Depression


Your Guide to Depression


BY: Kayla Gazdik, Meghan Gwilliam, Hailey Nielson and Jennie Boyer



Table of Contents


Specific Types
  • Major Depression 3
  • Atypical Depression 8
  • Bipolar Disorder 9
  • Cyclothymic Disorder          13
  • Dysthymia          14
  • Postpartum Depression          15
  • Seasonal Affective Disorder                     17
  • Premenstrual Dysphoric Disorder          19

General Symptoms           21

Main Causes          22

Diagnosis          23

Treatments          23
  • Antidepressants
  • psychotherapy
  • ECT and rTMS

Healthy Living          24

TR Implications          25

Organizations          25

Fact Sheets

Websites



What is Depression?

An illness that involves the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as passing blue mood. It is not a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.

A depressive episode is an intense feeling of sadness, of not caring anymore, or of discouragement. All of us, at one time or another feel depressed. The difference between an “everyday” depression and clinical depression is one of time, intensity, and degree of impact on our functioning.
Therapeutic Recreation, An Introduction (p. 60)


Types of Depression

Major Depressive Disorder (MDD)
Major depression is identified by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy activities that were once pleasurable. Such a disabling episode of depression may occur only once, but more commonly occurs several times in a lifetime. This type of depression is also known as clinical depression.

Common symptoms of MDD include:
  • Fatigue or loss of energy
  • Insomnia or hyposomnia
  • Decreased appetite/significant weight loss without dieting
  • Feelings of worthlessness or guilt almost everyday
  • Impaired concentration, indecisiveness
  • Restlessness or feeling slowed down
  • Recurring thoughts of death or suicide
  • Diminished interest or pleasure in almost all activities nearly everyday
Other types of Major Depression include:
  • Clinical
  • Chronic
  • Dysthymia
  • Double Depression


Who Is at Risk?
Major depression affects about 6.7% of the U.S. population over age 18, according to the National Institute of Mental Health. Overall, between 20% and 25% of adults may suffer an episode of major depression at some point during their lifetime. Major depression also affects older adults, teens, and children, but frequently goes undiagnosed and untreated in these populations.

Women
MDD affects women twice as often as it does men. Women have hormonal changes during puberty, menstruation, pregnancy, miscarriage, and menopause- which is why they experience it more often.
Women also have increased stress at home or at work, caring for an aging parent, and balancing family life with a career.

Men
Depression in men is significantly underreported because they are less likely to admit experiencing depression. There are 3-4 million cases in the US of men with Major Depression.
Signs of depression in men may include irritability, anger, or drug and alcohol abuse (substance abuse can also be a cause of depression, rather than the result of it). Suicide rate for men is four times more than women, but more women attempt suicide and don’t follow through with it.

Elderly
Clinical depression in the elderly is common. Although, that doesn't mean it's normal. Late-life depression affects about 6 million Americans age 65 and older. But only 10% receive treatment for depression. The likely reason is that the elderly often display symptoms of depression differently. Depression in the elderly is also frequently confused with the effects of multiple illnesses and the medicines used to treat them.

Physical conditions like stroke, hypertension, atrial fibrillation, diabetes, cancer,dementia, and chronic pain further increase the risk of depression. Additionally, the following risk factors for depression are often seen in the elderly:
  • Certain medicines or combination of medicines
  • Damage to body image (from amputation, cancer surgery, or heart attack)
  • Family history of major depressive disorder
  • Fear of death
  • Living alone, social isolation
  • Other illnesses
  • Past suicide attempt(s)
  • Presence of chronic or severe pain
  • Previous history of depression
  • Recent loss of a loved one
  • Substance abuse
Children/Adolescents
The core symptoms of MDD are the same for children/adolescents, although there is data that suggests that the characteristic symptoms may change for age.
Symptoms of complaints, irritability and social withdrawal are more common in children, whereas psychomotor retardation, hypersomnia, and delusions are more common in adolescents and adulthood.

What Triggers Major Depression?
Some common triggers of Major Depression include:
  • Grief from losing a loved one through death, divorce, or separation.
  • Social isolation or feelings of being deprived.
  • Major life changes- moving, graduation, job change, retirement.
  • Personal conflicts in relationships, either with a significant other or with a superior.
  • Physical, sexual, or emotional abuse.

