Everybody can get depression

Who has not experienced moments when you feel lonely and desperate and cannot enjoy anything. It is like wearing glasses that only allow you to see everything grey. Mood swings are part of the normal cycle of ups and downs in life. They are a healthy way of responding to negative experiences, loss, disappointments, or pressure. However, when this emotional state endures over several weeks or even months and the feeling of inner emptiness burdens your soul like lead it is a serious illness: depression. Patients suffering from diabetes often develop such a disorder.

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"A little while ago my children complained that my negative thinking became unbearable. Even my best friend observed that she had never seen me more pessimistic, bleak, and without energy. These outside observations prompted me to seriously consider whether I will ever be able to pull myself out of this terrible emotional misery." Edith, a 51 year old teacher, was a positive and optimistic person just half a year ago. She resumed her precious career as a teacher after her children started school despite the burden of managing a household with two kids. Until recently, she never viewed her 26 years of diabetes type-1 as major burden. She didn't always have her blood glucose level under control because she considered it necessary not to allow diabetes to intrude on her life too much.

Edith reports

"I still cannot explain it. Suddenly, a deep inner exhaustion and emptiness took hold of me. Many things I had managed effortlessly in the past such as preparing for school, regularly recording my blood glucose level, or preparing dinner suddenly appeared to be a huge burden. I had no energy and was unable to decide on anything. Instead of getting on with things right away I started brooding. Without warning I started questioning many things in my life. Even those things I always used to enjoy such as making music or painting failed to make me happy. My diabetes became a growing problem, too, because it became ever more difficult to deal with on a daily basis. I found myself wondering why I should keep managing the complexity of a good blood glucose level. After all, I expected very little from the future and was very pessimistic about whether I was capable of containing the progress of my incipient complications. When my husband confronted me I told him that he didn't understand and I retreated more and more into my shell."

Depressions are not a disgrace but a serious illness

Edith received help by talking openly to her diabetes therapist whom she told about her situation: "I remember exactly. In the discussion I was initially ashamed to talk about my bleak mood. I started to hum and hah and said that I was currently down, that I had no energy and had trouble sleeping. This was also the reason why my blood glucose level was not as good as it used to be. My doctor knows me extremely well. He asked only a few well targeted questions before he told me in no uncertain terms that I suffered from depression. That often happens to diabetes patients, he said. He had become suspicious that something was wrong after my last appointment. To be honest, I was elated that I finally knew why my emotional status had changed. I also remember him saying that depressions are easy to treat. That encouraged me. My doctor prescribed a drug against depression and arranged an appointment with a psychotherapist. Both treatments helped me tremendously."

Depressions are often underestimated

Professor Hegerl, director of the Depression section at the Department for Psychiatry at Munich University and spokesman of depression competence network, knows well the fact that most people hesitate admitting to suffer from a psychological condition: "People believe 'everybody is depressed sometimes'" Hegerl says. "Depressions are often underestimated and range somewhere between a cold and 'imagination in peoples' minds. However, in reality it is a dangerous illness that affects ones quality of life in fundamental ways. Frequently it even leads to a person questioning his entire life."

Like only very few other diseases depressions cause extreme psychological strain because they target the center of ones well-being and quality of life. A recent global study by the World Health Organization (WHO) revealed that depression is by far the most burdensome illness of all psychological and physical afflictions. The Years Lived with Disability (YLD) indicator measures severity and duration of a condition. It shows that depression is the single most important problem in developed countries.

Patients suffering from depression estimate its impact as more severe than those suffering from diabetes do.

Everybody can get depression

In Germany 4 million people (or five percent of the population) suffer from depression that requires treatment. The number of people that develop depression at some time in their life is three times as high. The lifelong risk of depression ranges between 15 and 18 percent. This means that every fifth or sixth person will be confronted with this illness during the course of his or her life.

Most of the time depression takes the form of episodes lasting weeks, months or sometimes years. If untreated, it can return and may become a chronic disease.

When life loses its meaning…

A sad potential consequence of depression is distressing for all concerned. Many depressed people feel useless. They feel ashamed for incidences that other people do not even notice. Patients frequently develop a sense of worthlessness and uselessness and believe their life has lost its meaning. In such a situation the patient developes the wish to simply cease existing as the only way out of theirmisery. The danger of suicide is a frequent side effect of a depression that develops sooner or later. It presents a high risk to the patient. The overwhelming majority of the 12,000 Germans committing suicide every year suffered from a depression.

