Relieving Depression and Anxiety By Lisa Glickstein, Ph.D, Triplet Mom Originally printed in May 2004 The human brain is an incredibly complex organ, responsible for memory, thought, and mood. Mood, in particular, is created by interpreting outside signals - seeing a beautiful spring day, holding a baby, experiencing a trauma - through chemical signals firing or misfiring within the brain. A crying baby can bring out feelings of love, or feelings of fear or even anger, in different individuals. Our genetic inheritance and our memories and experiences, combined with present life events, all contribute to mood. There is often a greater sense of shame for people suffering with mood disorders than any other diagnosis. As with any physical illness, getting beyond shame is an essential first step to finding help. Am I "crazy"? "Crazy" is not a medical term - it is a commonly used adjective that means "out of control" or acting extremely, for example "crazy in love" or "crazy with excitement." Other similar terms are "insane" or "out of your mind." All of these words try to describe behavior that is out of the ordinary, unexpected, or not relating to the outside world. Most of them came into use to describe individuals with serious mental illness, or even mental retardation, before the physical basis for such conditions were understood. During these times, these behaviors were attributed to moral weakness, possession by evil spirits, or punishment by a higher power. Even though we don't believe in these causes any longer, the judgment associated with them still sticks with the language that lay people use to describe mental or mood disorders. Rather, depression and anxiety are correctly termed "mood disorders" - that is, a problem with mood that is interfering with activities of daily living. What causes mood disorders? The biological basis of mood disorders is beginning to be better understood. Women or men may have an imbalance of the brain mood chemical, called serotonin. Although men certainly suffer from depression and anxiety, these disorders are more common in women. Estrogen is an "upper" - elevating mood during the first part of the menstrual cycle, while progesterone leads to premenstrual symptoms such as bloating, food cravings, irritability or sadness. Women with an underlying serotonin imbalance may be more susceptible to these mood changes, called pre-menstrual dysphoric disorder (PMDD), or during the hormonal upheaval in the year following pregnancy, leading to post-partum depression. Post-partum depression can begin any time during the year following childbirth, and is very common, occurring in 10% of women. A prior history of depression elevates the risk of post-partum depression to 25-50%, and fatigue is an independent risk factor. In addition to post-partum depression, it may take time to re-establish normal menstrual cycles or women may resume birth-control pills following delivery, and symptoms of PMDD may become worse. PMDD also seems to get worse as women age, so symptoms that were tolerable a year or more prior to pregnancy, may now be severe. A tragic or traumatic life event, for example pre-term birth, caring for a sick child, adjusting to triplets or more, dealing with loss of income, or marital stress, can lead to anxiety or depression in men or women at any time. Experiencing strong emotions can change brain chemistry, leading to mood disorder even following a successful resolution of the triggering event. In other words, coping with newborn triplets or more could trigger anxiety or depression in either partner that does not go away even as the babies get older and more manageable. How can I tell if I have depression or anxiety? In the worst cases of severe major depression, you cannot get out of bed, or you have thoughts of harming yourself or your children. Hearing voices that others don't hear, or having unsubstantiated feelings of being persecuted by others (paranoia) could indicate schizophrenia, a severe mental illness believed to be caused by significant malfunction or damage in the brain. These are symptoms of severe illness and require immediate intervention by a health professional. For most of us, thankfully, symptoms are mild or moderate, but this may mean that we take a long time deciding that they warrant medical attention. It is normal to feel sad, worried, or angry as a response to life events - job or home stress, a recent death or illness in the family, or marital or financial difficulties. It is when these emotional feelings are unusually severe, are coupled with intractable fatigue, insomnia, or tension, are long-lasting, or interfere with previously enjoyable activities, that you should be evaluated for clinical depression or anxiety. For example, if you feel sad even during an otherwise pleasurable outing with your kids or friends. Particularly for men, a loss of sex drive should be evaluated, particularly if sudden or accompanied by disrupted mood. How are depression and anxiety treated? There are four types of treatment available for depression. These include lifestyle changes, self-care, psychotherapy, and antidepressant medications. Lifestyle changes or self-care might be indicated for mild depression or as a preventive for people with prior history of mild depression and could include getting enough sleep, eating a healthful diet, changing birth-control method, or joining a peer support group. Self-care methods found to be beneficial in treating mild depression include frequent gentle exercise, social support, and the herbal remedy St. John's Wort (Hypericum perforatum). It is important to find an extract, pill form, or tea that contains the active compound, in consultation with an herbalist. These remedies are usually inexpensive and self-administered, but most likely will not alleviate moderate or severe depression on their own. In particular, a recent clinical study of St. John's Wort showed no benefit in treating moderate or severe depression. Psychotherapy involves talking with a trained professional to identify triggers for depression or anxiety, finding ways to eliminate them if possible, and learning new coping mechanisms for dealing with triggers now and in the future. Adjusting your expectations of yourself and others, unlearning negative responses, and finding ways to make change, can all be addressed through therapy. Psychotherapy can be expensive, although it is increasingly covered by health insurance. It is time-consuming (usually one hour per week for eight or more weeks), and may involve confronting uncomfortable emotions or life situations. It may take more than one attempt to find an appropriate therapist for you. However, psychotherapy has no side effects, and may minimize or even prevent future episodes of depression or anxiety. Related treatments are couples' therapy or joining a therapist-led support group. Finally, and increasingly common, are antidepressant medications. These include Prozac (also packaged as Sarafem for PMDD), Paxil, Zoloft, and Wellbutrin, as well as the older "tricyclic" antidepressants Elavil and Tofranil. Antidepressants, unlike the anti-anxiety drug Valium, are not habit-forming and have no street value. Antidepressants restore abnormal brain functioning to normal - they are not illegitimate, artificial or "cheating" approaches to feeling better. In fact, even individuals who may benefit from psychotherapy or lifestyle changes may need drug therapy to lift the mood enough to allow the other treatments to have some effect. The newer antidepressants, including Prozac, are no more effective than older drugs. Rather, they have fewer side effects and are easier to use, leading to increased prescriptions. A given patient may respond better to one drug and not at all to another, and for this reason several medications may need to be tried before the right drug is found. Also, all of the drugs take some time to become effective, and are normally prescribed for six months to a year before attempting discontinuation. Depression tends to be a recurrent disorder, and studies suggest that longer treatment may prevent relapse. Serious long-term side effects have not appeared. Although anti-depressant use during breastfeeding carries some potential risks for mild side effects, these are generally far outweighed by the risk of ongoing depression in the mother, and the benefits of breastfeeding. Some of the drugs, in particular, are less likely to cross into the breast milk, including Zoloft, Paxil, Pamelor, or Anafranil. What should I do if I think I need help or have more questions? A good place to start is with your primary care doctor. For men or women, this doctor can discuss your concerns, prescribe medication if indicated, and refer you to another doctor if needed. Women, particularly during the first post-partum year or, if they have a strong cyclic association with their moods, can also see their Ob/Gyn. These doctors are familiar with the hormonal associations with mood. Your primary care doctor can recommend a therapist or group; you may get a therapist recommendation from friends, or through a national support organization. Although it is not unexpected to have some feelings of failure or shame with any medical diagnosis, it is important to recognize that depression and anxiety are treatable, and to get beyond these reactions to obtain help.