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times they feel sad and don’t enjoy life. For some people the emotional pain

becomes so severe or prolonged that it becomes a problem. This is depression.

Because there seem to be different patterns of depression that respond to

Major

Depression is the most severe form of depression. It

symptoms are less intense than in Major Depression, Dysthymic Disorder

lasts for years. In fact the low mood and associated symptoms must be present on

most days for at least two years to qualify for this diagnosis. About 6% of the

several other important forms of depression. Adjustment Disorder with

Depressed Mood involves a drop in mood in response to a specific stressful

circumstance. Bipolar disorder involves low

mood periods similar to Major Depression, but with periods of elevated or

irritable mood as well. Depression can also occur as a biological reaction to

certain physical illnesses (e.g. strokes affecting the left frontal cerebrum,

hypothyroidism, pancreatic cancer) or to chemical substances (e.g. alcohol,

treatment depends on the type of depression. Patients with Major Depression

may be treated with medication, psychotherapy, or electro convulsive therapy (ECT).

The choice depends on the symptoms (severity and type), patient preference and

history of treatment response during prior depressive episodes. With more severe

forms of Major Depression it is generally necessary to use either medication or

ECT. Specific psychotherapies can be used along with medication, or as a sole

Major Depression are usually treated with medication (about 70% of people

respond well) or ECT (about 80% response rate). Psychotherapy may be an

important adjunct to treatment. Psychotherapy can help the person to decrease

Dysthymic Disorder have historically been treated with psychotherapy

alone. In recent years however, it has become apparent that more than half

(50-60% response rate) of patients with Dysthymic Disorder will respond to most

types of antidepressants[1].

Since the medications that have been available in the past 10-15 years are

relatively non-toxic, it is often worth trying antidepressant medication with

approaches to dysthymic disorder include Cognitive

Psychotherapy is based on the recognition that when

Psychotherapy investigates the ways in which problems

Psychotherapy explores the roots of adult dysfunction

Medications appear to work by increasing the

relatively safe and effective medications to treat depression became available

over forty years ago. These were the tricyclics antidepressants, named

for the presence of three rings in their chemical structure. They are just as

effective as the most recently marketed antidepressants. The primary effect of

most of the tricyclics antidepressants is to block the reuptake of

norepinepherine and/or serotonin, but in contrast to the ‘selective’

medications, their effects are more diverse. They frequently block effects of

other neurotransmitters like acetyl choline (causing dry mouth, blurry vision,

constipation, urinary hesitancy urinary obstruction, heart palpitations),

histamine (causing weight gain and sedation) and the a₁-adrenergic (norepinepherine)

receptor (causing low blood pressure on standing (dizziness, fainting and heart

palpitations) and sexual dysfunction). They can cause heart arrhythmias and

seizures (rarely in usual doses, but more commonly with overdoses). Thus, these

medications can be more dangerous than the more recently introduced

antidepressants, if taken as an overdose. This is of major concern since very

find medications with fewer and less serious side effects, led to the discovery

of other groups of medication that act more selectively. These include the

“selective serotonin reuptake inhibitors” or SSRI’s: fluoxetine (Prozac),

sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil) and citalopram (Celexa);

venlafaxine (Effexor; a selective serotonin and norepinepherine reuptake

inhibitor), trazodone and nefazadone (Desyrel and Serzone, “serotonin

modulators”), mirtazepine (Remeron, a serotonin and norepinepherine enhancer),

of antidepressants is the “monoamine oxidase inhibitors” or MAOI’s.

This group has been around about as long as the tricyclics antidepressants

(1950’s). They can be very effective antidepressants, and for certain people

can be the best treatment. But because of some potentially dangerous

interactions with a number of foods and medications, they are not usually tried

unless other treatments fail. They work by preventing the chemical messengers (serotonin

and norepinepherine) between nerve cells from being destroyed by the enzyme

monoamine oxidase. As with the other antidepressants, this increases the

strength of the chemical signal. The problem with these medications is that

there are a number of foods that contain a chemical, tyramine, which can raise

blood pressure if it is not destroyed in the intestines before it gets into the

blood stream. Normally the enzyme monoamine oxidase (present in the intestines

as well as the brain) destroys the tyramine before it can be absorbed. However

if a person takes the MAOI drugs, the enzyme is blocked and the result can be a

dangerous elevation in blood pressure. Many of the foods that need to be avoided

are high in protein and have been partially acted on by bacteria: aged cheese,

hard sausages (pepperoni, salami), pickled herring. Also several varieties of

wine and beer (but not distilled liquor) must be avoided. In addition there are

several medications that should not be taken with the MAOI’s, including

pseudoephedrine (Sudafed), diet pills with phenolpropanolamine (Dexatrim), and

the dietary and medication interactions, the MAOI’s have several possible side

effects, including reduced blood pressure, sexual dysfunction, weight gain,

to use as antidepressants these medications are also used to treat panic

(Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil) and

medications enhance the signals in nerves that transmit messages with serotonin.

