December 1998
Everyone experiences some unhappiness, often as a result of a change, either in the form of a setback or a loss, or simply, as Freud said, "everyday misery". The painful feelings that accompany these events are usually appropriate, necessary, and transitory and can even present an opportunity for personal growth. However, when depression persists and impairs daily life, it may be an indication of a depressive disorder. Severity, duration, and the presence of other symptoms are the factors that distinguish normal sadness from a depressive disorder.
Depression has been alluded to by a variety of names in both medical and popular literature for thousands of years. Early English texts refer to "melancholia," which was for centuries the generic term for all emotional disorders. Depression is now referred to as a mood disorder, and the primary subtypes are major depression, chronic and usually milder depression (dysthymia), and atypical depression. Other important forms of depression are premenstrual dysphoric disorder (PDD) and seasonal affective disorder (SAD). (The other major mood disorder, not discussed in this report, is bipolar disorder, or manic-depressive illness, which is characterized by periods of depression alternating with episodes of excessive energy and activity [see Well-Connected Report # 66, Bipolar Disorder])
Major Depression.
In major, or acute, depression, at least five of the symptoms listed below must occur for a period of at least two weeks, and they must represent a change from previous behavior or mood. Depressed mood or loss of interest must be present.
1. Depressed mood on most days for most of each day. (Irritability may be prominent in children and adolescents)
2. Total or very noticeable loss of pleasure most of the time.
3. Significant increase or decrease in appetite, weight, or both.
4. Sleep disorderseither insomnia or excessive sleepinessnearly every day.
5. Feelings of agitation or a sense of intense slowness.
6. Loss of energy and a daily sense of tiredness.
7. Sense of guilt and worthlessness nearly all the time.
8. Inability to concentrate occurring nearly every day.
9. Recurrent thoughts of death or suicide.
In addition, other criteria must be met: the symptoms listed above should not follow or accompany manic episodes (such as in bipolar or other disorders); they should impair important normal functions (such as work or personal relationships); they are not caused by drugs, alcohol, or other substances; and they are not caused by normal grief [see below]. One long-term study found that episodes of major depression usually last about twenty weeks.
Symptoms of depression in children may differ from those in adults. Symptoms include persistent sadness, an inability to enjoy favorite activities, increased irritability, complaints of physical problems such as headaches and stomach aches, poor performance in school, persistent boredom, low energy, poor concentration, or changes in eating or sleeping patterns or both. In one study, depressed children had a greater tendency to bully others, while anxious children were more often bullied.
Chronic Depression (Dysthymia).
Chronic, but mild depression, or dysthymia, is characterized by many of the same symptoms that occur in major depression but they are less intense and last much longerat least two years. The symptoms have been described as a "veil of sadness" that covers most activities. Typically, there are no disturbances in appetite or sexual drive; mania, severe agitation, and sedentary behavior are not present. Suicidal thoughts are not usually present. Possibly because of the duration of the symptoms, patients who suffer from chronic depression do not exhibit marked changes in mood or in daily functioning, although they have low energy, a general negativity, and a sense of dissatisfaction and hopelessness. They may suffer from episodes of major depression; in such cases, the condition is known as double depression. The family life of such patients is often impaired because of their decreased level of emotional, psychic, and physical energies.
Atypical Depression.
People with atypical depression generally overeat, oversleep, have a general sense of heaviness, and have strong feelings of rejection
Seasonal Affective Disorder.
Seasonal affective disorder (SAD) is characterized by annual episodes of depression during fall or winter, which remit in the spring or summer, and which may be replaced by a manic phase. Other symptoms include fatigue, a tendency to overeatparticularly carbohydratesand to oversleep in winter. (A minority of individuals with SAD has the more common depressive symptoms of undereating and being sleepless). SAD tends to last about five months in those who live in the northern part of America.
Premenstrual Dysphoric Disorder.
The syndrome of severe depression, irritability, and tension before menstruation is known as premenstrual dysphoric disorder (PDD) (also called late-luteal dysphoric disorder). It affects an estimated 3% to 8% of women in their reproductive years. A diagnosis of PDD depends on having five symptoms of depression [see above] that occur during most menstrual cycles, with symptoms worsening a week or so before the menstrual period and resolving afterward.
Grief.
The symptoms of grief (bereavement), and depression have much in common; indeed, it may be difficult to separate the two. Grief, however, is considered to be a healthy and important emotional response for dealing with loss; it normally has a limited duration. In people without any co-existing emotional disorder, bereavement usually lasts between three and six months. The grieving person endures a succession of emotions that includes shock and denial, loneliness, despair, social alienation, and anger. The recovery period following bereavement, during which the individual becomes reinvolved with life, takes about the same amount of time. If the grief is still severe after this period, however, it may affect a person's health or increase the risk for on-going depression. Some experts suggest that this severe persistent grieving state be categorized as a separate psychologic diagnosis termed complicated grief disorder, which would be related to post-traumatic stress syndrome and require special treatment.
Most people who are depressed do not seek psychiatric help. Because depression is so common, even in the absence of dramatic symptoms, family physicians should check for signs of depression during any comprehensive physical examination. In elderly people, because of the complex relationship between depression, drug interactions, and serious physical illness, it is especially important to obtain an accurate diagnosis. Unfortunately, one study reported that only 25% of family physicians accurately diagnose depression. Patients themselves may be unable to sense or admit to their own depression. In one study, although 21% of patients who visited their family physicians were depressed, only one percent described their problem as depression. To compound the problem, half the physicians in one study admitted to deliberately diagnosing a different problem, such as fatigue, anxiety, insomnia, or headache, in some of their patients who had depression. Reasons for doing this included uncertainty about the diagnosis, a concern that insurers wouldn't reimburse the patient for a diagnosis of depression, or because of the stigma attached to such a diagnosis.
A consultation with a mental health specialist, such as a psychiatrist, social worker, or psychologist, may be required if a family physician suspects a major depressive disorder. Some health professionals may administer a screening test, such as the Beck Depression Inventory or the Hamilton Rating Scale, which consists of about 20 questions that assess the individual for depression. Studies are finding that computerized phone interviews are valuable as screening tools for depression. It is important to note, however, that these tests are limited, and physicians and psychologists generally diagnose depression based on symptoms and other criteria.
