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The Doctor/Patient Relationship



Depressive Illness: The Medical Facts / The Human Challenge

NDMDA Brochure

ball What are Depressive Illnesses?

ball What Causes Depressive Illness?

ball Who Can Diagnose a Person with Depressive Disorder?

ball What Medications are Available?

[Finding the best treatment regimin] requires a rigorous, cooperative effort between doctor and patient, generally involving medication combined with psychotherapy and the support of family and friends. It is essential that you and your doctor work diligently together to find a treatment plan that will control your symptoms so that you have a chance to be happy and productive. It is even more important that a diagnosis of a depressive illness should not stun you to inaction, nor should you allow the stigma sometimes attached to disorders of the brain to discourage you from continuing with your treatment. Indeed, if your doctor has told you that you have a depressive illness, you are among the one-third of all people with the illness who are fortunate enough to receive a proper diagnosis. Let this brochure mark the beginning of your efforts to work with your doctor to treat and manage your condition. What follows are the medical facts about depression and manic-depression as well as the best advice from the perspective of a patient and a doctor on confronting the condition.

ball What Are Depressive Illnesses?

Depression (also known as unipolar disorder) and manic-depressive illness (also known as bipolar disorder) are medical illnesses involving disruptions in brain functions. Both are classified as mood disorders because many of their principal symptoms involve changes in patterns of mood or emotion. Although no single pattern of symptoms fits every person with a depressive illness, some symptoms are common to almost everyone.Unipolar disorder is typically characterized by periods of intense sadness (which may sometimes be paralyzing), feelings of helplessness, hopelessness or other symptoms such as sleep problems or loss of appetite. These periods last for weeks, perhaps even months, during which time normal functioning is compromised. In manic-depressive illness, people alternate between weeks or months of mania (intense highs, racing thoughts, grandiose and unrealistic plans and ideas), followed by even longer periods of extreme, debilitating depression.

ball What Causes Depressive Illness?

The direct causes of unipolar and bipolar disorder are not entirely clear, but a number of things are known about the type of individual at risk for developing mood disorders, and at what stages of life the risk may be particularly high. The tendency of these illnesses to run in families has been shown to involve a substantial genetic component; studies of twins and adopted children, where a child whose biological parent had the illness is raised in an adoptive family untouched by mood disorders, have provided researchers a means of distinguishing the influence of heredity from life events that may contribute to a depressive illness. Scientists also have shown that an environmental component generally involving stressful life experiences often precipitates the onset of symptoms. Examples include the death of a loved one, marital problems, emotional difficulty, abuse, and other psychosocial risk factors. Often, however, symptoms appear spontaneously, with no apparent triggering event or cause. The more episodes you have the more likely are they to occur spontaneously.

ball Who Can Diagnose a Person With a Mood Disorder?

Depending on the intensity of symptoms and how closely an individual case fits the "typical" pattern, a psychologist, social worker, or even a well-informed friend or family member can begin to help identify unipolar or bipolar illness. However, because depressive disorders are medical illnesses, only a psychiatrist or other physician can make the proper diagnosis and initiate the pharmacologic treatment that is necessary to control the conditions.

ball What Medications Are Available?

Today, a vast array of treatment options makes the treatment of unipolar and bipolar disorders one of the true success stories of contemporary medicine. While neither condition can be cured per se, approximately 75 to 80% of all cases can be effectively treated. In the remaining 20 to 25%, the impact and duration of manic and depressive episodes can be significantly reduced. Medication is the key for the vast majority of people with mood disorders, with counseling being an important adjunctive treatment. To the uninformed, medication may seem a dubious option. Some fear that a drug will change their basic personality, sedate them into a zombie-like state or cause them to become drug dependent. While it is true that there are side effects to many drugs, the benefits often far outweigh any problems. The sophisticated medications target particular chemicals in the brain, such as serotonin and norepinephrine, and act on different impulses and receptors to stimulate or block the passage of these chemicals. Following is a listing of the major categories of medication, along with a few brand names with which you may be familiar.

