Knowing the cause is one thing, rallying the resources for treatment is quite another. There has always been a mystifying element to mental health, something that challenges not only understanding but also acceptance, and in ways that don’t often accompany other ailments. And while leaps are made in medication and imaging, community treatment still lags. Awareness may be growing, but according to the professionals there remains much to be done. 

Other than the generally understood feelings of sadness, how does depression manifest itself in an individual? Peter Howard, Executive Director, Mental Health Community Center: There is a long continuum of depressive conditions. Being generally sad (dysthymic) or reacting to a loss (adjustment disorder) happen to most people in their lifetime. What most agencies are working with in “depression “ are genetic/biological conditions that leave individuals unable to function in day-to-day life. Most individuals are adversely affected in their personal relationships and unable to maintain work. Some folks are unable to get out of bed, the house and even care for themselves. It is much more than a general sadness, more of a feeling that life is not worth living. These conditions can fluctuate during a given month, season and year. Stuart Burstein M.D., Center for Revitalizing Psychiatry:Besides a depressed mood, a number of symptoms usually manifest themselves. Those include a sleep disturbance – frequent difficulty falling asleep or staying asleep, and sometimes early morning awakening as well. There’s generally a loss of interest in one’s usual activities that can manifest as a dampened energy for routine activities either in the field of work or home. Christina de Guia M.D., Child and Adult Psychiatry:We define it through the DSM-5, which is our diagnostic and statistical manual for mental diagnosis. The exact criteria is someone who’s had a low mood for at least over two weeks, who’s feeling that their energy is low, that they’re having a hard time concentrating from their base line. Sometimes they feel that life is not worth living, they feel hopeless, helpless and worthless. Appetite is sometimes non-existent, or sometimes they’ll eat too much. And they’ll have a hard time falling asleep or staying asleep. They’ll find that they’re not enjoying things in life as much as they used to. When I diagnose depression, I always go through those criteria first, and then how those symptoms affect their relationships with others. If it’s positive for most of those things, then I would say someone is diagnosed with a major depressive disorder. 

Is depression becoming more common? Howard:It does seem to me that depression is becoming a more common ailment. I’m not sure why exactly but our society has many economic, technological and other interactional changes that I am sure contribute to depression. 

Are there warning signs in particular that concerned people should look for? de Guia:If family members or friends have noticed that they’ve been more distant and isolative, and if it’s affected their ability to function at school or at work. 

How can people know if what they’re experiencing is something serious enough to see a professional about? Howard:For me the deciding factors are; is this affecting my personal relationships, is it negatively affecting my work and am I able to positively improve my situation by myself? If not, I would ask for help. Why try to do it alone? 

Do we know the cause of depression? de Guia: Depression is caused by a whole bunch of different things. It can be major losses or major traumas, if prolonged and there’s limited support. You can have a stressor that occurs in your life, and that can trigger symptoms of depression even though you’ve never been depressed before. Sometimes it’s genetically related, in a way, so if you’ve had a family member who’s had depression, then your likelihood is higher. And there are medical disorders that can contribute to having depression, such as diabetes, having a cardiac disorder, having endocrine disorders like hyperthyroidism. 

There are definitely lots of different causes. What have you found is the best approach to treating depression? Burstein: The usual treatment is a combination of medication and psychotherapy. Treatment of depression is a two-pronged approach. There are the physical treatments such as medications, and there is the verbal treatment that involves assisting them to mentally understand their disorder and develop tools for dealing with it. A characteristic of depression is depressive thoughts, or negative thoughts, and in the course of psychotherapy there is a chance to help them acquire a better understanding of themselves and ways to effectively deal with negative thoughts. deGuia: For many people, the first line of treatment is therapy, but it depends on the severity of your depression. If you catch it early enough, then you can manage to see a therapist once a week to try to figure out the source of a problem. As long as you’re not having thoughts about wanting to hurt yourself, then that’s a perfectly good way to start your recovery. For others, if it’s starting to get severe and you’re having those thoughts or actually engaging in self-injury, then considering medications might be in your best interest, in conjunction with therapy. Because meds by itself cannot help you. You need the right supports to put the stressful things into perspective and work out a way to help you get through. 

What type of medicines are effective and how do they act on the patient? Burstein:The most commonly prescribed medications, when it comes to major depression, are agents that affect serotonin alone or serotonin and norepinephrine. Those are two brain chemicals that we all possess. There can be what is called a chemical imbalance, either there may be less of the brain chemical available or it may not be acting so actively at the brain cell receptor site. 

Is there a difference in diagnosing children? de Guia:Definitely. For kids it’s more subtle, because kids don’t always have these classic symptoms of depression. It actually presents more as irritability, anger. It can still present as isolation and moodiness. But in kids, because they’re always developing and changing and the hormones raging as a teenager, it can be hard to decipher what is regular moodiness in teenagers and young kids versus is this a chronic depression. You always want to ask if the grades are changing and if it’s sudden, if it’s associated with mood changes or isolation from friends, not interested in sports anymore. When you see those changes along with mood issues, and it’s been going on for a month or two, you need to start looking into it.  

