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Dec 17, 2022

Mental Health

Depression

Different Types of Depression

Depression types: Major depressive disorder    Persistent depressive order    Post-partum depression    Seasonal depression

Depression medications: escitalopram     citalopram    sertraline     fluoxetine     paroxetine     venlafaxine     desvenlafaxine     amitriptyline     mirtazapine     nortriptyline     bupropion     trazodone

Depression is one of the most commonly experienced mental illnesses worldwide. 1 in 5 people will experience some form of depression at some point in their lives, and some people even experience it chronically for most of their life. At its core, depression is characterized by a persistent feeling of sadness and hopelessness.

How Is Depression Different from Being Sad?

This is an extremely common question and sometimes a difficult distinction to make. Everyone feels sad from time to time; it’s a normal and healthy human emotion. However, when this sadness and lack of interest in daily activities persists, it’s no longer healthy or “normal”. When this hopelessness appears out of nowhere and lasts for a significant amount of time, it is often then investigated and potentially diagnosed to be depression.

It gets hard to determine the line between sadness and depression, though, after a major event like a loved one dying or a significant relationship ending. In that situation, it’s sometimes hard to tell if the period of sadness that follows is a healthy reaction of grief or if it has developed into a mental health condition. In this situation, and any situation where you feel like you may be experiencing an unusually long or particularly difficult period of sadness or hopelessness, it’s important to speak with your healthcare provider about the possibility of a depression diagnosis.

When discussing depression with your healthcare provider, they will ask you questions about the timeframe and pattern of your depressive episode(s). With this information, they can help determine if you have clinical depression, and if so, which type of depression you may be struggling with.

Read our blog on What is Depression

Major Depressive Disorder (MDD)

Major depressive disorder (MDD) is the most common and most well-known mood disorder. It is characterized by a persistent low mood and disinterest in regularly enjoyed activities. MDD will often interfere with school and/or work as well as with regular day-to-day functioning. To be classified as major depressive disorder, symptoms must be present for at least 2 consecutive weeks, though your healthcare provider will take into account a longer period of time when discussing your symptoms with you.

A key factor with an MDD diagnosis is the frequency of depressive episodes. The depression is not necessarily persistent over time but comes in very strong waves separated by at least 2 months.

Signs and Symptoms:

Depression has very characteristic emotional symptoms, but it also commonly presents in physical symptoms. Studies have shown a direct correlation between the presence and severity or physical aches and pains to the presence and severity of MDD.

Physical

Physical symptoms associated with MDD are most often described as vague “aches and pains” usually in joints, limbs, the back, and/or the digestive system. While these are common complaints of those with MDD, these symptoms are not part of the diagnostic criteria. The physical symptoms that are most frequently associated with a diagnosis of MDD include:

  • Feeling tired or having little energy
  • Sleeping too much or sleeping not enough
  • Large increase or decrease in appetite
  • Moving or speaking so slowly that other people could have noticed OR being so fidgety or restless that you notice you are moving around more than usual
Emotional

The emotional symptoms are usually noticed first and are important for a depression diagnosis. These symptoms include:

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Feeling bad about yourself, or that you have let yourself/your family down
  • Trouble concentrating on things, such as reading a book or watching TV
  • Thoughts that you would be better off dead or of hurting yourself in any way

Diagnosing of Major Depressive Disorder:

A diagnosis for MDD has to be made with a healthcare provider. Firstly, you will likely undergo a physical exam in order to rule out any other medical conditions that could be causing your symptoms. This may involve bloodwork, as there are some medical conditions that can display in a similar way to MDD. Once other conditions have been ruled out, your healthcare provider will speak with you about your personal and family history of medical conditions including mental illness. They will then discuss your current and any previous signs and symptoms you are experiencing related to MDD.

A common diagnostic tool typically used at this point in diagnosis is called the Patient Health Questionnaire 9 (PHQ 9). This tool explores the frequency of physical and emotional symptoms of depression, rating each situation on a scale from 0 (not at all) to 3 (nearly every day). The final score then helps your healthcare provider to gain a better understanding of the specific areas and severity in which you are struggling.

