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.
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:
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.
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.
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:
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.
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:
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:
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.