Frequently Asked Questions

Q. When diagnosing depression in a client, how concerned should I be about identifying specific depression subtypes? Do specific subtypes suggest different treatment modalities?

A. For years now, clinicians have attempted to categorize depressions into “subtypes.” A few examples are: typical vs. atypical, reactive vs. biological and psychotic vs. non-psychotic. There are as many as 12 subtypes of Major Depressive Disorder, according to The Diagnostic and Statistical Manual, 4th Edition (DSM-IV).

The important question though is whether labeling a depression by subtype assists the clinician in treating the client more effectively, or whether diagnosing a specific subtype implies that a different treatment modality should be utilized. With few exceptions, the answer is no.

Subtypes generally are poor predictors of treatment response. There are some exceptions however: Seasonal Affective Disorder, for example, may respond to light therapy as well as antidepressants, and psychotic depressions all but always require antidepressant treatment augmented with antipsychotics.

Don’t be overly concerned about subtypes. Pigeonholing depression is short-sighted and undermines what’s most important: Treating the “whole” patient from a bio-psycho-social perspective.

Frequently Asked Questions Regarding Risk Factors for Developing Depression

What are some of the biggest risk factors for developing depression?

The three biggest risk factors for developing depression are: (1) Genetic predisposition. Many individuals that meet criteria for major depressive disorder have a significant family history for depression. Treating clinicians should always thoroughly examine the depressed client’s “family tree” for depression. (2) Environmental events. Individuals that have recently experienced situational factors such as the death of a loved one or close friend, a recent divorce or job loss are at risk for developing depression. (3) Physical illness. Physical illnesses such as diabetes and hypothyroidism are major contributors to depressive symptom emergence.

Are women more likely to develop depression than men? Why or why not?

Women are twice as likely to develop depression compared to men. It is a myth that this is primarily a hormonal issue. Instead, women are at twice the risk due to discrimination, poverty, oppression and the stresses of single parenthood.

Are there certain ethnicities that are more likely to be depressed than others?

Approximately 30 percent of Hispanics report suffering depression compared to 26 percent for whites, 20 percent for blacks, and 16 percent for Asians. However, approximately 75 percent of whites with self-reported depression go on to receive an official diagnosis vs. 62 percent for Hispanics, 58 percent for blacks and 47 percent for Asians.

If so, do we understand at all why this is?

Although a higher percentage of Hispanics REPORT suffering depression for example, they are less likely to be DIAGNOSED. This tells us that reporting symptoms does NOT correlate with recognizing depression and subsequently seeking a diagnosis. Factors impinging upon this lack of follow-up include: Poverty, lower socioeconomic status, low education attainment (less than an 8th grade education), and decreased access to mental health services.

What other issues seem to play a role in making one person more likely to be depressed than someone else?

Many people that eventually meet depression criteria take prescription medications that contribute to or even worsen the depression. Examples are medications for high blood pressure such as the “beta blockers.” Brand names of these drugs are Inderal and Tenormin. Medications used for the treatment of Parkinsons disease and corticosteroids for inflammatory conditions are other examples. Also, substance abuse complicates every aspect of both diagnosing and treating depression.

If you have any of these risk factors, is there anything you can do to protect yourself or minimize the effects of depression?

Nothing can be done about genetic predisposition other than recognizing family history and monitoring oneself for possible symptom development. If symptoms develop due to predisposition or environmental events, seeking the services of an experienced psychotherapist can be most helpful. Other ways to minimize the effects of depression are exercise (brisk walking three times per week), proper diet (high Omega-3 fatty acid consumption), and regular exposure to bright light.

What to do when your Partner is depressed

- It is important that the non-depressed partner realize that depression can be selfish and manipulative. Depressed partners build a safety net around themselves. They will grant their non-depressed partner access to their cocoon-like existence when they’re up to it, but will often inappropriately rebuff the partner at other times. The important issue here is for the non-depressed partner to choose to not take the inappropriate behavior personally. Inappropriateness comes with the territory in depression.

- The non-depressed partner should set clear and specific boundaries. A core symptom of depression is a decrease in energy levels. So it’s acceptable to help out with chores that would ordinarily be the depressed partner’s responsibility, but unacceptable, for example, to place a sick call to their work for them. This crosses the line into enabling, and enabling behaviors fuel co-dependency. When this happens, neither partner is healthy.

- The healthy partner should encourage and support the depressed partner, but resist the urge to badger or chastise them. If the depressed partner is not seeking help for their depression, it is perfectly acceptable to broach the issue of them doing so. However the decision to follow through has to be made by the depressed individual. Patience is the key here, so badgering and chastising behaviors will inevitably lead to the depressed person digging in their heels and resisting any further offers of help.

Non-Pharmacological Options for Managing Depression: What the Pharmaceutical Companies Will Never Tell You

- Bright light exposure represents a proven strategy for managing depression. Light receptors in the retina connect to circuits in the brain that regulate circadian rhythm. Sunlight is the prime stimulator of the eyes’ photoreceptors: it triggers a cascade of neurochemical reactions that aid in keeping the “body clock” in synch. Regular bright light exposure – either via sunlight or specially designed light boxes – can restore healthy circadian function to the brain and improve mood.