Importantly, for a diagnosis of MDD, these symptoms also need to cause distress or interfere with social, occupational, or other functional aspects of life. The symptoms also must not be attributable to any substances or other mental health conditions, such as schizophrenia or bipolar disorder.

Treatment Options for Major Depressive Disorder:

Your healthcare provider will likely begin your treatment with non-medication options such as self-directed care or talk therapy. However, if this isn’t improving your symptoms and/or your MDD is quite severe, they may also prescribe medication.

Non-medication Treatment Options

The first-line non-medication options for MDD treatment are self-directed. These include making changes to your lifestyle and/or following “do it yourself” programs or phone apps. It can be difficult to change your lifestyle while experiencing MDD, but there is a lot of evidence that small changes, such as increasing your exercise and eating a balanced, regular diet, can make a big difference.

The other main non-medication treatment is psychotherapy with a mental health care provider. Possible providers include counsellors, therapists, psychotherapists, psychologists, and psychiatrists. Each provider has their own area of expertise, and you can speak with your healthcare provider about which may be the best option for you.

The types of therapy offered differ based on provider and based on your particular needs. The options that are best suited for MDD treatment include:

  • Cognitive behavioural therapy (CBT)
    This type of therapy works to change thought patterns and therefore help reduce feelings of depression.
  • Interpersonal therapy (IPT)
    This therapy has a major focus on improving relationships with others and interpersonal aspects of life.
  • Dialectical behavioural therapy (DBT)
    This is a similar therapy to CBT but has more of a focus on accepting and then coping with and minimizing extreme emotions.
  • Psychodynamic psychotherapy
    This therapy aims to analyze the roots of what may be causing your depression in hopes to be able to then reflect on the “causes” and work through these issues to resolve the low mood.
Medications to Treat Major Depressive Disorder

There are many medication options for MDD, and each one effects every individual slightly differently. If one medication doesn’t seem to be working, there are dozens of other that you will be able to try.

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
    SSRIs are the most commonly prescribed antidepressant because they are usually effective and have fewer side effects than others. They work by decreasing the reuptake and therefore breakdown of a chemical called serotonin (the “happy” chemical). This then has a positive influence on mood, sleep, emotions, and appetite.
    Examples of SSRIs include escitalopram, citalopram, fluoxetine, sertraline.
  • Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
    SNRIs work in a similar way to SSRIs, stopping the reuptake of serotonin and norepinephrine (the “fight or flight” chemical). This improves your mood with increased serotonin, but also increases energy, alertness, and attention with more norepinephrine.
    Examples of SNRIs include desvenlafaxine, venlafaxine, and duloxetine.
  • See our blog that compares SSRIs with SNRIs

  • Atypical Antidepressants (ATAs)
    There are a few different atypical antidepressants, the most common being bupropion.
    Bupropion stops the reuptake of dopamine (the “reward” chemical), serotonin, and norepinephrine. This regulates out the chemicals that are potentially imbalanced and therefore reduces symptoms of depression.
  • Tricyclic Antidepressants (TCAs)
    TCAs cause a decreased reuptake of norepinephrine and serotonin. They differ from SNRIs, as TCAs work more on norepinephrine than serotonin. These are a second-choice antidepressant as they don’t work as well as SSRIs or SNRIs.
    Examples of TCAs would be amitriptyline and nortriptyline.
  • Monoamine oxidase inhibitors (MAOIs)
    MAOIs stop the enzyme that is responsible for breaking down serotonin, norepinephrine, and dopamine. An increased amount of these chemicals works to decrease negative symptoms of depression.
    An example of an MAOI is phenelzine.
Other Treatments

There are also other, more atypical, treatment options if the non-medication and medication options are not improving your symptoms. This is a discussion to have with your healthcare provider in order to determine if alternative treatment options may be right for you.

