(RxWiki News) Everyone occasionally feels blue or sad, but these feelings usually pass in a few days. When a woman has a depressive disorder, however, it interferes with daily life and her ability to function normally, causing pain for both her and the people who care about her.
Although depression affects both men and women, more women than men are likely to be diagnosed with depression in any given year. Efforts to explain this difference are ongoing, as researchers explore certain factors, such as possible biological and social factors, unique to women.
Many women with a depressive illness never seek treatment. But the vast majority--even those women with the most severe depression--can get better with treatment.
Different Forms of Depression
Depressive disorders that occur in both women and men take different forms. The most common types are major depressive disorder and dysthymic disorder. Minor depression is also common.
Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often it recurs throughout a person's life.
Dysthymic disorder, also called dysthymia, is characterized by long-term depressive symptoms, often lasting two years or longer; however, these symptoms are less severe than the symptoms of major depression. Dysthymia may not disable a person, but it prevents one from functioning normally or feeling well.
People with dysthymia may also experience one or more episodes of major depression during their lifetimes.
Minor depression may also occur. Symptoms of minor depression are similar to major depression and dysthymia, but they're less severe or don't last as long. That said, minor depression is not a condition any person should ignore.
Some forms of depressive disorder have slightly different characteristics than the three common types; sometimes these other types develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression.
Psychotic depression occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, experiencing hallucinations or having delusions.
Seasonal affective disorder (SAD) is characterized by a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those people diagnosed with SAD don't respond to light therapy alone. Antidepressant medication and psychotherapy also can reduce SAD symptoms, either alone or in combination with light therapy.
Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes that take a person suffering from the disorder from extreme highs (mania) to extreme lows (depression).
Depression's Signs and Symptoms
Just as all women are different, women with depressive illnesses don't all experience the same symptoms. Not only do depression symptoms vary, their severity, frequency and duration vary depending on the individual and her particular illness.
Common signs and symptoms of depression include the following:
- Persistent sad, anxious or "empty" feelings
- Feelings of hopelessness or pessimism
- Irritability, restlessness, anxiety
- Feelings of guilt, worthlessness or helplessness
- Loss of interest in activities or hobbies once pleasurable, including sex
- Fatigue and decreased energy
- Difficulty concentrating, remembering details and making decisions
- Insomnia, waking up during the night or excessive sleeping
- Overeating or appetite loss
- Thoughts of suicide, suicide attempts
- Persistent aches or pains, headaches, cramps or digestive problems that don't ease with treatment
The Causes of Depression
Scientists are examining many potential causes for and contributing factors to women's increased risk for depression. It's likely that genetic, biological, chemical, hormonal, environmental, psychological and social factors all intersect to contribute to depression.
Genetics can come into the equation if a woman has a family history of depression, which then increases her risk of developing the illness. However, this is not a hard and fast rule. Depression can occur in women without family histories of the disorder, and women from families with a history of depression may not develop depression themselves. Genetics research indicates that the risk for developing depression likely involves the combination of multiple genes with environmental or other factors.
Chemicals and hormones in the brain and body appear to be a significant factor in depressive disorders. Modern brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown the brains of people suffering from depression look different than the brains of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior don't appear to be functioning normally. Additionally, important neurotransmitters, the chemicals brain cells use to communicate, appear to be out of balance. But these images don't reveal why the depression has occurred.
Scientists are also studying the influence of female hormones, which change throughout life. Researchers have shown hormones directly affect the brain chemistry that controls emotions and mood. Specific times during a woman's life are of particular interest, including puberty; the times before menstrual periods; before, during, and just after pregnancy (postpartum); and just prior to and during menopause (perimenopause):
- Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that afflicts some women. Women affected by PMDD typically experience depression, anxiety, irritability and mood swings the week before menstruation so intensely that they have difficulty functioning normally. Women with PMDD don't necessarily have unusual hormone changes, but they do have different responses to these changes. They may also have a history of other mood disorders and differences in brain chemistry, making them more sensitive to menstruation-related hormone changes. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry associated with depressive illness.
- Postpartum depression is not uncommon among women who've just given birth because the hormonal and physical changes, not to mention the new responsibility of caring for a newborn, can be overwhelming, making new moms vulnerable to depression. Many new mothers experience a brief episode of mild mood changes known as the "baby blues," but some women experience postpartum depression, a much more serious condition that requires active treatment and emotional support. A study published in the December 6, 2006 issue of the Journal of the American Medical Association found postpartum women are at an increased risk for several mental disorders, including depression, for several months after childbirth. Other studies suggest that women who experience postpartum depression often have had prior depressive episodes. Some women may even experience it during their pregnancies, but their condition often goes undetected. Research suggests prenatal and postpartum visits to the doctor are good opportunities to screen moms-to-be and new moms for depression.