• - Bright light exposure represents a proven strategy for managing depression. Light receptors in the retina connect to circuits in the brain that regulate circadian rhythm. Sunlight is the prime stimulator of the eyes’ photoreceptors: it triggers a cascade of neurochemical reactions that aid in keeping the “body clock” in synch. Regular bright light exposure – either via sunlight or specially designed light boxes – can restore healthy circadian function to the brain and improve mood.
• - Yes, I must mention the dreaded “e” word. Two landmark studies have shown that just moderate physical activity – walking three times a week – is as effective as prescription antidepressants such as Zoloft. Physical exercise stimulates the synthesis of growth hormone that initiates the sprouting of new nerve connections. Simply put, exercise helps reverse the neurotoxicity of depression.
   
• - How we feel is critically affected by diet. A deficiency of omega-3 fatty acids – some of the key building blocks of brain tissue – is now strongly linked to depression. Omega-3 fats facilitate the brain’s use of the “feel-good” nerve chemicals – norepinephrine, serotonin and dopamine. Omega-3 supplements, typically in the form of fish oils, have demonstrated in multiple trials to have a considerable antidepressant effect.
• - Ever heard the expression “if you want to change the way you feel, change the way you think?” Modification of negative, pessimistic thinking is definitely reflected in corresponding shifts in brain activity for the better. You can often accomplish this free of charge by befriending positive, optimistic people or seeking out a mentor. Positive people typically won’t let you slip into apathetic thinking patterns when you’re in their presence. You can then model their upbeat attitude when you’re on your own.

Depression in Older Men

- Six million men suffer from depression each year. Older men with depression tend to live in an “emotional vacuum” by socially isolating themselves and comforting their depression through the use of alcohol. Older men who have never married and men that have lost their spouses are most vulnerable.

 

- Evidence indicates that testosterone may play a role in male depression, particularly in late-life – a condition referred to as “andropause.” Men with the lowest levels of testosterone are more than three times likely to suffer from depression than those with the highest levels, according to research. A study at McLean Hospital in Massachusetts tested 54 men with symptoms of depression and found that 43 percent of them had low testosterone levels. These men used a testosterone gel for eight weeks and reported a significant improvement in mood, sleep, appetite and libido.

- In general, as men age, they become less emotionally expressive, so older men with depression tend to “tough it out” in silence and are the least interested in seeking help.

- Research is beginning to support the idea of a “male-based depression,” in that men often act out their depression through expressions of anger and abuse of others.

- Depression in older men is often masked by physical illness such as heart disease, stroke or cancer, as well as by prescription medications with depressive side effects such as beta blockers and anti-parkinson’s agents.

Three Common Reasons People Give for NOT Seeking Treatment for Depression

1.  One reason people give for not seeking treatment for depression is that this is the type of thing one just rides out. They believe they will just “snap out” of the depression or that they can “will” it away. They convince themselves that their depression will disappear if they read just one more self-help book on the subject. They read these books but don’t change a single thought or behavior.

2. Depressed people avoid treatment for fear of having to undergo a probing examination of their psychological pain. Their excuse is that they will have to share this pain with someone they don’t know very well or even at all, rendering treatment all the more unbearable.

 

3. Another reason people give for not pursuing treatment for depression is the shame factor. Unless someone is going through a divorce, dealing with a death or experiencing some other major trauma, our society unfortunately continues to view depression as a sign of personal weakness. People therefore forego seeking help out of sheer embarrassment for even having these depressed feelings.

New Indications for Symbyax

Eli Lilly has gained FDA approval for its combination psychotropic medication product Symbyax to be used in the management of treatment-resistant depression. Symbyax was previously approved only for the treatment of depressive episodes associated with bipolar disorder.

The drug is a combination of the antipsychotic Zyprexa (olanzapine) with the antidepressant Prozac (fluoxetine) and is now the first medication approved for treatment-resistant depression. Patients that have not responded to a minimum of two separate trials of different antidepressants over an adequate trial period for each (four to six weeks) are considered treatment-resistant.

The “Zyprexa (olanzapine)” component of this drug molecule is linked to weight gain, hyperglycemia, hyperlipidemia and hypercholesterolemia.

Pristiq: New Antidepressant or Merely a Patent Extender?

The newest entry into the antidepressant market is Pristiq (desvenlafaxine).Pristiq (desvenlafaxine), is in the SNRI category of antidepressants and is manufactured by the Wyeth Corporation. This drug received FDA approval in March, 2008. Faced with the fact that Wyeth
is losing patent protection for its top-selling antidepressant Effexor XR(venlafaxine XR), the company needed a brand product that would potentially replace some of the revenue loss when Effexor XR goes generic in 2010. Sales of Effexor XR in 2007 hovered around 3.8 billion
dollars.

Wyeth claims that Pristiq has distinct advantages over Effexor XR. Among them are that patients can begin taking Pristiq at the therapeutic dose of 50 milligrams thereby circumventing the “start low, go slow” gradual increases associated with determining the appropriate dose for an individual. Another advantage of Pristiq, according to Dr. Philip Ninan, a Wyeth vice president for neuroscience, is that Pristiq is unlikely to interact with other medications metabolized by the liver.

But several analysts are skeptical of Pristiq, claiming that it has not set itself apart from other antidepressants on the market, and that its release appeared primarily to have the drug serve as a “patent extender” for Effexor XR. This is because Pristiq is a primary active metabolite of Effexor, meaning Pristiq is the chemical compound that results after Effexor is taken and then metabolized and processed by the body.

What are your thoughts on pharmaceutical companies that design “new” drugs from the active metabolites of predecessors that have lost patent protection?