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Depression & Dysthymia
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What You Need To Know

Twenty-five percent of women will suffer from at least one major depression in their lifetimes, yet contrary to medical opinion of the past, depression is less common among middle-aged women compared to women of other ages. Depression (including chronic minor depression, called dysthymia) is underdiagnosed and undertreated. Depression is not just "in your head;" it is also physical and constitutes a very significant independent risk factor for heart disease and osteoporosis because of the abnormal hormonal milieu that is present in someone who is depressed. Depression is often a message from one’s inner guidance that things are out of balance on some level of life.

Feeling stuck in a rut has biological and physiological effects on both the brain and the body. If we don’t grow and move forward in our life, our body comes to a biochemical standstill. If we don’t live and work in rewarding environments, and don’t know how to change our circumstances, then neurotransmitter levels such as serotonin and opiates decline significantly in both the brain and body. This has profound effects on mood, attention, and memory. It also has insidious effects on the physical body, including the cardiovascular system, bones, and immunity. For example, sustained depressed mood decreases a type of immune system cell known as the Natural Killer (NK) cell. It also increases the level of inflammatory chemicals known as cytokines and interleukins, which is why chronic fatigue and fibromyalgia are more common in those with dysthymia and depression.

Studies now show that people who have a low level of depression for years have low blood flow to the frontal lobes of their brains, including the areas for initiation and motivation. This makes them both depressed and forgetful. And years of such lower blood flow increases the chance of developing dementia, coronary artery disease, and cancer.

A special category of depression is postpartum depression. Maternal depression is frequently underdiagnosed. (About 10 to 15 percent of women are clinically depressed during pregnancy itself.) Fully 80 percent of women experience the baby blues for up to two weeks after delivery. Approximately 10 to 15 percent of women will go on to experience some form of mood disorder postpartum, ranging from major depression to anxiety disorders such as panic attack. If a woman has a history of depression, she is at significant risk postpartum. Women with moderate to severe PMS may be at increased risk for postpartum depression, especially those who feel their best during pregnancy and who respond well to natural progesterone.

Many women who suffer one postpartum depression will experience the same thing after each birth. True psychosis occurs in only about 1 in 1,000 births, and is characterized as being out of touch with reality, hallucinating, and hearing voices. Women with any history of depression or psychosis should be sure they discuss this with their health care provider before the baby is born, since the right treatment can prevent the problem from becoming severe.

Listen To Your Body

In major depression, as defined by psychiatric handbooks, a person not only suffers from depressed mood, but also has changes in appearance, behavior, speech, perception, and thoughts. When you are depressed, your insight and judgment can be affected, as can your ability to work, take care of yourself, and function in society. Depressed people may appear sad or have an expressionless face. Poor posture and grooming are sometimes evident. They derive very little enjoyment from normal daily activities and complain about loss of energy and numerous physical aches and pains that never bothered them before. (Statistics gathered at centers for chronic pain show that up to 90 percent of those with chronic pain have emotional stress factors such as depression that contribute significantly to their pain syndromes.)

Depression is often accompanied by sleep disturbances: you may be unable to get out of bed, or you may suffer from insomnia or early-morning awakening. Appetite disturbances—either overeating or loss of appetite—can result in significant weight gain or loss. Your thoughts can be affected by depression, and you may have difficulty concentrating and remembering things. (Many midlife women blame their memory loss on aging when it’s really caused by depression.) Your mind can go around and around in circles, and you may dwell on thoughts of guilt, self-blame, hopelessness, helplessness, and worthlessness. As depression deepens, thoughts of death and suicide can occur.

But not all depression is major. Betty, a client of Dr. Mona Lisa Schulz, is a woman who was stuck at mid-life whose mood and health were significantly affected by circumstances she chose not to change. Betty had seen her mother, now demented and in a nursing home, remain depressed and unmotivated for years. It terrified her that she would "end up the same way." Betty knew she needed to do something to change the path she was on and to improve the symptoms she was currently experiencing. Unsure of what to do, she called Dr. Mona Lisa for a consultation.

The following medical intuitive reading for Betty illustrates what dysthymia looks and feels like.

The Reading: Betty was 58 years old when she called for a reading. Her mind and body felt like a late model sedan—a car that was not built for excitement or speed but rather suitable for steady, reliable service. And although Betty would never be described as a ball of fire, her mind and body felt like they had lost their spark. She felt lethargic and lacking in any source of passion in her life.

