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Time to get up
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Symptoms of depression have long been confused with sleep disorders or anxiety. In many cases, patients don’t get the right medication or treatment, and consequently, they never fully recover. But with research and experience, and as people become more willing to talk about depression, doctors are learning how to recognize, diagnose and treat this disease to help people get on with their lives
By Paige Debergo
Time to get up
Symptoms of depression have long been confused with sleep disorders or anxiety. In many cases, patients don’t get the right medication or treatment, and consequently, they never fully recover. But with research and experience, and as people become more willing to talk about depression, doctors are learning how to recognize, diagnose and treat this disease to help people get on with their lives
By Paige Debergo
Major Depressive Disorder affects three million Canadians, mostly in their early 20s and 30s, and by 2020, the World Health Organization predicts that major depression will be second only to heart disease as a cause of disability. Perhaps more disturbing, a June 2003 report by the Canadian Mental Health Association states that, “Whereas youth had the lowest levels of mental distress in the population 20 years ago, they now exhibit the highest levels. Canada’s youth suicide rate has increased 300 per cent in the last 30 years.”
Research into depression and finding solutions for it have prompted the creation of increasingly specialized drugs. The last generation of medications to make strides in combating depression, drugs such as Prozac and Zoloft, are known as Selective Serotonin Re-uptake Inhibitors (SSRIs). They work with fewer side effects than older tricyclic antidepressants. Now, a new generation of medications, such as Remeron, is making its way to the marketplace with even fewer side effects, and with the added ability to tackle multiple symptoms within a single medication.
To find out why this multi-symptom approach is important, and to gain a better perspective on depression, The Health Journal talks with four physicians about recognizing and treating depression today: Dr. Roger McIntyre, psychiatrist and head of the Mood Disorders Psychopharmacology Unit with the University Health Network in Toronto; Dr. Peter Lin, medical director at the University of Toronto Health and Wellness Centre in Scarborough; Dr. Brian Bexton, psychiatrist and psychoanalyst at the Affective Disorders Clinic at the Sacré-Coeur Hospital in Montreal; and Dr. Colin Shapiro, psychiatrist and head of the Sleep and Alertness Clinic with the University Health Network in Toronto.
The Health Journal: Who is affected by depression in Canada?
Dr. Roger McIntyre: It is currently estimated that the lifetime prevalence of depression is approximately 10 per cent. This is a sizable percentage of Canadians — if you look at absolute numbers it’s about three million people who will suffer from this illness at some point in their life.
THJ: Do gender or genetic factors play a role in depression?
Dr. Brian Bexton: Depression, like many illnesses, has a familial pattern. So if you have a member of the family who has depression, other members of the family are two to three times more likely to have it also. If a parent is ill with depression, a son will have ten to 12 per cent chance of also getting depression. Because depression is more frequent in women, particularly during the fertile period of their lives, it goes up to 20 or 25 per cent for daughters.
RM: It is disconcerting that over the past 10 years there’s been an increased awareness of a trend insofar as the age of onset for mood disorders may be earlier and earlier. We are seeing more adolescents and people in their early 20s affected.
THJ: What is the difference between ‘the blues’ and clinical depression?
RM: Everyone goes through some period in their life after stress, or a loss, and so on, and may have periods of downcast that last days, maybe a week or two. Generally speaking however, the blues are transient and do not translate into functional difficulties.
People who have depression have longer periods of mood disturbance. They also have difficulties in other areas of their life, for example, problems with sleep, problems with their energy, terrible trouble with enjoyment from day to day activities. So the key distinction is duration and the severity.
THJ: How do external stress factors such as SARS or terrorist attacks affect depression?
Dr. Peter Lin: Certainly external factors will highlight the fact that you are vulnerable to depression. To separate the genetic versus environmental factors, take this example. Say perhaps genetically you are born with light skin, and when you go out into the sun you get sunburned. If you have genetically darker skin and go out in the same sun, you might not have any problem at all, you may just tan. Depression is the same way — clearly there is a component of genetics here and in some cases the external environment is just highlighting the fact that you are at risk.
THJ: Since clinicians must rely on symptoms, rather than a test to diagnose depression, what are some of those symptoms?
BB: First of all you have either a depressed mood or a decrease in interest or pleasure of activities for a period of at least two weeks. Sleep changes are also very common in depression; people may have trouble getting to sleep, they may wake up in the night, they may wake up early. Some people may stay in bed for 12 or 14 hours and when they get up they are still tired. I ask patients to rate their energy on a scale where 100 per cent would be normal and patients will say, “30 or 40 per cent.”
Some patients may be agitated, or have increased anxiety. Some are slowed down. Other symptoms are changes in appetite, people have problems in their concentration, feelings of worthlessness, feelings of guilt. Also, a lot of patients think about death. About 60 per cent of patients think about death; thoughts like, “What’s the point of living? What’s the point of going on?” And about 15 per cent of patients will either attempt or complete suicide, so it’s very important to look at that.
THJ: Are sleeplessness and anxiety indicators of a clinical depression?
Dr. Colin Shapiro: They certainly are components of clinical depression. I think they are two symptoms that are often overlooked. People sometimes think their sleeplessness is for some reason other than depression.
