Depression: Why Am I So Down?
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Tired out? Heavyhearted? Worried that things may never brighten up? When these symptoms last a while, they can signal depression, and it’s important to seek help if you are depressed.
Listen in to our depression basics show to hear clear, practical information about how to recognize depression's many symptoms such as lack of appetite or trouble sleeping. Plus, you'll learn where to go for an accurate diagnosis and what the latest treatment options are, so you can have a productive discussion with your healthcare provider.
As always, our expert guests answer your questions.
Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this show are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors, or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.
Now, here's your host, Heather Stark.
Hello, and welcome to our show, Depression: Why Am I So Down? I'm your host, Heather Stark. Depression is a very serious illness that affects at least one in ten American adults. Unfortunately, many people with depression never seek medical help. During our show we are going to discuss the warning signs and symptoms of depression so you will know if you or someone you love is suffering from the illness and how to get the help that is needed.
Joining us is Dr. Francis Mondimore. Dr. Mondimore is assistant professor in psychiatry at the Johns Hopkins University School of Medicine and attending physician in psychiatry at the Johns Hopkins Hospital in Baltimore. He received his M.D. from Johns Hopkins and also completed his residency in psychiatry at the Johns Hopkins Hospital. Dr. Mondimore is the author of four books for general audiences on mental health issues which have been translated into seven languages including the award-winning “Bipolar Disorder: A Guide for Patients and Families.” He has authored numerous book chapters and scientific articles as well.
Welcome, Dr. Mondimore
Dr. Francis Mondimore:
Glad to be with you.
Depression can affect a person mentally, emotionally, and physically. It can make it impossible to function in everyday life. The symptoms vary greatly, but most forms of depression can be helped with the right treatment. What are some of the different types of depression that people may experience? How are the symptoms different for each, Dr. Mondimore?
Actually, depression is surprisingly consistent from one person to another. It varies quite a bit in severity. It varies in the length of time that the symptoms trouble someone, but the collection of symptoms are basically the same: low mood, the inability to enjoy things, low energy level, sleep, appetite disturbance, difficulty with concentrating, negative and pessimistic thinking. And, as I said, the different types of depressive illnesses change how severe it gets and perhaps how long it lasts, but it's pretty much the same from one person to another.
Some people get symptoms that we call atypical depression where instead of not being able to sleep, they find themselves sleeping too much and rather than losing their appetite find that they have an increase in appetite. That can be different from one person to another.
The major category of depressive illnesses is major depression. It is characterized by periods of very severe depression, where a person is virtually incapacitated by depressive symptoms. These periods last for several weeks, but they often will last for several months, up to a year. And in a minority of people this can become a chronic sort of waxing and waning condition over many years. That's rather uncommon.
There is another type of depressive illness called dysthymic disorder or dysthymia. In that kind of an illness, people have less severe symptoms of depression so they often can function reasonably well but are very frequently and pretty consistently struggling with some depressed feelings all of the time. And this is a chronic illness that often goes on for years at a time.
People with bipolar disorder - which is a mood disorder characterized by periods of depression and periods of mania, where people get too much energy and can become very irritable - will also have long periods of being very depressed.
And then there are some other more controversial diagnoses that have been talked about. For example, there is something called minor depressive disorder, where people just have a few depression symptoms and some other categories that the field hasn't really agreed on as being particularly helpful. So, in a sense, it is a wide umbrella with many forms of illness, but in another way the depressive episode or the depressive syndrome pretty much looks the same in all of these illnesses.
My mother had bipolar disorder, and I remember going through depression with her. How can you tell the difference between a major depression and just normal ups and downs?
Everyone has gone through periods of being down. They're usually temporary. They are usually not very severe. It doesn't make people unable to function in what they do. It usually doesn't affect their appetites or their sleep pattern, or if it does, it only does so for a brief period of time. People retain the ability to be interested in the things that are usually interesting for them. They can cheer up. They can go to a movie or go to a ball game or something and forget their troubles for a little bit. So even though people may go through a period of being down, they're not like that all the time. They are able to react to things that happen. They feel good when good things happen.
In these depressive illnesses, that reactivity is lost, and people are just in this one mood state day after day, relentlessly, for no reason that they can usually put their fingers on. And then they also have all these associated symptoms which show that depression is a brain disease. Their thinking is sluggish. People will feel like they can't concentrate. They can't remember things. They can't read a book, can't read the newspaper, lose their appetite, and can’t sleep at night. When those sorts of things are going along with a depressed mood day after day, that is not a normal down.