Diagnosis
A health professional will perform a thorough medical evaluation, he or she will ask about your personal, family, and psychiatric history. You may also have to complete a depression screening test. The depression screening test is composed of simple questions surveying emotions and feelings in daily life.
There is no blood test, X-ray or other laboratory test that can be used to diagnose Major Depression. However, your doctor may run blood tests to detect other medical problems that have symptoms similar to those of depression.
Example of  a depression screening test:

This test is based on the predominant symptoms of major/clinical depressive disorder as listed in the DSM IV.  Please use the results of this test as a guide and not a diagnosis, only a licensed mental health practitioner can diagnose depression.  
1.
Have you felt sad or tearful for a majority of the day for at least the last two weeks?
   Yes
   No
2.
Have you lost interest in activities which you used to enjoy?
   Yes
   No
3.
Is it difficult for you to fall asleep most nights to the point that you do not get adequate sleep and are tired the next day?
   Yes
   No
4.
Do you feel you sleep a lot more than you should because of feeling fatigued most of the day for at least the last two weeks?
   Yes
   No
5.
Have you noticed a change in your appetite that has resulted in either not feeling hungry most days or feeling the urge to eat more than usual and has resulted in a change in your weight?
   Yes
   No
6.
Has your energy level decreased to the point that normal daily activities seem overwhelming?
   Yes
   No
7.
Have you noticed that it seems more difficult to stay focused on activities or to concentrate on complicated tasks?
   Yes
   No
8.
Have you thought about suicide or what it would be like if you were not around anymore?
   Yes
   No
9.
Do you find yourself getting angry easily or lashing out at people without a valid reason?
   Yes
   No
10.
Do friends or family tell you that they are concerned about you because of your feelings of sadness, your sleep patterns, or your anger?
   Yes
   No
11.
Is it more difficult for you to make decisions, even regarding simple matters which used to be easy?
   Yes
   No
12.
Do you cry more easily than you used to?
   Yes
   No
13.
Do you often criticize yourself about things you have done in the past or about decisions you have made?
   Yes
   No
14.
Have feelings of sadness or anger, changes in your sleep pattern, or a lack of motivation and energy gotten in the way of achieving goals or performing work activities?
   Yes
   No
15.
Does the future look bleak or even hopeless to you?
   Yes
   No


TO SCORE:
No depression (0): You are more lucky than most or have developed a positive attitude towards life an effectively means of warding off depression symptomatology
Mild Depression (1-4):  some of the items you responded to are symptoms of major depression, but you do not meet the diagnostic criteria for this disorder. However, these can be serious symptoms, especially if feelings of hopelessness or thoughts of suicide are predominant for you. If this is the case, you should seek out assistance, either through a licensed professional or through a close friend or family member who you feel you can trust. It is likely that you have a specific concern that you should look at. 0-Rarely or none of the time (<1 day)
Moderate Depression (5-9):  You have endorsed some symptoms of major depression and have not likely noticed that you are not feeling as well as you have in the past and that these feelings are starting to play a role in your daily activities. You may want to consider seeing a professional about your symptoms, if nothing more than to get a more accurate impression of how these symptoms are affecting your life.
Major Depression (10-15): You have endorsed many of the symptoms commonly seen in people who suffer from major depression. You should be concerned about these symptoms and it is likely that close friends and family members are also concerned. It is highly recommended that you consider seeing a psychiatrist or psychologist for an evolution. Depression is a serious disorder but is highly treatable.

http://allpsych.com/tests/diagnostic/depression.html

Treatment/Medication
Treatment options for clinical depression include: medications, electroconvulsive therapy (ECT or shock therapy) and psychotherapy or talk therapy.

Types of Medications include:
-Selective serotonin reuptake inhibitors (SSRIs)- common side effects include decreased sexual desire, digestive problems, insomnia, headache, restlessness.
-Serotonin and norepinephrine reuptake inhibitors (SNRIs)- similar side effects as above. Can cause increased sweating, dry mouth, fast heart rate, and constipation.
-Norepinephrine and dopamine reuptake inhibitors (NDRIs)- doesn’t cause sexual side effects (rare), make increase risk of having seizures.
-Atypical antidepressants- they have serious side effects, so they usually aren’t prescribed until patient has tried at SSRI without improvement. Side effects include dry mouth, blurred vision, constipation, urinary retention, fast heartbeat and confusion, weight gain.
-Monoamine oxidase inhibitors (MAOIs)- last resort because they have serious side effects. Require a strict diet because certain interactions with food could be deadly.


Atypical Depression
A subtype of major depression is atypical depression. Atypical depression signs and symptoms are similar to those of major depression. Yet, unlike a person with major depression, someone who has atypical depression will also have one or more of the following:
  • Significant anxiety
  • Oversleeping
  • Overeating or significant weight gain
  • Increased sensitivity to rejection.
  • Moods that worsen or improve in direct response to events

Despite its name, atypical depression is probably rather common. Some doctors believe that it is underdiagnosed. It is most common in women.
The main characteristic of atypical depression that distinguishes it from Major Depression is mood reactivity. A person with atypical depression will see his or her mood improve if something positive happens. In Major Depression, positive changes will not bring on a change in mood.