Are there concerns when prescribing medication to children as opposed to adults? de Guia:I always use the medicines that are FDA-approved to be used in kids. But many of these medicines have that black-box warning of increased risk of thoughts of wanting to harm yourself within the first couple weeks of taking the medication. Now, the recommendation is to tell the family and kids about the risk, and to follow up with them sooner. Because, definitely for some kids, it can trigger worsened irritability. 

Is depression something that can be cured, or is it something that people, once diagnosed, will be dealing with their entire lives? Burstein: There is acute depression and chronic depression. Chronic depression being where there have been more than one acute episode and it may be necessary for an individual to stay on medication for an indefinite period of time and continue in psychotherapy beyond a year. With the use of medication and psychotherapy, acute episodes frequently resolve in a period of six months to a year. 

How do you differentiate between acute and chronic? Burstein: It’s defined as acute if it’s the first episode. If there are subsequent episodes, the physician will look to the potential causes and ultimately make a determination as to whether this is part of a chronic pattern or simply a second acute episode for perhaps different reasons. So just because medication is working doesn’t mean a patient will have to be on the medication in perpetuity. de Guia:It depends. If there’s a family history and you’ve been depressed before and you’re undergoing a lot of stress and you have thoughts of wanting to hurt yourself, then maybe you would need to be on medicine for several years before weaning off it with therapy. If someone presents for a first-time treatment for depression and it’s managed with meds, they have to be stable for 9-12 months before you can talk about weaning off the medicine. You never want to stop cold turkey. However, if you have had two major episodes of depression, they recommend you should be on medication for three years to probably the rest of your life, because you’re at a higher risk. 

Is social stigma still a significant hurdle for those dealing with depression? Howard: Yes, stigma is a huge problem in further isolating this population. The idea that depression is their fault or something they can control is commonplace. We provide a place for people to come to and engage other people. We try to get them out of isolation and back into the community, because isolation can certainly make depression worse. de Guia:The problem is that people still don’t understand it, and they blame themselves for having depression, even though it’s not always their fault. If you’ve had chronic stressors or been abused or had a traumatic childhood, you’re just more at risk of developing depression, anxiety, post-traumatic stress disorder, and that’s not something you had control over. There’s still a shame there because people don’t understand. People blame themselves instead of getting help. Like other psychiatric disorders, it’s being talked about more, but there are still people who feel like it’s a shameful thing. I wish people would start looking at depression like a medical disorder. No one makes you feel bad for having diabetes. Burstein:It’s there, in terms of the family’s acceptance or understanding for the illness. It can also be present in terms of the employer’s concern with an individual who may identify themselves as having a depressive illness. It’s not necessarily workplace discrimination, but there can be a hypersensitivity about the worker’s performance. Howard: General education is probably the answer. If people understood more about depression, that this is a disease like diabetes, then they would be more accepting. 

How integral is external support to the treatment process? de Guia:If your access to support is limited and you feel like you’re struggling through your problems by yourself, and you feel like you have no one else you can talk to, that no one else understands and you feel like a burden on others, then that worsens your sense of isolation and that will worsen your depression. 

What research or treatments are being developed that make you excited for the future of your field? Howard: Big Pharma is always looking to new research on depression; studies are being conducted all the time in many countries. Burstein:There are continuing developments with regards to medications for the treatment of depression. Many of those developments reflect efforts to either curb side effects and/or increase the efficacy with respect to addressing certain brain chemicals like serotonin and norepinephrine, which are credited with a major role in the development and depression as well as recovery from depression. There are a number of other developing research activities which hold promise of getting us better focused on both the causes and treatment of depression, of revealing activity in the deeper brain centers that contribute to depression as a whole. There are newer treatments such as transcranial magnetic stimulation, which will promise further advancing our understanding and means for treating. 

If you had a blank check, what resources or services would you like to see brought to the area to help treat depression?  Howard:  There are many private and public services that can treat depression. Jewish Family and Children’s Services, Sarasota Memorial Hospital, Coastal Behavioral and Mental Health Community Center are a few public providers. But most public services have waiting lists and limits on what they can do. My blank check would provide individual evaluation and counseling/medication services to all people who request it. It simply would be more services than we currently have available for people without the ability to pay. de Guia:We have a fair amount of resources, but trying to get families to those resources is hard. If we had more case managers in the area who could go to families’ homes and identify families in need and get them access to resources, even in terms of transportation. Just having more therapists to go to the schools and meet the kids to provide them with that therapy could be really helpful. There’s a lot of bullying going on in our schools right now. It’s so prevalent and a lot of our kids our being overwhelmed. Burstein: There’s a great deal of depression among the homeless. One of every community’s problems nationwide is providing effective comprehensive treatment for homeless people with depression. In that regard, we have effective resources for dealing with the acute problem – there’s hospitalization, there’s medication and there’s outpatient follow-up – but like communities elsewhere and everywhere, we don’t have a sufficiently strong coalition of supportive residential and treatment services to keep people out of trouble as much as possible once they’ve recovered from the acute episode. This is not a Sarasota problem, this is a nationwide problem and we happen to be part of it. An area where we could provide more to the population as a whole would be in alerting them to the problems with depression in their midst, and helping family members of the affected individual to recognize depressive symptoms earier, so that treatment is obtained earlier in the course of the illness. That means doing everything we can to promote an enlightened viewpoint towards mental illness in general and depression in particular.