Major depression is actually the most common problem. We think that probably something like one in ten, perhaps as many as one in five people will go through at least a brief period of major depression once in their life. Now, do all of these people have a mental illness or do they all have a psychiatric disorder? Well, probably not. It just shows you how difficult it can be to draw the line between a brief but severe period of low mood and a depressive illness.
But major depression that is recurrent and severe probably affects at least one in 20 individuals. Many of them have recurring illness. About 20 percent of people that have major depression will go on to develop a chronic illness. And psychiatrists disagree about how to classify all of this and how to think about it.
What we certainly agree on is that these depressive illnesses are very treatable. And if a person is struggling over a significant period of time with depressed feelings, especially if they are accompanied by some of those other symptoms that I mentioned, they owe it to themselves to see someone for a good assessment and to get some recommendations as far as treatment, because we have gotten much, much better at identifying and treating these problems.
Do we know what causes depression? Does it depend on a person's brain chemistry or personality or genetics? And can it be brought on just by stressful life events or trauma?
The answer to both those questions is, yes. One thing that I really try and emphasize to people is that we should not try and decide if this is a psychological phenomenon with psychological causes or if this is a biological or chemical phenomenon with chemical causes because it is always both. Depression and all of the mood disorders really, we are beginning to think of them as very common illnesses which our genetic makeup influences. It may influence how easily symptoms come on and how easy or difficult the symptoms are to treat, but we also know that genetics and biology doesn't explain it all and that there are other factors.
There are factors in a person's upbringing. We know that people who have had a parental loss during childhood are much more prone to serious depression later in life. We know that a physical stress or illness can bring out symptoms of depression and get a depressive illness started. We know that psychological trauma or difficulty can have the same affect.
So it is always a combination of biology and psychology. And treating depression is always a matter of addressing both the biological with medication and the psychological with counseling and psychotherapy. The treatment of depression has to be a very broad combination of interventions that include medication, therapy, lifestyle, many different things.
We know that there are certain areas of the brain that appear not to be functioning exactly normally. It turns out that there are certain areas of the brain where new brain cells, new nerve cells are constantly being formed. And we used to think that by the time you were 18 months old or so, you had all the brain cells you were ever going to have and that new brain cells never grew. Now we know that that is not the case, and in fact there are certain areas of the brain where new cells are constantly growing. There is a constant replenishment and remodeling of brain cells that change the way they are connected to each other. And we think that that very active process is probably necessary in mood control, that some people have genetic defects in some of the chemical pathways of that process, and that those people are more vulnerable to a whole variety of stresses that can then set off a depressive illness.
That makes it sounds like depression is hereditary.
Well, it is. There is a very large hereditary component. We know that from many, many years of doing family studies. Hereditability means what percentage of risk is conferred by genetic factors. The hereditability of bipolar disorder, which is the most genetic mood disorder, is about 60 percent. So that means that 40 percent of the risk is conferred by nongenetic factors, and we can only guess at what those factors are. We think that things like stress and some of those other environmental factors are a big part of it.
When you look at major depression, the hereditability is more like 40 percent. So that means that your genes can make you 40 percent more likely to have a serious depression, but you might be lucky to basically dodge the bullet. We think that the reason that the incidence of depression goes up as people age is because our brains become less resilient and less able to deal with those stresses. So genetics is a part of it. But again, think of diabetes. You know, just because you have a parent that has diabetes that doesn't mean that you are going to get diabetes.
But it might increase your chances.
It definitely increases your chances, yeah.
We cover a lot of chronic illnesses here at HealthTalk. Can depression be caused by or coexist with another chronic illness, such multiple sclerosis or cancer?
It can certainly coexist with anything. Again, serious depression is a very, very common problem. And if a person has a physical illness of some type, well, that is going to naturally be a stress, both a physical and psychological stress. So that can make people more prone to depression.
The medical illness that is most closely tied to depression is actually heart disease, and we know that there is a relationship between heart disease and depression. People who are depressed are at a much higher risk for heart problems, for dying from heart problems. And people who have heart problems, if they are also depressed, their risk of doing poorly is also much higher. People who have heart attacks and become depressed after they have the heart attack are much more likely to have another heart attack.
