Therese Borchard writes, “It’s that time of year again when the highly sensitive types among us who thrive with lots of sunlight begin to wither with the plants as the sun begins to hide.Not only do we get less vitamin D (and deficiencies have been linked to depression), but the change in sunlight affects our circadian rhythm — the body’s internal biological clock that governs certain brain activity and hormone production. In some people, the change of mood-related chemicals can cause seasonal affective disorder (SAD), also known as winter blues or seasonal depression.” Read the rest of her blog.
Scientific American magazine reports a new study reports that suggests that some nutritional supplements, including omega-3 fatty acids and vitamin D, may boost the effectiveness of antidepressants. If so, the supplements might help relieve symptoms for the millions of people who don’t immediately respond to these drugs. Read the News
New research has shown that omega-3 fatty acids have numerous health benefits. But according to a new Cochrane review, there is insufficient evidence to suggest they are beneficial for major depression. Read the rest of the News
Depression blogger Therese Borchard writes, “It happens every year. As I watch the first golden leaves fall from the oak tree outside our house and listen to the sound of the cicadas ushering in autumn, my anxiety spikes. I used to think I was relapsing into depression, but having been through this year after year (and documenting it in my mood journal), I now know I’m just going through my annual bout of autumn anxiety: a nervous feeling in my gut that begins the last week of August and continues through the first weeks of September”. Read her Blog
Here are important things to check into when you find yourself in this position. Read the Blog
As many people know all too well, clinical depressions do not always improve after the first attempt at treatment. One in three people with depressions (I’ll explain the plural in a bit) find they have not gotten back to “normal” even after four different courses of standard treatment.
Depression is considered “treatment-resistant” if symptoms have not improved after two or more courses of well-established treatments of a sufficient dose and length of time, whether those treatments are evidence-based medications, psychotherapy, or other therapies that have been proven effective.
That “or more” can be problematic. The longer your depression persists, the greater the risk of financial costs, job loss, family stress, marital problems, and even possible brain changes. That’s why it’s a good idea to discuss a diagnosis of treatment-resistant depression with your practitioner after two failures of treatment. The earlier you address it, the better.
There are a number of reasons why your depression might not respond to a particular treatment. For one thing, there is no single type of depression; there are multiple causes. That is why it is actually most accurate to use the plural term (depressions), and why “one-size treatment” will never fit all.
For another, effective treatments that are not followed cannot work. If a person is not taking the doses of medication as prescribed or doesn’t stick with the recommended treatment, a depressive episode should not be considered “resistant.”
If my depression resists treatment, what are my options?
It’s easy to get discouraged when the treatments you’ve tried haven’t helped you reach recovery. (And remember: Better but not well is not good enough.) Above all, don’t give up hope. Here are some things to consider.
- Simply switching from antidepressant to antidepressant may not be useful. As shown in the STAR*D study, the largest American study of treatment-resistant depression, more proactive steps appear to be needed once treatment resistance has developed.
- Returning to a medication that worked in a previous depressive episode may be more effective than switching to a new one. If it doesn’t work as promptly as before, remember that it may do the job at a (safe) higher dosage taken for a longer time period.
- Give treatments a chance to work. While the typical time frame for good response to a medication is stated as four to six weeks, for many people it can take 8 to 12 weeks to see improvement.
- If medications or psychotherapy have been ineffective on their own, consider trying them in combination. Medications plus cognitive behavioral therapy, interpersonal therapy or dialectical behavior therapy traditionally outperform either treatment used alone.
- Augmentation of your antidepressant with an adjunct or “add-on” medication, often an atypical antipsychotic, may be helpful if you’ve had partial response to a treatment.
- Other “augmentation” agents that pro-vide benefits for some people include nutrition supplements such as Vitamin D, Omega 3, and folate.
- Electroconvulsive therapy (ECT), commonly known as shock therapy, has long been stigmatized in popular culture. It is an extremely safe procedure, acts rapidly, can be life-saving, and is sometimes the only effective treatment. It does produce memory problems for some.
- Other “neurostimulation” treatments, such as Transcranial Magnetic Stimulation (TMS), are coming into wider use. TMS is a non-invasive procedure that typically can be delivered in about an hour each day in an office setting.