Diagnosis and Treatment of Atypical Depression
A physical exam and test to look for a problem with the thyroid are two ways that a doctor may help diagnose Atypical Depression.
Diagnostic criteria calls for at least two of the following symptoms to accompany the mood reactivity:
  • Sleeping too much (Hypersomnia)
  • Increased appetite or weight gain
  • Having a more intense reaction or increased sensitivity to rejection, resulting in problems with social and work relationships
  • Having a feeling of being weighed down, paralyzed, or leaden

Treatment includes psychotherapy and/or medications. A person may also be referred to a specialist, such as a psychiatrist, psychologist, or other licensed professional for care.

Bipolar Disorder

Definition of Biopolar Disorder
Bipolar disorder is a condition in which people go back and forth between periods of a very good or irritable mood and depression. The "mood swings" between mania and depression can be very quick.

Causes, Incidence, and Risk Factors
Bipolar disorder affects men and women equally. It usually starts between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

Types of bipolar disorder:
  • People with bipolar disorder type have had at least one manic episode and periods of major depression. In the past, bipolar disorder type I was called manic depression.
  • People with bipolar disorder type II have never had full mania. Instead they experience periods of high energy levels and impulsiveness that are not as extreme as mania (called hypomania). These periods alternate with episodes of depression.
  • A mild form of bipolar disorder called cyclothymia involves less severe mood swings. People with this form alternate between hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be wrongly diagnosed as having depression.

In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people with bipolar disorder:
  • Life changes such as childbirth
  • Medications such as antidepressants or steroids
  • Periods of sleeplessness
  • Recreational drug use

Symptoms        The manic phase may last from days to months. It can include the following symptoms:

  • Easily distracted
  • Little need for sleep
  • Poor judgment
  • Poor temper control
  • Reckless behavior and lack of self control
    • Binge eating, drinking, and/or drug use
    • Poor judgment
    • Sex with many partners (promiscuity)
    • Spending sprees
  • Very elevated mood
    • Excess activity (hyperactivity)
    • Increased energy
    • Racing thoughts
    • Talking a lot
    • Very high self-esteem (false beliefs about self or abilities)
  • Very involved in activities
  • Very upset (agitated or irritated)

These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.
The depressed phase of both types of bipolar disorder includes the following symptoms:
  • Daily low mood or sadness
  • Difficulty concentrating, remembering, or making decisions
  • Eating problems
    • Loss of appetite and weight loss
    • Overeating and weight gain
  • Fatigue or lack of energy
  • Feeling worthless, hopeless, or guilty
  • Loss of pleasure in activities once enjoyed
  • Loss of self-esteem
  • Thoughts of death and suicide
  • Trouble getting to sleep or sleeping too much
  • Pulling away from friends or activities that were once enjoyed

There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.
Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.

Signs and tests

Many factors are involved in diagnosing bipolar disorder. The health care provider may do some or all of the following:
  • Ask about your family medical history, such as whether anyone has or had bipolar disorder
  • Ask about your recent mood swings and for how long you've had them
  • Perform a thorough examination to look for illnesses that may be causing the symptoms
  • Run laboratory tests to check for thyroid problems or drug levels
  • Talk to your family members about your behavior
  • Take a medical history, including any medical problems you have and any medications you take
  • Watch your behavior and mood
Note: Drug use may cause some symptoms. However, it does not rule out bipolar affective disorder. Drug abuse may be a symptom of bipolar disorder.

Treatment

Periods of depression or mania return in most patients, even with treatment. The main goals of treatment are to:
  • Avoid moving from one phase to another
  • Avoid the need for a hospital stay
  • Help the patient function as well as possible between episodes
  • Prevent self-injury and suicide
  • Make the episodes less frequent and severe
The health care provider will first try to find out what may have triggered the mood episode. The provider may also look for any medical or emotional problems that might affect treatment.
The following drugs, called mood stabilizers, are usually used first:
  • Carbamazepine
  • Lamotrigine
  • Lithium
  • Valproate (valproic acid)
Other antiseizure drugs may also be tried.
Other drugs used to treat bipolar disorder include:
  • Antipsychotic drugs and anti-anxiety drugs (benzodiazepines) for mood problems
  • Antidepressant medications can be added to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, antidepressants are only used in people who also take a mood stabilizer.
Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder if it does not respond to medication. ECT uses an electrical current to cause a brief seizure while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.
Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It is most often used after ECT.
Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stable and their behavior is under control.
Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the possible risks and benefits of treatment for their children.

Support Programs and Therapies
Family treatments that combine support and education about bipolar disorder (psychoeducation) may help families cope and reduce the odds of symptoms returning. Programs that offer outreach and community support services can help people who do not have family and social support.
Important skills include:
  • Coping with symptoms that are present even while taking medications
  • Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
  • Learning to take medications correctly and how to manage side effects
  • Learning to watch for the return of symptoms, and knowing what to do when they return
Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients find the right support services, and make sure the patient takes medication correctly.
Getting enough sleep is very important in bipolar disorder. A lack of sleep can trigger a manic episode. Therapy may be helpful during the depressive phase. Joining a support group may help bipolar disorder patients and their loved ones.
  • A patient with bipolar disorder cannot always tell the doctor about the state of the illness. Patients often have trouble recognizing their own manic symptoms.
  • Changes in mood with bipolar disorder are not predictable. It it is sometimes hard to tell whether a patient is responding to treatment or naturally coming out of a bipolar phase.
  • Treatments for children and the elderly are not well-studied.

