As described previously, depression has neurovegetative signs. These include:
- sleeping too little or too much
- problems with poor concentration
- low energy
- problems with memory
- feeling hopeless, helpless and/or worthlessness
- feeling suicidal or violent
- getting no pleasure from life
- having decreased sex drive
- being withdrawn
In this first blog on medication I will talk about SSRIs, or serotonin reuptake inhibitors. (The SSRIs are a group of medications that block the reputake of serotonin, a neurotransmitter.) This has the effect of improving depression after 5 to 6 weeks. In the depressed state, the level of serotonin is low, and by blocking the reuptake, it increases the perceived amount.
These medications include:
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Luvox (fluvoxamine)
- Celexa (citalporam)
- Lexapro (escitalpram)
- Paxil (paroxetine)
All of them are now available in generic form, and a decision to choose one would be made between the doctor and the patient.
In each case, the medication works as follows:
- In the first 2 weeks, sleep and appetite improve
- In the third, fourth, and fifth weeks, concentration, energy, and memory improve
- In the fourt to twelfth weeks, anxiety and depression begin to improve. So other symptoms get better before the mood and anxiety improve.
This is true with the entire class of medication.
At this time of year it is very common for people to feel sad about painful losses in their lives. This includes the deaths of loved ones:
One remembers that this is the anniversary of the time that they did not have them in their lives during Thanksgiving and Christmas. On some occasions this is merely a transient phenomenon that passes after the holidays, but in many cases the patient requires some kind of individual treatment.
This is called bereavement, which may lead to depression. A number of patients become acutely depressed, stay depressed, and require medication and therapy to handle the situation. Another part of the problem is that people feel they should be happy and joyous during this time and feel angry and upset that they do not feel the good feelings. This is a far more common problem than it was thought to be, and a lot of people do not seek the treatment they need.
Still another problem is that people say, “Well, I will just wait until after the holidays to see if I feel better and not need treatment,” thereby going through the holiday season feeling bad.
I do not believe there is an advantage to suffering unnecessarily for those who need treatment with medication and therapy. They should seek it as quickly as possible. Sometimes talking about the problems and revisiting the losses will be all it takes to put things in perspective, but sometimes people have vegetative signs of depression, and they may require medication intervention.
The inability to think, concentrate, and make decisions are prominent. Distractibility, memory difficulties, inability to concentrate on intellectual activities can be prominent. Children show a drop in grades reflective of poor concentration, and elderly individuals show memory difficulties, which may be mistaken for signs of dementia and are often called pseudo-dementia. The pseudo-dementia or memory problems will clear up if the patient is depressed and the antidepressant the patient is prescribed is effective. It is worth noting however that sometimes major depressive episodes are really a harbinger of irreversible dementia.
Suicidal thoughts, thoughts of death, and suicide attempts are frequent. Some patients have only brief, fleeting thoughts of this nature, but others have more serious plans and even make attempts, sometimes requiring hospitalization to protect the patient.
On some occasions a patient will present with delusional material, feeling the world is coming to an end, or they are responsible for the world’s problem. Often they cannot be talked out of this situation and may require special treatment. In general major depressive disorder is treatable with medications and therapy. The in the case of psychotic reaction, and antipsychotic may be necessary as well as an antidepressant.
In addition there are cases where the depression is due to alcohol intoxication, hypothyroidism, steroid exposure, or toxin exposure. These have to be ruled out as medical causes of a depression to delineate whether this is a true psychiatric illness.
Patient often present with anhedonia, which literally means “without pleasure.” They have lost interest in or have little pleasure in the activities that they previously enjoyed. Hobbies, for example, are not practiced anymore. Social withdrawal and isolation are prominent. Sexual desire decreases markedly.
A child may not want to play sports or be with friends. An adult who had hobbies that he or she enjoyed ceases to practice them, saying they no longer have any interest.
When patient present with these symptoms, they almost all agree that they are “just existing” and not really living.
I strongly encourage them to become more active. In particular I recommend doing sports activities including walking to get their heart rates up and a good sweat going. This will cause a release of endorphins, naturally occurring chemical substances that provide a sense of pleasure and joy. They are naturally occurring and do not have side effects. After a hard workout and a shower people will have good feelings that will last 4 to 6 hours. Endorphins improve focus, mood, concentration, and energy.
It is worth noting that a patient with depression may be either agitated or show psychomotor retardation. The agitation is consistent with being unable to sit still, pacing, hand-wringing, or rubbing skin or clothing. On the other hand it may show slowed speech, thinking, and body movements, pauses before answering, and decreased speed in speech. The inflection, amount, variety, or volume of speech may also be slowed and decreased.
Lower energy and fatigue are common. The person may feel tired even without exertion, and the smallest tasks require substantial effort. The time to complete these tasks may be extended. Even activities of daily living such as cleaning, washing, eating, and showering may take up to twice as long as usual, and indeed, the person has trouble getting out of bed.
Guilt, worthlessness, hopelessness, helplessness, and uselessness may all be part of the depressive picture as well. Self-blame or “being hard on oneself” may also be experienced. Strikingly, blaming oneself for the illness is a very frequent occurrence. A lot of people feel that their depression is something they can control by willpower, and that they are being weak or morally inferior by not being able to control it. This is a feature that may only lift as the depression lifts.
The person with a major depressive episode often describes himself as depressed, sad, hopeless, discouraged, or “down in the dumps.” If a person denies being sad it is sometimes useful to point out that the patient looks as though he is about to cry. Sometimes people complain of having no feelings or feeling anxious, but the depressed mood can be observed in a patient’s facial expression and demeanor. Some people have somatic (meaning body pains) rather than feeling some sadness. Many complain of irritability (see my blog on irritability from April 27, 2012) or an exaggerated sense of frustration (see my blog on frustration from June 4, 2012). These are called neurovegetative or psychosomatic symptoms. One feels an assault on one’s personal narcissism (see my blog on narcissism from May 11, 2012). As noted before, anger, irritability, and difficulty tolerating frustration may all be part of a biological and psychological component. Medications can be helpful as can psychotherapy.