~ Am I depressed? (Depression often is masked as unexplained symptoms such as chronic pain, constipation, headache, mood swings, or backache.)
~ What is my depression related to?
~ Would medication help me?
The discussion below may help you to answer them.
The Anatomy of Depression
Depression exists on a spectrum from the blues, which go away on their own, to the normal grief following a loss, to a more persistent and dangerous disorder. In major depression, as defined by psychiatric handbooks, a person not only suffers from depressed mood, but also has changes in appearance, behavior, speech, perception, and thoughts. When you are depressed, your insight and judgment can be affected, as can your ability to work, take care of yourself, and function in society. Depressed people may appear sad or have an expressionless face. Poor posture and grooming are sometimes evident. If you are depressed, you may derive very little enjoyment from normal daily activities, and you may begin to complain about numerous physical aches and pains that never bothered you before. (Statistics gathered at centers for chronic pain show that up to 90 percent of those with chronic pain have emotional stress factors such as depression that contribute significantly to their pain syndromes.)12 Depression is often accompanied by sleep disturbances: you may be unable to get out of bed, or you may suffer from insomnia or early-morning awakening. Appetite disturbances—either overeating or loss of appetite—can result in significant weight gain or loss. Your thoughts can be affected by depression, and you may have difficulty concentrating and remembering things. (Many midlife women blame their memory loss on aging when it’s really caused by depression.)13 Your mind can go around and around in circles, and you may dwell on thoughts of guilt, self-blame, hopelessness, helplessness, and worthlessness. As depression deepens, thoughts of death and suicide can occur.
If you recognize yourself in this description, I urge you to consult a physician or licensed mental health practitioner without delay. You and your practitioner will be able to evaluate whether or not you are suffering from a major depressive disorder and whether or not you need medication and professional assistance to work through the backlog of unfinished emotional business that may be contributing to it. Now is the time to address your unmet needs. Treatment can be lifesaving—especially if you also suffer from anxiety, which many women with depression do. In a 2009 study of more than 5,000 healthy Dutch midlife women, those with anxiety were shown to have a 77 percent increased risk of premature death.14 Depression is also an independent risk factor for both heart disease and osteoporosis, probably because depression is associated with increased levels of stress hormones, which have very potent physical effects. (See chapter 12, on bone health, and chapter 14, on heart health.)
Depression and Hormone Therapy
All sex hormones, including progesterone, estrogens, and androgens, can affect mood, memory, and cognition in complex and interrelated ways. Receptor sites for these hormones are found throughout the brain and nervous system, and nerve tissue itself has been found to produce them. Estrogen, the hormone that predominates during the first half of the menstrual cycle, has been shown, for example, to increase mood-enhancing beta-endorphins in menopausal women as well as in cycling women.15 It has also been shown to boost levels of serotonin and acetylcholine, neurohormones that are associated with positive mood and normal memory.16 Though androgens such as testosterone have not been as well studied as estrogen, they, too, appear to be associated with improvements in mood and vitality in some cases.17 Given this, it’s not surprising that many women report they feel better when they take some kind of hormone therapy. One of my colleagues tells me that she needs just a small amount of estrogen (less than 1 mg of estradiol twice per week) to keep her from getting the blues. As a physician, she swears by this. When the dosage of estrogen or androgen is too high, however, women often report adverse CNS effects such as headache and increased anxiety. Synthetic progesterone is frequently associated with depression in women. Bioidentical progesterone only rarely has this effect. The general consensus at this time, given the WHI study results, is that there’s not enough data to recommend HT as a primary treatment for depression. But I feel it is definitely worth considering in many women.
IRIS: A Cloud Descends at Midlife
Iris first came to see me when she was fifty-one. She had not had a period in six months. Iris was a very slim, attractive, healthy woman who exercised regularly, took nutritional supplements, and had a fulfilling career. She told me that starting about a year previously, a cloud had come over her mood, and she couldn’t shake it. She couldn’t pinpoint any particular life crises or other changes that might have precipitated her dark mood. Since her estrogen and progesterone levels were low, we decided to give estrogen replacement with natural progesterone a try.
When Iris came back two months later, she looked like a different person. She told me, “Within a few days of taking the estrogen and progesterone I felt like the lights went back on in my head.”
Iris continued to feel better for the next two years. But then her depression returned despite the hormone therapy. Iris told me that she had begun to have flashbacks and memories of sexual abuse from early childhood. In retrospect, she realized that these memories had begun to surface during perimenopause. Though she had tried to ignore them and get on with her life, she felt that they had finally culminated in depression, which she was initially able to quell with estrogen and progesterone. When even that stopped working, she realized that “the only way out was through.” She had to be willing to allow her body to feel and her brain to know what had happened to her as a child so that she could finally release the pain she’d been holding on to for a lifetime.