This rate of suicides dramatically exceeds the number of annual traffic related deaths. Suicide ranks as the second cause of death after accidents in the age group of 15 to 35 years. Experts further estimate the number of serious suicide attempts to be 10 to 15 times the number of successful suicides. This is the most important reason why consulting a physician is crucial. Only he or she can determine whether someone is encountering a time of mourning or disappointment related to a specific problem or has actually developed a serious depression.

Women are depressed more often than men

Women develop a depression two to three times as often as men. While many studies confirmed this finding, the reason for this gender bias remains unclear. A series of causes needs to be considered. First, women talk more openly about their anxieties and mood swings than men and are therefore easier diagnosed. Second are biological causes: women are more susceptible to depression at certain times such as menstruation or after giving birth due to changing hormone levels. Experts also suspected but have not yet confirmed that women are more susceptible to depression during or after menopause. It may be that higher susceptibility results from a estrogen shortage during menopause. Third, the role of women in society is considered a potential cause. Working women often face the dual challenge of balancing their career with managing the household single-handedly. Women who stay at home frequently have to battle the negative reputation of playing "merely the role of a homemaker."

Children can get depression, too

In the past people assumed that children and adolescents do not get depression. Today we know this is false. Researchers are alarmed by the growth of child depression rates. The Elderly are also not immune to depressive dysfunction. Men have the most difficulty in coping with depression as the rising suicide rate of men older than 75 years demonstrates.

Diabetes doubles the number of depressions

Diabetes increases the risks of simultaneously developing a depression. Several different assessment methods such as surveys, interviews, or random sampling confirmed this increase. We know that diabetes patients develop depressions twice as often as people without diabetes. At least every tenth diabetes patient is affected. Research also revealed that depression often correlates positively with poor control of metabolism, more complications, and a noticeably restricted quality of life. Particularly people with diabetes related complications suffer from a higher rate of depression.

This is the reason why the guidelines of both the German Diabetes Society and the American Diabetes Society agree on recommending that diabetes patients need to be regularly tested for depression.

Depression is a physical and a psychological problem

Unlike a broken leg, depression rarely results from a single cause. Most of the time a combination of factors contributes to the illness. In the past, depression was considered to result either from physical (endogenic depression) or psychological (reactive depression) causes. Modern science revised this assumption. A psychological problem such as the mourning of a death can mark the beginning of a depression. However, it is also true that depressed mood may result from a metabolic dysfunction of the brain. In contrast, certain physical conditions can generate psychological symptoms and consequences. This causal relationship can explain why diabetes patients face a higher depression rate. In sum, depressions can be explained by and an appropriate treatment needs to combine both, the physical, biological aspects on the one hand and the psychological and psycho-social ones on the other.

How does a depression emerge?

The predisposition to depression is either genetic or is due to upbringing. Patients with a genetic disposition tend to develop depressions when they encounter difficult situations, but this does not have to be the case. The precise nature of these genetic factors is unknown, though. The initial idea of finding a single gene responsible for depression did not materialize.

However, certain characteristics of personality such as low self-esteem can play their part when depression develops. Moreover, physical conditions such as a thyroid dysfunction may cause depression. It can also emerge in conjunction with certain medication such as high doses of cortisone. Changing hormone levels during menopause or after giving birth ("postpartum depression") are also known to cause depression.

In addition, it is widely accepted that a broad variety of pressures play an important role in initiating depression. Acute negative life events are particularly important. Every tenth person experiencing an extreme situation such as an accident or an armed robbery develops a depression. Psychosocial pressures that require adjustment to new circumstances such as the death of a relative or a separation often precede a depression. Events beyond ones control that are experienced as helplessness can facilitate the development of depression.

Furthermore, chronic pressures such as everyday stress and problems can generate a depression if they endure. These pressures may include exposure to chronic diseases such as diabetes, cardiovascular conditions or epilepsy. Not all patients show signs of these generating factors, although many depressions turn out from nowhere as if one had turned on a light.

A different "beat" of the brain

When depression has started the entire body will be affected. It releases more stress hormones, the muscle tone tightens, sleeping-waking cycles are disrupted as well as appetite and libido. Many researchers assume that a dysfunction of the brain's metabolism facilitates depressed mood, a loss of energy, recurring sense of guilt and a number of other psychological symptoms.

Our thinking, feeling, and acting are based on the activity of neurons in the brain. When a neuron is active an impulse moves along the nerve fiber to the synapses where it intersects with other neurons. The brain uses messenger substances - so-called neurotransmitters such as serotonin or noradrenalin - to carry the impulse from one neuron to another.

