How to Identify and Treat Depression

Depression is a severe illness.
Most people do not realize that. They see depression as a mood,
as a kind of disappointment, as a state that people can get over if they simply take themselves
in the hand, go on a vacation or do something that
would improve their mood. People who are suffering
from clinical depression, that is not the case. Virtually nothing can make them feel better. Clinical depression
is different from sadness. Sadness is something
that we all experience, it’s an emotion that’s very common. The difference between sadness
and clinical depression is that clinical depression
impacts on functioning. So things like depressed mood,
loss of interest or pleasure, lack of appetite or increased appetite,
insomnia or hypersomnia, psychomotor agitation or restlessness,
fatigue or loss of energy, feelings of worthlessness or guilt,
difficulty concentrating or making decisions and finally, thoughts of death, suicide or a plan to commit suicide,
are all typical symptoms of clinical depression. If depression is a biological illness,
what is the biology of the illness? What exactly is wrong with the brain
in people who are suffering from depression? There is really no definitive answer,
but there are some very important clues that we do have. In depression we know that
medications that make serotonin, the neurotransmitter serotonin,
more available in the brain, are effective in treating depression, we know that medications
that make noradrenalin, another neurotransmitter
more available in the brain, are also effective. So clearly,
problems in the availability of these neurotransmitters
at critical points in the brain, where neurons communicate
with other neurons, is a very important factor. Another system that we’ve been
studying for many years in the field is the cortisol stress response
system in the brain. The hypothalamus, a part
of the brain that is very old, that controls the pituitary gland and makes it secrete a hormone
that stimulates the adrenal glands that secretes cortisol,
the stress hormone. It’s possible that a short burst
of the stress hormone, which leads a person to perform
better and overcome his difficulty, is a positive, healthy,
productive thing, but the chronic increases in cortisol,
chronic anxiety, can predispose to depression by causing secondary changes
in the brain. There are very many different classes
of anti-depressants available. The most frequently used are specific
serotonin reuptake inhibitors, or the so-called SSRIs. These are the first line
treatments for depression when medication is employed and they are effective
in about 20%-30% of cases. When SSRIs do not work then so-called augmenting
medications are used. These are medications
which are added to the SSRIs in order to increase
their effectiveness, or a switch is made from SSRIs to an anti-depressant
from a different class. With the use of serial treatment –
60%, perhaps 70%, of people with depression
can achieve remission. The question is,
what about the remaining people? What about the remaining 30% or so? The answer is that there are a lot of people
whose depression is not successfully treated. They can have some
improvement in symptoms, things do get better for a while
before getting worse again, and, ultimately, they do develop
what is called chronic depression. And this is perhaps
one of the most major, one of the most significant challenges
facing psycho-pharmacologists today. We are now strongly
entering a phase where we see the limits
of the medications, where we have come
to some blind ends and where the newer medications are not always any more effective
than the older ones. I think today even biological
researchers of depression, like myself, are convinced
that psychological treatments are effective in depression, and clearly both chemistry
and psychology play important roles in depression
and its treatment. What we know about
depression is that not only is there
a biological influence which is generally why people
use medication to treat depression, but there’s also influence
of the way we think. So the idea in
cognitive behavioral therapy is that people start having
some negative thoughts, we call them
“Negative Automatic Thoughts”. If somebody was criticized quite often
by their parents or by their teachers, then they have a schema
that they’re not good enough. If they’re going along in their life
and everything is good, then they feel ok. But if they fail the exam and the schema that “I’m not
good enough” gets activated, then they’ll start thinking negatively,
like, “I’ll never be good enough, “I’ll never pass an exam again.”
What we want to do is help them see that these thoughts might be
what we call “distorted” or “erroneous”. In the treatment patients are asked
to identify their negative automatic thoughts. In other words, what was the thought
that was going through your head when you were feeling bad? Then we teach them how
to challenge these thoughts. We use a technique called
“Socratic questioning”: Do I know for certain
that this is true? How would somebody else
think about the same situation? These kinds of questions,
to help them challenge their negative thoughts
and come up with what we call “alternative thoughts”
or “rational responses”. It’s really important to understand that
treatment is not necessarily only biological. It’s not simply like:
“I have a headache, “I’m going to take an aspirin
and then I’m going to feel better.” You might feel better, but we would want to also understand
what the causes of the headaches are, so if we could change
that negative thinking then we can prevent
all future headaches or all future depressive episodes because they learn how to manage
their negative thoughts which will prevent them from
having depression in the future. The fact that serotonin
reuptake inhibitors are not effective in all cases led to a renewed focus
on the development of drugs that act on more than one system, and, in fact, several of these
are already available. The wave of the future
is the development of drugs that act not only on the serotonin
and or noradrenalin system but also on the dopamine system,
the so-called “multifunctional drugs”. Now there’s also a newer
form of therapy, called “mindfulness-based
cognitive therapy”, which is the idea that thoughts
just go through your head, because we all have thoughts
that go through our heads, and we just watch them
go through our heads, and we put them like a cloud…
the thought onto a cloud, and we let it go across the sky,
as apposed to starting to interpret it or misinterpret it
or make a big deal out of it. And the research has shown
that people who learn mindfulness-based cognitive therapy,
after they’d been depressed once, have a much less likelihood
to relapse. I think in many cases
of moderate depression psychological treatments are as
effective as medication treatments so it might be important to emphasize
that patients who are verbal, who like to talk
about their problems, who are motivated to talk
about their problems should be given a chance
to treat their depression with cognitive behavioral therapy. Patients who are unable
to talk about their problems or too depressed
to talk about their problems, should be given a realistic, optimistic, truthfully optimistic evaluation
of why they should take their medication so that they have
a much better chance of being well and able to work
and enjoy life in the future.

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