By Gregory S. Liptak, MD, MPH
University of Rochester Medical Center
SBA PAC Member 

It's normal to be sad or blue or anxious once in a while-it happens to everyone. But when depression begins interfering with your life, and it doesn't go away on its own, you probably need medical treatment. How do you distinguish the sadness or nervousness that's simply an occasional, inevitable part of the human condition from depression or anxiety that requires intervention and treatment? Sometimes it's not so easy. For example, let's look at two teenagers and what's going on in their lives. 
 
Making a Diagnosis  
Annie* is a 15-year-old girl who has lumbar-level Spina Bifida with shunted hydrocephalus. Her grades have been going down, she is having trouble sleeping, and has headaches. Her parents say she's been irritable lately. What else do we need to know? Does she have friends? Yes. And she still enjoys good relationships with her friends. Her headaches occur mostly in the evenings. She is not experiencing any vomiting or changes in her vision. She does mention being unhappy at school because some boys are teasing her. But Annie says she is not depressed. She looks a little worried, but she still smiles and jokes around occasionally. She does sound a little depressed, but a CT scan uncovered her real problem: Annie needs a shunt revision. This illustrates the first step in treating depression: Rule out physical causes first. There are medical conditions that cause depression, such as shunt malfunction, a severe infection, and some medications. Once the underlying medical condition is remedied, the depression disappears.
 
David* is an 18-year-old boy who, like Annie, has been having trouble in school. In fact, he dropped out of college after failing a few courses. His appetite is poor and he has little energy. David spends most of his time sitting around watching TV, feeling guilty about his college failure. Although David had friends in high school, he didn't know anyone at his college of choice and so now he has almost no friends. His parents are loving and supportive. Self-care is becoming a problem-David isn't taking care of his skin and is not bathing or taking his medications regularly. He no longer enjoys hobbies and activities that used to bring him pleasure. David does not maintain good eye contact and doesn't joke around the way he used to-he exhibits a somewhat flat effect. The diagnosis? Depression. After three weeks on Paxil, an antidepressant, David's symptoms improved markedly. 

*Not their real names.

In diagnosing depression, knowing the patient's history is crucial: health problems and conditions, medications, family history, and current environment. Is there a family history of depression? What is happening at home? Is the patient isolated, or does she have lots of friends? Does he find pleasure in activities that are normally enjoyable? Does the patient sleep well?  

Doctors can also learn a lot from their interactions with patients. Does the person look depressed? Does she make eye contact?

If depression is suspected, start by asking two questions:

1. During the past month, have you felt down, depressed or hopeless?
   
   
2. During the past month, have you been bothered by little interest or pleasure in life? 

If the person answers yes to either or both questions, further screening is indicated. And sometimes you can learn a lot by asking one simple question: Are you depressed? It's amazing how few doctors ask people whether they're depressed, and if so, whether they've thought about suicide. These are very important questions to ask.

For parents, the most telling question may be: How is this affecting my child's functioning? Does she sleep well? How is his appetite? Is he or she interested in things that used to interest him? Is she able to go to classes, do her homework, study, and concentrate? 

Symptoms of Clinical Depression
Everyone has experienced sadness and anxiety. But clinical depression and anxiety have more symptoms, the symptoms are more severe, they last longer-and they generally don't go away on their own. Clinical depression interferes with day-to-day functioning. People who are clinically depressed don't do what they used to do. The symptoms of depression may affect activities, motor abilities, appetite, and sleep.  Most people with depression exhibit reduced appetite, although some people, often teens, tend to overeat, especially sweet or high carbohydrate foods. Chocolate actually contains a small amount of an anti-depressant, although you would have to eat quite a bit to feel the effects. Insomnia is common in people who are clinically depressed, and may take different forms. Some people can't get to sleep, some can't stay asleep, some wake continually throughout the night, and others wake up too early and can't get back to sleep. People who are depressed often exhibit psychomotor agitation-pacing, wringing their hands, tugging at their clothes-and may seem restless all the time. Or there may be psychomotor retardation-meaning speech and thinking are slow, as if the person were moving in slow motion.

What Causes Depression?
There are more theories than facts about the causes of depression. We know that depression is linked to families. If one person has depression, his first-degree relatives (immediate family) are much more likely to also have depression at some time. With identical twins, if one is depressed, the likelihood of the other twin also being depressed is 46 percent. So family history is very important.
 