Persistent Depressive Disorder (PDD)

Persistent depressive disorder displays itself similarly to MDD, but the key differences are in the duration and severity of the symptoms. Unlike MDD which comes in waves, PDD persists at a decreased severity for most days for at least 2 years.

Signs and Symptoms:

The symptoms of PDD are similar to that of MDD, but in general are less intense. Because of this, the more severe MDD symptoms, such as thoughts of hurting yourself in some way, are not included in PDD diagnosis.

Physical

The physical symptoms that are linked to PDD are very common and can be mild or more severe. These include:

  • Feeling tired or having little energy
  • Sleeping too much or not sleeping enough
  • Large increase or decrease in appetite
Emotional

The emotional symptoms are, in general, the most prominent symptoms with PDD. They include persistent negative feelings about yourself as opposed to the more severe dark thoughts and feelings as with MDD. Emotional PDD symptoms include:

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble concentrating on things or making decisions

Diagnosing Persistent Depressive Disorder

For a PDD diagnosis, your healthcare provider will first rule out any other medical conditions or substances that could be contributing to your symptoms. They will then take a personal and family history of any medical conditions and mental illnesses, as mental illness is highly genetic.

After they have ruled out any externally contributing factors, they will discuss with you the length and severity of your symptoms. They may also ask you to complete the PHQ-9 diagnostic tool as your answers will give them a way to be able to discriminate between MDD and PDD. It is important for your healthcare provider to rule out MDD, as well as any other mental illness, before they made a PDD diagnosis.

In order to meet the diagnostic criteria for PDD, you need to have a depressed or low mood for most days as well as experience at least 2 of the previously mentioned symptoms for a period of at least 2 years. These symptoms also cannot have disappeared for more than 2 months at a time within those two years. This timeframe may be shifted slightly for children and adolescents, depending on the situation. Importantly, the symptoms must also be causing distress or impacting social, occupational, and/or other functional aspects of your life.

Once you have been formally diagnosed with PDD, your healthcare provider will begin to discuss treatment options.

Treatment Options for Persistent Depressive Disorder

Cognitive Behavioural Therapy

The treatment for PDD is similar to that of MDD. Since the symptoms tend to be less severe, the treatment may be less intense. Those with PDD often respond well to psychotherapy and may not need medication, but the treatment will be different for each person.

The main therapy recommended for those with PDD is CBT. However, there are multiple different options depending on your specific needs. Other therapies include:

  • Interpersonal therapy (IPT)
  • Dialectical behavioural therapy (DBT)
  • Psychodynamic psychotherapy
Medications for Persistent Depressive Disorder

If psychotherapies do not seem to be enough to manage your PDD, there are also medication options. These include:

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
    — SSRIs are the most commonly prescribed antidepressant for PDD.
    — Examples of SSRIs include escitalopram, citalopram, fluoxetine, sertraline.
  • Selective Norepinephrine Reuptake Inhibitors (SNRIs)
    — Examples of SNRIs desvenlafaxine, venlafaxine, duloxetine.
  • Atypical Antidepressants (ATAs)
    — The most common atypical antidepressants is bupropion.
  • Tricyclic Antidepressants (TCAs)
    — These antidepressants are less commonly prescribed for PDD.
    — Examples of TCAs would be amitriptyline and nortriptyline.
  • Monoamine oxidase inhibitors (MAOIs)
    — MAOIs are not commonly prescribed for PDD, unless other medications have not worked.
    — A MAOI example is phenelzine.

Post-partum Depression (PPD)

Postpartum depression is very common in new mothers and can be a very serious situation. Having a new baby is often viewed as a joyful and exciting time, so when you are feeling extremely down and depressed in the postpartum stage, it can feel very isolating. However, this is actually much more common than people think.

Because of the extreme fluctuations in hormones that occurs after birth, it is common for women to experience something called the “postpartum blues”. This manifests as being moody, irritable, and anxious, having trouble concentrating, and frequent bouts of crying. This usually goes away after a few weeks as you and the baby settle in, and your hormones begin to regulate again.

