Northwest Health Winter 2011

Hiding in Plain Sight

A surprising number of us experience depression. But there's good news: It's easy to diagnose and treat this condition.

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What common illness is underdiagnosed, highly treatable, and still carries a stigma? It's depression. Could you have it?

Sometimes called a black cloud, melancholia, feeling blue, or down in the dumps, by whatever name, depression is a common mental illness. It affects about 8 to 10 percent of the population at any one time; in a lifetime, about 20 percent of the population will receive a diagnosis of depression, and many more will experience some of its symptoms.

For those in the midst of a depressive episode, it can be a debilitating condition that affects their ability to function. Doug Smith, a Group Health member who has suffered numerous bouts of depression, describes it this way: "Imagine putting yourself in a room full of molasses and trying to swim. It just doesn't happen."

Considering the number of people who experience depression, it's a little surprising that it still carries a stigma, expressed something like this: If only the depressed person would do something — get busy, get out more — they would be fine.

It's that kind of thinking that has led to underdiagnosis of the illness in some populations. "People are reluctant to label the way they feel as depression because of the stigma," says Julie Lindberg, director of clinical operations for Group Health Behavioral Health Services.

"Still, we have made enormous progress in normalizing mental illness and mental health conditions," she says. "We've moved from thinking of them as character problems to thinking of them as medically valid conditions."

Group Health member Stevey Legters has experienced depression as the result of her bipolar disease. "For some reason, people don't consider mental health issues in the same vein as physiological issues," says Legters, a vibrant woman who exudes energy. "I've said it a million times — it's like a person with diabetes. You don't expect them to stop taking their insulin." Similarly, people with depression often need medication or other therapy to manage their disease. They can't just will themselves to be happy, she says.

What We Know About Depression

Depression is the result or the cause of a chemical imbalance in the brain. But beyond that, there is much variation in what triggers it, who it affects, and for how long.

A stressful event such as the death of a family member, a job loss, or the diagnosis of a serious illness, may bring feelings of sadness and being overwhelmed. That's normal, but for some people these feelings don't fade away and may intensify. For others, the feelings of hopelessness and sadness develop gradually or even in the absence of any specific event.

Some people are genetically predisposed to depression. Others are more susceptible because of age (it's highest in young and middle-aged adults), gender (women have depression more than men), a chronic illness, abuse of drugs or alcohol, or another specific condition.

Depression can be mild and ongoing, lasting a number of years, or it can be a single episode that sends the patient into a black hole. They may experience only that one episode, or it may recur again and again throughout their life. They may have bipolar disorder, which is characterized by moods that swing between periods of extreme distress and sadness, and periods of unusually high activity and energy.

Stevey Legters says she keeps a mood journal to increase her self-awareness and learn what triggers the depression. Doug Smith says he's found that supportive friends and family who understand his depression are helpful. He explains, "When someone is depressed and needs help the most, that's when they are least likely to be able to ask for it." Friends and family who understand when you need help are more likely to be able to persuade you to get it, he says.

A network of family and friends can make a big difference for someone who is prone to depression, says family physician Michelle Seelig, MD. "A person who has a social network that includes extended family and friends can tolerate or adjust to loss or challenges differently than those who don't have this," she says. Similarly, people whose lives are stable, who get enough sleep and eat well, are less likely to be affected by a setback than someone who is barely getting by. "The social fabric around you is as important as what you do to take care of yourself," says Dr. Seelig.

Depression and Other Diseases

There is an increasing body of evidence that indicates depression is more common when another chronic illness is also present. For instance, 15 to 25 percent of people with a history of heart attacks also have had an incidence of depression; it's present in 20 percent of the population that has diabetes.

What is less clear is whether having depression causes other illnesses, or the other way around. However, Elizabeth Lin, MD, a family medicine physician who also does research at the Group Health Research Institute, says it is clear that there is a strong mind/body connection. When people are depressed, there are measurable physiological changes in their bodies. There is more inflammation in their system, more adrenalin, and more heart rate variability.

There are also measurable changes in areas of the brain related to thinking and emotion. "With MRIs, we actually see which parts of the brain light up with fear and sadness," says Dr. Lin. "When people see that, they believe — it's not all in your head."

Not surprisingly, having depression often leads to poor self-care for both the depression, and any accompanying chronic illness. That ultimately results in a downward health spiral. "If you are depressed, you feel more hopeless, then you think — what's the point of eating healthy? Or of putting my shoes on and getting exercise? Or of taking my medication?" Dr. Lin says.

The good news, Lindberg and Dr. Lin agree, is that depression is very treatable. But first, it has to be diagnosed.

Learning to Recognize Depression

The symptoms of depression aren't the same for everyone. Some people are moody and have feelings of hopelessness. People may sleep or eat less, or they may sleep or eat more. Others may self-medicate their depression by abusing drugs or alcohol. Trouble concentrating, agitation, irritability, restlessness, loss of energy, unexplained aches and pains, general sadness. All can be symptoms of depression.

Despite these variations, depression is not difficult to diagnose. Remember the last time you went in for a routine physical? You were probably asked to fill out a form beforehand that included questions about your work, family life, and sleeping, eating, and exercise habits. When talking with patients about how they answered those questions, family physicians like Dr. Seelig are listening carefully.