Depression is an illness that can afflict anyone, regardless of age, race, class, or gender. About 17 million Americans are estimated to develop depression each year. In one large survey, 8.6% of adults over the age of 18 reported having a mental health problem for at least two weeks. However, the incidence may be higher since many people fail to seek help for depression and physicians are often reluctant to diagnose depression.
Gender.
Women, regardless of nationality or socioeconomic level, have significantly higher rates of depression than men.
Hormonal Changes. All women are at risk for emotional swings during extreme hormonal shifts, often experienced during the days before menstruation, the postpartum period after delivering a baby, and around menopause. Girls who go through puberty early (reaching the midpoint at 11 years or younger) are more likely to experience depression during adolescence than girls who mature later. Premenstrual dysphoric disorder (PDD) affects an estimated 3% to 8% of women in their reproductive years [see Well-Connected, Report # 79, Premenstrual Syndrome]. About 8% to 15% of women report diagnosable postpartum depression within three months of delivery, with women who have had prior depressive episodes having a much higher risk. The short period of mild depression that follows birth in nearly every woman is not considered postpartum depression, but instead the "postpartum blues". (It should be noted that many male partners of new mothers also suffer from depression surrounding the birth of a child.) Miscarriage poses a very high risk for depression, particularly in the first month after the loss. Older women with no previous successful pregnancies and those with a history of depression are at particular risk during this time. Depression often occurs around menopause (the perimenopausal period), when, in addition to hormonal changes, other factor (cultural pressures favoring young women, sudden recognition of aging, and sleeplessness) are involved. In one study, over half of perimenopausal women were diagnosed with major depression. Women taking hormone replacement therapy during this period were still as likely to become depressed as those not on hormonal therapy, but the depression tended to be less severe. Fortunately, average depression scores in women who were past menopause were nearly as low as those in premenopausal women. In fact, many women report that after menopause previous bouts of depression, particularly when were caused by seasonal changes or premenopausal syndrome, recede or stop completely.
Differences in Social Status. Married women with children have a higher risk for depression than do married childless women, single women, or single or married men. (Being divorced or separated is also a major risk factor for depression in anyone.) Studies have also reported that grandmothers who care for their grandchildren and mothers of toddlers, regardless of whether they worked or not, have a very high risk for depression. The perceived low status and isolation accompanying the role of housewife may also be factors, although work outside the home that fails to provide social support will not help protect against depression. Nevertheless, work outside the home may be beneficial, as indicated by a European study reporting that depression increased in men and fell in women between 1980 and 1995, a period coinciding with more women entering the work force.
Age.
Children and Teenagers. Experts estimate that 2% of children and between 4% and 8% of teenagers suffer from depression. The highest incidence occurs in girls after puberty. Symptoms for depression in children may differ from those in adults and may be evident only from reports of problems in school. Early diagnosis is important; one study reported that major depression persists beyond two years in 6% to 10% of young patients; 70% have a recurrence of depression within five years of treatment.
Elderly. Although a major survey reported that mental health problems occur more often in younger adults, depression is common in the elderly. It is not the aging process itself that causes depression. An Italian study found that very elderly people (age 90 and over) were no more likely to be depressed than younger adults, and the study found both groups to have a depression rate of about 10%. Interestingly, the more pessimistic an elderly person is, the less likely he or she is to experience depression. Such individuals are more able to accept the negative experiences that come with age than those with an optimistic personality. Certainly, anyone who experiences cumulative negative life events, physical illness, the death of a loved one, impaired functioning, or loss of independence can become deeply depressed. Only 17% of the elderly depressed individuals, however, are adequately treated. The characteristic symptoms of depression are not always present or readily apparent in older people. Many elderly people who are depressed may focus on their physical symptoms rather than emotional ones, often because they are unable or unwilling to express their feelings or are even aware that they are depressed. Others may be aware of their depression but believe that nothing can be done about it. Symptoms of late-life depressionaches and pain, confusion, agitation, anxiety, and irritabilitymay differ from depressive symptoms in younger people. They are often ignored or confused with other ailments common in the elderly, including Parkinson's or Alzheimer's disease, dementia, thyroid disorders, arthritis, stroke, cancer, heart disease, and other chronic conditions. Depression may even be a predictor of Alzheimer's disease or an impending physical illness before the symptoms of the disease itself become evident. Depression is also a side effect of many drugs that are commonly prescribed for the elderly. It is often very difficult, then, to determine if the patient's depression is a psychologic reaction to the illness, caused by the disease itself, or completely independent from the medical condition.
Social and Economic Considerations.
Being in a low socioeconomic group is a major risk factor for depression. However, people of all income levels are likely to be depressed if they have poor health and are socially isolated. Money, of course, allows greater access to good health care, but this factor does not explain all cases of depression in impoverished people. Western cultural attitudes that hinge income to social status may play a significant role in the connection between poverty and depression. In one British study, feelings of financial insecurity both caused and prolonged depression, while actual poverty or unemployment tended not to play any causal role. (Both factors, however, increased the duration of existing depression). A European study reporting higher rates of depression in men and lower rates in women over a period of time that coincided with more women entering the work force suggested that the depression men experienced may derive from a reduction in their social status. Another study reported that Mexican adults living in California who had immigrated to American had half the psychiatric illnesses as native-born Mexican-Americans. And the longer the immigrants lived in the U.S. the greater their risk for psychiatric problems. Traditional Mexican cultural effects and social ties, then, appear to protect newly arrived immigrants from mental illness, even when they are poor. Eventually, however, the consequences of Americanization lead to depressionprobably resulting from feelings of alienation and inferioritynot only in many Mexican Americans, but in other impoverished minority groups as well.
Accompanying Medical or Emotional Disorders.
Severe or Chronic Medical Conditions. Depression follows or is caused by many medications or serious medical problems. Thyroid disease can cause depression; it may even be misdiagnosed as depression and go undetected. A number of studies have associated low cholesterol and high triglyceride levels with depression, although it is not clear whether these factors or accompanying health problems reduce spirits. One study reported that nearly half of people with chronic tension headaches met criteria for either anxiety or depression; it wasn't clear whether the psychologic disorder preceded or followed the onset of headaches. Some experts believe that a syndrome of migraine headaches, anxiety, and depression, which occurs in some people, is caused by single genetic defect that regulates dopaminea chemical messenger in the brain. A number of drugs taken for chronic problems cause depression; among them are pain relievers for arthritis, cholesterol-lowering drugs, medications for high blood pressure and heart problems, and bronchodilators used for asthma and other lung disorders.