With postpartum depression, the symptoms are more severe and do not go away after a few weeks.

Signs and Symptoms:

It can sometimes be difficult to determine if some of the symptoms of postpartum depression are “normal” feelings while having a newborn. Such confusing symptoms include having trouble sleeping, having low energy, and having changes to your appetite. However, when these symptoms are severe and are not going away or improving after a few weeks, it’s very important to speak with your healthcare provider.

The symptoms associated with PDD are both emotional and physical, and include:

Emotional
  • Not feeling like “yourself”
  • Strong feelings of sadness, hopelessness, and/or guilt
  • Intense worrying or anxiety
  • Not worrying about the baby at all; not caring about baby
  • Experiencing panic attacks
  • Feelings of anger toward the baby
  • Thoughts of hurting yourself or baby*
Physical
  • Sleeping all the time, even if baby is awake and needs attention
  • Inability to sleep, even when tired and baby is asleep
  • Inability to eat, even when hungry or inability to eat because never feeling hungry
*If you are having thoughts of hurting yourself or your baby, seek medical attention immediately.

Diagnosing Post-partum Depression

If you experience the postpartum blues, it is important to let your healthcare provider know. They will then be able to follow you and your mental health as time goes on and assess if this has developed into postpartum depression.

Your healthcare provider will likely want to do a physical assessment in order to ensure your feelings are not being caused by an external contributing factor. They will then speak with you about how you have been feeling and behaving since the baby was born.

It’s extremely important not to feel embarrassed or guilty for experiencing PPD. Your healthcare provider will not judge you and will be grateful that you sought out help rather than letting you and/or your baby struggle because of it.

Treatment Options for PPD

Treatment for PDD is slightly more complicated since you will likely be breastfeeding a newborn. Some medications can cross from your blood into the breastmilk, and therefore be consumed by the baby. Your healthcare provider will take this into consideration when prescribing you any medication for PPD.

Non-medication Treatment Options

Being able to treat PPD, at least in part, without medication is important. Psychotherapy with a registered mental health care provider can help you sort out your feelings toward yourself and your new baby and is often very beneficial.

Medications for Post-partum Depression

If PPD is not being properly controlled by psychotherapy, your healthcare provider may prescribe you medication. Ideally, a medication that does not cross into breastmilk or is not dangerous to the baby should be prescribed. However, it’s also possible to take medication that does cross into the breastmilk as long as you have discussed other feeding options for your baby while on the medication.

The main antidepressants that is considered safe during pregnancy are the SSRIs citalopram, escitalopram, and sertraline. Other medications, such as other fluoxetine and paroxetine (also SSRIs) and nortriptyline (a TCA). Other antidepressants have not been fully established as safe for the baby to receive in breastmilk, and therefore should be avoided if breastfeeding.

Seasonal Affective Disorder (SAD): also known as Seasonal Depression

Seasonal affective disorder is a form of depression that comes and goes based on the time of year and the seasons. It comes in two main forms, depending on the timing of onset of the depression.

  1. Fall-onset: this SAD comes on as autumn arrives. The changing of the seasons from long, warm, sunny days to colder, shorter days is a very clear trigger for this depression. This is the more common form of SAD.
  2. Spring-onset: this refers to the SAD that comes on as winter ends, and spring begins. This response to the change from cooler, shorter days to longer, brighter days is less common.

Signs and Symptoms:

The symptoms differ slightly between fall and spring onset seasonal depression. The symptoms of fall onset are, in general, focused on a low mood and lack of energy, and tend to be slightly more severe than the symptoms experienced with spring-onset seasonal depression.