ball Treatments for Depression

For depression, your doctor may prescribe medications known collectively as antidepressants. The older lines of antidepressants include cyclics (Elavil, Norpramin, Tofranil, and Pamelor) and monamine oxidase inhibitors (MAOIs) such as Parnate and Nardil. A "second generation" of cyclics was later developed to help those who did not respond well to the older drugs. These atypical medications included Desyrel and Wellbutrin. During the past several years, the selective serotonin reuptake inhibitors (SSRIs), Prozac, Zoloft, and Paxil, have become the first-line treatment for depression. More recently, the selective serotonin noradrenergic reuptake inhibitors (SSNRIs), such as Effexor, and the 5HT2 antagonist Serzone, have come into use.Your doctor will discover that one class of medication is more effective than another depending on your type of depression, and he or she will choose a drug within that class which proves to have the lowest side effect profile for you. Not everyone has the same reaction to one drug, so it may take some time to discover the most effective--and the most comfortable--medication for you.

ball Treatments for Bipolar Disorder

Compared to the available treatments for depression, there are few medications to treat bipolar disorder. While antidepressants are commonly used to combat episodes of depression in people with manic-depressive illness, the manic phase is treated with mood stabilizers. Most physicians will choose either a derivative of the mineral lithium or a newer medication called Depakote as the initial treatment of choice for bipolar patients. The anticonvulsant Tegretol is also used, although further testing must be done before it can be considered by the U.S. Food and Drug Administration (FDA) as authorized treatment for bipolar disorder. For many years, lithium was the only approved treatment for bipolar disorder. It has been shown to dramatically or moderately reestablish stability and normal functioning in approximately 60% of people with bipolar illness; however, it appears that certain groups of patients, including those experiencing rapid cycling and mixed mania, are less likely to respond to lithium as a long-term maintenance treatment. Depakote, the only FDA-sanctioned alternative since lithium, was indicated for the treatment of mania associated with bipolar disorder in 1995. This represented new hope for all bipolar patients who find lithium ineffective or difficult to tolerate. Depakote's milder side-effect profile and broader spectrum of effectiveness are added inducements for patients to remain faithful to treatment regimens as prescribed. Other medications that a physician may prescribe belong to the class known as anticonvulsants, which includes Tegretol, initially developed for the treatment of seizure disorders such as epilepsy. These medications have proven effective in controlling the symptoms of some forms of bipolar illness, especially those that are resistant to lithium. These medications can be used alone or in conjunction with lithium or Depakote. Supplemental treatment of mood disorders can include mild to strong tranquilizing medications. During the early phase of a manic episode, it is very important to restore normal sleep as quickly as possible. This is an appropriate indication for the sedative properties of benzodiazepines such as Klonopin or Ativan. Symptoms such as highly disorganized thinking, hallucinations or catatonic behavior can be treated with neuroleptics like Risperdal and Mellaril.

ball How Long Before a Medication Begins to Work?

This is one of the most difficult issues a person with a depressive illness may face. In cases of depression, a given medication can take two to three weeks to produce a reduction in symptoms and several weeks longer to achieve complete relief. This can be a most trying time for a person with depressive illness, wondering when or if treatment will help. During this period, the help and support of family, friends, mental health professionals, and others is crucial for bolstering one's motivation to remain faithful to treatment as prescribed. Medication may begin to work more quickly in cases of bipolar disorder. In some cases, Depakote has been shown to induce syptomatic improvement in only a few days.

ball  What About Psychotherapy?

Because the symptoms of unipolar and bipolar disorders affect moods, emotions and thought--and because symptoms often can be triggered by a life crisis--it is important to be able to talk through your symptoms in the structured professional environment provided by a therapist. Therapy, in group settings and in family settings, can be important for understanding the relationship challenges created by a depressive illness. But since serious depression and manic-depressive illness involves biochemical and physiological changes, psychotherapy by itself is almost never a sufficient treatment.

ball Whom Should I Tell About My Illness?

There are no absolute answers to this question. As with any illness, the only people who truly need to know are you and your physician. You will find, however, especially if your symptoms are evident to others, that friends and family can be a great source of support and understanding--provided they know the truth. This can be especially true of close family members, who, if they are well informed about your condition, can work with you during difficult times to help you manage the illness. Because there is a genetic component to depression and manic-depressive illness, it may be that other family members will be encouraged to seek an evaluation if they experience a pattern of mood disturbances.

ball How Will These Mood Disorders Affect My Career?