Emotional and Personality Disorders. Chronic depression is a frequent companion to anxiety disorders. More than two-thirds of people with obsessive-compulsive disorder also suffer from depression. Personality disorders, such as borderline and avoidant personalities, appear to strongly predispose people not only to a first episode of depression but to relapses. (Personality disorders, as opposed to emotional disorders, are abnormal behavioral patterns. A person with a borderline personality disorder is one who acts impulsively and has a poor self-image and unstable relationships. An avoidant person is abnormally dependent and avoids strangers and unfamiliar situations.)
Substance Abuse and Addictions. It is estimated that 25% of people with substance abuse problems also have major depression. Internet addiction is a recent phenomenon that may a pose risk for depression. In a two-year study of 100 families in one region, spending even two or three hours a week on the Internet increased the risk for depression, perhaps because these so-called virtual interactions replaced real relationships. The more time spent on the web, the higher the depression scores. Larger studies are needed to confirm or refute these results.
Sleep Disorders. A study of male medical students found that young men who experience insomnia are twice as likely to suffer from depression at middle age, although the basis for the link is still unclear. Genetic factors may play a role in the association between sleep disorders and depression. In one study of patients diagnosed with depression, family members with certain sleep abnormalities were found to be at greater risk for depression than those with normal sleep patterns. Abnormal sleep patterns also often preceded the first episode of depression. Individuals with normal sleep patterns who are from families with abnormal sleep habits also appear to have an increased risk for mood disorders. People with abnormal sleep profiles may also respond less well to psychotherapy.
Family History.
A family history of mental illness, especially the mood disorders, such as bipolar disorder, major depression, and chronic depression, appears to predispose a patient to the development of depression. Often a combination of genetic, biologic, and environmental factors are at work. Children of depressed parents are at high risk for depression and other emotional disorders.
Risk Factors for Seasonal Affective Disorder.
Seasonal affective disorder (SAD) affects about one in 20 adults. About 80% of those who suffer from SAD are women. Obviously, people who live in the north are more apt to experience seasonal affective disorder than are Southerners.
Risk for Suicide.
Suicidal preoccupation or threats of suicide, especially from someone known to be unhappy or suffering from a recent loss, should be considered serious. Depression is estimated to contribute to 50% of all suicides. It is a major cause of death in young people, and any child with signs of severe depression or who expresses suicidal thoughts should be seen by a mental health professional as soon as possible. Suicide in the elderly is the third-leading cause of death related to injury; men account for 81% of these suicides, with divorced or widowed men at highest risk.
Effect on Physical Health.
Depression is now known to play a major role in exacerbating existing medical conditions and may even predispose people to disease. Studies indicate that depression may have adverse biologic effects on the immune system, blood clotting, blood pressure, blood vessels, and heart rhythms. The health of elderly people who are depressed when admitted to the hospital is likely to decline, and they are less likely to fare well during the recovery period than are elderly patients who are not depressed. Many studies have now shown strong associations between depression and an increase in the incidence and severity of strokes and heart attacks.
Heart Disease and Heart Attacks. In one 30-year study, men who were clinically depressed had a greater risk for heart disease and heart attack than men who were not depressed; this increased risk lasted for decades. Although some studies have failed to show an association between depression and heart disease in women, a recent study reported that depression is a significant risk factor for death in older womenparticularly from heart diseaseand the risk is equal to that from smoking or high blood pressure. Depression may even impair a patient's response to medication for heart disease. The more severe the depression, the more dangerous to the health, although some studies have indicated that even mild depression, including feelings of hopelessness, experienced over many years may harm the heart in people with no early signs of heart disease.
Stroke. Depression appears to increase the risk for stroke in both women and women. Researchers speculate that depression and stroke might have common patterns of development. Brain scans in the elderly, for example have reported greater atrophy in the brains of depressed individuals than in those of nondepressed ones.
Other Diseases. Some studies have linked past and current major depression with bone loss in women. Depression coincides with high pain scores in people with rheumatoid arthritis. In a study of elderly Japanese patients, the highest mortality rate occurred among those who were severely depressed, with cancer, suicide, and pneumonia as significant causes of death. (An unusually high suicide rate among those over 65 in Japan may, however, be specific to the culture.)
Impotence. In one study of 1,700 men ages 40 to 70, those who reported moderate to total impotence were 82% more likely to be depressed than men with no erectile problems. Researchers speculate that depressed men may be more self-critical and have less sexual desire than non-depressed men; both factors may effect performance. Depression may also have a direct effect on the nervous system that could lead to erectile problems. On the other hand, erectile dysfunction can cause depression, and the two conditions could perpetuate each other.
Increased Risk for Addictions. Severely depressed people are at high risk for alcoholism, smoking, and other forms of addiction. Pregnant women who drink may be increasing their child's risk for a future mental illness, as well as increasing their risk for delivering children with birth defects.
Impact on Others.
Effects on the Health of Offspring. One study has found that children of depressed parents are at greater risk for many medical conditions (e.g., urinary and genital disorders, headaches, lung problems) and hospitalizations. The association between depression in children and medical disorders was apparent only when either one or both parents were depressed. (In other words, depressed children whose parents did not suffer from mood disorders were at no higher risk for medical disorders.)
Effects on Marriage.
In one survey, nearly half of people who suffered from psychiatric disorders before or during their first marriage were divorced, compared to a divorce rate of 36% in those who those who never suffered from emotional disorders.
Effects on Jobs.
In one British study, 60% of personnel directors said that they would never hire anyone for an executive position who had been previously diagnosed with depression. About a quarter of these professionals felt that formerly depressed people couldn't even handle clerical or manual jobs. (As a comparison, only 3% of personnel directors said that they thought diabetes would impair anyone's performance.) This strong bias against psychiatric disorders may be higher in England than in some other countries, but it is still indicative of the prejudices present in many cultures that inaccurately and unfairly separate psychologic from physical conditions when assessing capability.
Psychosocial Factors.
Patients who have had serious bouts of depression usually cite a stressful life event as the precipitating factor for their illness. Recent loss of a loved one is the most frequently reported precipitant of acute depression, but all major (and even minor) losses cause grief. Traumatic events, such as a sudden loss of a loved one, abuse, or even natural events such as earthquakes, can cause severe immediate or delayed depression, from which recovery takes a long time. Most people are able to cope with the emotional pain and eventually move beyond it without becoming chronically depressed. People who do develop acute or chronic depression after loss may have predisposing factors, including genetic or biologic ones, that make them more vulnerable. The existence or absence of a strong social network of family, friends, or both also has a major positive or negative effect, respectively, on recovery.