It is likely that these messenger substances such as serotonin or noradrenalin are off balance in depression. Either their level is too low or the transmission malfunctions. Many anti-depression drugs therefore seek to rebalance the metabolism of the brain. However, it is also possible that excessively high levels of stress hormones such as cortisone generate depression.

Everybody is dispirited sometimes

You are probably familiar with the characteristics of a depression. Who has not lived through episodes of sadness, a broken heart, lost energy, and apathy? In these episodes self-doubt grows, one feels entirely useless, and cannot enjoy anything. It is like viewing life through dark glasses. Surely, there were times when you did not enjoy your food, when you had trouble sleeping, when you experienced inner unrest, and when you had trouble managing life properly. If this mood fades, these episodes are actually a healthy response to pressure or loss in life. Similar to pain as a sign of warning about danger, episodes of sadness and a broken heart are key events that help coping with certain negative experiences and to reorient accordingly.

When do depressions require treatment?

However, when these episodes endure they become counterproductive and depression develops. Rather than reflecting people with a depression start brooding. Instead of admitting emotions that facilitate problem solving they seek to avoid feelings. Their eyes stop shining and they look stone-faced. One can actually see the pain of a depressed person. Rather than recovering, a depressed person wears out more and more. Instead of solving problems depressed people become entrapped in self-guilt, negative thinking, and a sea of hopelessness. The key difference between just a sad person and a depressed one is that the latter cannot be distracted from his or her feelings. It does not matter to him or her whether the sun shines or it rains; and it makes no difference that nice things happen or the past has been good.

Types of depression

Depression affects each individual differently. There is no consistent picture. It does not have to become an enduring disease. More than a third of the affected people goes through a one-time episode. Others suffer from recurring phases of depression that can last several weeks, months or even years.

One can distinguish the following types of depressions:

How to detect depression

When people develop depression they change both, physically and in terms of their behavior and experience. The following list of symptoms point to a depression. However, depression symptoms appear in very different guises and some problems are caused by other diseases. You should consult an experienced doctor or psychotherapist who will determine whether or not your depression requires treatment.

• Melancholic mood: A feeling of a deep melancholy, discouragement and hopelessness. Many affected people reported a great inner emptiness, desperation and the "feeling of numbness." Their perception of life changes completely.
• A lack of energy and the inability to make decisions: Depressed people often cannot make up their mind. They weigh the pros and cons of everything without reaching a conclusion. Even simple things require great effort. Difficult things are postponed cannot be tackled.
• Ability to think and concentrate: People find it difficult to keep focused on something or to fully grasp complex issues. Many affected people report how difficult it is for them to leave aside some ideas over which they continuously mull without reaching a conclusion. Such continuous pondering distracts them from concentrating on other issues.
• Sense of guilt and inferiority: Often people are pained by a sense of being guilty of the illness themselves. They have a sense of inferiority when they compare themselves to others.
• Loss of interest and pleasure in activities: Things people used to enjoy in the past lose their attraction. Many patients withdraw from social circles and spend a lot of time in bed or on the couch.
• Change of facial expression: The facial expression and gestures of depressed people are often reduced; they lower their voice to a monotone sound; their handshake is weak.
• Lack of emotional response: The experience of emotions is drastically reduced. This symptom shows particularly in situations that are usually related to strong emotions such as moments of happiness, an accident, or other terrible events.
• Anxiety: Anxiety often accompanies depression. This observation is related to depressed peoples' worried brooding, and their sense of inferiority.
• Insomnia: Sleeping disorders are a typical symptom of depression. Despite their fatigue, depressed people find it difficult to fall asleep and when they do, their sleep is disturbed. Others wake up often and have trouble going back to sleep because they start to brood. Still others suffer from an enhanced need for sleep, but despite sleeping for a long time, they do not wake up refreshed . Furthermore, depressed people often wake up two or more hours earlier than usual.
• Appetite disorder: Eating is no longer fun but a neccessity to avoid losing weight. People actually often lose weight during an episode of depression. However, the opposite can also be the case. Germans call this depression related added body mass Kummerspeck (grief-fat).
• Lack of libido: Their sex life often reflects peoples' loss of energy during depression. Sex becomes rare. It is no longer considered as important and is a less passionate experience than in the past.
• Physical problems: A number of physical problems often reflect depression for which a doctor cannot find a somatic cause. People complain about pain, problems and hypersensitivity. This may affect all body parts and organs.

Interaction between depression and diabetes

You may have experienced some of these symptoms already because several derive from diabetes, too. Typical symptoms of a depression such as fatigue, loss of energy, reduced appetite or abating libido can also result from a mismanagement of blood glucose level. Make sure that the symptoms do not result from a derailed metabolism and avoid a premature conclusion of depression.