In addition to a depressed mood, Betty had problems with concentration and memory, and suffered from insomnia and excessive daytime fatigue and sleepiness. She also seemed to be at risk for a mild thyroid problem. She seemed to crave carbohydrates and sweets, too, and had a tendency to carry 30-40 pounds of extra weight around her midsection.

The Facts: For most of her life, Betty had suffered from mild depression. And because her mother had a long history of incapacitating depression, Betty had done whatever she could to prevent herself from sinking to her mother’s levels of despair. She had tried a variety of medications and spent thousands of dollars on psychotherapy and marriage counseling. Despite all of her efforts, Betty realized that her mood and health were plummeting at midlife and that she had become immobilized—stuck without any idea of what to do next.

Betty had taken antidepressants, which gave her a respite from her depression for a while. For example, years ago, her doctor had put her on Prozac. It helped for a while, but after two years, the medicine stopped being effective. She was then given Zoloft, which didn’t help at all. Next, Betty tried Effexor, which gave her some relief for three years, but it too stopped working. At the time of the reading, Betty was taking Celexa with no discernable effect. Unfortunately, at this point, her depression no longer responded to pharmaceutical medication.

Lately, she’d gained weight more rapidly than ever. She satisfied her intense carbohydrate cravings by eating small, low carbohydrate chocolates throughout the day. This gave her some energy, but the effect lasted only a short time—most of the time she felt tired and run down. She also complained of being forgetful and being unable to pay attention. In addition to all her other problems, Betty had also developed aches and pain in her joints in the previous year. Her doctor had diagnosed her with chronic fatigue and fibromyalgia.

Betty told Dr. Schulz that the most depressing aspect of her life was her job, which had all the excitement of a damp rag. She had worked as a "paper-pusher" for the government for more than two decades. Betty said that she often fell asleep at her desk, had trouble keeping numbers straight, and was even forgetting assignments. Even though Betty felt sleepy and lethargic every minute she was at work, she didn’t want to leave because she would forfeit her retirement pension—she’d accrued fifteen years of retirement pay, which she wouldn’t be entitled to unless she worked for the government eleven more years.

Betty has dysthymia, a type of low-grade chronic depression. Signs of dysthymia include:

  • depressed mood which lasts most of the day
  • depressed mood nearly every day
  • depressed mood that has lasted for at least two years
  • tendency to overeat or not eat enough
  • fatigue
  • no history of mania or hypomania
  • difficulty concentrating and remembering

Dr. Schulz puts it this way: "Depression is like concentrated perfume and dysthymia like cologne." Note: true bipolar manic depressive illness is in a different category altogether. The approach and treatment is also different.

What Causes This

No one knows what causes dysthymia, but it is more common in those who have a family history of it and in those who’ve had a history of abuse or trauma. Dysthymia is also related to one’s regular pattern of thought, exercise, and dietary choices. In many individuals there’s no one "cause" of dysthymia that can be nailed down.

Regardless of how, when, or where it comes from, it is clear that those with dysthymia and depression have imbalances in brain-body neurotransmitters such as serotonin, opiates, norepinephrine, and dopamine. Because all the neurotransmitters interact with each other in a seamless way, all of them are important for normal mood, memory, etc. Serotonin and opiates help with attention and memory, and they support the immune system. And sufficient levels of opiates are necessary to feel a sense of satisfaction in one’s accomplishments. These two neurotransmitters also elevate mood and are important for sleep and pain control. Dopamine and norepinephrine are important for energy and a sense of excitement, so if these levels are low, one is likely to feel lethargic and lack the motivation to make changes is his or her life.

Healing Alternatives

A wide variety of prescription antidepressant medications—such as Prozac, Zoloft, Effexor, or Celexa—are available that can help women with moderate to severe depression. Studies show that medication works best when combined with psychotherapy. While I typically regard these antidepressant measures as a bridge and not the ultimate solution to depression, consider an antidepressant medication if any of the following describe you:

  • You’ve had three or more episodes of depression.
  • You have suffered from low-level depression your whole life and have also had a major depressive episode (called double depression).
  • You have leftover symptoms after going off an earlier course of antidepressants.
  • You are having your first depression at midlife or later.

However, be aware that conventional antidepressant medications, especially the SSRIs, often don’t work over the long haul. Studies have shown that about 80 percent of people on antidepressants have a recurrence within three years after stopping medication. And because the brain’s receptors for serotonin rearrange themselves over time, many SSRIs stop working after about two years. Patients then must be switched to another medication. Slowly but surely, symptoms often return (if the patient isn’t doing other things to enhance neurotransmitter balance) and the patient is left doing what Dr. Mona Lisa Schulz calls the "SSRI Shuffle."

