exam. Diagnostic tests may include the following blood tests that can detect medical conditions that can cause depression symptoms:

• blood sugar (glucose) levels
• complete blood count (CBC)
• levels of hormones, such as thyroid hormone
• levels of inflammation markers, such as erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP)
• levels of minerals, such as calcium and iron
• levels of vitamins such as B₁₂, folate, and vitamin D
• liver and kidney function tests
• markers of infection, such as Lyme disease.

Imaging tests such as magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain may be ordered to rule out tumors, bleeding, or neurological disorders such as multiple sclerosis. Similarly, electrophysiological tests that assess electrical waves in the brain or heart are sometimes used to evaluate depression. These include an electrocardiogram (ECG) which diagnoses heart problems, and an electroencephalogram (EEG) which is used to rule out a seizure disorder (epilepsy).

Neuropsychological testing may help to diagnose cognitive and memory complaints. They also may be used if attention deficit/hyperactivity disorder (ADHD) or certain other mental health conditions that have a neurological basis are believed to play a role in symptoms. These tests are usually administered by a specially trained neurologist or neuropsychologist.

Commonly used short tests of cognitive functioning include the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). These tests generally take only a few minutes to administer and include some very basic questions, such as those related to what time it is and where you are. You may also be asked to identify certain everyday items, like a wristwatch. More complex questions require you to remember a series of words, copy a design, or follow written instructions.

The MMSE and MoCA are only rough screening tools for cognitive impairment, however. To obtain a diagnosis for a specific condition, such as dementia or ADHD, you will typically have to undergo a more complete evaluation. This usually involves one or more interviews with a neurologist or neuropsychologist as well as any number of questionnaires or tests, depending on what your concerns and symptoms are. These tests may be delivered orally, via computer, or with pen and paper. Poor sleep can impact mental health. Thus, a sleep study may help uncover reasons for interrupted sleep or unusual daytime drowsiness, such as obstructive sleep apnea, restless legs syndrome, or narcolepsy. These conditions may contribute to or mimic the symptoms of depression.

For a sleep study, you must be hooked up to several monitoring devices that record your breathing, movement, heart rate, and brain waves while you sleep. You are usually also asked to complete questionnaires about how you sleep and how tired you feel both before and after the sleep study.

Traditionally, these tests are conducted in a sleep clinic or hospital, but increasingly, at-home monitoring kits are becoming available. These are mostly prescribed to assess for sleep apnea.

Finally, physicians may order medication or drug testing to check blood levels of certain medications, or to look for drugs and other substances that may cause or worsen depression symptoms.

Once you’re diagnosed with depression, the next step is to get treatment. Even mild depression is unlikely to go away if you ignore it, and it may well worsen over time. Untreated depression often leads to greater problems in your life and can take a major toll on your physical health.

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