In addition, the concern when these factors are present is emphasized by the fact that if there is sleeplessness or there is anxiety amongst the depressed population, the rates of suicide are in fact higher. And so it is of particular concern that these two symptoms should be well treated, better than averagely treated, and are often under-treated or under-evaluated.
THJ: Can sleeplessness and anxiety be mistaken for another condition or overlooked as symptoms of depression?
CS: I think very often patients don’t give more of the psychological components of the illness to their family physician, they emphasize their physical components. And so the sleeplessness becomes confused and not recognized as part of the depressive illness.
RM: I work in a mood clinic and I’ve been struck by how many people get referred for sleep problems. And we go back and forth on this. Sleep difficulties remain not only a valid target, but an area of concern for patients that affects quality of life.
THJ: What are the primary goals of treating depression?
BB: We treat depression in several aspects; one is the biological component of depression, another is the psychological. It’s very important to treat depression with both psychotherapy and with medication because that is the best treatment. What we are looking for ideally is to achieve a remission and recovery from the illness. Also, once we achieve recovery and remission, we want to get normal functioning back and prevent relapse from occurring.
RM: As recently as two decades ago we thought this was a disease with a generally good outcome, but now there’s been a paradigm shift — we now conceptualize depression as a chronic disease state. People have this disease for the rest of their life. Importantly though, it is a treatable illness.
PL: We used to use the marker of saying, “How are you feeling?” which is how we would start the treatment. [The patient] would say, “I feel better” and we were very happy and would stop there. So were they better? Yes, better but they were not back to being normal.
This new concept is to treat [patients] all the way into a remitted state in which they are better, they’re functioning, they’re going back to work, they’re interacting with people. I think that has changed for us and I that’s a message that’s very useful for patients to hear.
THJ: What are the differences among the medications used to treat depression?
PL: I tell patients that in the olden days it was a shotgun approach; with the older type, tricyclic antidepressants, we would just shoot it in there and people would get better but the side effects were terrible because we were affecting everything. We got rid of a lot of that when we went to the one molecule that acts on serotonin by using SSRIs.
Now I think I’m seeing the research heading back out logically and more specifically. By doing that we can create sort of quasi-designer drugs, like Remeron, that will treat the depression but it may also help with sleep and anxiety, and get rid of the nausea and sexual dysfunction because we know that those side effects are issues.
That’s the excitement of where the research is now, because we’re actually getting smarter about how we tweak a very complex brain system.
THJ: What are the concerns around adequate treatment of persistent sleeplessness and anxiety among depressed patients?
CS: I think that is a concern — that many patients get a partial treatment and are sub-optimally treated. Some features of their depression may be resolved, but others such as sleeplessness or anxiety aren’t really dealt with.
In such situations, physicians add a second medication. There’s research, for example, from Texas that a third to one half of people on some antidepressants get another drug in addition.
There are a number of problems with that, not the least of which is that it doesn’t really optimally treat the underlying problem. It doesn’t really help the patients fully recover.
The other problem is that patients don’t always take all the medications they are supposed to and so there’s an issue with non-compliance. There’s a great desirability to have a single agent that deals with all of these components at one time.
THJ: What are the consequences of sub-optimal treatment?
CS: I think one is perpetuating the disease state. There is now a lot of evidence to support the idea that if you don’t resolve, for example, the sleeplessness component of depression, you set up a trail of events that leads toward a greater chance of relapse.
THJ: How well equipped are family physicians to accurately diagnose depression?
PL: I think, for the most part, busy family doctors are trying their best but we’re still missing the diagnosis, mainly because about 80 per cent of patients will come in with a physical complaint. Patients will talk about their bowel because they’re embarrassed about depression, and probably they do have a valid physical complaint. We know that the nervous system that controls your bowel is connected to the rest of your brain through your autonomic nervous system, so therefore if you have dysfunction in your brain it really can cause physical symptoms. But as family doctors we end up chasing a lot of physical symptoms.
Even if they come in with a psychiatric complaint, most of the time patients say, “I can’t sleep” or, “I have lots of anxiety and I can’t cope.” We start chasing off the anxiety by prescribing an anti-anxiety medication; then we prescribe something like benxodiazephine for sleep disturbance, but when you see that scatter of symptoms or anxiety or sleeplessness, think about depression first. Treating that will have far more benefit than treating each of the symptoms separately.
THJ: How can patients help family doctors who are often the first point of contact for a depressed individual?
PL: If they could [not be afraid to tell us how they’re really feeling] such as, “I’m feeling really anxious and a little bit down as well.” That’ll tip us off to go and not chase something else. The other thing is that family members or anybody else who can give us collaboration on symptoms would be useful. If they come in and say, “Mom has not been getting up in the morning and she’s been moping around.”
THJ: What are some of the lifestyle choices physicians can counsel their patients on to bring about long-term improvement?
BB: It is very important to have psychotherapy, to treat the psychological and not just the biological aspects. Then lifestyle changes such as a good diet and also getting patients to be physically active. We know that people who are physically active have fewer depressive episodes than those who are not active.
CS: My early research was on athletes and the effect on their sleep. And it’s true that the more physically active you are the more deep sleep you have and I suspect there is a lot of benefit. It’s been shown that even if you get a healthy person to do moderate exercise two to three times a week, it improves sleep quality as well as mood.
Paige Debergo is a freelance writer living in Toronto.
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