What can be done?

When you first detect symptoms of depression consult your primary physician. In most cases, he knows you and your environment best. Do not be ashamed to consult a doctor, because a depression is not a personal failure but a serious yet treatable illness.

Before diagnosing a depression your doctor will most likely rule out any other illness. For example he will test whether or not your thyroid works properly. When you have diabetes you should not prematurely accept the explanation that this is the reason for your discomfort. You have probably experienced already that diabetes is used as an excuse for physical problems that are hard to explain. Hence, consult the physician who treats you for diabetes and ask her/him about your personal symptoms of a depression. When making an appointment, make sure your doctor can take some time off his/her busy schedule. An extensive discussion is absolutely necessary to diagnose a depression.

When your primary physician finds a serious form of depression he/she will refer you to a specialist. This specialist can be a psychiatrist or a neurologist. A psychological psychotherapist can also check what kind of depression exists.

80 Percent treated successfully

What most people do not know: 80% of patients are treated successfully when the proper therapy is applied. Yet, the most important preconditions for success are an early diagnosis, the proper therapy, and the patient's willingness to accept the treatment. Medication and psychotherapy proved to be most effective. The highest success rate has been achieved by combining the two procedures. Professor Ulrich Hegerl explains: "A depressed person suffers from both, a physiological malfunction and a change of behavior and perception. However, these are two sides of the same coin. It is therefore mandatory to use medication and psychotherapy simultaneously."

Modern medication can help

Antidepressant medication is used for medium and serious depressions. They influence the metabolism of the brain. They facilitate the movement of messenger substances such as serotonin and noradrenalin along neural fibers. A majority of patients experiences the fading of depression symptoms within six weeks after starting a medication therapy. However, the patient has to accept the treatment. He or she should disposeof prejudices against medication as "psycho-pills".

Antidepressant medication does not generate an addiction. However, it takes some time before the effect of a drug is noticeable. The choice and dosage of medication is crucial. The effect can vary between a better or a sad mood and more energy. The most effective medication are so-called selective serotonin reuptake inhibitors like Prozac. Try cyclical anti-depressants or a high dosage of St. John's-wort for light forms of depression.

In most cases, selective serotonin reuptake inhibitors are the treatment of choice for people with diabetes because they do not cause weight gain or a change in blood glucose. Derivatives of St. John's-wort for depression treatment affect the same messenger substances in the brain. However, one needs to keep in mind that St. John's-wort derivatives can only treat light forms of a depression. Their dosage is difficult because the extract contains many chemical substances and it is unknown which one of them causes the anti-depressive effect. Only a few drugs contain a sufficient dosage of substances and there is a danger that they do not achieve the desired effect. Medium and serious depressions should therefore not be treated with derivatives of St. John's-wort.

Psychotherapy

The other important elements in the therapy of depression are consultations with properly trained experts (psychotherapists). Effective treatments for depressions are cognitive behavioral modification, interpersonal therapy and psychodynamic therapy. The goal of these psychotherapeutic interventions is to get a better understanding of the illness and its triggering problems.

A depressive illness also leads to a change of thinking, emotions, and behavior. As a consequence many affected people retreat to more privacy and discontinue their favorite activities. The lack of social contact and external stimuli subsequently increase the depressive mood and people tend to turn in on themselves and brood. Scientists call this the "downward spiral of depression" (see image).

The goal of therapy is to support the patient's escape from his/her own shell and to find ways out of the downward spiral of depression. It is often necessary to question inhibitory patterns of thinking and behavior and in cooperation with patients, to develope strategies of coping with stress and the burdensome experiences in life.

Edith's Conclusion

Edith was lucky because her doctor recognized her depressive illness early. He also initiated the right steps immediately. In retrospect Edith noted: "Medication truly helped me to finally regain more energy and to lift the gray veil that hung over my life. However, the consultations with the psychotherapist recommended by my doctor were also important. I learned that living with diabetes played a major role in developing depression. The incipient side effects of diabetes and subsequent anxieties about the future proved to be a bigger burden than I was prepared to realize. I always thought I can manage diabetes but that was a mistake. During the therapy I realized that I have to change my attitude towards diabetes and fundamentally adjust the limits of acceptable burden. This was most helpful."

Dr. Dipl.-Psych. B. Kulzer
Diabetes-Zentrum Mergentheim

Translation: Dr. Christian Tuschhoff, Dipl.-Psych. S. Woods

Recommended Link: Kompetenznetz Depression