People with depressive illnesses have been some of the most creative, accomplished, and successful people in history. Peter Tchaikovsky, Vincent van Gogh, Ernest Hemingway, Abraham Lincoln, and Virginia Woolf are all known, or believed to have been, sufferers of major depression or bipolar illness. However, many of the best known people with depressive illness did not receive any form of medication during their lifetime, and a few died by suicide. Left untreated or inappropriately treated, the symptoms of both depression and manic-depressive illness can diminish the ability of even the most talented people to perform a job well over an extended period of time.This was demonstrated in a study published in the Journal of Clinical Psychiatry which estimated that the total economic cost of all mood disorders in 1990 was almost $44 billion per year in the United States. Worker absenteeism and lost productivity on the job accounted for 56% of total dollars lost by employers. Although businesses may balk at the cost of providing employee healthcare, the long-term benefits pay off in terms of maximum productivity, and if at all possible, you should not let treatment costs prevent you from seeking help. In the long run, treating your illness is less costly, both in financial and human terms, than letting the illness progress.

ball How Do I Select a Doctor?

The partnership between you and your physician is the key to successful management of your mood disorder. And just as it is essential that you be open and forthcoming with your doctor, it is important for your doctor to meet your needs and expectations. That, after all, is how good partnerships are made. Here are some serious considerations:

ball Is your doctor competent to prescribe and monitor the proper use of medications?

Your doctor should have done a thorough medical evaluation before prescribing medications. If your doctor prescribes a drug, be sure he or she is aware of other medications you may be taking or other health conditions you may have developed that could interfere with or be exacerbated by an antidepressant or mood stabilizer.

ball  Is your doctor willing to explore treatment options in order to find the best "fit" for you?

No single approach to treatment is perfect for everyone. In the case of medication, you need to work with your doctor to balance the side effects of some drugs against their effectiveness for you. Similarly, for psycho therapy, some people may benefit most from a support group setting while others may find one-on-one therapy to be better suited to them. It is essential that your doctor work with you to find the best solution for you, and then monitor its success over time.

ball  Is your doctor comfortable with the idea of you seeking a second opinion about treatment?

Because depression and manic-depressive illness have symptoms and challenges that are unique to each person, it may be important for you to seek advice from more than one physician. Your doctor should recognize this and be supportive of your decision. He or she should also work with you to evaluate therapies recommended by other physicians you have consulted.

ball  Is your doctor treating "the whole person"?

Because they can affect your thoughts and behaviors, depressive illnesses are complex conditions that will impact your personal development, your relationship with friends and family, your employment, and almost every aspect of your life. Both unipolar and bipolar disorder can be associated with an increased risk for other problems, such as substance abuse, eating disorders, and suicide. In addition to simply prescribing medication, your doctor should recognize when it is appropriate for you to receive other treatments, including psychotherapy, for these related conditions.

ball Is your doctor understanding and caring?

When you are diagnosed with a depressive illness, there can be no more important objective for you than to receive the right treatment as soon as possible. If your physician, no matter how apparently qualified, seems not to listen to you or take a genuine interest in your recovery, he or she may not be the right doctor for you.

ball  Is your doctor ready to work with your family and friends?

While not everyone relies on the support of family in their treatment program, when feasible, it can be a vital component of treatment. Your doctor needs to be prepared to help educate those closest to you about depressive illness and explain what their roles can be in helping you manage it.

ball What is a Mood Chart?

One of the most helpful tools you and your doctor will use to design aneffective treatment plan is called a "mood chart," a chronological record tracking the feelings and behaviors associated with your condition. Its purpose is to let you and your doctor know the rhythms and cycles of your illness in order to better design treatment.To use a mood chart, you will need to begin by keeping a record of how you feel each day. Use a diary, for example, or a small notebook with dated pages. Each day rate your mood on a scale from 1 (worst I've ever felt) to 10 (best I've ever felt). On the same page record other pertinent information, including the medication you are taking and any key events that have taken place on that day. Because a person's moods can vary with time of day, for accuracy and continuity, try to record your mood at approximately the same time every day.Then, each day, plot your mood on the chart at right and connect each day'sentry by a line. Over time the chart will provide you and your doctor a fairly objective history of the way you have been feeling and the effectiveness of your current treatments. Mood charting is truly valuable in our stockpile of weapons against depressive illness.

This brochure was prepared with the assistance of Scientific Advisory Boardmembers Frederick K. Goodwin, MD and Robert M.A. Hirschfeld, MD; Philip Janicak, MD; National DMDA Executive Director Susan Panico; and Gary Goldsmith.1992, rev. 1996 NDMDA



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