Bluer Than Blue

Winter can be a time of darkness in more ways than one.

Being a cheerful Granite Stater in mid- to late-autumn can be a challenge. The foliage is gone, winter’s darkness looms and holiday pressures mount. It’s particularly tough in 2008, after we’ve endured months of bleak economic news. Since bouts of feeling blue are a normal part of human existence, how do we know when to seek help in coping with sad or discouraged feelings?

Depression is one of the most widespread mental illnesses, affecting nearly one in 10 adults each year, according to the American Psychiatric Association. Believed to be caused by genetic, biochemical and environmental factors, as well as personality tendencies such as pessimism and low self-esteem, depression is more common in women than men, but can touch just about anyone, from the very young to the very old.

Clinical depression involves pervasive depressed feelings that last for at least two weeks and interfere with a person’s functioning, says Marc Sadowsky, M.D., a psychiatrist at Southern New Hampshire Medical Center and New England Neurological Associates in Nashua. Depressive illness symptoms vary in severity and duration – sometimes lasting for years – and include sad mood, inability to experience pleasure, impaired concentration and decision making, sleep disturbance, changes in appetite or sleep, decreased energy and, at the extreme, recurrent thoughts of death or suicide.

Depression can also involve social withdrawal from friends and family and low self-confidence, says Ann Phillips Hotchkiss, Ph.D., a psychologist at Chestnut Hill Counseling Associates in Dover. It can show itself as anger or frustration, focusing on self-blame or blame of others or situations. The presentation of depression can be quite different in men than women, Hotchkiss says, and men are more likely than women to turn to drugs or alcohol in an attempt to deal with or mask depressed feelings.

The lowdown on treatment

The use of antidepressants to treat depression is controversial, with some arguing that medications are too often used as an attempted quick fix, one that poses potentially dangerous side effects, including increased suicidal thoughts among children and adolescent patients. Some adult patients, swayed by heavy pharmaceutical company marketing, go to their provider and ask directly for antidepressant medication, Hotchkiss says: “They see the ads on TV and kind of figure that that’s the treatment of choice.”

Sadowsky says that medication can be very effective in the right circumstances, although the risks are still not fully understood. “I suspect that there’s a subpopulation that is vulnerable to [medication side effects] and at this point we don’t have a good way of distinguishing who is in that population,” he says.

A combination of medication and cognitive behavioral therapy, which is a type of psychotherapy, is often considered the most effective treatment for depression. Receiving psychotherapy while taking an antidepressant, in addition to its therapeutic benefits, allows the therapist to monitor the patient’s response to medication. Experts caution that it’s especially important to frequently follow-up on any adolescent or child who has been prescribed an antidepressant, and to give parents specific instructions on behavioral changes to watch for. “Parents become key allies in the treatment of depression in a child,” Hotchkiss says.

Mild cases of depression often respond to psychotherapy alone, Hotchkiss points out. “I would say it’s seldom advisable to be on a medication alone if a person has never had psychotherapy. Sometimes a person has had psychotherapy and they’ve learned a number of skills [but] they still need to deal with something that’s a biologically- based depression. In that case they may need to continue on medication but have learned some cognitive and behavioral tools that they can implement on their own.”

Since depressive illness can interfere with a person’s awareness of the negative, Hotchkiss says, depression-related psychotherapy often involves examining cognitive patterns, identifying and changing negative thinking patterns and acquiring a set of behavioral skills to combat the depression. Those skills might be relaxation techniques or engaging in new activities.

Clinical-level depression, if untreated, will generally last three to six months or longer, says Hotchkiss. If you suspect you might be clinically depressed, it is usually advisable to visit your primary care doctor to rule out a purely medical problem before moving on to depression treatment.

Unfortunately, in the state of New Hampshire as elsewhere in the country, there are more people seeking psychiatric care than there are professionals to provide the services, so the wait to see a psychiatric professional can be quite long, Hotchkiss says. In such cases it’s not unusual for a primary care physician to prescribe a medication, with follow-up and continuing services provided by a psychiatric caregiver. NH

Hotchkiss offers the following tips for patients suffering from depression, advice that might benefit anyone’s attitude, clinically depressed or not:

Get moving. This is an idea that is increasingly supported by research. “If there’s one behavioral change somebody can make when they’re dealing with their depression, it is to increase exercise, because exercise releases the body’s own natural antidepressant, which are the endorphins,” Hotchkiss says.

Increase activities that give you pleasure or a sense of satisfaction. Nurture yourself in some way by setting aside time for yourself or engaging in a hobby.

Connect with other people. It’s especially difficult in today’s fast-paced society to maintain relationships with good friends and family members. People frequently transition from one place to another or from one job to another and lose a sense of family, co-worker solidarity and even old-fashioned neighborliness, Hotchkiss says.

But having relationships with other people has been shown to be an important factor in improving resiliency to stress. “One of the best things we can do to keep our mood up is to stay connected with the people that mean a lot to us,” Hotchkiss says. “Being with those people helps remind us of what’s really important to us in life. We don’t have to go it alone.” NH