While many people suffer from this disorder, clinical depression is often not well understood by many in the general population. By “Clinical Depression” we mean a chronic, disabling constellation of feelings of fatigue, sadness, worthlessness, and even desire for death, lasting longer than a couple of weeks, and which is not clearly started by a precipitating event (e.g. death of a loved one or breakup with friend) or which lasts very long after such an event (e.g. months). Affected individuals often cannot explain why they are feeling depressed, and other friends and relatives around them may also misunderstand such behavior and thus suggest “Just get over it!” If the affected individual is to have a meaningful life, clinical depression requires proper diagnosis and personalized treatment.
We are focusing this discussion on Unipolar Clinical Depression. The term “Unipolar Clinical Depression,” distinguishes this disorder from bipolar disorder in which the affected individual has unexplained changes in personality alternating between euphoria, restlessness and hyperactivity/anxiety, and depression.
Diagnosing Clinical Unipolar Depression:
Certain symptoms should serve as warning signs to alert that clinical depression could be at play. These include fatigue, extensive sleep, inability to get up and perform daily activities (e.g. study for school, hold a job, take care of dependents). They may also include feelings of sadness, worthlessness, loss of pleasure or interest in most previously favorite activities, decreased ability to think, concentrate, or make decisions, and feeling that one might be better off dead. There are several screening tools which may indicate the possibility of clinical depression. The most commonly used screening tool is the Patient Health Questionnaire- 9 (PHQ-9) survey (examples can be found online, e.g. https://www.mdcalc.com/phq-9-patient-health-questionnaire-9#next-steps ). This asks and scores the answers to several questions related to depression symptoms. The aggregate score is an indicator of the degree of depression. However, although this may give you an indication, a health professional should always be consulted for a final diagnosis, especially since no one symptom is specific for depression which manifests in different ways in different individuals. You may have to ask your healthcare provider to evaluate you for depression since some do not routinely screen for this. Also, there are multiple types of depression and combinations with other mental disorders that require a mental health professional to sort out.
General Treatment for Depression:
It is important to recognize that clinical unipolar depression is not necessarily a fatal disease; many highly capable individuals (including former President Abraham Lincoln) were able to cope with this disorder and still lead very meaningful lives. So, if you think you have clinical depression, seek a formal diagnosis and if positive, get personalized treatment. The goals of treatment are to restore you to functional, self-sustaining ability and a meaningful life. Treatment should also allow you to better manage this disease. The major forms of treatment (which are often used in combination) are:
- Psychotherapy: This is done by behavioral health specialists such as psychiatrists, psychiatric nurses, psychologists, or mental health social workers (LMSWs). The aim is to provide you with a better understanding of your condition (e.g. what things make it worse vs. better) and provide you with multiple coping skills. Here it is important to identify a therapist with whom you can have an good, long-term rapport, and you may have to meet with multiple therapists before settling on the one that is best for you. Similarly, each therapist has several psychotherapy approaches, and together you may have to try multiple ones before settling on the approach which works best with you. For example, cognitive behavioral therapy (helps you to change unhelpful thought processes and develop personal coping strategies) works for some individuals but is not the best approach for others.
- Medication: In this modern era, we are blessed with having several anti-depressant medications available which one can try. Again, not every medication (or dose of a particular medication) works for everyone, and you will likely have to try multiple medications and doses before settling on the best regimen. It is especially important to understand that these medications usually do not render immediate beneficial effects. It may take weeks on a particular medication before you feel any improvement (usually 1-2 weeks at a minimum). Also, some of these medications have side effects (some serious) which you and your healthcare provider should be on the lookout for, especially in the early stages of taking a new medication. Some medications may even increase the risk for suicide for some individuals. So talk to your doctor right away if it exacerbates your symptoms. You may need to switch medications due to such side effects (see also our blog on “Tips on Taking Medications”).
- Electroconvulsive therapies: These are specific electrical brain stimulating therapies which are often reserved for cases in which the above two general therapies are unsuccessful. Methods have greatly improved over the early trials of such treatments many years ago, and this can now be performed under well controlled, safe situations. However, this does not work for everyone, and some may have only transient relief.
- Other treatments or additions to the above approaches which may be helpful: Performing various relaxation techniques and regular physical exercise may also help many (but not all experience mental health benefits). Both are good for overall health, independent of dealing with depression. And do not forget giving priority to those activities which used to give you pleasure (e.g. music, dancing, hobbies). Finally, scientists and doctors are continuing to research depression, and more effective treatments may be on the way.
Your mental health provider may want to periodically measure your improvement, using survey instruments such as the PHQ-9 mentioned above. Over time both of you will hopefully identify what single or combination treatments work best for you individually.
NOTE: It is very important that you also get a full medical workup to assess your physical health since there are many disorders not directly associated with the brain which can mimic depression (e.g. severe anemia, thyroid disease, heart disease). Rarely some physical brain disorders may be at play. Many primary care physicians can diagnose and manage mild forms of clinical depression. However, if you have a separate mental health provider, it is also especially important that your physical health and mental health providers communicate with each other since your physical health can affect your mental health (and vice versa). Also, some medications used to treat physical conditions such as heart disease, may promote depression as a side effect. Thus, a thorough review of all the medicines you are taking is particularly important. Finally, do not forget that drug dependency (e.g. alcoholism) can cause treatable depression. Similarly, the use of alcohol or illicit drugs (e.g. heroin, cocaine, opiates) can make your depression worse.
Don’t give up hope:
It may take a while to diagnose and identify the treatment which works best for you so be patient. Also, many of the people you interact with will not understand what you are really going through. There are several books available to help explain to them the nature of clinical depression (e.g. “Undoing Depression” by Richard O’Connor). In the meantime, if you feel yourself spiraling down and becoming suicidal, please reach out for help. If suicidal or experiencing an acute mental health crisis, please call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TYY: 1-800-799-4TTY (4889) or the National Suicide Prevention Lifeline website: https://www.uptodate.com/external-redirect.do?target_url=http%3A%2F%2Fwww.suicidepreventionlifeline.org%2F&token=Or7v6ARWAbZn5SccEnrdvHwhSdzQ5%2FzYISwtFHqat7NV22%2Be2BoqmPi4HRy5AOzPaimq849SRlcl8bAuvaNl5A%3D%3D&TOPIC_ID=15342 . Severe depression requires more intensive treatment. You may require some short-term hospitalization (as with other physical disease flare-ups) to get you back on track. There are plenty of people you can reach out to for help, including members of our Take CHARGE Team, via our Mental Health Consultation page.
For more general information on depression, you may visit the National Institute of Mental Health Website: https://www.nimh.nih.gov/health/publications/depression/index.shtml
By David Gordon and Albert Ujkaj
Take Charge of Your Health, LLC