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Symptoms of Depression
The symptoms of depression include:
Note that not all of these symptoms may be present in every case of depression. For an official diagnosis of depression, at least five of the symptoms must be present for two weeks or more. While it's normal to feel sad, tired, bored, or irritable occasionally or in certain situations, a person with major depression experiences these symptoms throughout the day, nearly every day, for weeks or months on end.
Types of Depression
The American Psychiatric Association (APA) recognizes many different types of depression. Each of these disorders is defined and their symptoms are described in the DSM-IV - the Diagnostic and Statistical Manual of Mental Disorders - published by the APA.
Major Depressive Disorder (or "major depression") refers to what's commonly called "depression" in layman's terms. A person with major depressive disorder has a depressed mood and/or a loss of interest or pleasure in daily activities for at least two weeks, and often much longer. This change in mood negatively impacts the person's functioning at work, in family life, at school, and/or socially. Some people only experience a single depressive episode from which they recover and regain their positive outlook. Others struggle with recurrent depression and experience many periods of depression throughout their life. It's estimated that 10-25% of women and 5-12% of men experience major depression at some point during their lifetime. At any given time, 5-9% of the female population and 2-3% of the male population are struggling with major depression. (See the DSM-IV criteria for major depressive disorder.)
Dysthymic Disorder (or "dysthymia") is milder but longer-lasting form of depression. People with dysthymia find little joy or excitement in life - but instead feel bored, worried, sluggish, and/or irritable - for long stretches of time. Unlike a major depressive episode, which although severe may only last for weeks or months, dysthymia can persist for years (or even decades in some cases). Adults that developed dysthymia early in life may believe that it's normal to feel depressed all the time, and as a result they often do not recognize the disorder or take steps to treat it. Dysthymia affects about 3% of the population at any given time, and about 6% of all people will experience dysthymia at some point in their life.
Bipolar Disorder, also known as manic depression, is characterized by extreme mood swings alternating between depression and mania. During the depressed phase, a person with bipolar disorder can experience the symptoms associated with major depression. During the manic phase, however, they experience an elevated mood that can include excessive energy, elation, euphoria, racing thoughts, little need for sleep, impulsivity, overconfidence, and feelings of importance or grandeur. Although mania can be enjoyable, it can also be a destructive force that impairs judgment, causes feelings of being overwhelmed or out-of-control, and leads to inappropriate or reckless behavior such as drug use, spending sprees, or promiscuous sex. In the extreme form, a manic person may lose touch reality and even experience hallucinations. The duration of the manic and depressed phases can vary, with some people cycling between the two in a matter of weeks and others remaining depressed or manic for years. In general, the depression experienced by people with bipolar disorder can be severe, and about 10-15% end up committing suicide.
Prescription Drug Treatments
Prescription drugs for depression can be divided into five classes: older drugs such as tricyclics and MAOIs and newer drugs like SSRIs, SNRIs and novel types.
Older Antidepressants: Tricyclics and MAOIs
Tricyclic antidepressants (TCAs) are an older class of depression drugs. TCAs can cause side effects such as dry mouth, constipation, bladder problems, sexual dysfunction, blurred vision, dizziness, and drowsiness. Examples include Elavil® (amitriptyline), Tofranil® (imipramine), and Anafranil® (clomipramine).
MAO inhibitors (MAOIs) are now the rarest type of depression drugs. MAOIs work by inhibiting the activity of monoamine oxidase, an enzyme responsible for breaking down serotonin, dopamine, and norepinephrine. These three neurotransmitters regulate mood and emotion in the brain, and depressed individuals often have unusually low levels of one or more of these neurotransmitters. ("Neurotransmitters" are chemical messengers used to send signals from one nerve cell, or "neuron", to another in the brain.) By inhibiting monoamine oxidase, MAOIs prevent the breakdown of these neurotransmitters and thus increase their activity. Unfortunately, monoamine oxidase is also responsible for breaking down many other compounds, including certain drugs and amino acids found in common foods. For this reason, people taking MAOIs must be extremely careful not to take certain drugs and must follow a restricted diet. For example, if a person on an MAOI eats foods containing the amino acid tyramine (including beer and wine, aged cheeses, avocados, many fruits, certain beans, sour cream and yogurt, and chocolate), an excess of tyramine will build up in their body and they may experience hypertensive crisis.
Because TCAs and MAOIs pose serious safety risks and frequently cause side effects, they have fallen out of favor with physicians and patients and are now rarely prescribed. Today, most people taking antidepressant drugs take newer medications such as selective serotonin reuptake inhibitors (SSRIs).
Selective Serotonin Reuptake Inhibitors (SSRI)
The most significant advance in pharmaceutical treatments for depression came in 1988 with the release of Prozac® (fluoxetine), the first in a new class of antidepressant drugs called selective serotonin reuptake inhibitors, or SSRIs. The release of other SSRI drugs such as Paxil® (paroxetine) and Zoloft® (sertraline) followed within a few years, and SSRIs quickly became more popular than the tricyclic and MAOI drugs used for depression since the 1950's. Both doctors and patients preferred SSRIs over the older antidepressants because SSRIs are both safer and less likely to cause side effects.
It soon became clear, however, that SSRIs do pose certain safety risks and have their own set of side effects:
Although SSRIs remain the most frequently prescribed medications for depression, their high potential for problematic side effects such as weight gain and sexual dysfunction has led an increasing number of physicians and patients to turn to natural/alternative medicines for depression relief. In the past, doctors and educated consumers had legitimate concerns about the effectiveness of natural remedies: Because the supplement industry is unregulated, it's filled with low-quality products marketed using unproven claims. But a new generation of pharmaceutical-grade natural antidepressants offer ingredients backed by solid clinical research manufactured according to strictquality-control standards, and they're far less likely to cause side effects like sexual dysfunction and weight gain.
