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Her rocky three-year marriage was coming to an end, but Mary Bear never let on to her coworkers how lifeless and empty she felt. "All my energy went toward putting on a happy face and being functional at the office," recalls Bear, who was 27 at the time and worked as an accountant in Atlanta to support herself and her one-year-old daughter. "But on the inside I was twisting down a dark silo." At home she barely had the strength to pop a frozen pizza or macaroni and cheese into the microwave. Shortly after dinner, she would put her toddler to bed and then crawl under the covers herself. "Sleep was my only escape," Bear recalls.
She had been seeing a therapist, which brought brief pockets of relief, but gradually Bear's depression worsened. By the time her daughter was three, lethargy had almost completely taken over. Bear would spend entire weekends prone on the couch. "Sarah would play dress-up or bring her Lego toys to the side of the sofa, so she could be close to me," Bear recalls. "She'd say, 'Look at this, Mommy,' and I'd open my eyes for a second, reply, 'That's nice, Honey,' and then close them again. I felt numb, not physically present. Alone in my room, I would cry because I knew I was missing my little girl's childhood."
But perhaps the saddest aspect of Mary Bear's story is that variations of it are played out in millions of homes every day. An estimated 19 million Americans are diagnosed with clinical depression every year. And a full 12 million of them are women, according to the National Institute of Mental Health. About one in eight women can expect to develop depression during her lifetime; this occurs most frequently between ages 25 and 44.
Of course, it's normal to feel down when you're going through a rough patch, such as a divorce, a job loss or the death of a loved one. But clinical depression is a different beast from situational depressions, which usually ease and lift with time. True depression is generally characterized as a persistent, profound, and inescapable sense of sadness, hopelessness, apathy, and fatigue. Sufferers often say they lose interest in all or most of the activities that once gave them pleasure. "Some who are affected more mildly are able to perform typical activities but with substantial effort," says Nada Stotland, M.D., professor of psychiatry and obstetrics/gynecology at Rush Medical College, in Chicago, and vice president of the American Psychiatric Association. For others, depression can be much more severe, rendering them unable to work or care for themselves or their families. And symptoms can be chronic or transient, with depressed episodes interspersed with periods of normalcy.
Perhaps because symptoms of clinical depression exist on such a sweeping continuum, fewer than half of those who experience the disorder will ever seek care and many who do are misdiagnosed. But letting a deep sadness go unchecked or under treated can do more than derail work and relationships: Recent findings suggest that depression may cause crucial brain structures to shrink and may increase the risk of heart disease, Alzheimer's, and cancer. That's why it's critical to understand and recognize depression's signals, so you -- or someone you love -- can get the right help.
Nearly twice as many women as men experience depression, and scientists have only recently begun to understand the complex factors that contribute to this gender gap.
Family history: Research suggests that genetics accounts for one-third to one-half of the risk of developing depression. "If a parent or sibling has depression, you're two to four times more likely to develop it," says Charles Nemeroff, M.D., chairman of psychiatry and behavioral sciences at the Emory University School of Medicine, in Atlanta. Women may be more vulnerable because of sex-specific genes linked to depression. A recent study of 81 families with severe recurring depression identified four chromosome regions (areas where genes reside) that are associated more strongly with depression in women than men. More than 80 percent of the women in the study who inherited a particular form of a gene called CREB1 developed depression. "More and more we're finding that gender matters," says study author George S. Zubenko, M.D., professor of psychiatry at the University of Pittsburgh School of Medicine.
Body chemistry: Depression is related to a shortage of the neuro-transmitter serotonin, which acts as a messenger between brain cells and helps regulate mood. "Men may be somewhat protected because they produce about 52 percent more serotonin in their brains than women do," says Marianne Legato, M.D., founder and director of the Partnership for Gender-Specific Medicine at Columbia University, in New York City.