Biologic Factors.
Neurotransmitters. Neurologic factors appear to play a primary role in major depressive episodes. Depression is linked to abnormalities in neurotransmitters (chemical messengers in the brain)most importantly, serotonin, acetylcholine, and a group of neurotransmitters known as catecholamines (which consist of dopamine, norepinephrine, and epinephrinealso called adrenaline). The degree to which these chemical messengers are disturbed may be determined by other factors such as light or genetic susceptibility. For example, researchers have identified a defect in the gene known as SERT, which regulates serotonin, that has been linked to depression.
Hormones. The role of hormones in depression is not clear, but female hormones play roles in premenstrual dysphoria, postpartum depression, and SAD. These forms of depression recede or stop after menopause. Researchers are looking at certain steroid hormones in the brain that regulate progesterone and the activity in areas of the brain that control reproductive hormones. Low levels of these steroids may play a role in depression.
Changes in Brain Structure. Brain scans have shown that a particular area of the brain (the prefrontal lobe) that influences emotional control and regulates serotonin production is less active and considerably smaller in elderly depressed people than in those who do not suffer from depression. The more severe the depression the greater the atrophy in the brain.
Other Possible Causes of Depression.
Medications. Many drugs, such as beta-blockers, corticosteroids, antihistamines, analgesics, and anti-parkinsonism medications, can cause depression. Withdrawal from many medications can also cause depression.
Infections. Studies are finding a higher rate of mood disorders among people born to mothers who were pregnant during flu outbreaks; the risk seems to be greatest during the second trimestera crucial developmental period for the brain.
In spite of the effectiveness of treatments, more than two-thirds of people with depression do not receive any therapy for it; one study indicated, in fact, that only 3% of older depressed people were being treated.
Choosing a Therapist.
Sometimes the level of dysfunction may be serious enough to warrant hospitalization in order to provide protection from further deterioration or self-harm. In most people, however, depression can be treated in an office setting by a psychiatrist or other therapist. Patients can locate a mental health professional in their areas by asking their doctor for a referral or contacting one of the mental health organizations [see Where Else Can Help be Obtained for Depression, below]. Psychiatrists have a medical degree; these professionals, medical physicians, and some psychiatric nurse clinicians are the only ones who can prescribe medication. Although other mental health professionals cannot prescribe drugs, most therapists have arrangements with a psychiatrist for providing medications to their patients. Psychoanalysts have a degree in psychiatry, psychology, or social work as well as several years of training at a psychoanalytic institute. Psychologists have graduate-level training, including an internship in a mental healthcare facility. A clinical social worker has a master's degree and two years of supervised experience in mental health and human services. Advanced-practice psychiatric nurses have a master's degree and can provide therapeutic services. The patient should describe problems briefly but specifically over the phone to any prospective therapist to get a sense of whether he or she will suit the patient's needs. An advanced degree does not necessarily guarantee quality therapy. The patient's belief in his or her health provider may be the most important component in recovery, as indicated by studies reporting that placebos relieve depression in about half of patients and in some cases actually work better than psychotherapy. Patients should, therefore, not by shy about considering a change in their therapist if they lack confidence in their current one.
Treatment Guidelines for Depressed Adults.
Most adult patients with major or chronic depression are given a trial period of an antidepressant. Some form of psychotherapy is also usually recommended; the type prescribed should be, like the medications, tailored to the needs of the patient. The combination of antidepressants and therapy appears to be more effective than either treatment alone for most patients, possibly because patients are more likely to take their medications regularly when they are also undergoing therapy. For those who fail medications and psychotherapy, other techniques, such as electroconvulsive therapy (ECT), are safe and effective. In severe cases that do not respond to any conservative treatment, psychosurgery may be beneficial.
Treatment Guidelines for Specific Patient Groups.
Children and Adolescents. Studies indicate that children and adolescents with major depression respond as well to placebosso called "sugar pills"as they do to tricyclic antidepressants. Although, they tend to respond better to the newer antidepressants known as selective serotonin reuptake inhibitors (SSRIs), some experts believe teenagers with mild to moderate depression should receive psychotherapyespecially cognitive-behavioral therapy or supportive therapybefore medications are tried. For children and adolescents with very severe depression that does not respond to psychotherapy, the American Academy of Child and Adolescent Psychiatry now recommends SSRIs. These drugs should be combined during the early acute phase with a mixture of psychotherapies, including cognitive-behavioral, interpersonal, and psychodynamic therapies. Initial drug treatments should continue for at least six months and a maintenance phase should last another year or longer.
Elderly Adults. Experts generally recommend SSRIs for elderly patients because they have fewer side effects than older antidepressants, particularly the tricyclics. One study found that in elderly patients with mild depression only the SSRIs and the new so-called heterocyclic drugs were helpful, but only modestly so. Because of these modest benefits and because all antidepressants increase the risk for falls in older people, some experts recommend psychotherapy or attention intervention for elderly patients with mild depression. Some studies indicate that for severe depression in the elderly, SSRIs are not as effective as tricyclic antidepressants. It should be noted, however, that tricyclics are more likely to cause adverse effects on the heart than SSRIs. The tricyclics amitriptyline (Elavil) and imipramine (Tofranil) also have other severe side effects in older adults, who should use these drugs with caution.
General Guidelines.
Antidepressants are very effective; one study reported that up to 90% of patients with major depression will improve with good compliance and adequate doses of the right antidepressant drug. Side effects can be avoided or moderated if the regimen is started at low doses and built up over time. Current antidepressants are not addictive. A great deal of leeway exists in choosing an appropriate antidepressant; overall, they seem to be equally effective, although individual responses vary. Lack of compliance is probably the major barrier to success; for example, according to one study, as many as 70% of elderly depressed patients do not adhere to antidepressant drug regimens. Some patients with accompanying problems, such as anxiety, may require additional drugs that treat those symptoms.
For people who have never been treated for depression, medications are usually maintained for six months or longer after depression has been resolved. Patients who improve within two weeks of taking medications may not require lengthy treatment. Some patients may require indefinite maintenance therapy. These patients include those who have had three or more recurrences of depression, people over 50 who have never had major depression before, those with two episodes and a family history of depression or bipolar disorder, and people who have had severe, sudden, or life-threatening depressions within the past five years. Most patients have a recurrence of depression within five years after treatment has stopped.