Iris consulted a skilled art therapist, who helped her work actively with her dreams and the creative process. She also signed up for a series of weekly full-body massages, which helped her release muscle tension. She later told me, “I was so surprised when the tears came the first time the massage therapist touched me. But I felt safe and secure, and she intuitively knew enough to simply let me do what my body needed to do. I just lay there and let myself feel everything. I let myself sob.”
Within six months, Iris’s depression lifted completely and has not returned. She continues with her hormone therapy because it feels right for her. Many times, depression lifts only when a woman gets in touch with her anger, anger that may have been suppressed by “niceness” for years. Anger is always preferable to depression because it mobilizes us and leads to change. It’s a stage, not a destination. But I can assure you, it’s a very powerful stage that can be liberating and life-giving!
Antidepressants Do Not Cure Depression
Antidepressant drugs have long been the first treatment offered for women suffering from depression. One popular category of antidepressants, SSRIs, work in part by increasing the availability of the neurotransmitter serotonin in your brain. Popular examples of these drugs include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and sertraline (Zoloft). Another commonly prescribed group of drugs are the tricyclic antidepressants (TCAs), which include imipramine (Tofranil) and amitriptyline (Elavil).
While many have found these drugs helpful, there is strong reason for caution. First of all, data published in 2009 from the more than 136,000 women in the WHI study indicate that both SSRIs and TCAs have been linked with an increased risk of death, and SSRIs have also been linked to an increased risk of stroke in postmenopausal women.18 Although this risk is indeed small, it may not be a chance you want to take, considering that recent research shows that the benefits of these drugs have been greatly overstated. In a 2008 article published in the New England Journal of Medicine, former FDA psychiatrist Erick H. Turner, M.D., reported that 94 percent of studies showing SSRIs have therapeutic benefits were published, compared to only 14 percent of the studies that showed either no benefits or inconclusive benefits.19 Considering all the medical literature, Dr. Turner determine
d that SSRIs helped those with severe depression more than those with mild to moderate depression—but the bottom line was that in most patients with depression, they were no more effective than a placebo.
A newer study, published in January 2010 in the Journal of the American Medical Association, not only confirmed Dr. Turner’s findings about SSRIs, but also found that patients with mild to moderate depression received the same amount of relief from TCAs as they did from a placebo.20
You should also know that the side effects of these medications can be quite troublesome. Prozac and other SSRIs can cause nausea, loss of appetite, headache, nervousness, insomnia, restless leg syndrome, and difficulties with libido and sexual dysfunction. The tricyclic antidepressants can cause blurred vision, dizziness, dry mouth, heart rate disturbances, constipation, and difficulties with memory. Those who take these medications often have to try a different drug or dosage level in order to find the one that works best for them.
There are apt to be additional side effects from the long-term use of these drugs. This is certainly true of any drug that alters brain chemistry, and many of the popular psychotropic drugs on the market today are too new for anybody to say with authority that they are safe in the long run. Candace Pert, Ph.D., the scientist who discovered the receptor sites for many important chemicals in the brain associated with mood, commented:
I am alarmed at the monster that Johns Hopkins neuroscientist Solomon Snyder and I created when we discovered the simple binding assay for drug receptors twenty-five years ago. Prozac and other antidepressant serotonin-receptor-active compounds may also cause cardiovascular problems in some susceptible people after long-term use, which has become common practice despite the lack of safety studies.
The public is being misinformed about the precision of the SSRIs [Prozac, Zoloft, Paxil, etc.] when the medical profession oversimplifies their action in the brain and ignores the body as if it exists merely to carry the head around.21
I couldn’t agree more, especially in light of a PMS drug that has been heavily marketed to women. This drug, Sarafem, is simply Prozac (fluoxetine) under a new name and with a new indication—an indication guaranteed to support women’s continued mistrust of their body’s wisdom.
If your depression is severe enough to warrant trying prescription medications, I recommend you start with a six-month trial to be sure you are giving the drugs a chance to work. Half of those who stop their medication within three months of starting get depressed again. (I also suggest supporting your treatment with the Program for Boosting Mood, on page 383.) Optimally, the medicine will result in a gradual lifting of your depression. This will give you the energy to mobilize your own resources to make positive changes in your life. Think of these drugs as a bridge to help you cross a particularly rough stream in your life, but don’t plan to live on that bridge for good. The true cure for depression lies in learning the skills associated with full emotional expression and then taking positive action.
Many experts believe that depression is a recurrent disease. Of the patients who experience a major depression, 50 to 85 percent have additional episodes after they are successfully treated. Studies have shown that about 80 percent of people on antidepressants have a recurrence within three years after stopping medication.22 Though these statistics seem grim, they would be much less so if all of us were willing to take a good look at what depression really is.
All too often antidepressants are given in a vacuum, as though depression were just a “Prozac deficiency.” But depression is not a simple chemical disorder that lands on you when you least expect it. And depression is not a natural human condition. Studies have shown that depression is virtually nonexistent among many indigenous peoples. Depression is a consequence of how we live our lives. To get over it, we must be willing to make some changes that will support healthy brain biochemistry. Otherwise, depression is likely to recur. Antidepressant medication and getting help are associated with a very significant placebo effect. When you feel you are getting help, your body naturally gets better. I have never prescribed antidepressants of any kind unless my patient was also willing to enter some kind of therapeutic relationship with a counselor to help her sort out the aspects of her life that needed improvement. In other words, we, as a society and as individuals, need to understand that getting on the right medication does not guarantee a cure for depression.