- Menopause isn't called "the change of life" for nothing. Hormonal changes typically increase during the transition between premenopause and menopause. While some women may transition into menopause without any problems with mood, others experience an increased risk for depression. This increased risk seems to occur even among women without a history of depression. However, the good news is that once the hormonal changes and fluctuations largely diminish after menopause, women have a lower depression risk.
As researchers learn more about how various chemicals and hormones affect the brain and mood, the possibility of treating depression by addressing these potential factors grows.
Stress can be another trigger for depression in women. Stressful life events such as trauma, the loss of a loved one, a difficult relationship or any stressful situation--whether welcome or unwelcome--often occur before a depressive episode. Additional work and home responsibilities, caring for children and aging parents, abuse and poverty can also trigger a depressive episode.
Evidence suggests women respond differently than men to these events, making them more prone to depression. In fact, research indicates women respond in such a way that prolongs their feelings of stress more so than men, increasing the risk for depression. However, why some women faced with enormous challenges develop depression and some with similar challenges don't is unclear.
Illness and Depression
Depression often coexists with other illnesses that may precede the depression, follow it, cause it, be a consequence of it or a combination of these. The interplay between depression and other illnesses differs for every person and situation. Regardless, these other coexisting illnesses need to be diagnosed and treated.
Depression often coexists with eating disorders such as anorexia nervosa, bulimia nervosa and others, especially among women. Anxiety disorders, such as posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia and generalized anxiety disorder, also sometimes accompany depression. Women more than men have a coexisting anxiety disorder. In fact, women suffering from PTSD are especially prone to having depression.
Although more common among men than women, alcohol and substance abuse or dependence may occur along with depression. Research indicates among both men and women in the U.S., the coexistence of mood disorders and substance abuse is common.
Depression also often coexists with other serious medical illnesses such as heart disease, stroke, cancer, HIV or AIDS, diabetes, Parkinson's disease, thyroid problems and multiple sclerosis. It can even make symptoms of the illness worse: Studies have shown both women and men diagnosed with depression and a serious medical illness tend to have more severe symptoms of both illnesses. They also have more difficulty adapting to their medical condition, not to mention higher medical costs than patients who don't have coexisting depression. Research has also shown treating the depression along with the coexisting illness can help ease both conditions.
Depression and Young Girls
Before adolescence, girls and boys experience depression at about the same frequency. However, by adolescence girls become more likely than boys to experience depression.
Research has found several possible reasons for this imbalance. The biological and hormonal changes of puberty likely contribute to the sharp increase in rates of depression among young girls. Additionally, some research suggests girls are more likely than boys to continue feeling bad after experiencing difficult situations or events, indicating a possible increased risk for depression, as occurs with grown women. Another study found girls tended to doubt themselves, doubt their problem-solving abilities and view their problems as unsolvable more so than boys; girls with these views were more likely to have depressive symptoms as well. Girls also tended to need a higher degree of approval and success to feel secure.
In addition to possible biological and emotional factors, girls may undergo more hardships--poverty, poor education, childhood sexual abuse, and other traumas--than boys. One study found that more than 70 percent of girls with depression experienced a difficult or stressful life event prior to a depressive episode, but only 14 percent of boys experienced the same.
Depression and Older Women
As with other age groups, more older women than older men experience depression, but as stated previously, rates decrease among women after menopause. Evidence suggests depression in postmenopausal women generally occurs in women with prior histories of depression. In any case, depression is not a normal part of aging.
The death of a spouse or loved one, retiring from work or dealing with a chronic illness can leave women and men alike feeling sad or distressed. After an adjustment period, some older women regain their emotional balance, but others don't and may develop depression. When older women do suffer from depression, it may be overlooked because older adults may be less willing to discuss feelings of sadness or grief, or their depression symptoms may be less obvious. As a result, their doctors may be less likely to suspect or spot the condition.
For older adults who experience depression for the first time later in life, other factors, such as changes in the brain or body, may be at play. For example, older adults may suffer from restricted blood flow (ischemia). This condition prevents normal blood flow to the body's organs, including the brain. If the brain is starved for the nutrients supplied by the blood, an older adult with no family or personal history of depression may develop what some doctors call vascular depression. Vascular depression isn't the only threat with ischemia: It can increase a person's risk for a coexisting cardiovascular illness, such as heart disease or a stroke.
Diagnosing and Treating Depression
Depressive illnesses, even the most severe cases, are highly treatable. As with many illnesses, the earlier treatment can begin, the more effective it is and the greater the likelihood a recurrence can be prevented.
