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School of Medicine
Depression: What You Need to Know as You Age
If you’re one of the more than 14.8 million American adults who experiences major depression, you may feel so bad that you can’t get out of bed, be around the people you love or participate in activities that you usually enjoy. Actually, there are more than 50 different symptoms of major depression, ranging from the well-known—crying and sadness—to those you might never associate with depression, such as anger, workaholism and back pain.
Depression is a disease that affects every aspect of a person’s life, not just mood, says Johns Hopkins expert Andrew Angelino, M.D., Chair of Psychiatry at Howard County General Hospital. The World Health Organization predicts that by 2020, depression will be the second-leading cause of disability in the world, just behind cardiovascular disease.
People who are depressed are far more likely to have other chronic medical conditions, including cardiovascular disease, back problems, arthritis, diabetes, and high blood pressure, and to have worse outcomes. Untreated depression can even affect your immune response to some vaccines.
Depression is not just debilitating; it can be deadly. An estimated one out of five people with depression will attempt suicide at some point.
Causes and Risk Factors
Depression is not a mood you can just get over. It is a disease in which the brain ceases to register pleasurable activities, says Angelino. Indeed, MRI studies with depressed people have found changes in the parts of the brain that play a significant role in depression.
Women are about twice as likely as men to be diagnosed with depression. You’re also more likely to develop depression if you are between ages 45 and 64, nonwhite, or divorced, and if you never graduated high school, can’t work or are unemployed, and don’t have health insurance. Other risks for depression include factors such as these:
- Experiencing stressful events in your life, such as losing your job, having problems in your marriage, major health problems, and/or financial challenges.
- Having a bad childhood, such as one involving abuse, poor relationships with your parents, and/or your parents own marital problems.
- Certain personality traits, such as getting extremely upset when you’re stressed
- A family history of depression, which can increase your own risk three or four times.
Depression is far more common than you might think, with nearly one out of 10 adults depressed at any time, about half of them severely.
Symptoms and Diagnosis
Symptoms of depression vary widely but can be divided into three main categories:
- Emotional and cognitive (thinking) symptoms include a depressed mood, lack of interest or motivation in things you typically enjoy, problems making decisions, irritability, excessive worrying, memory problems and excessive guilt.
- Physical symptoms include fatigue, sleep problems (such as waking too early, problems falling or staying asleep, sleeping too much), changes in appetite, weight loss or gain, aches and pains, headaches, heart palpitations, and burning or tingling sensations.
- Behavioral symptoms include crying uncontrollably, having angry outbursts, withdrawing from friends and family, becoming a workaholic, abusing alcohol or drugs, cutting or otherwise hurting yourself, and, in the worst cases, considering or attempting suicide
Depression can be classified as:
- Major depressive disorder (MDD), which includes depressed mood and/or reduced interest and pleasure in life, considered “core” symptoms, and other symptoms that significantly affect daily life.
- Dysthymia, (dis-THI-me-a), a milder form of depression that can progress to MDD.
- Postpartum depression, which occurs within weeks of giving birth.
- Psychotic depression, which comes with delusions and/or hallucinations.
- Seasonal affective depression, which occurs as the days get shorter and improves with spring.
Trying to avoid depression is not easy, says Angelino, particularly if you have a genetic predisposition toward the disease. If you know you’re at risk of depression, it’s important to be aware of the symptoms and recognize them early. Also important is optimizing your health to provide a kind of protective armor, says Angelino. Other advice:
Walk away from depression. Exercise definitely helps, says Angelino—not just because it helps maintain a healthy weight, which in turn helps maintain self-esteem, but because it’s measurable. “You can see what you accomplished, and that’s a big thing for keeping you from becoming demoralized or stressed,” he says. It doesn’t have to be much. Angelino points to a study published in American Journal of Preventive Medicine that found that just a half hour a day of walking or gardening could prevent depression.
Follow an antidepression diet. Think fish, vegetables, whole grains and lean protein, which studies have suggested can affect mood and brain chemistry. Studies have found that diets high in omega-3 fatty acids—a healthy fat found in fish, certain nuts and dark green leafy vegetables—have antidepressant effects, with low levels associated with an increased risk of depression.
Find a good therapist. Therapy is nearly always part of a treatment plan for depression, but studies have found it can also help prevent depression or a relapse. There are three commonly used forms:
- Cognitive behavioral therapy (CBT), which teaches you to reframe how you view the world and develop tools to cope with depressive feelings.
- Interpersonal psychotherapy, which teaches you about depression and links depressive symptoms to recent events in your life.
- Problem-solving therapy, in which you identify a problem, develop solutions, pick the best ones, create and implement a plan, and then evaluate your success.
Keep a job. Whether paid or volunteer, work provides a sense of purpose, says Angelino. Just don’t work too hard. Japanese researchers found that employees who worked at least 60 hours a week and felt like they had too much work to do were 15 times more likely to develop depression than their less-stressed colleagues.
Diagnosis & Treatment +
The first step in treating depression is seeking help. Successful treatment requires that you and your doctor design a treatment plan that is right for you. That could mean medication, therapy or both.
Dozens of medications are available to treat depression, most of which work on various chemicals in the brain that control mood. Two types of older antidepressants, monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs), are rarely used as a first-line treatment because of side effects. Instead, your doctor is more likely to prescribe a newer antidepressant. These fall into four classes: selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and atypical antidepressants (trazodone and mirtazapine).
Other medications used to treat depression include atypical antipsychotics, mood stabilizers and anti-anxiety medications.
