Marks Psychiatry

An article published in the October issue of the American Journal of Psychiatry (164:1539-1546) concluded that the earlier in life a person develops major depression, the more likely they are to have long term social and occupational problems. The authors studied a group of 4 thousand people ages 18-75 with major depression from both primary care and psychiatric offices. For each individual, they established the person’s age when they had their first depressive episode. The age groups were defined as childhood onset (age less than 12), adolescent onset (ages 12-17), early adult onset (ages 18-44), middle adult onset (ages 45-59) and late adult onset (age greater than 60).

The authors found that pre-adult onset (age less than 18) was associated with higher rates of never being married, impaired social functioning, more lifetime episodes and impaired occupational functioning. The people in this group also tended to have more medical problems and concurrent psychiatric illnesses in addition to depression. This is in contrast to those who developed their first episode in middle or late adulthood. These individuals experienced less comorbid psychiatric and medical illnesses and were overall higher functioning.

These aren’t encouraging findings, but it makes sense that the longer a person is depressed or struggles with depression on and off throughout their lifetime, the more opportunity for the illness to impair their quality of life.

Many people have difficulty with the idea of needing a medication “forever” and may spend years resisting treatment. We know that depression causes significant disability in some and rivals other illnesses such as heart disease in lost time from work and over decreased productivity. This study is another in the growing literature that describes the long term affects of having depression long term. Getting good, consistent treatment early can help one’s course so that developing depression early in life does not have to result in having your life permanently derailed.

[tag]depression, depression treatment, early depression[/tags]

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The Substance Abuse and Mental Health Services Administration published a report on the incidence of depression in adults by occupation. They found the 2 occupational categories with the highest incidence of depression were personal care services and food preparation. They also found that that 7 percent of all full-time workers experienced an episode of depression in the past year.

Personal care service is a broad category but included childcare workers, home care aids and animal caretakers. Food preparation included cooks, bartenders and servers. The lowest rates of depression were found in the job category of engineers, architects and surveyors.

The report offers no explanations for these findings. However, it did show that part-time workers and they unemployed had higher rates of depression, 9.3 and 12.7 respectively compared to the 7 percent of full time workers. This suggests that working full-time is somewhat protective for developing depression.

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Several recent studies show that in some elderly patients who met criteria for depression, a large percentage of them visited their doctors with only pain complaints. There seems to be a direct relationship between the number of pain complaints and the likelihood of having depression. That is, the more pain symptoms the more likely the person is depressed.

Chronic pain can trigger or worsen depression in a person of any age, but these findings suggest that depression can be more easily missed in the elderly population because they may not look like the typical depressed person. Since aggressively treating depression can improve the pain symptoms (if they are determined to be depression related), it is important to consider depression (and get an evaluation for it) in an elderly person with multiple physical complaints.

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A symptom of depression can be anxiety, but a person can also have a co-morbid (meaning simultaneously occurring) anxiety disorder that is a separate entity from their depression. Some anxiety disorders that can occur with depression are Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Social Phobia and Post-Traumatic Stress Disorder. It is not uncommon for the anxiety to present prior to the depression. In fact, according to an article in the Journal of Psychiatric Research (2003;37:187-92), the prevalence of generalized anxiety occurring with major depression is close to 70%. This is a high percentage.

Other studies show that 28% - 38% of those with bipolar disorder have a separate anxiety disorder. One study in the American Journal of Psychiatry (2004;161:2222-9) showed that an anxiety disorder occurring with bipolar disorder was associated with an earlier age of onset. The authors noted that teenagers developing bipolar disorder at an earlier age likely began with anxiety problems as a prelude to developing the mood symptoms.

Why is this important? Unfortunately we have seen that anxiety disorders can worsen the course of depression or bipolar disorder, making it harder to achieve remission of symptoms. The untreated symptoms can lead to substance abuse as a way to self-medicate. If a person is in the throws of serious mood episode (depression or mania), it can be easy for all those involved to overlook the anxiety disorder or not aggressively manage the anxiety because of the attention to the mood symptoms. So these findings emphasize the importance of diagnosing and managing comorbid anxiety disorders in individuals with major depression or bipolar disorder.