Treating depression is so important because we know that if a person is depressed, it often makes other illnesses much more difficult to treat, especially illnesses that are stress-related anyway. A good example is migraine headaches. Anyone who has migraine will tell you that going through some big psychological stress can set it off. And if a person is depressed, their migraine can be more difficult to control.
So there is a very tight connection. The trap that people do not want to fall into is to think that because they have a medical illness, it's normal for them to be depressed. That is not the case.
If somebody thinks that they are depressed, how do they go about getting that diagnosed?
It's a medical illness, and you go to a doctor. There was an educational campaign a number of years ago targeting primary care providers in learning how to screen their patients for depression and how to identify depression.
Another factor that has changed the way we treat depression is the availability of these newer anti-depressant medicines, or I guess they are not so new now. Before 1990 the anti-depressants were difficult medicines to prescribe. Dosing was tricky. They were very poisonous medications in overdose. They had a lot of side effects, so most doctors referred their patients to psychiatrists.
That changed with these newer anti-depressants which are much easier to dose, are not toxic, and have far fewer side effects than the older medicines. So the family practitioners and the internists are becoming much better at identifying depression and much more comfortable in treating depression. Again, this is a common illness.
There was a study done by the Rand Corporation a number of years ago. The Rand Corporation is sort of an economic think tank. It's not a scientific institute. But they were very interested in [learning] what illnesses had the greatest economic impact, and part of that investigation was looking at what illnesses caused people to visit their doctor the most. What they found was that about one in ten patients who came to family practice had major depression. They may have had something else as well, but one in ten had major depression.
So no matter what kind of doctoring you do, you are going to see a lot of people with depression. And I think doctors are getting a lot better at recognizing and beginning to treat depression and knowing when to refer to a specialist. And of course the specialist is the psychiatrist.
If I think I am depressed and I make an appointment with my family doctor, what can I expect from that doctor's appointment?
The doctor will ask you if you are having any of the symptoms that I mentioned earlier: low mood, loss of interest in things, inability to enjoy things, change in sleep either up or down, change in appetite up or down, concentration. And if a person is having all of those symptoms and it has gone on for several weeks, that is a pretty good indication that they have a depression.
Then you want to see if there other things going on that would explain some of these feelings. So they might check thyroid, for example, because people who have low thyroid can be very lethargic, they can sleep too much, they can put on weight and have some of the symptoms of depression, and actually they can have low mood at times. So they will check things like blood levels, such as hemoglobin because when people are anemic they are tired all the time, they don't have very much energy. Again, it can mimic some of the symptoms. Doctors will do pretty much what they always do when a patient comes with symptoms. They will do a physical exam or basic blood tests.
At this point, we do not have a specific test for serious depressive illness. We do not have a blood test that we can do or a scan that we can do, so it is really a matter of making the diagnosis clinically. Family history is often very helpful because these are illnesses that have a significant genetic component. So very frequently a person who wonders if they are having depression will have [it in their] family background. They will have a parent or aunt or uncle or grandparent who had a serious depression.
Or they will have a history of something else which can be a sort of a mask for depression, maybe an uncle who was an alcoholic, for example - because alcoholism and drug abuse are frequent complications of depression - or a distant family relative that attempted suicide. So if they have got that family history, that's also an indication. And then sometimes there are other clues that indicate that there is something more biological going on. So, for example, in women, if they have changes of mood premenstrually on a regular basis, that's an indication of something biological.
What kind of questions should the patient ask the doctor? Is there anything special that they should ask?
I think in the beginning it's up to the patient to be really honest about all of the symptoms that they are having, as they would do with any kind of thing that they are worried about, any kind of illness. And then it's up to the doctor to say, “Okay, this is what I think is going on, and this is what I think we should do next.” And then the questions can begin. If there is a particular medication that is recommended, then of course there will be questions about the medication.
But the issue with the treatment of depression is that it is unfortunately - haphazard is perhaps sounding a little too negative - but the treatment of depression is empiric [based on trial and error, meaning that a variety of drugs may be tried before finding one that works]. We know that almost everybody with depression, 80 percent at least, can be substantially helped by medication. But we also know that only about 50 percent of people get better with the first anti-depressant that they take and that frequently people have to be tried on several different anti-depressants before they have a full response. So those are some of the things to expect.
What if the patient doesn't get treatment? Will most people who suffer from depression get worse if they aren't treated?
