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Diagnosis: Depression

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A person is usually diagnosed with major depression if he or she experiences five or more of the following symptoms during a two-week period:

* a persistent sad, anxious or empty mood
* feelings of hopelessness or pessimism
* feelings of guilt, worthlessness or helplessness
* loss of interest in activities that were once enjoyed, including sex
* decreased energy or fatigue; difficulty concentrating, remembering or making decisions
* insomnia or oversleeping; weight loss or weight gain
* thoughts of death
* restlessness or irritability
* physical symptoms that don’t respond to treatment, such as headaches, chronic pain or digestive disorders

Dedicated readers of the local Sunday newspaper are likely familiar with the display ad. “Depressed?” it begins. “Volunteers suffering from depression are needed for a clinical research study of an investigational medication...”The ad was placed by PCSD Feighner Research Institute, established in San Diego in 1973. FRI is an independent site for clinical neuropsychopharmacologic research, which means it conducts trials to study the effects of drugs not yet approved by the Federal Drug Administration to treat mental health disorders. A large chunk of the institute’s studies involve medications for treating major depression, an often-debilitating illness estimated to affect one in five people.

Through the decades, FRI has conducted trials on what later would become familiar names—Prozac, Zoloft, Paxil, Wellbutrin, Effexor—the new-generation antidepressants. Volunteers are sought for different phases of trials, which may last for more than a year. They receive a broad range of free medical services, modest compensation and the satisfaction of knowing they’ve contributed to medical science. Who wouldn’t want to get in on this?

“It’s getting harder and harder to recruit for antidepressant drug trials,” says Gordon Hendrickson, FRI’s chief operating officer. “It’s one of the biggest problems in the industry.” Advertise a study to test a new obesity drug, he says, and the phones go crazy; an ad for an antidepressant study, though, may bring only 10 calls.

A main reason for the current paucity of volunteers, Hendrickson says, is the large number of antidepressants on the market that work effectively. Patients are reluctant to forgo a drug they know works with what amounts to a medical shot in the dark.

Depression is the number-one health “hit” on the Internet, and a quick scan of the numbers shows why. Just about anyone can develop major depression, experts say. It cuts across racial, ethnic and socioeconomic lines. Males and females have a 20 percent chance of developing depression during their lifetimes, although the odds double for women during child-bearing years. The disease can strike at any age, often manifesting in the mid-20s. While the stigma of depression continues to fade (“Oh, just snap out of it!”), only about 40 percent of people with major depression seek treatment for it.

“We’ve found in less than a decade that major depression disorder is one of the most common diseases,” says Dr. Lewis Judd, chairman of the UCSD psychiatry department.

“Major depression is quite chronic,” Judd explains. “Over time it’s expressed dimensionally, so at one point there may be no symptoms, and at another point there’s many.”

Drugs to treat depression have long been available, but it was the highly publicized launch of the antidepressant Prozac in 1988 that brought depression into the spotlight of public discussion and to greater consumer acceptance of drugs to treat the disease.

Judd says that there are more than 50 antidepressants currently on the market. “There’s such a spectrum that, when their use is combined with psychotherapy, we can manage more than 80 percent of depression cases.” Treatment with medication alone is about 65 percent successful, he says.

Antidepressants don’t work for all patients, and it’s not unusual for a patient to try two or more, or a combination of drugs, before finding a successful regimen. Generally, the drugs are well tolerated, but there are side effects. Nausea is the primary complaint with most antidepressants, followed by an inability to achieve orgasm, reported by about 20 percent of users.

Antidepressants made front-page news in March, when the FDA announced it wants drug manufactures to put an additional warning on 10 common antidepressants saying suicide is a possible side effect. The agency conceded there were no studies showing a link, and it remains to be seen if prescriptions for the drugs fall off.

Judd, like most psychiatrists, is optimistic about the future of antidepressants. “We’re developing drugs that are much more specific, more effective, more precise in their influence on the brain,” he says. “We’re getting close to being able to predict from a functional MRI who will or who won’t respond to a drug.”

Major depression is “the common cold of psychiatry,” says Dr. Stephen M. Stahl, a Carlsbad-based psychiatrist whose 1996 book, Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, is the leading source of information in the field. He’s also an adjunct professor of psychiatry at UCSD and the founder of the Neuroscience Education Institute, which offers programs in psychopharmacology.

Stahl believes the current crop of antidepressants may have been “targeted too broadly” by physicians. “We’ve gone past the problem of recognition of depression, and now we’re to the possibility of misdiagnosis and errant treatment,” he says.

He refers to a relatively new concern in psychiatry: bipolar depression masquerading as unipolar depression (a description used in defining major depression disorder). Bipolar disorder—also called manic-depressive illness—is marked by dramatic and rapid mood changes of highs and lows. These are the folks who may not sleep for days, go on wild spending sprees and have grandiose and completely unrealistic ideas. Slipping into the depressed cycle, a bipolar person has some or all of the symptoms of major depression.

Stahl says that the mania phase in a bipolar individual often is not as nearly pronounced as textbook examples have it, and the depression state can be similar to that seen in low-to-moderate major depression. A bit of bipolar can be good, he adds, because it can lead those people to highly creative, productive cycles. (Historic bipolar figures include composers George Handel and Franz Schubert and artist Vincent Van Gogh.)

A misdiagnosis of major depression for a bipolar leads to problems: Antidepressants don’t work and can make the patient extremely agitated and anxious. Bipolar disorder can be successfully treated with a different class of drugs—commonly the mood stabilizer lithium.

Stahl, who notes that about 60 percent of all antidepressants are prescribed by a primary physician rather than a psychiatrist, believes as many as half of the cases of major depression are misdiagnosed and are, in fact, cases of bipolar depression. It’s not unusual for the bipolar patient—finding no relief in antidepressants—to drop out of treatment altogether.

Poway psychiatrist Bernard Bogard, a graduate of UCSD Medical School, has been in practice since 1987. He began his career as a “talk therapist,” using interpersonal skills to treat patients. With the advent of Prozac and similar antidepressants, he switched his focus to psychopharmacology, prescribing drugs to treat mental disorders. His typical patient is a woman in her 30s or 40s who exhibits six or seven of the major depression signs.

Following an evaluation, Bogard will prescribe drugs to treat a patient’s mind or behavior disorder and then see the patient at regular intervals to fine-tune the prescription or switch to a different drug.

“With today’s medications, there’s a two in three chance of any one antidepressant helping an individual,” Bogard says. “Patients have every reason to be hopeful that their treatment will be beneficial.”

There are certain types of depression that don’t respond to antidepressants. In these cases, electroconvulsive therapy (ECT) may be used—especially if the patient is highly delusional or suicidal.

ECT, or shock therapy, has come a long way from those days memorialized in black-and-white newsreels of the 1940s and ’50s, with pained-looking patients writhing about. ECT now is administered under anesthesia. Electrodes are placed at precise locations on the head, and a short stimulation causes a seizure in the brain, which a patient doesn’t consciously experience. It’s believed that the shock causes a large amount of helpful brain chemicals to be released. ECT patients usually require three treatments a week for a total of eight to 12.

Antidepressants may also be given, and a patient may require “maintenance” treatments.

“Patients starting off with the illness of depression see everything in a negative light,” says Bogard. “This negativity becomes so easy to grab on to, and a person continues to tear himself down.

“It’s one of the most gratifying aspects of psychiatry to see these symptoms go into remission through treatment. A person’s quality of life improves, and they are able to have normal relationships. They become comfortable with themselves.”

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