SSRIs work by increasing the activity of serotonin, a neurotransmitter in the brain that regulates mood and emotion. ("Neurotransmitters" are chemical messengers used to send signals from one nerve cell, or "neuron", to another in the brain.) SSRIs are called "selective serotonin reuptake inhibitors" because they block, or inhibit, the reuptake transporters responsible for collecting and recycling serotonin. By blocking the action of reuptake transporters, SSRIs decrease the amount of serotonin removed from the synapse (the gap between two neurons across which neurotransmitters move), thus increasing the amount of serotonin that remains available to stimulate the postsynaptic neuron (the neuron being activated by serotonin). (For more detailed information, see Wikipedia's entries on SSRIs and serotonin transporters and About.com's article on neurotransmitters .)
Like most antidepressant drugs, SSRIs do not work immediately but become effective gradually over many weeks. In general, SSRIs start working after about a month and may take 2-3 months to become fully effective.
In the United States, the following SSRI antidepressant drugs are available (brand name in parentheses):
Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Serotonin norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs in that they work by inhibiting the reuptake of mood-related neurotransmitters. But in addition to serotonin, SNRIs also increase the activity of norepinephrine. Because norepinephrine is involved in motivation and energy, SNRIs may have a more activating and energizing effect than SSRIs.
In the United States, the following SNRI antidepressant drugs are available (brand name in parentheses):
Novel Antidepressant Drugs
The most popular novel antidepressant drug (meaning that it does not fall into one of the classes discussed above) is bupropion (Wellbutrin®). Bupropion works by increasing the activity of dopamine and norepinephrine, to mood-related neurotransmitters. Unlike other modern antidepressants, bupropion does not affect serotonin. Because dopamine and norepinephrine are involved in the regulation of energy and motivation, bupropion has more of a stimulant-like effect than SSRI drugs.
St. John's Wort
The natural depression remedy supported by the strongest evidence is hyperforin-rich St. John's Wort extract. Over 30 controlled clinical trials have shown that high-quality St. John's Wort effectively relieves depression. In fact, studies comparing St. John's Wort to prescription antidepressants have found that it works just as well as these drugs, but with fewer side effects. With this in mind, most people should turn to high-quality St. John's Wort extract as their first choice for a natural depression treatment, starting with a dose of 600-900mg daily and increasing to 900-1800mg per day if necessary. According to the research, a compound called hyperforin is responsible for the antidepressant effects of St. John's Wort, and only St. John's Wort extracts standardized to contain 3-5% Hyperforin effectively relieve depression. Unfortunately, most St. John's Wort products sold in the United States contain little or no Hyperforin, and as a result provide no benefit for depression. When deciding on a brand of St. John's Wort for depression, it's critical that you choose a product that is standardized to contain at least 3-5% hyperforin, the clinically-proven amount. Also, keep in mind that St. John's Wort usually requires at least three weeks to begin working, and may not produce its full effects for a month or two.
Another natural antidepressant backed by scientific evidence is SAM-e (S-adenosyl-L-methionine). The research behind SAM-e isn't as strong as the evidence for St. John's Wort, but it is nevertheless promising. SAM-e works quickly, and most people start noticing improvement in days rather than weeks. Unfortunately, the active dose of SAM-e, 800-1600mg daily, can cost $100 or more per month, making it far more expensive than other natural options.
5-HTP (5-hydroxytryptophan) is a third natural compound shown by clinical research to treat depression effectively. 5-HTP, an amino acid, allows the brain to produce more serotonin, a neurotransmitter that regulates mood and emotion. ("Neurotransmitters" are chemical messengers used to send signals from one nerve cell, or "neuron", to another in the brain.) Low serotonin levels have been linked to depression, and many prescription antidepressants work by increasing serotonin activity. For most people, taking 50-300mg of 5-HTP per day helps improve mood in just a few weeks without causing side effects. Some websites discuss concerns over the safety of 5-HTP, but these misconceptions are unfounded. In fact, 5-HTP has an excellent safety record, and extensive research has shown it to be one of the safest natural depression remedies available. 5-HTP is a good choice for treating depression when used alone, and 5-HTP supplements can be purchased in most vitamin and health food stores. But 5-HTP may work best for depression when combined with another proven remedy such as St. John's Wort.
Other popular natural cures for depression include herbs such as Ginseng and Ginkgo, amino acids like l-tyrosine and phenylalanine, and certain nutrients including B vitamins such as B6, B12 and folic acid. In general, the evidence behind these remedies is still inconclusive, although Ginseng and Ginkgo have been shown to relieve depression in the elderly.
Choosing the Right Natural Treatment
Hundreds of supplements containing herbs, amino acids, hormones, vitamins, minerals, and other natural substances are marketed as natural treatments for depression, but despite the claims of the companies selling these products, the majority deliver lots of hype but little help. But effective and safe natural depression remedies do exist. So how do you recognize which options are worthwhile and which are worthless? You must judge potential treatments according to a few key considerations:
First and foremost, the best supplements for depression are those with ingredients proven to relieve depression in well-designed clinical studies. Of the dozens of herbs, amino acids, and nutrients claimed to cure depression, only a handful are backed by credible scientific research.