The Unholy Ghost: Depression

“My melancholy – she is the most faithful mistress I have ever known” --Soren Kierkegaard

Andrew Solomon, author of “The Noonday Demon: An Atlas of Depression,” describes depression as “the aloneness within us made manifest. It destroys not only your connection to others, but also the ability to be peacefully alone with yourself.” Depression is among the most burdensome diseases in the world. The annual economic consequences of depression are estimated at 83 billion dollars in the US. Up to 20% of the adult population experiences a major depressive episode at some time in their lives. Depression rates in the gay population are thought to be significantly higher, and as high as 40% in patients with HIV.

Depression has been an area of intensive clinical study in recent years, both in defining what it is, what causes it, and in formulating effective treatments. According to the DSM-IV, depression is defined by the following:

-Feelings of sadness or hopelessness
-Loss of interest in pleasurable activities
-Changes in sleep patterns, like sleeping too much, or not being able to sleep well. The classic complaint is waking up in the early morning and not being able to go back to sleep.
-Changes in appetite, such as eating too much, or not eating enough
-Loss of energy
-Trouble concentrating
-Thoughts of worthlessness or guilt
-Thoughts about death or suicide

A major depressive episode includes at least five of the above symptoms, which are present most of the day, nearly every day, for at least 2 weeks, and cause significant distress or dysfunction. A minor episode includes two of the symptoms, at least one of which is feelings of hopelessness or loss of interest in pleasurable activities. In addition to emotional symptoms, depression can also manifest in physical symptoms, such as headaches, muscle aches, or abdominal pain.

Most cases of major depression occur between ages 30-40, but can occur at any point from childhood to old age. Episodes usually last from several months to a year. Many people with major depression have recurrent episodes throughout their lives. Genetic factors can predispose some people to depression, especially when combined with environmental influences. Life stressors, such as chronic illness or the death of a loved one, can be triggers for depression. Use of cocaine and crystal meth can affect brain chemistry and contribute to the onset of depression. Some depressive episodes occur without any obvious trigger.

Depression has become one of the most important factors in the HIV/AIDS epidemic. Major depression increases the risk of becoming infected with HIV. People with untreated depression may attempt to “self-medicate” with alcohol and other drugs, and have more self-destructive behavior patterns, such as using crystal meth and engaging in unprotected sex with multiple partners. Concurrently, people infected with HIV are at higher risk for developing depression. This is thought to be due to several factors, including the direct effects of the virus on the brain and central nervous system, low testosterone levels (common in HIV infection), and also from the social isolation, guilt, and stress that often accompany a diagnosis of HIV. People with depression who are HIV positive are less likely to take their HIV medications, and are at increased risk for progression of their HIV disease.

Fortunately, depression is treatable. The first step in treatment is to visit your doctor for a thorough physical examination. He or she may perform lab tests to see if your symptoms have an “organic” cause (thyroid disease, diabetes, etc). When a diagnosis of depression has been established, you can discuss with your doctor what treatment option is best for you.

Aerobic exercise, when performed regularly (three times per week), can help with depression. Psychotherapy and antidepressant medications are the main ways depression is treated clinically. Cognitive behavior therapy (CBT) works to change negative thinking and behavior patterns. Interpersonal therapy (IPT) focuses more on working through troubled relationships which can contribute to depression. The most common antidepressant medications are the SSRIs (selective serotonin reuptake inhibitors) such as Prozac and Zoloft, which work to normalize neurotransmitters in the brain and improve mood. Once the medication is started, it takes about four weeks to get the full benefit, and most patients need to take the drugs for at least six months in order to minimize the risk of relapse. They are popular drugs and have helped many people with depression, but they can have serious side effects, and should be used only under close medical supervision.

For more information on depression, visit the National Institute of Mental Health website at www.nimh.nih.gov/health/publications/depression