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I saw a segment on The Today Show this morning about the millions of antidepressants prescribed. Questions arose as to whether or not this is an indication of Americans wanting a quick fix or are doctors over-prescribing the medications. This opens a pandora’s box of issues ranging from who should treat depression to the state of health care (e.g. doctor’s offices becoming mills where many patients are churned in and out with little time to talk). I could go on about many of these issues, but only have time for one today and that’s the issues of what is unhappiness versus depression?

People experience depression differently, but there are a set of criteria that we use to diagnose depression. But rather than list the criteria, let me paint a picture of a depressed person for you. Symptoms vary depending on the person and the severity of their illness, but generally speaking:

• people who are depressed may have trouble experiencing pleasure in anything
• their limbs may feel heavy
• they may sleep all day or have trouble sleeping
• they may have trouble thinking and concentrating such that it affects their work
• they may have constant anger and irritation that is unusual for them
• they may go days without bathing because they just don’t care
• some people describe noticing that colors look duller
• some even feel like life isn’t worth living

This is not an exhaustive list, but some the symptoms depressed people may experience.  This is in contrast to feeling down after a relationship breakup, or having trouble getting out of bed to go to a job you hate. No amount of medication is going to prevent people from feeling bad when bad things happen. I tell patients, whatever problems they have will still be there with medication. The difference is, for a person who is depressed, medication can strengthen their foundation so they can more effectively use their emotional resources to deal with their problems. Depression exhausts your emotional reserves so that you may be unable to handle the stresses of life in your usual way. There are some who have poor coping mechanisms and have trouble dealing with the day to day problems of life and are not depressed but may feel chronic distress. This person may respond better to therapy to help them handle their problems differently.

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A study published in the American Journal of Psychiatry, June 2007 issue addressed the effect of sibling relationships on a person later developing depression. We’ve known for years that troubles in childhood significantly impact one’s future risk of developing depression or other emotional disturbances. However, the childhood troubles mostly focused on our relationship with our parents and there has been little focus on our relationship with our brothers and sisters.

The study included 229 men and what is most interesting to me is that they initially recruited these men from 1939 – 1942 as college sophomores ages 18-19 and followed them for 30+ years. They completed questionnaires every two years and many are continuing to be followed. Upon entering the study, their parents were also interviewed and they obtained extensive family, social and medical history on each participant.

All of the men began with no mental health problems and the study found that those who had poor or destructive relationships with their siblings were more likely to develop depression by age 50. These results held true when they controlled for hereditary factors such as a family history of depression. This further supports their findings that developing depression later in life was not simply due to having a genetic predisposition to depression. They also found that poor sibling relationships predicted a greater tendency to use mood-altering drugs.

There were many limitations to the study and many unanswered questions, but it does introduce a vulnerability in our development that can permanently alter our future relationships. If further research reinforces this link between poor sibling relationships and depression, we could have a focus of family intervention that could change the course of someone’s mental health future.

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Individuals with an disorder such as bipolar disorder can behave in ways that make them question whether their actions are part of their personality or part of their illness.  For example, two common symptoms with bipolar disorder are hypersexuality and hyperreligiousity.  However, defining what is “hyper” is not always an easy task.  It can be very difficult to tease out what is the person’s personality and what is being driven by the disinhibition that you can see with a manic episode.  It is often during a euthymic period (neither manic nor depressed) that a person can do some introspection and get a sense of who they are.  It can be sobering for some to realize their free spiritedness, high sex drive, etc. may have been their illness.  They are then left to figure out who they really are.

In a similar way, chronic irritability that may seem a part of someone’s personality could be persistent depression that once treated significantly improves.  In these cases, a person may feel relief to know they are capable of feeling happy or having a good outlook on life.

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