Once you find something that works, don’t change a thing. Just as someone with diabetes requires ongoing treatment, most people who have developed chronic, recurring depression need to continue treatment indefinitely.
By John F. Greden, MD. Dr. Greden has been practicing psychiatry for 35 years. His clinical specialties include treatment-resistant depression and maintenance of wellness. The Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences at the University of Michael Medical School, he is also the founder and executive director of the UM Comprehensive Depression Center (depressioncenter.org) and the founding chair of the National Network of Depression Centers.
Are you waking up just feeling “blah”? Like you don’t want to do anything except lie like a couch potato and watch TV, and even that is unsatisfying? You not only feel low energy, but kind of miserable. Perhaps you’re mad at yourself for not getting the house cleaned or not getting your work done and papers filed. Perhaps you’re feeling a bit lonely, left out by friends or unsupported by family. You may dwell on mounting bills or the fact that you’re 10 or 20 pounds overweight. You may feel aches and pains in your neck or back. Or you may just may feel grouchy and want to remain undisturbed by life’s demands and conversational opportunities. You may compare yourself unfavorably to your friend, roommate, cousin, or neighbor, who always seems to be on time, well-groomed, and on track to meet her goals. We all have those “blah” days, but why do they happen and what can we do about them?
Some of us have brains that are more sensitive to the effects of stress. Researchers are just beginning to uncover the biochemistry behind this differential. The most common forms of antidepressants target the neurotransmitters serotonin and norepinephrine because research shows that low levels of these chemical motivators are part of what makes us depressed. However, only some people respond well to the most common forms of antidepressants, while others try drug after drug with no substantial mood improvement. A recent research study may reveal the reason why. A study published earlier this year in Proceedings of the National Academy of Sciences suggests that differences in the way our brain’s process a chemical called galanin makes some of us less resilient and able to bounce back after difficult experiences.
Less sunshine during the winter months can give us the blues, and this effect is more pronounced for some people than others. Researchers Keller and colleagues studied hundreds of people and found that during the spring, moods improved along with doing more outdoor activities. We are also more cognitively flexible and able to think creatively about solving our problems in the spring, compared to winter. A subgroup of us suffer from Seasonal Affective Disorder in which the winter blues turn into full-blown depression along with associated changes in sleep, appetite, and motivation. Sufferers are more likely to be women. Exposure to outdoor sunlight also provides us with vitamin D; a substance with clear links to depressed mood.
Most people in the US have insufficient or deficient levels of Vitamin D. The reasons are not clear, but could be related to nutrition and insufficient sun exposure. People with dark skin are more vulnerable to vitamin D deficiency, due to a decreased ability to process vitamin D from sunlight. Vitamin D deficiency has been statistically linked to depression. In a large Dutch study by Hoogendijk and colleagues (2008) of over 1,200 persons aged 65 and older, levels of vitamin D were 14% lower in persons with minor depression or major depressive disorder when compared to those not showing depressed mood.
Hormones are substances produced by the endocrine glands that influence many bodily functions, including growth and development, mood, sexual function, and metabolism. Levels of certain hormones, such as those produced by the thyroid gland, can be factors in depression. In addition, some symptoms of depression are associated with thyroid conditions. Hormones fluctuate during the menstrual cycle and may create vulnerability to sad or depressed mood in the premenstrual period, as well as during peri-menopause, and menopause. There are individual differences in how much our moods are vulnerable to the effects of hormones. If you are more vulnerable, you may want to consult a physician to see if medications are needed to help regulate your hormones. Or you could try alternative medicine treatments, such as acupuncture to reduce hormone-related mood imbalance.
Our moods are not only a function of what happens to us, but also of how we view the events in our lives and the meanings we assign to them. There are stages in most of our lives in which we seem to be working hard and doing all the right things, but don’t see many external rewards coming our way. We may not be paid what we feel we are worth or be able to afford as nice a house, car, or vacation as our friends. We may struggle to find the right partner while our friends or siblings seem to have no problem finding love. We may have to work longer and harder than our friends to get the same grade on a test or earn a living. We may experience a difficult breakup or loss. Life just naturally isn’t fair and periods of struggle, suffering and loss are inevitable. If we expect fair or special treatment all the time or expect things never to change, we are bound to be disappointed. So if you’re feeling sad because of recent events, remind yourself that hard times are part of life and will pass. Or deliberately broaden your view and focus on the good parts of your life or the experiences you are proud of.