A number of studies have found that cognitive behavioral therapy and interpersonal therapy can be just as effective as medication. The problem is that sometimes you are too depressed to engage in therapy, which is why a combination of medication and therapy usually works better.
Angelino always recommends that his patients enjoy exposure to light, particularly in the winter. Your best bet: Get the light outside, not through a window. Sunlight is one of the best sources of vitamin D, which Angelino deems essential for mood regulation. You may also want to talk to your doctor about supplementing with vitamin D.
Several novel therapies are available if traditional medications and psychotherapy don’t work:
- Electroconvulsive therapy, in which an electrical current “reboots” areas of the brain associated with depression
- Repetitive transcranial magnetic stimulation, which sends magnetic pulses to stimulate parts of the brain involved in regulating mood.
- Vagus nerve stimulation, in which electrodes are implanted around a nerve that helps regulate mood.
- Ketamine infusion, in which a pediatric anesthetic has shown fast and dramatic improvements in treatment-resistant depression.
Living With... +
Once you’ve had an episode of depression, you have a high risk of recurrence. That’s why it is so important to not only treat the initial episode to full recovery, but to follow the prevention advice above to prevent a relapse. In addition, try to:
Practice patience. It can take several weeks for most antidepressants to kick in.
Keep in touch. You should initially see your doctor every couple of weeks after starting treatment (more often if you’re having suicidal thoughts). Tell your doctor about any bothersome side effects. Most go away after a couple of weeks, but if they continue, your doctor can prescribe another medication. Also let your doctor know if you don’t feel better in a few weeks. You may need a different medication or to add another one. Do not stop taking any medication without your doctor’s OK.
Johns Hopkins experts continue their work in understanding and treating depression in ways that can translate into better health today. Notable research you can access includes these findings:
Light exposure at night may be linked to depression and learning issues. In a 2012 study published in the journal Nature, Johns Hopkins researchers demonstrated that chronic exposure to bright light at night activated cells in the eye that, in turn, increased stress hormones linked to depression and learning and memory problems. Risks include working the graveyard shift and even sitting in front of a computer at home at night.
Meditation can be effective in treating anxiety and depression. Johns Hopkins research published online in The Journal of the American Medical Association Internal Medicine in early 2014 found that meditating may provide as much relief from anxiety and depression as antidepressants.
For Caregivers +
If you are the spouse or partner of someone with depression, or caring for a relative who is depressed, here’s how you can help yourself and your loved one.
Realize that depression is a biological illness. It’s not a mood that the person can just get over.
Help get the right diagnosis and treatment. Depression still carries a stigma, and some people may not want to admit or even know that they are ill. But the right diagnosis is the first step to the right treatment.
Provide support throughout the recovery period. That could mean renting funny videos that will make you both laugh or taking regular walks outside. But don’t push—someone with depression often barely has the energy to get dressed. Celebrate the small victories.
Stay alert. Watch for any signs that your loved one may be considering suicide and tell the doctor immediately.
Cardiovascular (car-dee-oh-vas-cue-ler) disease: Problems of the heart or blood vessels, often caused by atherosclerosis—the build-up of fat deposits in artery walls—and by high blood pressure, which can weaken blood vessels, encourage atherosclerosis and make arteries stiff. Heart valve disorders, heart failure and off-beat heart rhythms (called arrhythmias) are also types of cardiovascular disease.
Cognitive behavioral therapy (CBT): Two different psychotherapies—cognitive therapy and behavioral therapy— in one. Cognitive therapy can help you improve your mood by changing unhelpful thinking patterns. Behavioral therapy helps you identify and solve unhealthy habits. When used in conjunction with each another, these therapies have been shown to improve problems such as depression, anxiety, bipolar disorder, insomnia and eating disorders.
Heart palpitations (pal-peh-tay-shuns): The feeling that your heart is thumping, racing, flip-flopping or skipping beats. Strong emotions, caffeine, nicotine, vigorous exercise, medical conditions (such as low blood sugar or dehydration) and some medications may cause heart palpitations. Call 911 if you also have chest pain, shortness of breath or unusual sweating, or feel dizzy or faint.
Immune response: How your immune system recognizes and defends itself against bacteria, viruses, toxins and other harmful substances. A response can include anything from coughing and sneezing to an increase in white blood cells, which attack foreign substances.
Interpersonal therapy (IPT): A treatment often used for depression that lifts mood by teaching you how to relate with others in a healthier way. A therapist will help you identify troubling emotions and their triggers, express emotions in a more productive way and examine past relationships that may have contributed to your current mental health issues.
Lean protein: Meats and other protein-rich foods low in saturated fat. These include boneless skinless chicken and turkey, extra-lean ground beef, beans, fat-free yogurt, seafood, tofu, tempeh and lean cuts of red meat, such as round steaks and roasts, top loin and top sirloin. Choosing these can help control cholesterol.
Omega-3 fatty acids (oh-may-ga three fah-tee a-sids): Healthy polyunsaturated fats that the body uses to build brain-cell membranes. They’re considered essential fats because our body needs them but can’t make them on its own; we must take them in through food or supplements. A diet rich in omega-3s—found in fatty fish, like salmon, tuna and mackerel, as well as in walnuts, flaxseed and canola oil—and low in saturated fats may help protect against heart disease, stroke, cancer and inflammatory bowel disease.
Whole grains: Grains such as whole wheat, brown rice and barley still have their fiber-rich outer shell, called the bran, and inner germ. It provides vitamins, minerals and good fats. Choosing whole grain side dishes, cereals, breads and more may lower the risk for heart disease, type 2 diabetes and cancer and improve digestion, too.