Prognosis

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to make sure that mania and depression are treated as early as possible.
Some people stop taking the medication as soon as they feel better or because the mania feels good. Stopping medication can cause serious problems.
Suicide is a very real risk during both mania and depression. People with bipolar disorder who think or talk about suicide need immediate emergency attention.

Complications Stopping medication or taking it the wrong way can cause your symptoms to come back, and lead to the following complications:

  • Alcohol and/or drug abuse
  • Problems with relationships, work, and finances
  • Suicidal thoughts and behaviors
This illness is hard to treat. Patients, their friends, and family must know the risks of not treating bipolar disorder.


Cyclothymic Disorder

Definition of Cyclothymic Disorder
This is a mild form of bipolar disorder (manic depressive illness) in which a person has mood swings over a period of years that go from mild depression to emotional highs.

Causes, Incidence, and Risk Factors The causes of cyclothymic disorder are unknown. Major depression, bipolar disorder, and cyclothymia often occur together in families. This suggests that these mood disorders share similar causes.

Cyclothymia usually begins early in life. It appears to be equally common in men and women.

Symptoms

  • Episodes of hypomania (see: Bipolar disorder) and mild depression occur for at least 2 years (1 or more years in children and adolescents)
  • Mood swings are less severe than in bipolar disorder or major depression
  • Symptoms are persistent, with no more than 2 symptom-free months in a row

Signs and Tests The diagnosis is usually based on your mood history. Your health care providers may order blood and urine tests to rule out medical causes of mood swings.

Treatment Mood stabilizing medication, antidepressants, talk therapy, or some combination of these three therapies may be used to treat cyclothymic disorder.

Some of the more commonly used mood stabilizers are:
  • Lithium. Lithium has been used for years in patients with bipolar disorder, and it may also help patients with cyclothymic disorder.
  • Antiseizure drugs. Valproic acid (Depakote), carbamazepine (Tegretol), oxcarbazepine (Trileptal), and lamotrigine (Lamictal) are the most established mood stabilizing antiseizure drugs.
Some people with cyclothymia may not respond to medications as well as patients with bipolar disorder.

Support Groups

As with other illnesses, you can ease the stress of living with cyclothymia by joining a support group whose members share common experiences and problems.

Prognosis Less than half of people with cyclothymic disorder will eventually develop bipolar disorder. In other people, cyclothymia will continue as a chronic condition or disappear with time.

Complications The condition can progress to bipolar disorder.



Dysthymic Disorder/ Chronic Depression
Dysthymia is a chronic type of depression where a  person's moods are regularly and consistantly low. Symptoms experienced are not as severe as those with major depression. People who suffer from dysthymia often function normally but are consistently unhappy.  This feeling can linger for long periods of time, usually 2 years or longer.  

Causes of Dysthymia
Although the cause of dysthymia is currently unknown, this form of chronic depression is thought to be stemmed from brain changes when coping with emotions.  Dysthymia is also known to run in families and found more in women.  Therefore, major life stressors like illness, anxiety, alcohol abuse, or drug addiction is commonly seen in patients with dysthymia and may increase chances of dysthymia.

Signs and Symptoms
Symptoms of dysthymia are very similar to those of major depression but on a less intense scale.  They include the following:
  • Sad or empty feeling
  • Difficulty sleeping ( too much or too little)
  • Insomnia
  • Feelings of helplessness, hopelessness and worthlessness
  • Feelings of guilt
  • Loss of energy
  • Changes in appetite ( overeating or loss of appetite)
  • Low self-esteem
  • Mental and physical sluggishness
  • Aches and pains
  • Thoughts of suicide
Commonality of Dysthymia
The National Institute of Mental Health listed approximately 10.9 million Americans ages 18+ are affected from dysthymia.  Although dysthymia doesn’t limit normal functions as other types of depression, it still has a major effect of personality and quality of life.

Diagnosis
Although dysthymia cannot be diagnosed through blood tests, X-rays, or other laboratory tests, your doctor can make a diagnosis though evaluating your moods and other mental and physical health symptoms. A thorough medical evaluation will be performed, with careful attention to your personal and family psychiatric history. Your doctor will know that with dysthymia, symptoms will last at least a year and is less severe than symptoms in major depression.
Your doctor will also make sure that your symptoms are not a result of substance abuse or a previously existing medical condition.  They can do this by testing your blood and urine to rule out anything else.


Seasonal Affective Disorder

Definition of Seasonal Affective Disorder
Seasonal affective disorder (SAD) is a kind of depression that occurs at a certain time of the year, usually in the winter.