Childhood Adverse Events
Stressful life events can wear down our physical and mental resources, making us more vulnerable to both depression and physical illnesses. A history of childhood trauma, including abuse, poverty, or loss of a parent, can reset our developing brains to be less cognitively flexible. It seems that our brains naturally go into a “fight, flight, freeze” response to stress or threat and we often have to use our prefrontal cortex or executive center to get out of this state. Prolonged stress in childhood can make our brains less interconnected and resilient.. Our brains can more easily get “stuck” in negative thinking patterns or stressed out states and we become less able to change tracks.
Stresses Piling Up
As Robert Sapolsky argues in his book Why Zebras Don’t Get Ulcers, our human stress response systems were designed to respond to acute, time-limited stressors that normally require a physical response. When our ancestors had chased off that marauding tiger, they could relax and eat. The stressors in today’s world are much more chronic and less controllable by taking action, and we often don’t get the break afterwards to recover and regroup. Financial stress, loneliness, constant fighting with loved ones, being bullied, long commutes, academic or job demands, or unemployment can drag on and have a cascade of effects across many areas of our lives. When stresses hit us one after the other without time for recovery, they can leave us depleted and despondent, with insufficient pep to bounce back.
You may be feeling bad because you’re sitting around brooding about life’s disappointments or trying to find a reason why things aren’t going your way. Research studies by University of Michigan psychologist Susan Nolen-Hoeksema and colleagues show that sitting around thinking about your negative mood or negative events just makes everything worse! One negative thought leads to another until you get buried in a mountain of problems and negative predictions. This leads to a loss of perspective and motivation that interferes with actually doing something about the problem! If you find yourself in a negative thinking cycle, get up immediately and do something else pleasant or neutral to engage your mind. This can be as simple as emptying the dishwasher, rearranging your closet, going for a walk, talking to a friend or getting on with a work project.
Your Inner Critic
Do you have a critical inner voice constantly judging and criticizing everything you do, especially when things don’t go your way? The inner critic compounds the effect of anything negative in your life by blaming you for it. It keeps drawing your attention to the negative and spoils your pleasure when something positive happens by telling you ”it won’t last” or “you don’t deserve it”. This negative dialogue takes you out of the moment and makes you feel depressed. Negative thinking is, at minimum, a symptom of depression, and may be a causal factor in interaction with negative life events. The first step to combat an inner critic is to become aware of what it’s saying. Second step is to externalize it. You could give your critic a name and imagine what it looks like (e.g., a grumpy old crone or a vicious barking dog). Then begin telling it to back off or talk back to it. The inner critic generally has a negatively biased perspective and overestimates your responsibility for and control over outcomes in your life. It also often has perfectionistic expectations. Tell it to give you a break for a change!
Our human brains are wired of be part of a social group, and we experience loneliness as chronically stressful and depressing. Unfortunately, some of us have toxic or neglectful families that don’t provide support or presence when we need it. Or we may feel that our friends are moving on in finding romantic relationships or having kids and leaving us behind. Research using fMRI brain scans shows that even minor social rejection lights up the same areas of our brains as physical pain. Feeling left out, rejected, or excluded makes us sad and can also lead to rumination about what is wrong with us that further darkens our moods. We become scared of further rejection and isolate ourselves, perpetuating the negative cycle. While there may not be a immediate cure for loneliness, it helps to get out in the world and pursue your natural interests, which can lead to expanding your social network. Staying in touch with old friends or family and deliberately seeking opportunities to connect may help as well.
The reasons for a down mood may be multifaceted and difficult to determine. If you feel depressed for two weeks or more, seek a medical consult to rule out or treat underlying biological factors. Consider consulting a mental health professional for help in managing stress and expectations, negotiating life changes, or dealing with the emotional aftereffects of past traumas and dysfunctional families. If you can’t afford therapy, antidepressants may help to change the underlying biology. Exercising outdoors can provide both sunlight and mood elevation. Develop a toolkit of stress-reducing activities, such as regular exercise, yoga or meditation, watching funny movies, playing team sports, doing something creative or novel, hanging out with and/or confiding in understanding friends.
By Melanie Goldberg, Ph.D.
Dr. Goldberg is a clinical psychologist with a private practice in Mill Valley, California.