Women not only make less serotonin, they also experience fluctuations of estrogen and progesterone throughout their reproductive lives, which can then cause fluctuations in their stores of the neurotransmitter. Estrogen can work to block the action of a brain enzyme known as monoamine oxidase, which reduces serotonin production. Falloffs in estrogen, which can happen before a menstrual period, after childbirth, or during midlife as women approach menopause, may lead to a temporary serotonin deficit. While not every woman is affected by this ebb and flow, "it seems that some women's brains are much more sensitive to fluctuations," says Louann Brizendine, M.D., director of the Women's Mood and Hormone Clinic and professor of psychiatry at the University of California, San Francisco. And this hormonal flux may switch on an inherited vulnerability to depression in certain individuals.
"The menopausal transition appears to be a period of increased risk for some women, whether they've experienced a prior depression or not," says Peter Schmidt, M.D., a clinical researcher in the behavioral endocrinology branch at the National Institute of Mental Health. That's likely due to this life stage's sometimes-dramatic hormonal dips and surges. In fact, a four-year study of 436 women between the ages of 35 and 47 found that those in perimenopause whose cycles were longer or shorter than usual by seven days or more were 55 percent more likely to report feeling depressed compared with premenopausal women whose cycle fell in the typical 22- to 35-day range.
Social factors: Work and family roles, relationships, and stress are also typical triggers of depression, more so in women than men. "Women tend to base their self-image on the success of their relationships in a way that is less true for men," says Ellen Haller, M.D., director of the adult psychiatry clinic at the University of California, San Francisco. "So their happiness often depends on the happiness of others."
Women are also more inclined to have a ruminative thinking style that increases their risk for depression. In a study of 1,300 randomly selected men and women, Susan Nolen-Hoeksema, Ph.D., professor of psychology at Yale University, in New Haven, Connecticut, found that women were more apt to replay stressful events and conversations in their heads endlessly, fixating on possible negative consequences. Such over-thinkers were prone to more prolonged and severe bouts of depression.
Even though more than 80 percent of people with depression are successfully treated with psycho-therapy, medication, or a combination of both, taking action often requires more physical or mental stamina than someone who is depressed can muster. Friends or family members may be needed to take the reins, too. Ask for recommendations of mental health providers or practices that specialize in women's health. Psychologists, licensed social workers, and doctors of education experienced in treating depression can make a diagnosis and provide counseling, but they can't prescribe medication. Most, however, will work with a psychiatrist who can prescribe and, in many cases, also provide therapy.
Cognitive behavioral therapy (CBT) and inter-personal therapy are the two most effective types of talk therapy for depression. Sessions of CBT once a week for 16 to 20 weeks can help women who tend to ruminate to examine more precisely -- and change -- the distorted views that perpetuate their depressions. And cognitive therapy appears to be as effective as medication in the treatment of even severe depression, each yielding a 58 percent response rate in patients after 16 weeks, according to a recent pair of studies published in the Archives of General Psychiatry.
Interpersonal therapy, on the other hand, focuses on what's going on in your relationships that may be contributing to depression, such as grief, marriage problems, difficulty adjusting to motherhood, or other stresses such as a job change or a move to a new town. The treatment course is similar to CBT.
For many people, neither therapy nor antidepressants alone provide sufficient relief (some 30 percent of patients do not respond to their current medications). In fact, depressed individuals appear to improve the most on a combination of therapy and antidepressants, according to a 2004 review of clinical trials involving more than 1,800 patients published in the Archives of General Psychiatry.
But some women such as Mary Bear hesitate before taking medication, believing they should be able to simply pull themselves up by their own bootstraps. "Needing medication was like admitting that I hadn't worked hard enough in therapy," says Bear, who started antidepressants at the suggestion of her internist. "But once I was on it, the medication brought clarity and allowed me to act on the insights I'd gained in therapy and make changes in my life." Others worry about side effects, especially in light of recent reports linking antidepressants to suicide and violent behavior in some children and teens. The FDA is investigating whether these risks apply to adults -- and answers can't come soon enough, given that 75 percent of antidepressant prescriptions are written for women. The FDA has been cracking down, having recently issued warning letters to companies whose ads are felt to mislead or omit important risks and side effects. But it is well established that antidepressants are not addictive and that they won't fundamentally change your personality, meaning you will neither feel like a zombie nor be loaded up on "joy juice." You'll even be able to feel appropriate sadness, but the feeling of dragging around a ball and chain will likely be gone.