Like all symptoms, depression is one way your body’s inner wisdom tells you that something in your life is out of balance. Often its message is that a part of you has ceased to grow or has stagnated, or that you have lost the passion for living that is a natural part of being alive. It may also be a hint that you are angry with someone but do not feel free to express that anger directly. Depression may result from unresolved grief over the loss of a loved one through separation or death.
The best cure for depression that I know is to be completely honest with yourself about everything you are feeling—even, and especially, those feelings you’ve been told you shouldn’t have, such as jealousy, anger, guilt, sorrow, and rage. All of these feelings are part of being human. They will never hurt you if you simply acknowledge them, express them safely, accept yourself for having them—and realize that you’re having them for a reason. All so-called negative emotions occur when you don’t feel that you’re getting your needs met, whether those needs are for closeness, intimacy, validation, recognition, or something else entirely. (For a listing of needs and emotions, I recommend the website of Marshall Rosenberg, founder of the Center for Nonviolent Communication—www.cnvc.org.) Once you can identify your unmet needs, you’ll be in a better position to take action to meet them. I’ve never seen depression lift without the sufferer taking some kind of positive action to help herself. This could be as simple as volunteering at an animal shelter.
In my experience, staying in dead-end jobs and/or relationships is a major factor associated with unremitting, chronic depression in women. If you feel depressed and “dead,” and this has been going on for six months or more, it is probable that either you have unresolved grief about an important loss in your life or you have anger, resentment, or resignation about continuing to participate in a relationships or job that does not replenish you at the deepest levels. Many women at midlife finally have enough ego strength, life skills, and support systems in place to safely feel and release the unacknowledged pain of their pasts. For those who are willing to do this kind of work, depression and other symptoms may be alleviated rather quickly. There is no medication, supplement, exercise, or herb that will cure this problem. However, they can be a valuable support as you work on the problems that are preventing you from moving forward in your life.
I’d suggest that you consider an antidepressant medication if any of the following describe you.
~ You’ve had three or more episodes of depression.
~ You have suffered from low-level depression your whole life and have also had a major depressive episode (called double depression).
~ You have leftover symptoms after going off an earlier course of antidepressants.
~ You are having your first depression at midlife or later.
Program for Boosting Mood
The following lifestyle suggestions are excellent whether you want to support a regimen of prescription drugs for depression or whether you’re trying to avoid psychotropic drugs and have opted instead to try the supplements presented on page 385.
~ STOP DRINKING. Alcohol consumption can make depression particularly persistent. This is partly because alcohol is itself a depressant, and partly because women too often use alcohol as a way to suppress their feelings.
~ ENGAGE IN REGULAR EXERCISE. Exercise changes brain chemistry by increasing beta-endorphins, lowering catecholamines, and increasing monoamines, and both aerobic and nonaerobic forms have been shown to be helpful in individuals with mild to moderate depression. (In some studies, 50 percent of people with depression were cured with exercise alone.)23 Exercising twenty to thirty m
inutes per day four to five times per week can have a significant positive effect on your mood. It doesn’t matter what you do—even dancing around the house to the radio will help—though the longer the exercise and the higher the intensity, the better the effects, according to a 2008 Scottish study.24
John Ratey, M.D., associate clinical professor of psychiatry at Harvard Medical School, believes that exercise is the single best thing we can possibly do for our brains and that it’s at least as good for depression as prescription medication, if not better. Ratey, the author of Spark: The Revolutionary New Science of Exercise and the Brain (Little, Brown, 2008), explains that exercise helps the brain stay young, vibrant, and resilient because it can boost the formation of new brain cells, increase memory and the capacity for learning new things, and improve motor function and auditory attention, among other benefits. (See www.johnratey.com.)
~ GET OUTSIDE IN THE NATURAL LIGHT AS MUCH AS YOU CAN. This helps combat seasonal affective disorder (SAD) and raises your brain levels of serotonin naturally. In the winter, you may need a light box or full-spectrum lightbulbs to get enough light. (See Resources.)
~ TAKE A GOOD MULTIVITAMIN THAT SUPPORTS YOUR BODY AND BRAIN, AND MAKE AN EFFORT TO EAT WELL. If you are to function optimally, it is important that your brain gets balanced levels of serotonin, essential fatty acids (particularly omega-3 fats), and glucose. Avoid refined carbohydrates, eat protein at least three times a day, and be sure to include a source of omega-3 fat in your diet regularly. Eating balanced amounts of complex carbohydrates (with protein) provides the body with appropriate amounts of tryptophan, a building block of serotonin. (See chapter 7.)
The Wisdom of Menopause Page 46