The first step to getting appropriate treatment is to visit a doctor. Certain medications and some medical conditions, such as viruses or a thyroid disorder, can cause the same symptoms as depression. Additionally, ruling out that the depression is part of bipolar disorder is important. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests, depending on the medical condition. If a medical condition and bipolar disorder can be ruled out, the physician should conduct a psychological evaluation or refer the person to a mental health professional.
The doctor or mental health professional typically conducts a complete diagnostic evaluation. The patient should provide as complete a history of symptoms as she can, including when they started, how long they've lasted, their severity, whether they've occurred before and, if so, how they were treated. The health care professional should also ask about a family history of depression, if the patient is using alcohol or drugs and if she is thinking about death or suicide.
Once depression is diagnosed, the patient and her diagnosing health care provider can discuss treatment options. The most common treatment methods are medication and psychotherapy.
Antidepressant medications work to normalize naturally occurring brain chemicals called neurotransmitters. Serotonin and norepinephrine are two neurotransmitters targeted by many antidepressants, but other antidepressants work on dopamine, another neurotransmitter. These particular chemicals help regulate mood, although researchers aren't entirely unsure exactly how.
Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed antidepressant medications. SSRIs include the following drugs:
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Escitalopram (Lexapro)
- Fluvoxamine (Luvox)
Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta).
SSRIs and SNRIs tend to have fewer side effects and are more popular than older antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs). Because medications affect everyone differently, there is no one-size-fits-all medication. Therefore, for some people, tricyclics or MAOIs may be the best choice. Sometimes finding the right medication can take time, as a patient first tries one particular drug then another until one emerges as the most beneficial. Research funded by the National Institute of Mental Health has shown depression patients who didn't improve after taking the first medication prescribed to him or her often fared better after switching to a different medication or adding another one as part of the treatment plan.
For all classes of antidepressants, the patient must take regular doses for at least three to four weeks, sometimes longer, before she's likely to experience its full effect. No patient should discontinue an antidepressant until instructed to by her doctor; even if she's feeling better, a patient who decides to stop taking her medication on her own risks a relapse of the depression. The decision to stop taking medication should be made by the person and her doctor together and should be done only under the doctor's supervision. Some medications need to be tapered to give the body time to adjust. Although antidepressants aren't habit-forming or addictive, abruptly ending one of these drugs can cause withdrawal symptoms or lead to a relapse. Some individuals, such as patients with chronic or recurrent depression, may need to stay on the medication indefinitely.
Sometimes other medications, such as stimulants or antianxiety medications, are used with an antidepressant, especially if the patient has a coexisting illness. However, neither antianxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.
Antidepressants, Pregnancy and Breastfeeding
At one time, doctors assumed that depression during pregnancy was rare or never occurred at all. Recent studies, however, have shown women can experience depression while pregnant, especially if they have a prior history of the illness. In fact, a majority of women with a history of depression will likely relapse during pregnancy if they stop taking their antidepressant medication either prior to conception or early in the pregnancy, putting both mother and baby at risk.
Distressingly for a mom-to-be concerned about the welfare of her unborn child, antidepressant medications do pass the placental barrier, potentially exposing the developing fetus to the medication. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage or birth defects, but other studies don't support these findings. Some studies have indicated fetuses exposed to SSRIs during the third trimester may be born with such withdrawal symptoms as breathing problems, jitteriness, irritability, difficulty feeding or low blood sugar. In 2004, the FDA issued a warning against using SSRIs in the late third trimester, suggesting clinicians gradually taper expectant mothers off these medication in the third trimester to avoid any ill effects on the baby.
Although some studies suggest exposure to SSRIs in pregnancy may adversely affect an infant, generally the effects are mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy increase their risk for developing depression again and may put both themselves and their infant at risk.
In light of these mixed results, moms-to-be being treated for depression and their doctors should consider the potential risks and benefits--to both the mother and the fetus--of taking an antidepressant during pregnancy and make decisions based on individual needs and circumstances. In some cases, a woman and her doctor may decide to taper her antidepressant dose during the last month of pregnancy to minimize the newborn's withdrawal symptoms and, after delivery, return to a full dose during the vulnerable postpartum period.
Just as antidepressants pass from mother to child in utero, these drugs are excreted in breast milk, usually in very small amounts. The amount a breastfeeding infant receives is usually so small it doesn't even register in blood tests. Few problems have been reported with infants nursing from mothers taking antidepressants. However, as with antidepressant use during pregnancy, both the risks and benefits to the mother and infant should be considered when deciding whether to take an antidepressant while breastfeeding.
Side Effects of Antidepressants
Antidepressants may cause mild and often temporary side effects in some people. However, if a depression patient experiences any unusual, persistent or troublesome reactions or side effects that interfere with her ability to function normally, she should report them to her prescribing doctor or pharmacist immediately.