"In the course of discussing how their work is going, their level of physical activity, how they're eating and sleeping, there will often be indications of their mental well-being," she says. "Based on their answers, I might bring up the concept of depression and ask them about it."

Doctors who practice at Group Health Medical Centers and elsewhere also routinely administer a depression screening tool (see sidebar). If you answer positively to two particular questions — which are also part of the Health Profile questionnaire on the Group Health member site — your doctor will ask additional questions. Though the full tool only has nine questions, its effectiveness in diagnosing depression is proven and widely accepted in the medical community.

Once Dr. Seelig introduces the idea of depression, she says that many of her patients express a sense of gratitude that someone is giving them a chance to talk about their feelings and the impact of their mental health on their life.

Getting Treated

Anyone who thinks they may have depression should schedule a visit with their family physician. It's a good idea to do this if you have symptoms of depression every day for more than two weeks, and those symptoms are interfering with your normal activities.

At Group Health Medical Centers, many patients are treated for their depression by their primary care doctor. And that's a good thing, says Lindberg of Behavioral Health Services. "We are integrating mental health into primary care because we want to treat the whole person," she says.

Most family doctors are trained to diagnose and begin treatment for someone with depression, says Gavin Vilander, who oversees Behavioral Health Services for Group Health members in Eastern Washington, including Spokane and the Tri-Cities. "Some people go directly to their family doctor because that's who they are comfortable talking with," he says.

Family doctors don't have to rely solely on their own knowledge in treating patients with depression. They can access the expertise of specialists at Behavioral Health via a phone consultation. Those specialists include psychiatrists, nurse practitioners with psychiatric training, psychologists, and master-level therapists trained in cognitive behavioral therapy, an effective form of talk therapy. They can also refer patients to these experts.

Any Group Health member can also call Behavioral Health Access Services directly for an appointment. (Coverage varies by health plan, so be sure to check your policy for specifics, or call Customer Service toll-free at 1-888-901-4636 for more information.)

Treatment for depression may involve medication, lifestyle changes, talk therapy, or a combination of those. Talk therapy is done one-on-one or in a group setting at a Group Health Behavioral Health location or community clinic.

Studies have found that all of these methods can be effective. But just as some patients with heart disease must try several medications before finding the right one, it can take several tries to find the right drug, or the right treatment, for an individual case of depression. For instance, many drugs used to treat depression have side effects. In some cases, those side effects decrease within a few weeks of taking the drug. In other cases, trying a different drug might eliminate or decrease side effects. And with talk therapy, some people respond better in an individual setting; others prefer a group setting.

Doug Smith has found that getting treated at Group Health Medical Centers has a big benefit: "What Group Health care offers that I didn't have before was a team of professionals that approached problems in different ways. They actually talk to each other so they can share information about the patient. They do more than just check off on their schedule that they've met with a patient that day. They're interested in the patient's success."

Whatever treatment is prescribed, follow-up care is critical, says Dr. Seelig. "When you monitor and adjust care as needed, we get really great results with our patients."

Dr. Lin notes that the first step is often education — helping the patient understand the treatment and be willing to try it. "Then, don't give up on them," she says.

Dr. Seelig adds, "They need to know that with effective treatment, they can have rewarding, meaningful lives. They can feel better. It is possible for the black cloud to lift."

Tips for Overcoming Depression

Stevey Legters and Doug Smith offer the following tips for others with depression:

  • If your doctor recommends medication, don't be afraid to take it.
  • Know that the first medication you try might not work or may have unpleasant side effects. Be persistent and willing to try another until you find one that does work.
  • Individual talk therapy is helpful, but group therapy, available at Behavioral Health Services, is beneficial as well. Patients do learn from each other.
  • Surround yourself with supportive people. "Know which friends you can talk to, who you can communicate your real feelings to," says Legters.
  • Learn to be a partner in your health care. "Learn how to support yourself emotionally, and how to manage your own illness," says Smith.
  • Legters suggests putting together a self-help toolbox. For her, that means helping others so she doesn't focus too much on herself; learning the depression triggers and staying away from them; and asking for what she needs — like a hug.
  • If you are diagnosed with depression, don't let fear keep you from following the prescribed therapy. "Sometimes, you don't want to try it, because you think — what if it doesn't work? It's hard to embrace a solution that has a positive and negative potential," says Smith.

Children, Adolescents, and Depression

Depression doesn't affect only adults. Children and teens also have depression. But the symptoms can be different.

Very young children may have difficulty verbalizing how they feel. They may have unexplained physical symptoms such as stomachaches or headaches. They may display aggressive behaviors or become withdrawn, lose interest in things they used to enjoy, engage in risk-taking behaviors, or become interested in morbid topics. Sleeping and eating habits may change.

Older children or teens may become moody, irritable, or angry — symptoms that can be difficult to distinguish from normal adolescent hormonal swings. They, too, can have changes in sleep and eating patterns, unexplained physical symptoms, and may speak or move more slowly than usual.

Parents who are concerned that their children may have depression should consult their child's doctor.

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