Virtually all antidepressants have side effects and complicated interactions with other drugssome are very serious. Some are mentioned in the individual drug discussions below, but many are not, and patients should inform the physician of any drugs they are taking, including over-the counter-medications. There is an increased risk of oral health problems caused by dry mouth associated with long-term use of all antidepressants. The risks appear to be highest with heterocyclic antidepressants, with multiple drug use, and with the presence of oral infections. Patients can increase salivation by chewing gum, taking vitamin C tablets, using saliva substitutes, and rinsing the mouth frequently. Abrupt withdrawal from many antidepressants can produce severe side effects; no antidepressant should be stopped abruptly without consultation with a physician.
Selective Serotonin-Reuptake Inhibitors and Other Designer Antidepressants.
Selective serotonin-reuptake inhibitors (SSRIs) are now the first-line treatment of major depression. They work by increasing levels of serotonin in the brain. Because they act on serotonin specifically, they have fewer side effects than tricyclic antidepressants, which affect a number of chemicals in the body. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa).
Benefits of SSRIs. SSRIs appear to help people with most forms of depression including mild to moderately severe major depression, seasonal affective disorder, and dysthymia. SSRIs are even proving to be effective for premenstrual dysphoric disorder. In fact, in such cases, intermittent fluoxetine therapy (taking the drug only during the 14-day premenstrual period) may be as effective as continuous therapy and be associated with fewer adverse effects. SSRIs also benefits people other disorders, including obsessive-compulsive disorder, panic disorder, and bulimia. They also reduce impulsive aggressive behavior in both psychiatric patients and in people with no mental health problem. Patients taking SSRIs report not only relief of depressive symptoms, but also a higher level of efficiency, more energy, and better relationships with other people. Fluoxetine appears to be safe for pregnant women and the developing fetus, although pregnant women should avoid any medications, if possible. Antidepressants have been detected in mother's milk, although one study found no adverse effects on one-year old infants whose mothers took SSRIs while nursing their young.
Duration of Effectiveness and Use. It takes two to four weeks for SSRIs to be effective in most adults and longerup to 12 weeksin the elderly and those with dysthymia. By 14 weeks, depression should be in remission in everyone who responds to the drugs. Unfortunately, recurrence is common once the drugs are stopped. One recent study of patients taking fluoxetine suggested that patients should continue taking Prozac for 38 weeks to prevent relapse. Another study examined patients using paroxetine and found that those who continued with the full dose of Paxil for 28 weeks had half the chance for relapse when compared to those who reduced their dose.
Side Effects of SSRIs. The most common side effects are nausea and gastrointestinal problems. Others include anxiety, drowsiness, sweating, headache, difficulty sleeping, and mild tremor. These effects usually wear off over time. During the first few weeks of treatment, some patients lose a small amount of weight, but, in general, they regain it.
Sexual dysfunction, including delayed or loss of orgasm and low sexual drive, occurs in 30% to 40% of patients on SSRIs and account for a substantial amount of noncompliance. (Citalopram, a newer SRRI, may pose a lower risk than other SSRIs for this side effect.) Taking a supervised drug "holiday" on the weekend may improve sexual function during that time. (Withdrawal symptoms may develop and include return of depression, sleep problems, exhaustion, and dizziness. Prozac, with its longer duration of action, appears to be associated with a lower risk for withdrawal symptoms than shorter-lasting SSRIs, but a weekend off this drug may not be long enough to restore sexual function.)
Elderly people taking these drugs should take the lowest dose possible, and those with heart problems should be monitored closely. SSRIs can cause agitation, impulsivity, nausea, and dry mouthwhich can increase the risk for cavities and mouth sores. The elderly are at increased risk for falling. (It has been thought that SSRIs posed less of a risk for falls and hip fractures than other antidepressants, but recent studies indicate that, in this regard, they are no safer.) Over the years, some patients taking SSRIs have reported a group of side effects, known as extrapyramidal symptoms, which are similar to those in Parkinson's disease and affect the nerves and muscles controlling movement and coordination. They are uncommon and when they develop they tend to occur within the first month of treatment.
High doses or interactions with other drugs may cause hallucinations, confusion, changes in blood pressure, stiffness, and irregular heart beats. Death from overdose is extremely rare. Serious interactions can occur with certain drugs, including other antidepressants, such as tricyclics andof particular noteMAOIs [see below]. Other serious interactions have occurred with Demerol, illegal substances such as LSD, cocaine, or "ecstasy", and the antihistamines terfenadine (Seldane) and astemizole (Hismanal). (Seldane has been taken off the market). Any medication must be taken with caution during pregnancy. People may drink alcohol in moderation, although it may compound the drowsiness experienced with SSRIs; some SSRIs increase the effects of alcohol.
Heterocyclic and Other Designer Antidepressants. A number of drugs are being designed that, like the SSRIs, target specific neurotransmitters that regulate depression. Most act on mechanisms that elevate both serotonin and noradrenaline and some may be more effective for severely depressed patients than are the SSRIs. Some are known as heterocyclic antidepressants. These drugs tend to have fewer adverse effects on sexual function than SSRIs, and some people have reported enhanced sexuality with some of them. It should be noted that most of these "designer" drugs are still new, and widespread use may increase reports of adverse effects. Common side effects include drowsiness, nausea, dizziness, and dry mouth, but drugs vary in others effects. Dry mouth is a particular problem with long term use of heterocyclics.
Bupropion. Bupropion (Wellbutrin) is particularly promising for a number of conditions, including it use as a treatment for quitting smoking (Zyban). It causes less sexual dysfunction than SSRIs. Side effects include restlessness, agitation, sleeplessness, headache, rashes, stomach problems, and in rare cases, hallucinations and bizarre thinking. Weight loss occurs in about 25% of patients. High doses increase the risk for seizures, particularly in those with eating disorders or those with other risk factors for seizures.
Venlafaxine. Venlafaxine (Effexor) is another designer antidepressant that is gaining popularity. In one comparison study, venlafaxine was similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. In a group who required higher doses of an antidepressant in order to obtain a response, venlafaxine was slightly more effective. Venlafaxine has a variety of side effects, and high blood pressure and depressed central nervous system function can occur in high doses. Some patients report severe withdrawal symptoms, including dizziness and nausea.