These are the most common side effects associated with SSRIs and SNRIs:
- Headache, which is usually temporary
- Nausea, which is often temporary and usually short-lived
- Insomnia and nervousness, including trouble falling asleep or waking often during the night, which may occur during the first few weeks but often subside over time or with a reduced dose
- Agitation or jitteriness
- Sexual problems, including reduced sex drive and problems having and enjoying sex
Tricyclic antidepressants also can cause side effects:
- Dry mouth, which can be combated by drinking plenty of water, chewing gum and cleaning one's teeth daily
- Constipation, which can be addressed by eating more fiber, such as in bran cereals, prunes and certain fruits and vegetables
- Bladder problems, including difficulty emptying the bladder or a weakened urine stream
- Sexual problems, including reduced sex drive and problems having and enjoying sex
- Blurred vision, which often passes soon and usually doesn't require a new corrective lenses prescription
- Daytime drowsiness, which usually passes soon but does discourage driving or operating heavy machinery
The more sedating antidepressants are generally taken at bedtime, which helps prevent side effects that interfere with sleep or cause daytime drowsiness.
Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested they may have unintentional effects on some people, especially adolescents and young adults. In 2004, after a thorough review of published and unpublished controlled clinical trials of antidepressants involving nearly 4,400 children and adolescents, the FDA revealed 4 percent of those young participants taking antidepressants thought about or attempted suicide--although no suicides occurred--compared to 2 percent of those participants receiving placebos. This finding prompted the agency in 2005 to require a black box warning label, the most serious type of warning on prescription drug labeling, on all antidepressants alerting health care professionals and patients about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed makers of all antidepressant medications extend the warning to include young adults through age 24.
The black box warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for include the following:
- Worsening depression
- Suicidal thinking or behavior
- Any unusual changes in behavior such as sleeplessness, agitation or withdrawal from normal social situations
While the warning can make parents of children with depression and even some adults diagnosed with the condition reluctant to take the medications, results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggest the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders. The study was funded in part by the National Institute of Mental Health.
The FDA has also issued a warning against combining an SSRI or SNRI with a triptan medication, commonly used for migraine headache. This combination could cause a life-threatening interaction called serotonin syndrome, which is marked by agitation, hallucinations, elevated body temperature and rapid changes in blood pressure. Although this drug interaction is most dramatic with MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.
Several types of psychotherapy, sometimes called talk therapy, can help people with depression. Some regimens are short, lasting 10 to 20 weeks, and other regimens are longer, depending on the patient's needs.
Two main types of psychotherapies, cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.
For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people diagnosed with the condition, psychotherapy may not be enough. Studies have indicated, for example, that adolescents may be best served with a combination of medication and psychotherapy to treat their major depression and reduce the likelihood for recurrence. Similarly, a study of depression treatment among older adults found patients who responded to initial treatment with medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.
Helping Yourself Even While Suffering From Depression
People dealing with depression may feel exhausted, helpless and hopeless; therefore, taking action to help themselves may be extremely difficult. But realizing these feelings are part of the depression and don't reflect actual circumstances is vital to recovery. As a person recognizes her depression and begins treatment, negative thinking can fade.
Here are some tips from the National Institute for Mental Health to help people diagnosed with depression help themselves in their recovery:
- Get out. Go to a movie, a ballgame or another event or activity you once enjoyed. Participate in religious, social or other activities.
- Exercise. Physical activity helps stimulate the release of brain chemicals linked with elevated mood.
- Set realistic goals for yourself. Take small steps to prevent stress and anxiety. When faced with a large task, break up into smaller ones, set some priorities and do what you can as you can.
- Don't hide from others. Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
- Expect your mood to improve gradually, not immediately. Don't expect to suddenly snap out of depression. Often during treatment for depression, sleep and appetite begin to improve before the depressed mood lifts.
- Postpone important life-changing decisions until you feel better. While being treated for depression, don't rush to get married or divorced, add another member to the family or change jobs, especially if the change is considered with the hope that it'll end the depression. Discuss decisions with others who know you well and have a more objective view of your situation.
- Be confident in the power of positive thinking. With time and treatment, negative thoughts will be replaced with positive ones as your depression responds to treatment.
Getting Help in a Crisis
Women are more likely than men to attempt suicide. If you're thinking about harming yourself or attempting suicide, tell someone who can help immediately:
- Call 911 for emergency services
- Go to the nearest hospital emergency room
- Call 800-273-TALK (800-273-8255) toll-free to reach the 24-hour National Suicide Prevention Lifeline and be connected to a trained counselor at the nearest suicide crisis center
Although depression can leave a woman feeling as if her world is crumbling around her and she's powerless to do anything about it, she does indeed have that power. Seeking help from health care professionals and beginning a treatment regimen can help women not only recover from their depression but also put them on the road to a much brighter tomorrow.