Laval Families Magazine continues with its new series on mental health. In this issue, we continue the discussion on depression with the second of three installments, taking an in-depth look at the complexity of clinical depression. Dr. Mary Tsonis, psychologist and founder of Your Psychology Clinic in Laval, answers Lori Leonard’s questions.

Q: Is depression similar to alcoholism? Can it be caused by alcoholism or certain drugs?

A: Alcoholism is an addiction, a dependence. It is not a mood disorder. Chronic drinking and some prescription and non-prescription drugs can affect mood, and lead to depression, as stated above. However, many self-medicate with drugs or alcohol to manage symptoms of depression. As many as 40% of people with depression struggle with over-use of alcohol.

Q: What is the usual drug of choice to treat depression? Is there a usual drug of choice?

A: Before I go into detail about drug treatments of choice for depression, it is important to mention that research has shown that the most effective way of treating depression is medication IN COMBINATION with therapy. There are a number of psychotherapeutic approaches, but the most researched and documented as effective is cognitive behavioral therapy (CBT); however, psychotherapy usually also involves psychoeducation and self-management training. It is VERY important to find a therapist that you are comfortable with, as the therapeutic alliance plays a key role in recovery.

There is evidence that people with mild depression should try other interventions first, such as psychotherapy and lifestyle changes; however, severe depression requires medication in combination with other treatments.

Depression is often thought of as a “chemical imbalance” in the brain. This means that certain brain chemicals, or neurotransmitters, are not at the levels they should be in order to maintain a positive mood. The neurotransmitters implicated in depression are serotonin, norepinephrine, and dopamine. Thus, medication is a common treatment for depression, and the objective is to improve the brain chemistry through drugs.

There are a variety of medications to treat depression. There are a variety of combinations of drugs to treat depression as well as other important symptoms such as anxiety or sleeping difficulties that often accompany depression.

The medications used for depression are usually classified into categories based on which neurotransmitters they are designed to affect. Two older categories of antidepressants include: Tricyclic Antidepressants and Monoamine Oxidase Inhibitors. These are still prescribed, as they do work, but can have side effects such as drowsiness, dry mouth, and weight gain. There are a few categories of “newer” antidepressants. These are: Selective Serotonin Reuptake Inhibitors (e.g. Prozac, Paxil, Zoloft, Celexa, Cipralex), Serotonin Norephinephrine Reuptake Inhibitors (e.g. Effexor, Cymbalta, Pristiq), and Norepinephrine Dopamine Reuptake Inhibitors (e.g. Wellbutrin). Abilify is now being prescribed as an add-on medication, to be taken with the prescribed antidepressant, in cases where the antidepressant alone is not as effective as hoped.

In some cases, anti-psychotic or mood-stabilizing medication may be used in addition to antidepressants. One such commonly prescribed drug is Seroquel XR, which is approved for use in both the manic and depressive phases of bipolar disorder.

Q: How long does it take for these drugs to take effect?

A: Anywhere from two to eight weeks. If the first medication one is trying works within a few weeks, then great, but it can be a problem if there is no effect and the medication has to be changed. In such cases, it can be a while before an improvement is seen.

Q: Is depression seen more in men or women, and why?

A: Research has reliably shown to-date that women have higher rates of major depression than men by a ratio of 2:1. This may be, in part, to hormonal aspects inherent in being a woman, such as the onset of puberty, PMS, pregnancy and post-partum and menopausal hormonal changes; however hormones alone are not responsible for depression, and likely an interaction of hormonal issues and other factors contribute to higher rates of depression amongst women. Moreover, lower rates amongst men does not necessarily mean they suffer from depression less than women. They may simply be underdiagnosed and are less willing to seek help, likely as a result of greater stigma associated with depression amongst men as it is a condition thought to reflect “weakness”.

More recent research is suggesting that the experience of depression and the expression of depression differs across the sexes. That is, relying only on men's disclosure of “traditional” symptoms could lead to an under diagnosis of depression in men and that clinicians should consider other clues when assessing depression in men. A recent study by Martin et al. (2013) in JAMA indicated that sex differences in depression rates disappear when alternative and versus traditional symptoms, or male versus female versions, of depression are considered.

The researchers developed two scales. The first, the Male Symptoms Scale (MSS), included alternative male-type symptoms of depression, including irritability, anger attacks/aggression, sleep disturbance, alcohol or drug abuse, risk-taking behavior, hyperactivity, stress, and loss of interest in pleasurable activities. The researchers found that men reported significantly higher rates of anger attacks/aggression, substance abuse, and risk-taking behavior compared with women. The second scale, the Gender Inclusive Depression Scale (GIDS), included all of the MSS symptoms, plus 7 traditional symptoms of depression, including sad/depressed mood, loss of vitality, tiredness, ambivalence, anxiety/uneasiness, and complaintiveness or feeling pathetic. Using the MSS scale that included alternative, male-type symptoms of depression, the researchers found a higher prevalence of depression in men (26.3%) than in women (21.9%) (P = .007). Women, on the other hand, reported significantly greater rates of stress, irritability, sleep problems, and loss of interest in things they usually enjoyed, such as work, hobbies, and personal relationships. No sex difference in the prevalence of depression as assessed by the GIDS that included alternative and traditional depression symptoms was found. According to that scale, 30.6% of men and 33.3% of women met criteria for depression. In terms of severity of depression, the researchers found that 63.2% of men and 62.0% of women fell into the mild category, meaning that they had 1 to 4 symptoms; 28.3% of men and 28.9% of women fell into the moderate category, with 5 to 9 symptoms; and 8.5% of men and 9.1% of women fell into the severe category, with 10 to 15 symptoms. No significant sex differences were demonstrated at any severity level, according to the report.

Q: Is depression seen in children? Why?

A: Children can also be depressed. In fact, depression can even exist in infants; it is a condition called infantile depression and it is often seen in babies who are institutionalized and under stimulated, as well as neglected or abused. Children get depressed for a variety of reasons, some of which are the same as for adults. Depression in children is a fascinating topic and I believe a most serious one. Although trained in not taking my work home with me, nothing touches my heart in my practice, and saddens me as much as children who are depressed or the stories of my adult clients who were depressed as children. I believe this topic should be given full attention in another series.

Q: Is depression a significant illness?

A: Absolutely. Depression if untreated, can be debilitating and prevent someone from living a “normal” life. In more severe cases, it can also lead to psychotic episodes, to suicidal ideation, and to suicide. It has physical symptoms and important cognitive and behavioural limitations that significantly impair a person’s ability to function and carry out the activities of daily living. People cannot get out of bed, their attention, concentration, and decision-making processes are affected. They lose pleasure in activities they previously enjoyed. Their motivation plummets. They have difficulty doing basic tasks and chores. They are easily overwhelmed by routine tasks and responsibilities. They are overwhelmed and very sensitive to sensory stimulation (e.g., lights, sounds, noise bother them). They withdraw from social contacts and events.

Q: Can depression ever be cured?

A: It can definitely be treated. Some people become depressed as a result of an acute stressor or chronic stress. Once the stress is relieved, the depression can lift and they may never experience another bout of it. Some people may experience several episodes of depression during their lifetime. Some people are chronically depressed, and this may be more genetically or biologically based and may require life-long treatment. But depression CAN be managed, just like diabetes, high blood pressure, or a thyroid condition, and its impact on lives can be minimized.

Please stay tuned for the final installment in this series, appearing in our February edition, where we will discuss treatment plans, high risk factors such as suicide, stigma in the work force and how our nutrition and lifestyle can affect our mood.