Causes, Incidence, and Risk Factors

  • SAD may begin during the teen years or in adulthood. Like other forms of depression, it occurs more often in women than in men.
  • People who live in places with long winter nights are at greater risk for SAD. A less common form of the disorder involves depression during the summer months.

Symptoms Symptoms usually build up slowly in the late autumn and winter months. Symptoms are usually the same as with other forms of depression:

  • Hopelessness
  • Increased appetite with weight gain (weight loss is more common with other forms of depression)
  • Increased sleep (too little sleep is more common with other forms of depression)
  • Less energy and ability to concentrate
  • Loss of interest in work or other activities
  • Sluggish movements
  • Social withdrawal
  • Unhappiness and irritability
SAD can sometimes become long-term depression. Bipolar disorder or thoughts of suicide are also possible.

Signs and Tests There is no test for SAD. Your healthcare provider can make a diagnosis by asking about your history of symptoms.

The health care provider may also perform a physical exam and blood tests to rule out other disorders that are similar to SAD.

Treatment As with other types of depression, antidepressant medications and talk therapy can be effective.

Managing Depression at Home:
  • Get enough sleep.
  • Eat a healthy diet.
  • Take medicines the right way. Learn how to manage side effects.
  • Learn to watch for early signs that your depression is getting worse. Have a plan if it does get worse.
  • Try to exercise more often. Look for activities that make you happy.
  • Practice good sleep habits.
Avoid alcohol and illegal drugs. These can make depression worse over time. They may also affect your judgment about suicide.
When you are struggling with depression, talk about how you're feeling to someone you trust. Try to be around people who are caring and positive. Volunteer or get involved in group activities.

Light Therapy
Light therapy using a special lamp with a very bright light (10,000 lux) that mimics light from the sun may also be helpful.
  • Start treatment during the fall or early winter, before the symptoms of SAD begin.
  • Follow your health care provider's instructions about how to use light therapy. A common practice is to sit a couple of feet away from the light box for about 30 minutes every day. This is usually done in the early morning, to mimic sunrise.
  • Keep your eyes open, but do not look straight into the light source.
Symptoms of depression should improve within 3 - 4 weeks if light therapy is going to help.
Side effects of light therapy include:
People who take drugs that make them more sensitive to light, such as certain psoriasis drugs, antibiotics, or antipsychotics, should avoid light therapy.
A check-up with your eye doctor is recommended before starting treatment.
With no treatment, symptoms usually get better on their own with the change of seasons. However, symptoms can improve more quickly with treatment.

Prognosis The outcome is usually good with treatment. However, some people have SAD throughout their lives.



Postpartum Depression

Definition of Postpartum Depression
Postpartum depression is moderate to severe depression in a woman after she has given birth. It may occur soon after delivery or up to a year later. Most of the time, it occurs within the first 3 months after delivery.
Causes, Incidence, and Risk Factors
The exact causes of postpartum depression are unknown. Changes in hormone levels during and after pregnancy may affect a woman’s mood. Many non-hormonal factors may also affect mood during this period:
•Changes in your body from pregnancy and delivery
•Changes in work and social relationships
•Having less time and freedom for yourself
•Lack of sleep
•Worries about your ability to be a good mother

You may have a higher chance of postpartum depression if you:
•Are under age 20
•Currently abuse alcohol, take illegal substances, or smoke (these also cause serious medical health risks for the baby)
•Did not plan the pregnancy, or had mixed feelings about the pregnancy
•Had depression, bipolar disorder or an anxiety disorder before your pregnancy, or with a previous pregnancy
•Had a stressful event during the pregnancy or delivery, including personal illness, death or illness of a loved one, a difficult or emergency delivery, premature delivery, or illness or birth defect in the baby
•Have a close family member who has had depression or anxiety
•Have a poor relationship with your significant other or are single
•Have money or housing problems
•Have little support from family, friends, or your spouse or partner

Symptoms
•Agitation or irritability
•Changes in appetite
•Feelings worthless or guilty
•Feeling withdrawn or unconnected
•Lack of pleasure or interest in most or all activities
•Loss of concentration
•Loss of energy
•Problems doing tasks at home or work
•Significant anxiety
•Thoughts of death or suicide
•Trouble sleeping

A mother with postpartum depression may also:
•Be unable to care for herself or her baby
•Be afraid to be alone with her baby
•Have negative feelings toward the baby or even think about harming the baby (Although these feelings are scary, they are almost never acted on. Still you should tell your doctor about them right away.)
•Worry intensely about the baby, or have little interest in the baby

Signs and Tests
There is no single test to diagnose postpartum depression. Diagnosis is based on the symptoms you describe to your doctor or nurse.
Women with postpartum depression should have blood tests to screen for medical causes of depression.