For some people, particularly young adults and children, antidepressants may well be dangerous. The United Kingdom equivalent of the FDA (the CSM) banned the use of all SSRIs for treating depression in children and adolescents because of an increased risk of suicidal behavior shortly after the drugs were begun.1  SSRIs can cause nausea, loss of appetite, headache, nervousness, insomnia, restless leg syndrome, and difficulties with libido and sexual dysfunction.

A six-month trial of antidepressant medication may be worth considering, however, if you feel miserable and stuck. Optimally, the medicine will result in a gradual lifting of your depression. This will give you the energy to mobilize your own resources to make positive changes in your life.

Hormones are another treatment option. All sex hormones, including progesterone, estrogens, and androgens, can affect mood. Estrogen has been shown, for example, to increase mood-enhancing beta-endorphins as well as serotonin and acetylcholine, neurohormones that are associated with positive mood and normal memory. Though androgens such as testosterone have not been as well studied as estrogen, they, too, appear to be associated with improvements in mood and vitality in some cases. The general consensus is that there’s not enough data to recommend HRT as a primary treatment for depression. But I feel it is definitely worth considering in many women.

Spiritual and Holistic Options

Depression is not a "Prozac deficiency." It is a consequence of how we live our lives. (Studies have shown that depression is virtually nonexistent among many indigenous peoples.) To get over it, we must be willing to make some changes that will support healthy brain biochemistry. The true cure for depression lies in learning the skills associated with full emotional expression and then taking positive action. You must be completely honest with yourself about everything you are feeling—even, and especially, those feelings you’ve been told you shouldn’t have, such as jealousy, anger, guilt, sorrow, and rage. All of these feelings are part of being human. They will never hurt you if you simply acknowledge them, express them safely, and, ultimately, accept yourself for having them. Then you must take action. I’ve never seen depression lift without the sufferer taking some kind of positive action to help herself. This could be as simple as volunteering at an animal shelter.

Staying in dead-end jobs and/or relationships is a major factor associated with unremitting, chronic depression in women. If you feel depressed and "dead," and this has been going on for six months or more, it is probable that either you have unresolved grief about an important loss in your life or you have anger or resentment or resignation about continuing to participate in relationships or jobs that do not replenish you at the deepest levels.

Consider working with a coach or therapist. Getting a vocational coach is a way to "rent" someone who can provide the initiation and motivation you are lacking. A vocational coach can help assess your skills and talents, and make recommendations for future job assignments, including an entirely new career. Similarly, getting cognitive behavioral therapy can also help rewire the thought patterns that are present in dysthymia, including low self esteem and lack of optimism.

Use the power of your thoughts to your advantage. Remember, every thought you think changes neurotransmitter levels. The following are a few affirmations to get you started with the right kind of thinking. Repeat these out loud in the mirror, looking into your eyes twice per day, once in the morning and once in the evening. You will notice a positive change within 30 days if you do this consistently:

  • I have the Power within me to feel good every day.
  • I love and appreciate myself.
  • I appreciate my body for its wisdom and ability to be healthy.
  • The universe provides me with all the guidance I need to live life fully.

A host of nutritional supplements—used with or without conventional antidepressants where appropriate—can help reconstitute one’s mood system in both the brain and body. Work with a holistic psychiatrist or a practitioner knowledgeable in the nutritional support of mood disorders. (If you have a willing health care practitioner who isn’t yet familiar with an integrative approach to mood, I recommend you suggest he or she read the article by Dr. James Lake cited here: Lake, J. 2004. The integrative management of depressed mood, Integrative Medicine, 3:34-43.) The following suggestions are a start:

  • SAM-e (S-adenosyl-L-methionine): SAM-e is produced naturally by the body, although the amount decreases as we age and seems to be lower in people with depression and dementia. Because SAM-e helps build brain and body levels of serotonin, opiates, dopamine, and norepinephrine, supplementing with SAM-e can help elevate mood, instill a sense of emotional well-being, and promote vitality. It can also support joint health (including mobility and joint comfort), can boost antioxidant activity, and support immune function. The usual dose is 400 mg twice per day or up to 800 mg three times per day before meals.2  Many studies have validated the safety of SAM-e alone or in combination with a synthetic antidepressant. SAM-e tends to work for a much longer period of time than SSRIs. It can also be given along with SSRIs as a way to lower the dose of the medication. Studies have also shown that SAM-e has equivalent or superior antidepressant efficacy compared to tricyclic antidepressants. Note: SAM-e should not be used in those who have bipolar disorder or agitation.
  • Omega-3 fats: These fats are very important for optimal brain and nervous system functioning. This is especially important for women on low fat diets, because many women with depression have been following a diet that is so low in fat, they can’t make the proper brain chemicals to lift depression. Omega-3 fats can also be used to treat postpartum depression. I recommend taking a total of 1,000–5,000 mg of EPA and DHA per day.
  • Vitamins and other nutrients: Deficiencies of biotin, folic acid, vitamin B6 (pyridoxine), vitamin B12, and vitamin C have all been linked to depression. Vitamin B6 deficiency, for example, has been shown to lower levels of serotonin. This vitamin plays a role in the production of the monoamine neurotransmitters, which are important for mood stabilization. (The recommended dose of Pyridoxine is 50-500 mg per day.) Vitamin B12 and folate are co-factors in the synthesis of SAM-e in the body and may enhance its antidepressant effects. Folate (at a dose of 800 mcg–5 gms per day) and vitamin B12 (at a dose of 1 mg per day) have individually been shown to improve mood and energy and also improve responsiveness to conventional antidepressants. They may also enhance the antidepressant effects of SAM-e. Note: Folate and B12 levels should be tested before taking large doses, and B vitamins should always be taken along with a multivitamin that contains all the other B complex vitamins. Magnesium deficiency is associated with anxiety in many women. Taking 400–1,000 mg a day can often work wonders. Deficiencies of calcium, copper, and the omega-6 fatty acids may also relate to depression.
  • St. John’s Wort: More than 30 placebo-controlled clinical studies have shown that St. John’s wort is as effective as conventional antidepressants for treating moderate depressed mood. The active ingredients hypericin and hyperforin appear to increase brain neurotransmitter levels, which maintain normal mood and emotional stability. Usual dose is 300 mg, three times per day for most brands. Note: St. John’s Wort should not be taken in those who are on certain anti-cancer agents, immunosuppressant drugs, protease inhibitors, coumadin, or SSRIs.3
  • Valerian: If you have an anxiety component with your depression, add valerian to your Saint-John’s-Wort. The usual dose is 100–300 mg standardized extract containing 0.8 percent valerenic acid.
  • Ginkgo: If your depression is associated with attention and memory problems and you are age fifty or older, consider Ginkgo biloba in addition to Saint-John’s-Wort. The usual dose is 40–80 mg three times per day.
  • Inositol: Inositol is an effective over-the-counter alternative to many commonly prescribed antidepressants. Although the exact mechanism is unknown, it appears to be linked with the serotonin system, affecting the same pathways of brain chemistry as do the tricyclic and SSRI antidepressants, but without the side effects. I’ve prescribed inositol for several patients, who have tolerated it well. One, a person with a very significant family history of depression, used it following the loss of a loved one. She reported, "In the past, before inositol, I would have gone through my grief and then fallen into a black hole. This time I could still feel all of my feelings deeply, but I was able to move through them without a depression hangover." Usual therapeutic starting dose is 12 g per day; however, inositol has been shown to be well tolerated in doses as large as 18–20 g per day.
  • 5-hydroxytryptophan (5-HTP): This compound is naturally produced in the body from the amino acid tryptophan, which is an important precursor to serotonin. Although tryptophan is found in many foods, it can be difficult to consume enough tryptophan in the diet to overcome serotonin deficiency. (Tryptophan supplements were once widely used as sleep aids, but they were taken off the market after some products were found to be contaminated.) 5-HTP can be extracted from plants and is now available as a nutritional supplement. It has been used for decades in Europe as an approved treatment for both depression and sleep problems. The side effect of nausea is sometimes reported, but an enteric-coated formulation should help avoid this. The usual dose is 100–200 mg three times per day. Note: Don’t use 5-HTP if you are on an SSRI-type antidepressant like Zoloft or Prozac.
  • Acetyl l-carnitine: This amino acid helps increase attention and stimulate memory, and it acts as a mild antidepressant. It may help allay the mild cognitive symptoms of inattentiveness that occur with dysthymia. The dose is 500 mg twice a day.

Take more risks. This is the most effective and long-term way to change dysthymia. Risk-takers are rarely depressed or tired-looking. Try challenging yourself by such means as taking courses at a university, traveling to an exotic place, volunteering at a stimulating place or even just taking a different route to work.

