Managing Your Depression (6 page)

A newer theory of depression is that the interaction of your genes with your environment and life experiences shapes the complex network of cells in your brain (called neurons). This shaping is thought to work in this way. The brain is sensitive to stressful and traumatic events during vulnerable periods in your life. Negative stimulation, such as stress or illness, changes the action of certain genes. This altered gene activity, in turn, affects the normal functioning of your brain. In summary, negative stimulation changes gene activity which results in dysfunction of the neural network in your brain. When that happens during a vulnerable period, the brain does not work well, and the result is depression.

Depression often runs in families, which supports the idea of a genetic basis for the illness. You may have genetic factors that make you more likely to suffer from depression, but this does not guarantee that you will have the illness. If you are genetically prone to depression, you may not have an episode unless you also experience certain stressful life events. These experiences are thought to affect the genes that regulate your brain functioning. Examples of stressful life events include major trauma (a major loss or death), chronic stress, hormonal changes (such as during peri-menopause or postpartum), medical illness, substance abuse, sleep disorders, and others. Depression is not entirely genetic, and it is not entirely related to life experiences.

The symptoms of depression are psychological, behavioral, and physical. Major depression is characterized by feeling sad or depressed with loss of interest in activities. According to the standard diagnostic manual of psychiatric disorders (the DSM-IV-TR), to be diagnosed with major depression, you must have at least five of the following symptoms, lasting for two weeks or more:

• sad, depressed, or irritable feelings most of the day

• loss of interest or pleasure in most activities

• sleep changes—too much, too little, or with early morning awakening

• weight loss or gain (without trying)

• loss of energy

• decreased ability to think or concentrate

• restlessness or the sensation of being physically slowed down

• thoughts of worthlessness, hopelessness, guilt

• thoughts of death and suicide

An updated version of the diagnostic manual, the DSM-5, is scheduled for publication in the spring of 2013. The symptoms required to diagnose depression are expected to remain constant. For an in-depth discussion of these symptoms of depression, see Beck and Alford,
Depression: Causes and Treatment
.

What does an episode of depression feel like? Living with it is very hard on you and your family and friends. Depression is not just “feeling blue” for a day. It is far beyond sadness. With depression comes deep despair, physical and emotional pain, and suffering. There is often a near paralysis, being unable to participate in and enjoy life, physically and mentally. With depression, the world is gray and murky and you see only the negative side of life. You may feel guilty, worthless, and without hope. Irritability may be your main response to the world around you. You lose interest in the things you used to like and may not experience any pleasure. Motivation is nearly gone. Sleep may not come, or there may be too much of it, yet it is hard to get out of bed and move about. Fatigue is overwhelming. Food has no taste. You withdraw from people and activities and may lose friends. Communication and small talk is a major effort. Your thinking slows down, and it is hard to concentrate and focus. School and work suffer. Projects and assignments and the mail pile up, and you may spend hours just staring, unable to approach the task at hand. The thoughts you have are often distorted and negative, yet they seem quite believable to you. Your thinking may be quite disorganized. And at times, you may believe that death will bring relief.

Bipolar Disorder

Bipolar disorder, which used to be called manic-depressive disorder, is also a relapsing and remitting mood disorder that significantly affects daily life. As with major depression, it is thought to be caused by a dysfunction in the network of neurons in the brain. Bipolar disorder is characterized by periodic episodes of extreme elevated mood or irritability followed by periodic episodes of depression. These episodes come in cycles, in a different pattern for each person. In bipolar disorder, many people spend more of their illness time in the depressed phase rather than the elevated (manic) phase of the disorder. The symptoms of bipolar depression are similar to those of major depression.

To be diagnosed with a manic episode, according to the DSM-IV-TR, you need to have experienced an elevated or irritable mood that impairs your functioning for at least one week as well as three or more of the following symptoms:

• inflated sense of self or grandiosity

• increased physical and mental activity and energized or psychomotor agitation

• decreased need for sleep

• racing thoughts

• distractibility, poor concentration

• pressured speech, which means a certain way of being more talkative than usual

• irritability

• high-risk behavior (such as excessive spending, impulsive sexual behavior, and so on)

There are different types of bipolar disorder that span a spectrum of these symptoms. The type depends on the intensity and duration of the elevated mood symptoms. A manic episode is as described above, hypomanic episodes are shorter and less intense, and mixed episodes are a combination of depression and mania or hypomania that occur at the same time.

What does bipolar disorder feel like? Living through the different phases of depressed, manic, hypomanic or mixed episodes is very hard. When depressed, you may withdraw from friends and family or feel too irritable to be with people. You may often be unable to concentrate and function well at work or school. Being manic or hypomanic is like having a storm inside your head. Your thoughts and speech race from topic to topic without completing a thought. You may be too disorganized and distracted to function well without realizing it at the time. In fact, when manic, you might think that you can do anything you choose, and that you have great ideas. You may start and stop multiple projects without finishing any of them. You feel a minimal need for sleep, yet you feel energized, not tired. You may have extreme impulses and may engage in high-risk activities, such as exorbitant shopping, excessive sexual behaviors, or driving too fast. Your impulses may lead to making poor financial or business decisions. All of this has an effect on your life and in your relationships with friends, family, and work colleagues.