Probably the most well accepted theory right now is that depletion or dysregulation of certain neurotransmitters causes depression. Neurotransmitters are chemicals that send signals from one nerve to another. Although many neurotransmitters have been found, medical research has identified three in particular that control our moods-norepinephrine, serotonin, and dopamine.

Depression is more common in women, probably due to hormonal differences. There are some studies showing increased incidence of depression in people with Spina Bifida. Young people with Spina Bifida are at higher risk of depressed mood and lower self-worth, and are more likely to think about suicide. People with Attention Deficit Disorder (ADD) have a higher incidence of depression, possibly from repeated school failures, self-esteem issues or even due to a chemical imbalance-no one knows for sure. People in northern climates tend to experience more depression, especially in winter. 

Stress is associated with depression. Under stress, the hypothalamus secretes corticotropin-releasing hormone (ACTH), which increases the level of cortisol in the blood. This causes the body to produce adrenaline to support a "flight or fight" response, which is the body's natural reaction to danger. The problem is that under chronic stress, our systems become more sensitive to smaller amounts of stress, which affects the balance of chemicals in our bodies, thus increasing the risk of depression. Not surprisingly, depression is more common following a significant loss of some kind.

Low self-esteem is associated with depression, which is one reason why people with Spina Bifida are more likely to be depressed. Other psychological risk factors for depression include decreased social support and isolation. Learned helplessness-where someone feels, rightly or wrongly, that there is nothing they can do to improve their situation-may be a component of depression. For example, imagine an 8th grader who tries hard to make friends, but none of her efforts are successful. After a while, she quits trying and gives up. And even after starting at a new school with all new kids, she doesn't try to make friends, because she has learned to be helpless. 

Anxiety: Sister to Depression
If someone is anxious, they're also much more likely to be depressed, and the reverse is also true. Many of the medications used to treat depression are also used to treat anxiety. Like depression, anxiety tends to run in families. Symptoms of anxiety include feeling tense or fearful, a sense of dread, panic or even terror. People who are anxious may be worried all the time. Anxiety interferes with concentration and tends to result in a preoccupation with self. 

Symptoms of obsessive-compulsive disorder (OCD) include repetitive, purposeful behaviors that serve to reduce anxiety. Dr. Liptak recommends the book Just Checking, written by a young woman with OCD. When people would talk to her, she would count their words. Like depression, severe OCD behaviors eventually interfere with functioning. 

How to Treat Depression
There are many ways to treat anxiety and depression. Many studies have shown that exercise alone can have a profound effect; so one healthy response to depression is to increase exercise. Wheelchair-based sports programs are great, providing both physical activity and social contact. Hippotherapy-horseback riding (link to Overview on Therapeutic Riding in About SB) -is lots of fun and stretches the muscles and joints as well.

Medications and counseling may both be indicated. Counseling can be crucial, especially if the person has low self-esteem or learned helplessness. Sometimes it's very helpful for the entire family to receive counseling. Medications alone won't improve self-esteem or eliminate behaviors based on learned helplessness.

The medications of choice today are the SSRIs (selective serotonin reuptake inhibitors), which include Prozac, Paxil, Zoloft, Effexor, and Serzone. Each has its unique potential side effects, which can sometimes be severe. A word of caution: Don't stop the drugs suddenly; taper off. Abrupt discontinuation can cause dizziness, fatigue, headache, nausea and/or insomnia. That there is considerable evidence that St. John's Wort actually works, at least for adults. He notes two caveats, however: If you use complimentary treatments like herbs, make sure you research the area and buy from a reliable company. If you are taking St. John's Wort, be sure to tell your doctor before taking prescription antidepressants.  They should not be taken at the same time.

How long do you treat depression with medication?
The answer is that it depends. For someone who is experiencing depression for the first time, it makes sense to treat it actively for around six to eight weeks and then taper off the medication. 

For someone with a history of depression who has a difficult home environment, low self-esteem or isn't taking care of themselves very well, medication and counseling are both indicated and typically should continue for at least three to four months. Depression can be very different for different people, but generally, doctors don't want to medicate anyone for over six months, although there are cases where treatment can extend into years. 

Get Help
If you or someone you know seems to be depressed, talk with a doctor or nurse about it. Depression and anxiety are very treatable. If your health care provider doesn't react appropriately when you bring up concerns about depression or anxiety, you might want to think about finding a more responsive one. 

This information does not constitute medical advice for any individual. As specific cases may vary from the general information presented here, SBA advises readers to consult a qualified medical or other professional on an individual basis.