Nefazodone. Nefazodone (Serzone) has less severe side effects, including sexual dysfunction, than SSRIs. The drug can also be combined with SSRIs. However, it may cause an abrupt drop in blood pressure after standing up suddenly.
Other Designer Antidepressants. Mirtazapine (Remeron) and maprotiline (Ludiomil) are other effective antidepressants that have few side effects. In one trial of patients with a high incidence of severe depression, mirtazapine was more effective than fluoxetine and it had fewer side effects. Maprotiline increases the chance for seizures in high-risk people and may cause heart rhythm disturbances.
Tricyclic Antidepressants.
Before the introduction of SSRIs, tricyclics had been the standard treatment for depression. Some of the most frequently prescribed tricyclics are amitriptyline (Elavil, Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil), and trimipramine (Surmontil).
Benefits of Tricyclics. Tricyclics are as effective as SSRIs and may still offer benefits for many people with chronic depression who do not respond to SSRIs. Imipramine has been shown to be of particular benefit for those with dysthymia. The tricylclic protriptyline (Vivactil) appears to help people with tension headaches.
Side Effects of Tricyclics. Side effects are fairly common with these medications, and those most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Blood pressure may drop suddenly when sitting up or standing. The tricylclic protriptyline (Vivactil) is associated with weight loss and causes less drowsiness than does Elavil. It can, however, cause insomnia and nightmares if the drug is taken too close to bedtime. Protriptyline also causes sun sensitivity and people who took this should take precautions against sunlight when they go outdoors.
Tricyclics can have serious, although rare, side effects and can cause fatal overdose. Tricyclics may pose a danger for some patients with certain heart diseases. One study comparing nortriptyline with paroxetine, an SSRI, reported nine times more adverse cardiac events with the use of the tricyclic than with the SSRI. Also of concern is a recent study reporting that tricyclics, particularly imipramine, may be responsible for 10% of cases of a lung disease called idiopathic pulmonary fibrosis (IPF), which can cause lung inflammation and scarring. Initial symptoms are breathlessness and dry cough. (Two other investigative tricyclics, mianserin (Bolvidon) and dothiepin (Prothiaden), also increased the risk.)
Monoamine Oxidase Inhibitors (MAOIs).
Monoamine oxidase inhibitors (MAOIs) are usually indicated when other antidepressants prove ineffective. They may be effective for atypical depression and for people with eating disorders, post-traumatic stress disorder, and borderline personality. MAOIs include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate). One recent study reported that a patch form of an MAOI worked much faster than an oral form, which takes up to six weeks to be effective. MAOIs commonly cause orthostatic hypotension (a sudden drop in blood pressure upon standing), drowsiness, dizziness, sexual dysfunction, and insomnia. The most serious side effect is severe hypertension, which can be brought on by eating certain foods having a high tyramine content. Such foods include aged cheeses, most red wines, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans, and concentrated yeast products. MAOIs also can cause birth defects and should not be taken by pregnant women. MAOIs can have serious interactions with a number of drugs, including some common over-the-counter cough medications, psychostimulants (such as Ritalin), and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. There should be at least a two to five-week break between taking MAOIs and other antidepressants. (A European MAOI, moclobemide, appears to be safe when used with an SSRI, but it is not yet available in the U.S.)
Other Promising Treatments.
Estrogen. Estrogen replacement therapy (ERT) may relieve menopausal-associated depression and even relieve depression in elderly women who do not respond to standard antidepressants. ERT has other health benefits and risks, which a physician should discuss with the patient. (Hormone replacement therapy that contains both progesterone and estrogen may cause mild depression.) One study showed that estrogen given under the tongue (sublingually) successfully relieved the symptoms of postpartum depression, whereas antidepressant therapy and counseling provided only temporary relief.
St. John's Wort. St. John's Wort (Hypericum perforatum) is an herbal remedy that is helping mild to moderate depression in many patients. It is widely prescribed in Germany, and one short-term British study reported that it was effective and had fewer side effects than standard antidepressants. A long-term trial is now underway in the U.S. to determine its safety and effectiveness. Even those with mild depression should not use St. John's Wort without consulting a physician. This herbal substance is not regulated and there is no guarantee of quality in any brands currently available. The product should contain at least 0.3% hypericin, the active substance in St. John's Wort. Although no dose levels have been established, trials indicate that 300 milligrams taken three times a day may be effective. It takes between two and three weeks for the drug to have an effect. Common side effects include gastrointestinal problems, dry mouth, allergic reactions, and fatigue. It may also increase sensitivity to the sun, and some people have reported temporary nerve damage after sun exposure. People with severe depression, children, and pregnant or nursing women should not take this substance. It should never been combined with other antidepressants. Studies indicate that the herbal substance may be similar to MAOI inhibitors. Some experts, then, suggest avoiding high amounts of foods and substances that have tyramine, such as red wine, meat, and aged cheese.
Substance P. Substance P is a brain chemical that is believed to have a role in mood disorders; agents that inhibit it have been found to have both antidepressant and antianxiety effects. In one investigative trial of patients with major depression, a substance-P blocker termed MK-869 was as effective as an SSRI and had similar side effects although less sexual dysfunction. It also reduced anxiety, independent of its effect on depression.
Augmentation Strategies.
Augmentation strategies generally involve the use drugs not typically thought of as antidepressants in combination with an antidepressant. Such strategies are being used for patients who fail standard therapies or who need to quickly speed up the response of the antidepressant. Augmentation therapies include use of lithium, psychostimulants, thyroid hormones, beta-blockers, and anti-anxiety drugs. In one small study, high doses of thyroid hormone combined with an antidepressant had very mild side effects and were very effective in half of severely depressed treatment-resistant patients. Another study reported good results when thyroid hormone was followed by small doses of lithium. The anti-anxiety drug clonazepam (Klonopin) plus fluoxetine (Prozac) produced greater early improvement than Prozac alone in one study. Pindolol (Visken)a beta-blocker normally used for heart diseasewas effective against depression in another study when combined with the antianxiety drug buspirone (BuSpar). In another study, it was used with the SSRI paroxetine (Paxil) to hasten response. After ten days, depression in nearly half the patients taking the combination was in remission compared to 25% of patient taking Paxil only.
The benefits of psychotherapy are not always easily measured, and studies comparing the different methods have found insignificant differences in benefit. What seems to be most important is the patient's attitude toward therapy and the therapist.