Treatment
A new mother who has any symptoms of postpartum depression should contact their doctor or nurse right away to get help.
Here are some other helpful tips:
  • Ask your partner, family, and friends for help with the baby's needs and in the home.
  • Don't hide your feelings. Talk about them with your partner, family, and friends.
  • Don't make any major life changes during pregnancy or right after giving birth.
  • Don't try to do too much, or to be perfect.
  • Make time to go out, visit friends, or spend time alone with your partner.
  • Rest as much as you can. Sleep when the baby is sleeping.
  • Talk with other mothers or join a support group.

The treatment for depression after birth often includes medication, therapy, or both. Whether or not you are breast-feeding will play a role in what medicine your doctor recommends. You may be recommended to a mental health specialist. Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are types of talk therapy that often help postpartum depression.
Support groups may be helpful, but they should not replace medication or talk therapy if you have postpartum depression.
Having good social support from family, friends, and coworkers may help reduce the seriousness of postpartum depression.

Prognosis
Medication and professional talk therapy can often successfully reduce or eliminate symptoms.

Complications
If left untreated, postpartum depression can last for months or years.
The potential long-term complications are the same as in major depression. Untreated, postpartum depression may put you at risk of harming yourself or your baby.

Prevention
Having good social support from family, friends, and coworkers may help reduce the seriousness of postpartum depression, but may not prevent it.
Women who had postpartum depression after past pregnancies may be less likely to develop postpartum depression again if they start taking antidepressant medications after they deliver. Talk therapy may also be helpful in preventing it.


Premenstrual Dysphoric Disorder

Definition of Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder is a mental illness that describes mood changes occurring exclusively during the two weeks before menses. While 80% of women experience some physical and emotional problems during this time, only 3% - 8% meet the definition of PMDD. Premenstrual dysphoric syndrome is most commonly found in women in their late-30s to mid-40s.

Causes
The exact cause is unknown. Psychological, cultural, and social factors may play into PMDD. Some people believe it may involve genetics but no one knows for sure.

Symptoms
Below is a list of the most common symptoms of depression. It is persistent, rather than occasional symptoms that identify true depression.
  • Decreased appetite with weight loss or increased appetite
  • Decreased enjoyment of hobbies, interests, and usual activities
  • Difficulty concentrating, thinking, remembering, and making decisions
  • Fatigue, lack of energy, or feeling tired frequently
  • Feeling guilty, worthless, or helpless; low self-esteem and self-deprecating thoughts
  • Feeling hopeless or overwhelmingly pessimistic and negative
  • Feelings of sadness, anxiety or emptiness
  • Persistent thoughts of death and dying or suicide
  • Restlessness (need to move around or fidget) and irritability
  • Sleeping too much or too little (hypersomnia or insomnia); waking early morning
  • Slow or labored thinking, speech, and motion
  • Unexplained medical problems that don't respond to treatment

Nearly every woman will experience one or more of these symptoms, to some degree, at some point in her life. Depression symptoms, by themselves, are not the same as depression. These symptoms can also be caused by other conditions. For instance, attention deficit disorder can cause difficulty concentrating, and anemia can cause fatigue.

Diagnosis
In addition to the above PMDD symptoms, to be diagnosed with PMDD these symptoms must occur only during the two weeks before menses for at least two consecutive cycles. Other diagnostic criteria for PMDD include:
  • The symptoms of PMDD must be severe enough as to interfere with day-to-day functioning (for example, avoiding friends or decreased productivity at work).
  • The symptoms must not be an exacerbation of another illness.

Treatment
There are several treatments available for premenstrual dysphoric disorder. Both pharmacological and lifestyle changes are options for PMDD treatment. Dietary changes such as abstaining from caffeine, reducing sodium and avoiding alcohol may be helpful. Exercise is also helpful in treating the symptoms of PMDD.
Other non-pharmacological treatments for PMDD include:
  • Relaxation therapy – reduces blood pressure, heart rate, rate of breathing and slows brain waves. Therapy may be specific to PMDD or general as in yoga or meditation. Studies show conflicting results on efficacy.
  • Light therapy – usage of natural, full-spectrum lighting. Clinical efficacy of bright light therapy is uncertain.
  • Sleep deprivation – as in major depressive disorder, those with PMDD seem to respond to sleep deprivation treatment. Depressive symptoms of PMDD were reduced after a night of recovery sleep following a night of sleep deprivation.
  • Cognitive behavioral therapy (CBT) – focuses on anger control as well as emotion and thought restructuring. Although clinical evidence suffers from poor study design, CBT is thought to be effective. (more information on:Therapy for Depression)
Medication treatment is also available for PMDD. Antidepressants, anxiolytics (anti-anxiety) and mood stabilizers are all commonly used. Other pharmacological PMDD treatments with supporting clinical evidence include:
  • Vitamins and minerals such as calcium supplements and magnesium
  • Hormone medications like drospirenone and ethinyl estradiol (Yaz), an estradiol transdermal patch (Esclim) or danazol
  • Diuretics
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like mefenamic acid (Ponstel) or naproxen sodium (Naprelan)
  • Beta-blockers like atenolol (Tenormin) or propranolol (Inderal)

