Causes of Depression

Depression and other Illnesses

Bipolar Disorder

CAUSES OF DEPRESSION

Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different
genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with
the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.

In some families, major depression also seems to occur generation after generation. However, it
can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.

People who have low self-esteem, who consistently view themselves and the world with pessimism
or who are readily overwhelmed by stress, are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear.

In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic
and unwilling to care for his or her physical needs, thus prolonging the recovery period. Also, a
serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Later episodes of illness typically are precipitated by only mild stresses, or none at all.

Depression in Women

Women experience depression about twice as often as men. Many hormonal factors may
contribute to the increased rate of depression in women-particularly such factors as menstrual
cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause.
Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

A recent NIMH study showed that in the case of severe premenstrual syndrome (PMS), women with
a preexisting vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were reintroduced, they again
developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.

Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and requires active intervention. Treatment by a sympathetic physician and the family's emotional support for the new mother are prime
considerations in aiding her to recover her physical and mental well-being and her ability to care
for and enjoy the infant.

Depression in Men

Although men are less likely to suffer from depression than women, three to four million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors
are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.

Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.

Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as
such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference.
In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

Depression in the Elderly

Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. Depression in the elderly, undiagnosed
and untreated, causes needless suffering for the family and for the individual who could otherwise
live a fruitful life. When he or she does go to the doctor, the symptoms described are usually
physical, for the older person is often reluctant to discuss feelings of hopelessness, sadness, loss
of interest in normally pleasurable activities, or extremely prolonged grief after a loss.

Recognizing how depressive symptoms in older people are often missed, many health care professionals are learning to identify and treat the underlying depression. They recognize that some symptoms may be side effects of medication the older person is taking for a physical problem, or
they may be caused by a co-occurring illness. If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling
life. Recent research suggests that brief psychotherapy (talk therapies that help a person in day-to-day relationships or in learning to counter the distorted negative thinking that commonly
accompanies depression) is effective in reducing symptoms in short-term depression in older
persons who are medically ill. Psychotherapy is also useful in older patients who cannot or will not take medication. Efficacy studies show that late-life depression can be treated with psychotherapy.

Improved recognition and treatment of depression in late life will make those years more enjoyable
and fulfilling for the depressed elderly person, the family, and caretakers.

Depression in Children

Only in the past two decades has depression in children been taken very seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, grouchy, and feel
misunderstood. Because normal behaviors vary from one childhood stage to another, it can be
difficult to tell whether a child is just going through a temporary "phase" or is suffering from depression. Sometimes the parents become worried about how the child's behavior has changed, or
a teacher mentions that "your child doesn't seem to be himself." In such a case, if a visit to the
child's pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed. Parents should not be afraid to ask questions: What are the therapist's qualifications? What kind of therapy will the child have? Will the family as a whole participate in therapy? Will my child's therapy include an antidepressant? If so, what might the side effects be?

The National Institute of Mental Health (NIMH) has identified the use of medications for depression
in children as an important area for research. The NIMH-supported Research Units on Pediatric Psychopharmacology (RUPPs) form a network of seven research sites where clinical studies on the effects of medications for mental disorders can be conducted in children and adolescents. Among
the medications being studied are antidepressants, some of which have been found to be effective
in treating children with depression, if properly monitored by the child's physician.

Ferketick AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to
heart disease among women and men in the NHANES I study. National Health and Nutrition Examination Survey. Archives of Internal Medicine, 2000; 160(9): 1261-8.

Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y,
Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment
of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278:1186-90.

Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 1998; 44(9):839-50.

Schmidt PJ, Neiman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects
of gonadal steroids in women with and in those without premenstrual syndrome. Journal of the American Medical Association, 1998; 338:209-16.

Vitiello B, Jensen P. Medication development and testing in children and adolescents. Archives
of General Psychiatry, 1997; 54:871-6.

DEPRESSION AND OTHER ILLNESSES

DEPRESSION AND CANCER

Get Treatment for Depression
At times it is taken for granted that cancer will induce depression, that depression is a normal part
of dealing with cancer, or that depression cannot be alleviated for a person suffering from cancer. But these assumptions are false. Depression can be treated and should be treated even when a person
is undergoing complicated regimens for cancer or other illnesses.

Prescription antidepressant medications are generally well-tolerated and safe for people being treated for cancer. There are, however, possible interactions among some medications and side effects that require careful monitoring. Therefore, people undergoing cancer treatment who develop depression, as well as people in treatment for depression who subsequently develop cancer, should make sure to tell any physician they visit about the full range of medications they are taking.
Specific types of psychotherapy, or "talk" therapy, also can relieve depression.

Treatment for depression can help people feel better and cope better with the cancer treatment process. There is evidence that the lifting of a depressed mood can help enhance survival.8 Support groups, as well as medication and/or psychotherapy for depression, can contribute to this effect.

Treatment for depression in the context of cancer should be managed by a mental health professional—for example, a psychiatrist, psychologist, or clinical social worker—who is in close communication with the physician providing the cancer treatment. This is especially important when antidepressant medication is needed or prescribed, so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional that specializes in treating individuals with depression and co-occurring physical illnesses such as cancer may be available.