Cognitive-Behavioral Therapy.
Cognitive-behavioral therapy focuses on identification of distorted perceptions that patients may have of the world and themselves, changing these perceptions, and discovering new patterns of actions and behavior. These perceptions, known as schemas, are negative assumptions developed in childhood that can precipitate and prolong depression. Cognitive therapy works on the principle that these schemas can be recognized objectively and altered, thereby changing the response and eliminating the depression. First, the patient must learn how to recognize depressive reactions and thoughts as they occur, usually by keeping a journal of feelings about and reactions to daily events. Then, the patient and therapist examine and challenge these entrenched and automatic reactions and thoughts. As the patient begins to understand the underlying falseness of the assumptions that cause depression, he or she can begin substituting new ways of coping. The patient is often given "homework" that tests old negative assumptions against reality and demands different responses. Over time, such exercises help build confidence and eventually alter behavior. Cognitive therapy is a time-limited treatment lasting three to four months.
Research indicates that cognitive therapy might be used as a second-stage treatment for mopping up any residual depression in people who have completed successful regimens of antidepressants. In one study, depression recurred within two years in only 25% of patients who received cognitive behavioral therapy compared with 80% of those who received standard management techniques. Cognitive therapy may also be particularly helpful for adolescents with mild symptoms of major depression, for women with non-psychotic postpartum depression, and for preventing children of depressed parents from developing the disorder later on. In this latter case, therapy should involve the whole family.
Psychodynamic Psychotherapy.
Based on Freudian theory, psychodynamic psychotherapy concentrates on working through unresolved conflicts from one's childhood. Depression is viewed as a grieving process for the loss of a parent or other significant person or for the loss of their love. Freud theorized that the depressed individual can only express rage at this loss by turning it against her- or himself and transforming it into depression. The therapeutic goal of the patient is to interpret and understand these early feelings by re-experiencing them. In recent years what used to be a long-term course of therapy is now often shortened to several months.
Interpersonal Therapy (IPT).
Based in part on psychodynamic theory, interpersonal therapy acknowledges the childhood roots of depression but focuses on symptoms and current issues that may be causing problems. ITP is not as specific as cognitive or behavioral, and all work is done during the sessions. The therapist seeks to redirect the patient's attention, which has been distorted by depression, outward toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (three to four months of weekly appointments). Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes, and isolation
Supportive Psychotherapy or Attention Intervention.
The intent of supportive psychotherapy or attention intervention is to provide the patient with a nonjudgmental environment by offering advice, attention, and sympathy. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur; one study, in fact, found that it offered no other benefits.
Electroconvulsive Therapy.
Electroconvulsive therapy (ECT), commonly called shock treatment, has, unfortunately, received bad press since it was introduced in the 1930s. ECT has been refined over the years and now successfully treats more than 90% of patients suffering from mood disorders. A muscle relaxant and short-acting anesthetic are administered and a small amount of current is sent to the brain, causing a generalized seizure that lasts for about 40 seconds. Most patients receive six treatments spaced every two to five days; others receive up to 15 treatments, which are followed by six to 12 additional treatments spaced every other week or longer for another two to four months. Hospitalization is not necessary for the treatment. Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness, and heart disturbances. Many experts urge that ECT be used earlier in the course of major depression, although most insurers or HMOs will not pay for early treatment. ECT may be beneficial for patients who cannot, for any reason take antidepressant drugs, for suicidal patients, and for elderly patients who are psychotic and depressed. Some physicians feel it is safer too use ECT than many antidepressants for patients who are pregnant or have certain heart problems, and it may also be helpful for young patients who fit the adult criteria for ECT.
Transcranial Magnetic Stimulation.
An experimental treatment called transcranial magnetic stimulation (TMS) may target affected areas of the brain more precisely than ECT. The only side effect reported is a mild headache. It appears not to cause seizures, memory lapses, or impaired thinking. One recent study found that after one year relapse rates were significantly lower after TMS than after ECT, although only a few, small studies have been conduced using this procedure.
Phototherapy.
Phototherapy is recommended as the first line treatment for seasonal affective disorder (SAD). The patient sits a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) for about 30 minutes every day. Studies now indicate that it is best performed immediately after wakening in the morning. Some people report mood improvement as early as two days after treatment; in others depression may not lift for three or four weeks. (If no improvement is experienced after that, then the depression is probably caused by other factors.) Side effects include headache, eye strain, and irritability, although these symptoms tend to disappear within a week. Patients taking light-sensitive drugs (e.g., those used for psoriasis), certain antibiotics, or antipsychotic drugs should not use light therapy. Patients should by examined by an ophthalmologist before undergoing this treatment.
Cingulotomy.
A surgical technique called cingulotomy interrupts the cingulate gyrus, a bundle of nerve fibers in the front of the brain, by applying heat or cold. A recent variation of this procedure using MRI scans to guide the surgeon produced long-term improvement in 53% of patients with severe depression. The procedure is generally safe with few serious complications; it does not affect either intellect or memory.
Acupuncture.
One small study reported that acupuncture was effective in relieving depression in 64% of women, a result comparable to medications or psychotherapy. Larger studies are required to confirm this result.
Diet.
Some people report relief from depression by eating foods or diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. Vitamin B3 (niacin) is important in the production of tryptophan and is produced from processing vitamin B3 (niacin). Dietary sources of niacin include oily fish (such as salmon or mackerel), pork, chicken, dried peas and beans, whole grains, seeds, and dried fortified cereals. The omega-3 polyunsaturated fatty acids found in fish oil may independently reduce depression. (There's no definite proof that any of these foods improve depression but, in any cases, they are all healthful.) A high-carbohydrate drink available over the counter called PMS Escape increases tryptophan level and may alleviate depression from PMS for about three hours. It should be strongly noted that impurities found in L-tryptophan diet supplements have been associated with eosinophilia-myalgia syndrome (EMS), a disorder that elevates certain white blood cells and causes muscle pain. An epidemic of EMS with some reported fatalities occurred in 1989; recently similar impurities have been detected in diet supplements containing 5-hydroxy-1-tryptophan (5HTP)a form of tryptophan.
Vitamin B12 and calcium supplements may help reduce depression that occurs before menstruation. Studies have found an association between drinking caffeinated beverages and a lower incidence of suicide, indicating that coffee or tea might help reduce depression.
Exercise.