Choosing the right type and dose of antidepressants is very much a process of trial and error for doctors and patients. Women tend to respond best to a class of drugs known as selective serotonin reuptake inhibitors, which increase the brain's serotonin. The downside is that some of the side effects can be more problematic for women than for men. "Women can get headaches and nausea, and have more difficulty maintaining concentration, focus, energy, and sexual desire and orgasm," says Dr. Brizendine. Other classes of antidepressants include monoamine oxidase inhibitors, dual-action drugs and tricyclics, which affect both serotonin and norepinephrine (another neurotransmitter). Some women need a combination of antidepressants, while others respond to an antidepressant plus a stimulant to counteract fatigue. Still other women do best when their menstrual cycles are stabilized with continuous oral contraceptives or hormones.
It can take from six to eight weeks for an antidepressant to work, so patience is key. It's crucial to stay on the medication for four to nine months after symptoms disappear to lessen the chances of a relapse. Once a person has had an episode of depression, she is 50 percent more likely to have another, explains Dr. Stotland. A second incidence gives her a 65 to 70 percent chance of having a third. If you feel as though your depression is returning, talk to your doctor about increasing your dose or adding booster therapy sessions every month or two.
While successful treatment doesn't make you immune from ever feeling sad again, it does keep you from getting stuck in a gloomy mood. Today Mary Bear, 43, is remarried, and she has a successful career as a headhunter and a good relationship with her now-17-year-old daughter. "The biggest thing I've learned is to trust my feelings and my intellect," says Bear. "I don't get as down as I used to, and if I have a bad day, I remind myself that everyone has them once in a while. If the mood goes on for more than 10 days, I now know help is within reach."
If you or a loved one has consistently experienced several of the following problems for more than two weeks and the symptoms represent a marked change from usual behavior, talk to a doctor:
Exercise: Although the exact mechanisms aren't clear, exercise appears to increase serotonin, boost feel-good endorphins, and reduce overall levels of stress hormones. A recently published study of 80 men and women between the ages of 20 and 45 with mild to moderate depression found that those who did 30 minutes of aerobic exercise three to five times a week reduced their symptoms by 47 percent within three months.
St. John's wort: Like all dietary supplements, this herbal doesn't need FDA approval to be marketed. For years it has been clinically shown to alleviate mild depression. But to avoid possible drug interactions, be sure to check with your doctor before taking St. John's wort or any other supplement.
DHEA: This hormonal supplement, a chemical cousin of testosterone and estrogen, significantly improved mood and libido in more than 50 percent of participants in a recent trial of men and women ages 45 to 65 suffering from mild to moderate depression. Lead researcher Peter Schmidt, M.D., of the National Institute of Mental Health, found that 50 to 150 mg three times a day was effective. However, women at risk for or who have had cancers that grow in response to hormones, such as breast cancer, should not take it.
Transcranial magnetic stimulation: This technique is yielding promising results in clinical trials. A doctor fits a device containing a powerful magnet, similar in strength to those used in MRI scanners, on a person's head, aiming it at a specific spot on the brain. An electric current stimulates the neural circuits linking the cortex, the structure that enables us to think critically and solve problems, with the limbic system, where we process emotions. This action theoretically restores normal functioning in the brain circuits involved in depression. In studies, patients' depressions lifted after they underwent a one-hour, relatively painless treatment five days a week for up to six weeks. Occasional follow-ups were needed.
Originally published in Ladies' Home Journal magazine, August 2005.