The some common side effects include nausea, diarrhea, headache, anxiety,

insomnia or somnolence, tremor, sexual dysfunction, reduced motivation. When

these occur they are generally not dangerous, but annoying. In addition, some of

these SSRI’s are associated with a ‘discontinuation syndrome’ if they are

stopped abruptly. While also not dangerous, symptoms include nausea, anxiety,

insomnia and headache. This occurs most frequently with paroxetine, fluvoxamine

and venlafaxine (see below); it is much less common with sertraline, and rarely

to their use as antidepressants, SSRI’s have also been used to treat panic

disorder, bulimia, obsessive compulsive disorder, excessive anger/aggression and

(Remeron):  an

Bupropion (Wellbutrin): Its mechanism of

Nefazadone (Serzone): This medication seems

Venlafaxine (Effexor): In low doses (e.g. 75

antidepressants: Members of this group include imipramine (Tofranil),

amitriptyline (Elavil), doxepin (Sinequan), clomipramine (Anafranil),

protriptyline (Vivactyl), trimipramine (Surmontil), nortriptyline (Pamelor),

addition to the antidepressant uses of these drugs, one or more of them have

found use in treating: panic attacks ± agoraphobia (imipramine and clomipramine),

obsessive compulsive disorder (clomipramine), attention deficit disorder (imipramine),

primary incontinence (imipramine), neuropathic pain (doxepin, maprotiline,

amitriptyline), migraine headaches (amitriptyline and doxepin), bulimia (imipramine

and desipramine), generalized anxiety disorder (imipramine) and at times to

other anxiety disorders (doxepin), insomnia (amitriptyline and doxepine) and

two most commonly used members of this group are phenelzine (Nardil) and

tranylcypromine (Parnate). In recent years another MAOI, selegiline (Eldepryl)

has been used in low doses (5-10 mg) to treat Parkinson’s Disease. At these

lower doses it is selective enough that it does not required the dietary

restrictions needed with the others, however in the doses that are effective

treatment of depression (20-60 mg/day), the dietary restrictions must be

followed. Some side effects seen with MAO inhibitors include: low blood pressure

(feeling faint) when standing up, elevated blood pressure (if taken with certain

foods or medications), daytime sedation and/or insomnia at night, constipation,

Treatments:

Therapy (ECT): This

treatment can be highly effective for patients with severe depression. Some

studies show an 80% response rate for treating major depression with ECT[4]. Many studies comparing it

to antidepressant medication in major depression show it to be at least as

effective as medication, and possibly more so. The first reports describing the

effectiveness of this treatment came out around 1940[5].

Modern ECT takes place in a medical setting where careful monitoring of the

patient during treatment can take place. Prior to the treatments the patient

must be carefully evaluated to look for any complicating physical problems. At

the start of the procedure, a short-duration anesthetic is administered,

followed by medications to relax the muscles. The psychiatrist then positions

electrodes on the patient’s scalp and passes a current through them. This

produces a seizure lasting 30-45 seconds. Because a muscle relaxant is used,

there is generally little movement or chance of injury from muscle contractions.

Because short-acting anesthetic agents are generally used, the patient may begin

to regain consciousness within a matter of minutes after the treatment. The most

common side effects of the procedure include headache and transient memory

disturbances. Generally the patient receives two to three treatments a week,

with the end point being complete recovery or a failure to show further

improvement with additional treatments. It is fairly typical after the course of

treatments conclude to use antidepressant medication or periodic ‘maintenance

ECT’ to prevent relapse. The problem of memory disturbance has been studied in

detail. It depends to some extent on details of the treatment (electrode

placement, electric current wave-form, frequency of treatments) and of the

patient (advanced age, history of brain injury or brain disease). In general

memory problems resolve entirely over a few weeks to a few months. Studies have

perforatum) has been used extensively in Europe to treat mild-to-moderate

severity depression. In Germany it accounts for 25% of antidepressant

prescriptions. Attempts have been made to standardize this herb (e.g. 300 mg of

plant extract containing 0.3% Hypericine). However, because it is not know what

the active ingredient might be, there is really no way to know precisely the

potency of a given batch. Most of the studies done on St. John’s Wort have

been poorly designed (often vague or broad criteria for depression and for

treatment response, lack of a placebo control group, comparison to low doses of

pharmaceutical antidepressants). There have been some more recent studies that

have attempted to address these shortcomings. Some of these studies show equal

efficacy to prescribed antidepressants)[6]

while others indicate St. John’s Wort is less effective[7].

Some cautions now exist about the use of St. John’s Wort. It must be

remembered that even though it comes from a flowering vine, St. John’s Wort is

a drug. In addition to the fairly common side effect of nausea, it is known that

St. John’s Wort hastens the metabolism of certain other drugs, thereby

reducing the amount of the other medication in the patient’s body. These drugs

include oral contraceptives, theophylline, cyclosporine, warfarin and the AIDS

drug indinavir . The use of St. John’s Wort by patients depending on these

medications can reduce the medication’s effect (which in some cases could be

disastrous: at least two cases of incipient heart transplant rejection have been

traced to the use of St. John’s Wort by transplant patients taking the

anti-rejection drug cyclosporine). It may well be that St. John’s Wort will be

shown to be an effective treatment for mild or moderate depression. However as

we have discovered with all powerful and effective medications, there are

inevitably some risks that must be known and understood to use the medication

For some people, depressive episodes occur