While there are many different treatments for depression, they must be carefully chosen by a trained professional based on the circumstances of the person and family. Recovery from depression takes time. Medications for depression can take several weeks to work and may need to be combined with ongoing psychotherapy. Not everyone responds to treatment in the same way. Prescriptions and dosing may need to be adjusted. No matter how advanced the cancer, however, the person does not have to suffer from depression. Treatment can be effective.

Williams JW Jr, Mulrow CD, Chiquette E, et al. A systematic review of newer pharmacotherapies
for depression in adults: evidence report summary. Annals of Internal Medicine, 2000; 132(9): 743-56.

DEPRESSION AND DIABETES

Get Treatment for Depression
While there are many different treatments for depression, they must be carefully chosen by a trained professional based on the circumstances of the person and family. Prescription antidepressant medications are generally well-tolerated and safe for people with diabetes. Specific types of psychotherapy, or "talk" therapy, also can relieve depression. However, recovery from depression takes time. Antidepressant medications can take several weeks to work and may need to be combined with ongoing psychotherapy. Not everyone responds to treatment in the same way. Prescriptions and dosing may need to be adjusted.

In people who have diabetes and depression, scientists report that psychotherapy and
antidepressant medications have positive effects on both mood and glycemic control. Additional
trials will help us better understand the links between depression and diabetes and the behavioral
and physiologic mechanisms by which improvement in depression fosters better adherence to diabetes treatment and healthier lives.

Treatment for depression in the context of diabetes should be managed by a mental health professional—for example, a psychiatrist, psychologist, or clinical social worker—who is in close communication with the physician providing the diabetes care. This is especially important when antidepressant medication is needed or prescribed, so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional that specializes in treating individuals with depression and co-occurring physical illnesses such as diabetes may be available. People with diabetes who develop depression, as well as people in treatment for depression who subsequently develop diabetes, should make sure to tell any physician they visit about the full range of
medications they are taking.

Anderson RJ, Lustman PJ, Clouse RE, et al. Prevalence of depression in adults with diabetes: a systematic review. Diabetes, 2000; 49(Suppl 1): A64.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)Web site: http://www.niddk.nih.gov

DEPRESSION AND HEART DISEASE


Get Treatment for Depression
Effective treatment for depression is extremely important, as the combination of depression and
heart disease is associated with increased sickness and death. Prescription antidepressant medications, particularly the selective serotonin reuptake inhibitors, are generally well-tolerated and safe for people with heart disease. There are, however, possible interactions among certain medications and side effects that require careful monitoring. Therefore, people being treated for heart disease who develop depression, as well as people in treatment for depression who subsequently develop heart disease, should make sure to tell any physician they visit about the full range of medications they are taking.

Exercise is another potential pathway to reducing both depression and risk of heart disease.
A recent study found that participation in an exercise training program was comparable to treatment with an antidepressant medication (a selective serotonin reuptake inhibitor) for improving depressive symptoms in older adults diagnosed with major depression.7 Exercise, of course, is a major
protective factor against heart disease as well.

Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine, 1999; 159(19): 2349-56
National Heart, Lung, and Blood Institute (NHLBI)Web site: http://www.nhlbi.nih.gov

DEPRESSION AND PARKINSON'S DISEASE

Treating depression can help people feel better and cope better with their Parkinson's treatment.
While prescription antidepressant medications are generally well-tolerated and safe for people with Parkinson's, more research is needed to determine which antidepressants work best for people with different subtypes of Parkinson's. Specific types of psychotherapy, or "talk" therapy, also can
relieve depression. Studies have demonstrated the improvement of Parkinsonian symptoms in
patients receiving electroconvulsive therapy. Although there are many different treatments for depression, they must be carefully chosen by a trained professional based on the circumstances of the person and family.

Treatment for depression in the context of Parkinson's disease should be managed by a mental
health professional—for example, a psychiatrist, psychologist, or clinical social worker—who is in close communication with the physician providing the Parkinson's disease treatment. This is especially important when antidepressant medication is needed or prescribed, so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional that
specializes in treating individuals with depression and co-occurring physical illnesses such as Parkinson's disease may be available. People with Parkinson's who develop depression, as well as people in treatment for depression who subsequently develop Parkinson's disease, should make
sure to tell any physician they visit about the full range of medications they are taking.

Cognitive and emotional aspects of Parkinson's disease. National Institute of Neurological
Disorders and Stroke, National Institute on Aging, and National Institute of Mental Health working group meeting, January 24-25, 2001. Unpublished summary

National Institute of Neurological Disorders and Stroke (NINDS). Web site: http://www.ninds.nih.gov

BIPOLAR DISORDER

What Causes Bipolar Disorder?
Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors
act together to produce the illness.

Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and
mind work and grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all
the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.

In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses,
does not occur because of a single gene. It appears likely that many different genes act together,
and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the
vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.

Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery
or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually
may be able to predict which types of treatment will work most effectively.

NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268.
Rockville, MD: National Institute of Mental Health, 1998.