I don't think that the study of what happens is good enough to be able to answer that question. It's clear that in some people it will get worse over time. In some people depression can be a very progressive illness and can be a very chronic illness. Now, that doesn't mean that those people are less treatable, because there will be people who have struggled with depression for many years, and then when they finally do get treatment, they have a very successful response to treatment, and they stay well.
However, in most people who have a major depression, the symptoms will last approximately six months to a year, and then the symptoms will go away on their own. That happens probably, probably 70 to 80 percent of the time when a person goes through a major depression. But a substantial number of those folks will have another depression at some point in their life, and there is a little bit of evidence that the more episodes a person has, the more likely it is that they will have a future episode and that there is sort of an acceleration of the illness over time. That appears to be especially true of bipolar disorder.
Does that mean that if you get on medication, you have to take medication forever? I mean, do patients recover and stop treatment? If they stop treatment, what's the relapse rate?
The relapse rate is very high. Now, there are people - on the order of 90 percent - that will have another episode of depression at some point in their lives. Now, for some people that next episode may not happen for 20 years. There are certainly people like that. And those people can stop treatment after a year. However, the current wisdom is that if a person has a major depression, especially if they have one before the age of 30, the probability that they will have more episodes fairly quickly. The chances of relapse are so high that we now usually recommend that people take the long-term view as far as medication is concerned.
The other thing is that a lot of times when people come to treatment for very severe depression, they have actually had more minor problems with depression for a much longer period of time. So, for example, people will frequently come and have their first episode that is so bad that they get into treatment in their 30s or their 40s. Then when they get better, they suddenly realize that they had actually been struggling from depression much longer than they had realized. When they get better, they realize that they have had some symptoms of depression for much longer than that.
It may be at some point in time we will be able to do some kind of test to see when the biological functioning has returned to normal, and we will be able to do some kind of test episodically. That would be nice, but we are not there yet.
Well, let's talk about treatment. What kind of treatment is currently available for people suffering from depression?
Well, of course, the mainstay for these very serious episodes of depression, these incapacitating episodes, is anti-depressant medicines. Now, there is evidence that when people have less severe illness that psychotherapy is as effective as medication. And psychotherapy can be sufficient for some people. However, when people are incapacitated, they need medical intervention.
And part of the reason for that is when people are severely depressed, they really aren't capable of benefitting from psychotherapy, because psychotherapy requires the person to sort of step back, look at themselves objectively and understand how they can change to make their lives better and make themselves feel better. When a person is in the grip of a serious depression, all of that objectivity is lost, and they will be hopeless. It will be impossible for them to engage in psychotherapy, and then they will feel like a failure and that it is their fault that they are still ill when psychotherapy doesn't work. So when the depression is very, very bad, that's when medication is necessary.
Could you review the different types of anti-depressant medications available? And what about side effects for each of them?
There are about two dozen anti-depressants on the market now. The most commonly prescribed are what are called the selective serotonin reuptake inhibitors (SSRIs). That's just a long label that refers to their effect chemically in the brain. Prozac, or fluoxetine, was the first of them, and now there are about, oh, four or five, Prozac, Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), Lexapro (escitalopram). They all work approximately the same way. The advantage is that for most of them, once a day dosing will work. People don't have to worry about taking pills several times a day. They are not sedating. They don't cause a lot of the gastrointestinal side effects that some of the earlier anti-depressants had.
The most common side effect with these medications is actually one that kind of snuck up on everybody, and that was the problem with sexual functioning that these medications can cause. It happens in about one-third of people that take them, and these are problems with loss of interest in sex so that people have a loss of libido and can have delayed orgasm. But because most people don't get these symptoms, and because they are otherwise so safe and have such a benign side effect profile, they are often the ones that are prescribed first.
There is another group of medications. There are two on the market now. Effexor (venlafaxine) is one, Cymbalta (duloxetine hydrochloride) is another, and these medications have a very powerful effect on serotonin, but they also work through an effect on another brain chemical called norepinephrine. And because they work on those two chemicals, they are actually called dual reuptake inhibitors.
They have some of the same side effects of the SSRIs. They can raise blood pressure in some people. They can have more gastrointestinal discomfort in some people. So they have a slightly greater side effect burden. There is a little bit of evidence that they are more broadly effective for more people.