Exercise may reduce mild to moderate depression and, in many cases, may be as effective as psychotherapy. Either brief periods of intense training or prolonged aerobic workouts can raise chemicals in the brain, such as endorphins, adrenaline, serotonin, and dopamine, that produce the so-called runner's high. One study found that teenagers who were active in sports have a greater sense of well being than their sedentary peers; the more vigorously they exercised, the better was their emotional health. Physical activity, particularly rhythmic aerobic and yoga exercises, helps combat stress and anxiety. And, of course, weight loss and increased muscle tone can boost self-esteem.
Social Support.
A strong network of social support is both important for prevention and recovery from depression. Support from family and friends must be healthy and positive; one study of depressed women showed, however, that overprotective as well as very distant parenting was associated with a slow recovery from depression. Studies indicate that people with strong spiritual faiths have a lower risk for depression. Such faith does not require an organized religion. People with depression might find solace from less structured sources, such as those that teach meditation or other methods for obtaining spiritual self-fulfillment.
National Foundation for Depressive Illness
P.O. Box 2257
New York, NY 10116
call (212-268-4260) or (800-239-1265) or on the Internet (http://www.depression.org/)
National Depressive and Manic-Depressive Association
730 N. Franklin St.
Suite 501, Chicago, Ill. 60610
call (800) 826-3632) on the Internet (http://www.ndmda.org/)
Makes referrals to local support services and offers a free information package.
National Institute of Mental Health
5600 Fishers Lane
Parklawn Building
Rockville, MD 20857
call (800-64-PANIC) or on the Internet (http://www.nimh.nih.gov/)
National Alliance for the Mentally Ill (NAMI)
200 N. Glebe Rd.
Arlington, VA 22203-3754
call (800-950-6264) or on the Internet (http://www.nami.org/)
NAMI is a national grass roots organization providing ways for self-help and support organizations to
individuals and families of people with psychologic disorders.
American Institute for Cognitive Therapy
call (212-308-2440)
Association for the Advancement of Behavior Therapy
call (212-647-1890) or (800-685-AABT)
The American Psychiatric Association
call (202-682-6000) or on the Internet (www.psych.org)
The American Psychological Association
call (800-964-2000) or on the Internet (www.apa.org)
The National Association of Social Workers
call (202-408-8600) or on the Internet (www.naswdc.org)
The American Psychiatric Nurses Association
call (202-857-1133) or on the Internet (www.apna.org)
National Mental Health Association
1021 Prince St.
Alexandria, VA 22314-2971
call (800-969-6642) or on the Internet (http://www.nmha.org)
This organizations will give the names and numbers of regional chapters and provides information on
200 mental health topics.
Society for Light Treatment and Biological Rhythms
842 Howard Avenue
New Haven, CT 06519, USA
fax: (203-764-4324) or on the Internet (http://www.websciences.org/sltbr/)
Emotions Anonymous
PO Box 4245
St. Paul, MN 55104
call (612-647-9712) or on the Internet (http://www.mtn.org/EA/)
Offers a 12-step program to help people experiencing emotional difficulties. Has 1,400 groups worldwide.
National Organization for SAD
PO Box 40133
Washington DC 20016
This organization supplies the names of light box companies and other information on seasonal affective
disorder.
On the Internet
Mental Health Net (http://www.cmhc.com/)
American Academy of Child and Adolescent Psychiatry (http://www.aacap.org/)
Information on cognitive therapy (http://www.cognitivetherapy.com/)
Internet Mental Health (http://www.mentalhealth.com/)
is a free encyclopedia of mental health information.
Cognitive-Behavioral therapy. Harvard Men's Health Watch, April 1998
Comparison of paroxetine and nortriptyline in depressed patients with ischemic heart disease. Journal of the American Medical Association, 1/29/98
Dealing with the depths of depression. FDA Consumer, July-August 1998
Depression: Benefiting from treatment advances. Johns Hopkins Medical Letter, November 1998
Diagnostic criteria for complicated grief disorder. American Journal of Psychiatry. July 1997
Effects of antidepressant treatment on neuroactive steroids in major depression. American Journal of Psychiatry. July 1998
Effects of electroconvulsive therapy in adolescents with severe endogenous depression resistant to pharmacotherapy. Biology of Psychiatry, 1998
Estrogen replacement and response to fluoxetine in a multi-center geriatric depression trail. American Journal of Geriatric Psychiatry. Spring 1997
Distinct mechanism for antidepressant activity by blockage of central substance P receptors, Science, 9/11/98
Family structure and depressive symptoms in men preceding and following the birth of a child. American Journal of Psychiatry. June 1998
Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Archives of General Psychiatry, December 1997
How to choose a therapist. Consumer Reports on Health, October 1998
Late-life depression: Usually treatable, usually ignored. Consumer Reports on Health. March 1998
Light therapy. HealthNews, 3/10/98
Listening to St. John's Wort. Harvard Health Letter. October 1997
Mental health affects response to heart treatments. HealthNews, 1/27/98
Neurodevelopment of children exposed in utero to antidepressant drugs. The New England Journal of Medicine, 1/23/97
Personality and personality disorders predict development and relapses of major depression. Psychiatr Scan. April 1997
Randomized controlled trial of amitriptyline versus placebo for adolescents with "treatment-resistant" major depression. Journal of the American Academy of Child and Adolescent Psychiatry, May 1998
Should you take St. John's Wort? HealthNews, 4/20/98
St John's Wort: Herbal Prozac? Consumer Reports on Health, May 1998
Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. JAMA, 9/24/97
Use of pattern analysis to predict differential relapse of remitted patients with major depression during one year of treatment with fluoxetine or placebo. Archives of General Psychiatry, April 199
Use of selective serotonin-reuptake inhibitors or tricyclic antidepressants and risk of hip fractures in elderly people. Lancet, 5/2/98 8
Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.
Board of Editors
Harvey Simon, M.D., EditorinChief
Massachusetts Institute of Technology; Physician, Massachusetts General Hospital
Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital
John E. Godine, M.D., PhD, Metabolism
Harvard Medical School; Associate Physician, Massachusetts General Hospital
Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital;
Active Staff, Children's Hospital
Irene Kuter, M.D., D. Phil, Oncology
Harvard Medical School; Assistant Physician, Massachusetts General Hospital
Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital
Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service,
Massachusetts General Hospital
Carol Peckham, Editorial Director
Cynthia Chevins, Publisher
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