General Symptoms of Depression
According to the National Institute of Mental Health, symptoms of depression may include the following:
  • Difficulty concentrating, remembering details, and making decisions
  • Fatigue and decreased energy
  • Feelings of guilt, worthlessness, and/or helplessness
  • Feelings of hopelessness and/or pessimism
  • Insomnia, early-morning wakefulness, or excessive sleeping
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable, including sex
  • Overeating or appetite loss
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
  • Persistent sad, anxious, or "empty" feelings
  • Thoughts of suicide or suicide attempts

Example: Lately Amy hasn't felt like herself. Her friends have noticed it. Kara was surprised when Amy stayed home instead of going to the movies like they do every Friday. Amy spent the day sleeping.
Staying in more than usual isn't the only change in Amy. She's always gotten great grades, but over the past couple of months she’s started getting bad grades. She has trouble concentrating. She forgot to turn in a paper and is having a hard time getting motivated to study.
Amy feels tired all the time but has difficulty falling asleep. She's gained weight too. When her mother asks her what's wrong, Amy just feels like crying. But she doesn't know why. Nothing particularly bad has happened. Yet Amy feels sad all the time and can't shake it.
Amy may not realize it yet, but she is depressed.

General Causes of Depression Many theories about the causes of depression have emerged throughout the years.  Factors the have been suggested as causes of depression include:
  • Abuse: Past physical, sexual, mental or emotional abuse can become a huge trigger for depression later on in life.
  • Certain Medications: Some drugs used to treat other existing medical conditions can increase your risk of depression.
  • Conflict: personal conflicts, disputes with family members or friends as well as other internal conflicts can make your receptive to depression
  • Death or Loss: The death or loss of a loved one is a huge trigger for depression. Even though this is a natural occurrence in life, it can still have major effects in your life and cause depression.
  • Major Life Events: Major events, both good and bad can cause depression. Moving, graduating, new jobs, divorce, retiring or a new stage of life can lead to depression.
  • Personal Problems: Everyday problems that people face. Everyone has issues they face day by day.  Social isolation, school, education, work, and even other mental and physical problems can trigger an ongoing problem of depression.  
  • Substance abuse:  According to sources, nearly 30% of people with substance abuse  problems also suffer from major or clinical depression.  

General Diagnosis of Depression
With most medical conditions, doctors use blood tests and other laboratory tests, however depression cannot be found through laboratory tests.  One effective ways doctors diagnose depression is through talking with the patient.  While  physical examinations can reveal the overall state of health and physical symptoms of depression talking with the patient can revel other things that will help the diagnoses.  A patient can report thing like daily moods, behaviors, feelings, thoughts and lifestyle habits that will help with the diagnoses.
As mentioned above, the questions a doctor may ask a patient is key in diagnosing depression.  Some questions are the following:
  • Have you been having feelings of hopelessness and depression? How long?
  • Have you noticed an increase or decrease in appetite?
  • Do you use drugs or alcohol to change the way you feel? How much do you use?
  • Do you have any family history of depression or any other mental or emotional disorders?
  • Have you noticed a decrease in sex drive?
  • Have you been sleeping more or less than usual?

These questions can help the doctors diagnose depression in patients.  

A depression diagnosis is difficult to make because  clinical depression can appear in people in very ways. For example, some depressed people withdraw into a state of recluse while others are aggressive and agitated. Appetite can increase or decrease as well as sleep.  Others may become irritable or even agitated.  Depression can affect people in so many different ways and depression is experienced differently by all.  

Although as discussed above, depression isn’t something a laboratory test can find, other tests can help diagnose it as well.  The following are some different tests that can help doctors diagnose depression on top of the questions above. The self-reporting scale is a checklist of symptoms that helps you understand what you are dealing with. A psychological test can help determine temperament, organization and planning skills, and coping mechanisms through questions, responses to images and accomplishing tasks. Blood tests can also help understand if pre-existing conditions are causing depression symptoms.  Tests combined with a skilled physician questioning you can help diagnose depression in patients.

General Treatment of Depression
Antidepressents
Antidepressants are medications used to treat symptoms of depression. They improve depressive symptoms by increasing the availability of certain brain chemicals called neurotransmitters that contribute to the brain’s interpretation of emotions.
These are some specific antidepressants:
  • Selective serotonin reuptake inhibitors (SSRIs)- Common side effects include decreased sexual desire, digestive problems, insomnia, headache, restlessness.
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs)- These have similar side effects as SSRIs. They can cause increased sweating, dry mouth, fast heart rate, and constipation.
  • Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)- These don’t cause sexual side effects- only happens rarely, however it may increase risk of having seizures.
  • Atypical antidepressants- These have serious side effects, so they usually aren’t prescribed until patient has tried at SSRI without improvement. Side effects include dry mouth, blurred vision, constipation, urinary retention, fast heartbeat and confusion, weight gain.
  • Monoamine oxidase inhibitors (MAOIs)- These are used as the last resort because they have serious side effects. They require a strict diet because certain interactions with food could be deadly.

