David S. Klein, M.D.

Depression Pain Related

Depression

Depression is more than the "blues" that affects so many people. Depression, in the largest part, is a disease that results from a biochemical imbalance in the brain, and is a true medical condition. Depression is not a "weakness," and it has been demonstrated repeatedly that the patient who suffers from depression may have increased mortality due to other conditions, such as atherosclerotic heart disease, heart attack, cancer, as well as from suicide.

There are many different medical types of depression. For example, one type of depression that occurs during the holiday season often results from a common condition, called "Seasonal Affective Disorder," or S.A.D. This condition affects many millions of Americans, and results in tremendous loss of productivity.

Depression results from a chemical imbalance in the brain that results from a decrease in the presence of certain neurotransmitters, such as "seratonin" and "norepinephrine." If certain nerve endings in the brain fail to secrete enough of these neurotransmitters, depression can result. Interestingly, there are many different types of depression, each with its' own set of symptoms. Early insomnia, or inability to get to sleep, middle insomnia, or inability to stay asleep, may be manifestations of two entirely different neurotransmitters. Proper treatment requires the use of the medication that restores the right neurotransmitter. The responsibility to relate ACCURATELY the symptoms of depression, such as insomnia, will increase the liklihood that your physician will choose the medication right for the individual situation.

Interestingly, depression can be present IN THE ABSENCE OF AN OVERT MOOD COMPLANT!

Of the many types of depressive illnesses, they may demonstrate patterns of exacerbation and remission. If the presenting symptom is periodic depression alone, this is referred to as a "Unipolar" pattern. If depression alternates with periods of elation or mania, this is referred to as a "Bipolar" pattern, "Cyclothymia" referrs to periodic ups and downs not severe enough to be considered "mania" or "depression."

TYPICAL PRESENTATION OF DEPRESSION

The average age of onset is in the mid-20's. Criteria for diagnosis include:

1. Depressed mood
2. Loss of energy or motivation
3. Weight loss or gain
4. Alteration in sleep patterns: too much, too little, poor quality sleep
5. Agitation or physical slowing\
6. Inability to concentrate
7. Suicidal thoughts

Not all symptoms need to be present to consider the diagnosis of depression.

Brown RP, Gerbarg PL: Herbs and nutrients in the treatment of depression, anxiety, insomnia, migraine, and obesity.J  Psychiatr Pract. 2001 Mar;7(2):75-91.

Although a multitude of pharmaceutical agents are available for the treatment of mood disorders, anxiety and insomnia, many patients have difficulty tolerating the side effects, do not respond adequately, or eventually lose their response. Many therapeutic herbs and nutrients have far fewer side effects and may provide an alternative treatment or can be used to enhance the effect of prescription medications. In the article, the authors review the quality of the evidence supporting the clinical effects of a number of commonly used types of complementary/alternative medicine (CAM) for mood disorders, anxiety, and insomnia. They review data on the use of St. John's Wort, S-adenosyl-methionine (SAM-e), B vitamins, inositol, omega-3 fatty acids, and choline for mood disorders; data on the use of kava and other herbal agents and fish extract for anxiety and insomnia; and data on valerian and melatonin for insomnia. The authors also discuss the use of CAM to treat migraines, which may be comorbid with mood and anxiety disorders, and obesity, which can occur as a side effect of psychotropic medications. They consider the data on feverfew and butterbur for migraines and on chromium picolinate and the combination of ephedrine and caffeine for obesity. The authors also review issues related to comorbid medical illness, side effects, drug interactions, dosage, and brand selection.

SEASONAL AFFECTIVE DISORDER

As a result of the decrease in the intensity of sunlight that occurs during the Fall, Winter and early Spring, the brain slows the secretion of certain hormones, and an imbalance of the neurotransmitter "seratonin" can result. Recognition of S.A.D. is not automatic. Many physicians, unfortunately, are not sensitive to these types of illness, and vigilance on the part of the physician may be lacking. It bears emphasis that treatment can only begin after RECOGNITION of the problem, by the physician, or the well-informed patient. Seasonal Affective disorder develops slowly, andinsidiously, often beginning during November or December, and lasts until late Spring. This problem can return year after year, or it can occur once or twice and never again re-occur. Treatment is generally easy, but treatment can begin only after the patient recognizes that there is a problem, and then seeks help.

Treatment can consist of a vacation to the lower latitudes, a week-end at the beach, and recently, "light therapy" has become increasingly popular. These approaches are similar in that they each rely upon increasing levels of ambient light, which has an effect on the pineal gland, deep within the brain, which then releases increased levels of Melatonin.

Melatonin, which is available over the counter at pharmacies and grocery stores, may be useful in the treatment of S.A.D. as well as for a variety of sleep related disorders. Unfortunately, many of the over-the-counter preparations are of low quality, and results may be unpredictable. One very useful source for a high quality melatonin is a compounding pharmacy in Orlando, Florida, and they are willing to ship by U.P.S..

For more information on S.A.D, see below.

REACTIVE DEPRESSION

depression is one type of depression that tends to occur after a traumatic event, after the loss of limb, serious illness, or loss of a person or object very meaningful to the individual. After the normal grief period, most people recover and move on with their lives. Some, however, suffer for prolonged periods of time, either eventually recovering, or experiencing worsening of the depressive symptoms. One example of a type of reactive depression is "Post Traumatic Stress Disorder," or PTSD. PTSD can occur in otherwise strong and well adjusted individuals. PTSD is often associated with war time experiences, but it more commonly occurs following civilian accidents, or troubling life's events.

Symptoms of reactive depression may include: Loss of energy, weakness, spells of crying, excessive drinking or substance abuse, bouts of rage, sleep and eating disorders.

Alcoholism and drug abuse is quite common in the person who suffers from reactive depression.

Treatment can only take place after recognition. Diagnosis is most commonly established by the family physician, but not all family physicians are equally skillful in recognition and treatment of psychiatric disorders.

Medications most commonly used to treat reactive depression include: Tricyclic anti-depressants (e.g. amitryptaline, Elavil) anti-depressants of the selective seratonin reuptake inhibitor (SSRI) class (e.g. Prozac, Zoloft) or selective seratonin norepinephrine re-uptake inhibitor (SNRI) class (e.g. Effexor, Serzone). All are very useful to treat depression.

If, among the complaints is that of insomnia, Paxil is a good first choice. If lethargy, sleepiness and inability to "motivate" is a presenting problem, Zoloft may be a better choice. If fibromyalgia is present, Serzone or Effexor may be better.;Eating disorders, weight gain and increased alcohol consumption are commonly associated with reactive depression. Diagnosis can be made only if the diagnosis is kept in mind.

For more information on Seasonal Affective Disorder, click here

David S. Klein, MD, FACA, FACPM, FACMIMS
Director, Pain Center of Orlando
www.suffernomore.com