And there are some other anti-depressants that are sort of in classes by themselves. Wellbutrin, or bupropion, is one. Remeron, or mirtazapine, is another. And these, again, have a slightly different chemical profile, a slightly different side effect profile. To talk about side effects of anti-depressants, you would have to have 20 discussions about the 20 different anti-depressants. But the SSRIs and the Cymbalta, Effexor, which are the SSNRIs, are very benign as far as side effects.
The original anti-depressants are called tricyclics, and that refers to the [chemical] shape of the molecule, of the pharmaceutical where there are three rings in the molecule. These are more difficult medications to take. They tend to be sedating. They very commonly cause people to have weight gain, and people have to be much more cautious about their diet. They can cause dry mouth. They can cause blood pressure changes. So they have to be dosed very carefully, and usually people have to start at very low doses and work up to higher doses to be able to avoid those side effects.
But they are very effective in some people, more effective than the newer anti-depressants. And people can get used to these problems. And all of these side effects of the anti-depressants are worse in the first few days, and by and large they get better after that. The sexual dysfunction is an exception, because if a person has significant sexual dysfunction from these medications, that tends not to get better, and alternatives need to be sought.
There is another group of medications called the monoamine oxidase inhibitors (MAOIs). Again, it's a big label that refers to what they do chemically. These medications work by inactivating a particular enzyme in the body that's involved in breaking down brain chemicals. But this enzyme is also important in breaking down adrenaline, so people have to be very careful about taking any kind of medications that have adrenaline-like effects, and they have to avoid certain foods that have amino acids in them with adrenaline-like effects.
So the MAO inhibitors are sort of another notch up on the hard-to-take scale. However the MAO inhibitors can be uniquely effective for some people and to give them relief where nothing else has given them any relief. And, again, people learn how to watch their diet, read the label on their over-the-counter medications, make sure that all of their doctors know what they are taking and make adjustments and be on the medication and depression-free and not be troubled by side effect problems.
We have talked a little bit about medication. Let's skip over to psychotherapy and do a little talking about talk therapy. There are different kinds of therapy available. Can you describe for us the options for those who might need therapy?
The form of psychotherapy that's been the best studied in depression is what's called cognitive therapy. And in cognitive therapy, the therapist helps the patients identify depressive patterns of thinking that make them more vulnerable to feel bad about themselves. For example, people can make some little mistake at work or at home and the first thing that occurs to them is, I can't do anything right. Well, that's not true, you know. There is really nobody who can't do anything right.
But what the therapist does in these situations is to help people identify those kinds of ingrained, automatic thinking patterns, where people are criticizing themselves all the time and reinforcing their perceived inadequacies all the time, and challenging those thinking patterns and helping people to develop more positive thinking patterns and more realistic thinking patterns.
Is that done one-on-one or in a group?
It's pretty much done one-on-one because it's individualized. It really involves a person talking at great length about their feelings and their thinking patterns, and basically it's a way of giving a person a proactive, healthy way of coping with things. A lot of therapy for depression is stress management and identifying the ongoing situations and relationships that are a constant source of stress and disappointment and getting people to learn how to achieve mastery over those kinds of situations.
So, again, that is very, very individualized. But in the treatment of depression, we tend to emphasize the here and now and not go delving into the past. Some people, of course, have been through some terribly traumatic event that they have perhaps not made peace with, not been able to work through or put behind them, and in those cases it can be helpful to go back and revisit those situations. But this idea that therapy is talking about what happened when you were toilet trained and so forth is absolutely not true.
Group therapy is very helpful for some people. It's especially helpful for people that are very uncomfortable in social situations and have trouble with communication. And it can be a situation in which people can develop a lot of skills in communication and in expressing themselves.
So psychotherapy is really all about a person getting to know themselves and learning ways of coping with the bad things that happen in life in an effective way and to identify ineffective coping mechanisms and replace them with effective coping mechanisms. So it's very, very individualized.
If anyone listening is having thoughts of suicide or they are feeling overly sad or hopeless, what are the resources that they can take advantage of right now, Doctor?
Well, of course, it's important to think of this as a medical illness and so getting medical attention is number one on the list. If a person is desperate, then that is an emergency, and that's what emergency rooms are for at hospitals. And people in emergency rooms, the doctors and the nurses, see people that have having suicidal thoughts every day, so they are very good at identifying the severity of the problem, making a diagnosis, and getting people hooked up with the resources that they need.
And for family and friends who are experiencing this, the emergency room is also a good resource for them. Is that right?