Depression in Women

Some women’s depression symptoms worsen in relation to changes in their female hormones: estrogen and progesterone. This may happen at certain points in the menstrual cycle or at other times when hormone levels fluctuate, such as during the transition to menopause (peri-menopause) or after the birth of a child (post-partum). The relationship between mood and hormones is not well understood, but research is progressing. A valuable resource where you can learn more about current thinking and research on psychiatric issues throughout a woman’s reproductive life is the Web site
www.womensmentalhealth.org
. There you will find a library of information, a blog, and a newsletter of up-to-date topics on depression and PMS, peri-natal and postpartum depression, fertility and mental health, and menopausal symptoms.

To find a potential association between hormone levels and your depression, use the Mood Chart on
page 46
to track your moods.
Make sure that you include the days of your menstrual cycle and other important dates on the chart, such as the birth of a child or your last menstrual period. Then share the completed chart with your doctor.

Depression and Anxiety

Approximately half of those who suffer from depression also suffer from anxiety at the same time. This adds a great burden to the weight of feeling depressed. Anxiety is a condition where you feel excessive apprehension, nervousness, and worry about several events or activities. It is often accompanied by feeling restless or shaky, with difficulty concentrating, irritability, and disturbed sleep. The intensity, duration, and frequency of the anxiety or worry is out of proportion to the actual feared event and causes distress. The fear feels very real and scary at the time. You may feel nervous, jittery, worried, and sweaty, with your heart racing or skipping a beat, an upset stomach, and muscle aches. People experiencing severe anxiety symptoms often go to the Emergency Department for fear that something physical is wrong. The good news is that many treatments for mood disorders, including those mentioned in this book, are also effective for treating anxiety.

The Stigma of Mood Disorders

Mood disorders such as depression and bipolar disorder still carry a stigma, even in the year 2012. A stigma arises when some people judge you because of your illness and then label you with a negative stereotype or image. Some people believe that it is socially unacceptable to have a mood disorder. They may try to make you feel ashamed or disgraced because of your illness. Some people may believe you are incompetent, potentially dangerous, weak in character, or undesirable just because of your illness. They will be judgmental and critical of you.
But they are mistaken! Their beliefs are absolutely not true!

There is nothing unacceptable about having a biologically based condition such as depression or bipolar disorder (or diabetes or
heart disease, for that matter). Unfortunately, many people are not informed about mood disorders as an illness, and they believe in the stigma. They may try to force their inaccurate beliefs and attitudes on you. Ill-informed beliefs and judgments may come from your friends, family, or strangers who just don’t know any better. Remember that their misinformation is driving this behavior—it is not a reflection of you.

Having an illness with a stigma attached is an additional burden for you to carry on top of the depression symptoms you already feel. Having to deal with others’ inaccurate reactions to and criticism of your illness can magnify the suffering you experience. You may feel you are constantly choosing whether to feel hurt, and deal with that, or correct their misinformation, if you feel you have the mental energy to do so. When others attach a stigma to your illness, it can put a strain on your relationship with them at home, at work, or in social situations. Often, you need to step back and understand that you may never be able to turn around the other person’s thinking no matter how hard you try. Consider what you know about the person—the source of their distorted beliefs—and try to ignore the comments of those whose opinion you cannot change.

Fatigue and Depression

Fatigue is a common symptom that affects people in both the general community and medical care settings, including psychiatry. It is considered to be a core symptom in mood disorders, affecting more than 75 percent of patients with major depression. Fatigue can significantly impair your ability to function and carry out your daily tasks. It may make it more difficult to get up and out of bed, get dressed, care for yourself or your family, prepare meals, or get out of the house to do errands or go to work. You may feel fatigue even when you think you are getting enough sleep, which can be quite frustrating.

What exactly is fatigue? There is no single definition. It is different
from just feeling sleepy or tired. Fatigue can be thought of as a combination of symptoms, with three main dimensions: physical, mental, and emotional. You may have several of these together. The multiple components of fatigue have been described in this way:

Physical

• loss of energy

• heavy limbs

• persistent tiredness even without physical exertion

• exhaustion

• reduced activity tolerance

• decreased physical endurance, stamina

• increased effort required to accomplish physical tasks

• generalized weakness

• slowness or sluggishness

Mental and cognitive

• mental dulling

• word finding and recall problems

• problems focusing and sustaining attention

• difficulty concentrating

• decreased mental endurance

• slowed thinking

Emotional and psychological

• lack of motivation

• apathy, decreased interest

• weariness

• irritability

• boredom

• low mood

The various dimensions of fatigue are included in the DSM-IV-TR definition of depression, for example, physical fatigue (loss of energy), mental fatigue (difficulty concentrating), and emotional fatigue (loss of interest and pleasure, called
anhedonia
).

Depression-related fatigue has various possible causes, which
may be difficult to sort out. But it is important to identify which one applies to you, if possible, so that you and your provider can address and treat the problem of fatigue effectively.

First, fatigue may be a
primary symptom
of your depression, along with other feelings of low mood, sadness, or loss of interest. Often the fatigue improves along with the treatment for depression. However, fatigue can also be a
residual symptom
of depression, persisting after treatment in 22.5 to 38 percent of people who are otherwise in remission. This means that, in some people, fatigue persists even after most other depression symptoms have improved or gone away following treatment with antidepressant medication. Residual fatigue can be difficult to resolve, but therapeutic options are available—speak with your psychiatrist if you are having persistent fatigue.