Fall-onset:
  • Feeling sad and/or irritable
  • Crying frequently
  • Feeling tired and having decreased activity levels
  • Sleeping more than usual
  • Withdrawing from social situations
  • Increased appetite, often including weight gain
Spring-onset:
  • Feeling irritable and agitated
  • Poor appetite and often weight loss
  • Inability to sleep
  • Feeling restless and anxious
  • Potential violent urges or behaviours

Diagnosing Seasonal Depression

If you are noticing fluctuations in your mood at any point in the year that are causing you distress or getting in the way of your daily functioning, it’s important to speak with your healthcare provider. They will discuss how you have been feeling and assess whether they feel as though your mood may be related to the time of year. Having an idea of the timing you usually experience mood changes is very helpful for a SAD diagnosis. The main distinction between SAD and MDD is the timing, so your healthcare provider will speak extensively with you in order to determine if you are experiencing SAD and, if so, if it’s fall or spring onset.

Your healthcare provider will then want to complete a physical exam, likely including bloodwork, in order to rule out any external contributing factors. Once they have concluded that your feelings and behaviour are not related to other medical conditions, medications, or other mental illnesses, they will begin discussing treatment options.

Treatment Options for Seasonal Depression

Seasonal depression is usually first treated with non-medication treatment. If this does not help alleviate symptoms, your healthcare provider may also prescribe medication for you.

Non-medication Treatment Options

A very common option that has shown to be effective in treating seasonal depression is called “light therapy”. This involves sitting in front of a light therapy box that emits (safe) UV rays toward you. It is recommended to sit in front of this light for at least 20 minutes per day as soon as you wake up for the period of the year that you are experiencing SAD.

There are also other self-directed treatment options for mild forms of SAD, such as:

  • Trying to get as much natural sunlight as possible
  • Make your home and work environment as bright as possible
  • Sit near windows when indoors
  • Increase exercise levels and eat a healthy balanced diet

When SAD is more severe and/or self-directed options aren’t working, there is also the option of psychotherapy. There are a number of mental health care providers who can help you manage your SAD. Of particular efficacy is CBT (cognitive behavioural therapy), which aims to help you redirect your thoughts and behaviours. This can help you to change the way you think and act and therefore help reduce your SAD symptoms.

Medication for Seasonal Depression

Medication options for SAD vary from supplements to antidepressants. Since the depression is seasonal, the medication would usually also be seasonal, and only taken before/during the season in which seasonal depression presents.

  • Vitamin D supplementation
    — This is not a “medication”, but rather a supplement. It’s thought that perhaps the reduced amount of vitamin D from lack of sunlight may partially contribute to fall-onset SAD, and therefore this supplementation may be effective in reducing symptoms.
  • Antidepressants
    — SSRIs: The most commonly prescribed antidepressant for seasonal depression
    — Bupropion
References:
  1. Major vs. persistent depressive disorder: Understanding dysthymia. (2022). Retrieved 25 July 2022, from https://www.medicalnewstoday.com
  2. Chand SP, Arif H. Depression. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430847/
  3. Bains N, Abdijadid S. Major Depressive Disorder. [Updated 2022 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559078/
  4. Persistent depressive disorder (dysthymia) - Diagnosis and treatment - Mayo Clinic. (2022). Retrieved 27 July 2022, from https://www.mayoclinic.org
  5. Major vs. persistent depressive disorder: Understanding dysthymia. MedicalNewsToday (2022). Retrieved 27 July 2022, from https://www.medicalnewstoday.com
  6. Reynolds, C., & Kamphaus, R. (2013). Persistent Depressive Disorder (Dysthymia) BASC3 (5th ed., pp. 1-2). American Psychiatric Association.
  7. Depression patient health questionnaire. (2022). Retrieved 26 July 2022, from https://www2.gov.bc.ca
  8. Postpartum depression - Diagnosis and treatment - Mayo Clinic. (2022). Retrieved 28 July 2022, from https://www.mayoclinic.org
  9. Melrose, S. (2015). Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depression Research and Treatment, 2015, 1-6. doi: 10.1155/2015/178564
  10. Seasonal Affective Disorder (SAD). (2022). Retrieved 28 July 2022, from https://psychiatry.org
  11. Treatment - Seasonal affective disorder (SAD). (2022). Retrieved 28 July 2022, from https://www.nhs.uk

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