Right. There certainly are people who are so depressed and they are so hopeless that they can't even conceive of getting any help, they can't even imagine feeling better, and they can feel that there is no point in getting any treatment. Depression can alter or obscure a person's view to that extent. However, the medical system recognizes this situation and so there are always mechanisms to get people into treatment even if they don't see the need or see any use in getting treatment themselves.
There are laws and procedures in place so that people who are very psychologically ill in the community and who are in a dangerous situation can be brought into the emergency room by a variety of types of personnel. It can be as easy as calling 9-1-1 in some communities. And in many communities the local hospital or local community mental health center will have a team that will go out into the community and do an assessment in the home. Some communities are lucky enough to have those kinds of teams available. In fact, all of that is through a hospital emergency room, because they know what is available and how to get to it.
The important thing, I think, is that there is help available, and the emergency room is a good place to go there.
Now we need to open the program to questions from our audience. We have an e-mail from Mason, Ohio, and she asks, “Is there a medication that will not hurt your liver? My doctor recently took me off all medicines due to my high liver cell counts.”
All of these medications are handled in the liver. There really aren't too many that can damage the liver. People can have a flare-up or inflammation of liver from just about any medication, psychiatric and otherwise. That is more like an allergic event. It's more like an individual kind of a reaction, not really a side effect, and that's possible with just about anything.
Most of the anti-depressants do not particularly cause liver problems. When I hear that this person was on several different medications, it sounds like it's a slightly more complicated story. But by and large people do not need to worry about anti-depressant medication hurting their liver; these medicines are not toxic to the liver.
We have an e-mail from Indianapolis, Indiana. “How can I recognize or separate the baby blues from the depression, or is it the same thing?”
Great question. Most women have at least a few hours of what has been called the baby blues, where they perhaps are tearful, feel overwhelmed, and so forth. But that is usually extremely short-lived. When a woman gives birth and during the first year after the birth develops several weeks of the symptoms that I have talked about, that is more than the baby blues.
The difficulty is that every new mom has heard about the baby blues, and so may think that being depressed every day for a month after the baby is born is just the baby blues. That is not the case. If depressed moods, losing interest in things, feeling that one maybe isn't going to be a good mother or can't take care the baby, if that goes on for more than few days, it's time to get an evaluation for that, because that can be the beginning of something more serious.
Don't try and figure this out on your own. You know, it's like the person who is beginning to have chest pain, “Well, should I go to the emergency room?” If you have chest pains, you need to do something now. Don't try and figure it out. Don't be worried about being embarrassed if you get there and you haven't had a heart attack. That will be good news.
The same [is true] with depression. These are very treatable illnesses, but they are tricky to diagnose.
We have another question from Colorado Springs, Colorado. “I would like to hear what is being done about long-term depression. What can be done for people with years of dealing with this illness?”
They are a difficult group of people to treat. Frequently these people have a very multifactorial illness. Maybe they have a lot of depression in their family. I saw a patient recently who had a depressive illness, but it also turned out her thyroid wasn't quite normal. She had not been eating very well for a long period of time because of the depression, so it basically is like any other very complicated, chronic illness. The solution for a particular individual is completely individualized.
We know that a lot of people with very chronic depression actually have features of their illness that are more similar to bipolar disorder. They might be very minor. They might be very subtle, such that even psychiatrists don't really pick up on them. But those kinds of indications can point in another direction as far as medication.
I would say that a person who has been on a whole lot of different medicines and has not had a lot of effect should get a second opinion. Find a university medical center nearby with a mood disorder specialty clinic. And most big medical centers will have a group of people who specialize in treating just this illness. And many of them have a special consultation clinic, and people can get a second opinion there. So that can be helpful.
The important thing is not to give up. There was a study that came to a close I guess about a year ago where it's called the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study, and it was an attempt to look at, of all of the different kinds of ways of treating depression, which one works the best.
Well, which one did work the best?
What they found is that there is no “best.” This was a very elaborate study in which people went through one step with one intervention. If that didn't work, they went to another step, and there were several different possibilities there. If that didn't work they went to another step. There were like four steps, and what they found was that at every step, there was a group of people who got better.
Sometimes it took to the fourth step, but the longer you stay at it, the greater the chances of finding something that's going to be helpful.
I want to thank you for joining us tonight, and thanks to all of you for listening at home.
From HealthTalk, I'm Heather Stark.
Video: YOU ARE NOT DEPRESSED, STOP IT!
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