Develop an optimistic attitude toward life. Optimism—the ability to perceive the glass as half full instead of half empty—is a natural protectant against depression.

Get regular physical exercise. Exercise raises the brain chemicals beta–endorphin and serotonin, thereby lifting depression. Exercising twenty to thirty minutes per day four to five times per week can have a significant positive effect on your mood. It doesn’t matter what you do—even dancing around the house to the radio will help.

Increase your exposure to natural full-spectrum light. Natural light boosts brain serotonin levels and can help with symptoms of depression—especially the depression associated with seasonal affective disorder. If you can’t get out in natural light during the dark months of the winter, full-spectrum natural light bulbs and light boxes are available.4

Stop drinking alcohol. Alcohol is a known depressant, and is also a refined carbohydrate that can wreak havoc with blood sugar levels. By the way, depression is particularly common in those who come from alcoholic family systems. These individuals are often extremely sensitive to sugar.

Follow a whole foods diet that balances blood sugar and insulin levels. This often helps depression dramatically. Avoid refined carbohydrates and caffeine, and eat protein at least three times a day.

Get adequate sleep. Insufficient sleep worsens depression.

One final note: Because depression is often anger turned inward, it’s common to feel yourself getting angry at the first sign of the depression lifting. If that happens, pat yourself on the back. It means that you are mobilizing your energy and reclaiming your power. Congratulations on your progress.

Learn More | Recommended Reading or Resources
References
  1. Jureidindi, JN et al. 2004. Efficacy and safety of antidepressants for children and adolescents. British Medical Journal, 328:879-83.
  2. DeVenna, M., & Rigamoni, R. (1992) Oral S-adenosyl-L-methionine in depression. Curr. Ther. Res., 52, 478–485; Di Benedetto, P., et al. (1993). Clinical evaluation of S-adenosyl-L-methionine versus transcutaneous electrical nerve stimulation in primary fibromyalgia. Curr. Ther. Res., 53, 222–229; Muskin, P.R., Ed. (2000). Complementary and alternative medicine and psychiatry (review of psychiatry) (Vol. 19, pp. 8–18). Washington, DC: American Psychiatric Association Press; Shehin, V. O. et al. (1990). SAMe in adult ADHD. Psychopharmacology Bulletin, 25, 249–253; Agnoli, A., et al. 1976. Effect of s-adenosyl-l-methionine (SAMe) upon depressive symptoms. J. Psychiatr Res. 13:43–54; Bell, K.M. 1988. SAMe treatment of depression: A controlled clinical trial. Am. J. Psychiatry 145:1110–1114.
  3. Kim, H. L., Streltzer, J., & Goebert, D. (1999). St. John’s wort for depression: A meta-analysis of well-defined clinical trials. J. Nerv. Ment. Dis., 187 (9), 532–538; Schrader, E. (2000). Equivalence of St. John’s wort extract (Ze 117) and fluoxetine: A randomized, controlled study in mild–moderate depression. Int. Clin. Psychopharmacol., 15 (2), 61–68; Woelk, H. (2000); Comparison of St. John’s wort and imipramine for treating depression: Randomised controlled trial. BMJ, 321 (7260), 536–539.
  4. Brainard, G. C., Hanifin, J. P., Greeson, J. M., Byrne, B., Glickman, G., Gerner, E., & Rollag, M.D. (2001). Action spectrum for melatonin regulation in humans: Evidence for a novel circadian photoreceptor. J. Neurosci., 21 (16), 6405–6412; Graw, P., Gisin, B., & Wirz–Justice, A. (1997). Follow-up study of seasonal affective disorder in Switzerland. Psychopathology, 30 (4), 208–214; Joffe, R. T., Moul, D. E., Lam, R. W., Levitt, A. J., Teicher, M. H., Lebegue, B., Oren, D. A., Buchanan, A., Glod, C. A., Murray, M. G., et al. (1993). Light visor treatment for seasonal affective disorder: A multicenter study. Psychiatry Res., 46 (1), 29–39; Oren, D. A., Jacobsen, F. M., Wehr, T. A., Cameron, C. L., Rosenthal, N. E. (1992). Predictors of response to phototherapy in seasonal affective disorder. Compr. Psychiatry, 33 (2), 111–114. (Erratum in: Compr. Psychiatry [1992], 33 (6), 419.
Last updated: December 28, 2006