Psychotherapy
Regimens of psychotherapy vary from short-term (10-20 weeks) to long-term. The two main types of psychotherapy are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). These have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative ways of thinking and behaving that may contribute to their depression. IPT helps people understand and work through struggling personal relationships that also may contribute to their depression.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression, psychotherapy may not be a sufficient treatment. Studies have shown that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression. Also, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.

Electroconvulsive Therapy
Electroconvulsive therapy (ECT) may be useful if insufficient results are shown for medication and/or psychotherapy. ECT formerly had a bad reputation because it was associated with causing brain damage. However, recently it has improved and can provide relief for people experiencing extreme depression who have not been successful with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she is not aware of the electrical impulse administered in the process. A patient typically undergoes this process several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Howmany times a patient needs this therapy is dependent on their type of depression and the severity of symptoms.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. These side effects typically resolve soon after treatment. Research has shown that after one year of ECT treatments, patients showed no signs of these side effects.

Repetitive Transcranial Magnetic Stimulation
Repetitive Transcranial Magnetic Stimulation (rTMS) is a newer way of treating depression that can be used if all other treatments fail.

When the brain is stimulated with rTMS, a magnetic coil is placed against the scalp about three inches beyond the hairline and to the left of the center of the head. The magnetic coil is made from two plastic loops, connected to look like a “figure 8.” Each of the two loops in the coil is about three inches wide.
rTMS works by creating magnetic pulses in the loops of the coil. These magnetic field pulses produce small electric currents that stimulate nerve cells in the brain. These magnetic pulses also stimulate muscles and skin in the scalp and cause a moderate tapping sensation to be felt in the scalp under the coil. rTMS does not involve passing electrical currents directly through the scalp. Therefore, in contrast to ElectroConvulsive Therapy (ECT), it does not require anesthesia.
Several studies suggest that a several-week course of daily rTMS treatments may improve depression for up to several months. In addition, these studies suggest that rTMS is generally safe and does not cause the memory loss associated with ECT. In rare cases, rTMS has been reported to induce seizures.


Healthy Living with Depression
Here are some small things that can make a big difference in everyday life:
  • One day at a time
  • Try not to isolate yourself
  • Keep your body healthy
  • Avoid alcohol and drugs
  • Ask for help if you are stressed
  • Talk to a friend
Depressions can be treated! Between 80 and 90 percent of people with depression can be helped. There are many different antidepressant medications and psychotherapy alone. People with moderate to severe depression most often benefit from antidepressants. Getting help for depression is key and vital to feeling better. Get the right help and recognize the symptoms of depression as something that can become better.


TR Implications
These are some ideas for of how to use Therapeutic Recreation to ease and improve your depression or depressive symptoms.
  • Engage in mild activity or exercise. Go to a movie, a ballgame, bowling, take a walk, or any other event or activity that you enjoy.
  • Participate in religious, social and fun activities.
  • Set realistic goals for yourself.
  • Break up large tasks into smaller tasks, set some priorities and do what you can as you can.
  • Try to spend time with other people and confide in a someone that you trust. Try not to isolate yourself- let others help you.
  • Expect your mood to improve gradually, not immediately. Do not expect to suddenly “snap out of” your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
  • Postpone important decisions until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
  • Remember that positive thinking will replace negative thoughts as your depression responds to treatment.


Organizations:

Teen Suicide Hotline: (1-800-784-2433)
1-800-SUICIDE

Suicide Hotline: 1-800-SUICIDE
(1-800-784-2433)

Depression Hotline: 630-482-9696

American Psychiatric Association (APA)
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901
Phone: 703-907-7300

American Psychological Association
750 1st Street, NE
Washington, DC 20002-4242
Phone: 202-336-5510
TollFree: 1-800-374-2721

Depression and Bipolar Support Alliance (DBSA)
730 N. Franklin Street, Suite 501
Chicago, IL 60610-7224
Phone: 312-642-0049
Fax: 312-642-7243

Depression and Related Affective Disorders Association (DRADA)
2330 West Joppa Road, Suite 100
Lutherville, MD 21093
Phone: 410-583-2919
Email: drada@jhmi.edu

National Alliance for Research on Schizophernia and Depression (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021
Phone: 516-829-0091
TollFree: 800-829-8289
Email: info@narsad.org

National Foundation for Depressive Illness, Inc. (NAFDI)
PO Box 2257
New York, NY 10116
TollFree: 800-239-1265

International Organizations:

WHO ( World Health Organization)

Befrienders International

Samaritans

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