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Depression in bypass patients: non-drug treatments work

It is a known fact -surgery may mend the body but it may also depress the mind. This is especially true with heart surgery. It is estimated that 1 in every 5 patients who underwent coronary artery bypass graft (CABG) surgery suffer from major depression. Many others may suffer from milder forms of depression. However, it is also a known fact that negative feelings are bad for the heart, thus creating a vicious cycle that delays recovery and reduces quality of life.

According to researchers at the Washington University School of Medicine

“Depression around the time of surgery predicts postoperative complications, longer physical and emotional recovery, worse quality of life and increased rates of cardiac events and mortality [death].”

Thus, the researchers conducted a study which involved 123 CABG patients who developed depressive symptoms within one year of surgery. The patients were randomly assigned to three groups, namely:

• 40 patients were assigned to standard care
• 41 patients received 12 weeks of cognitive behavior therapy which consisted of 50- to 60-minute sessions with a psychologist or social worker involved identifying problems and developing cognitive techniques for overcoming them, including challenging distressing automatic thoughts and changing dysfunctional attitudes.
• 42 patients underwent 12 weeks of supportive stress management, wherein the received counselling from social worker or psychologist coping with stressful life events.

The depressive symptoms were monitored before the therapies, at 3, 6, and 9 months.

The study results show that the two non-drug treatments helped in resolving the depressive symptoms better compared to standard care.

The percentage of patients who experienced depression remission are:

• 71% of patients in the cognitive behavior therapy group
• 57% of patients in the supportive stress management group
• 33% of patients in the usual care group

Cognitive behavior therapy seems to be the best strategy, not only against cardiac surgery-related depression but also secondary psychological outcomes, such as anxiety, hopelessness, and perceived stress. Supportive stress management also showed some benefits against depression, “but it had smaller and less durable effects than cognitive behavior therapy.” In comparison, current standard care is not seem to be that effective in resolving depressive symptoms among CABG patients. A previous study has shown that although the medical needs of heart patients are usually met by standard care, there are non-medical needs that usually go unmet but are nevertheless just as important in clinical outcomes.

In fact, the American Heart Association (AHA) issued a science advisory this year recommending routine screening for depression in cardiac patients.

               

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Is prolonged grief a mental disorder?

Resource post for June

It can happen to anybody - losing a loved one - a child, a partner/spouse, a sibling, a parent. We grieve because grief is an extension of our capacity to love as human beings. But after some time we have to move on and carry on with our lives. The intensity of grief lessens, the pain starts to heal. But what if it doesn’t?

There are cases when grief just wouldn’t go away and remains unresolved for months, and even years. This what experts call Prolonged Grief Disorder (PGD) or Complicated Grief.

Symptoms

It seems that PGD is a form of depression associated with bereavement. The feelings of grief of people with PGD extend six months or longer after the bereavement (”separation distress”) and can manifest in cognitive, emotional and behavioural Symptoms.

According to the Grief-Healing Support Group, PGD is characterized by the following symptoms:

• Feelings: Anger, sadness, guilt, despair, overwhelm, denial, betrayal, emptiness etc
• Thoughts: This is not real, This is unfair, I will never get over this, It’s my fault etc
• Responses: Withdrawal from social groups/events, addictive or reckless behaviour, avoidance of places and people or of being alone
• General Health: Fatigue, loss of motivation, sleeping problems, loss of appetite, pain and anxiety symptoms.

Those suffering from PGD become socially withdrawn and suffer not only from poor mental but also physical health outcomes.

Incidence

Studies have shown that 10 to 15% of people who have experienced bereavement suffer from PGD, and become severely depressed or even suicidal. In African Americans, the incidence pf PGD is even higher - up to 21%.

Therapies

It has only been recently that PGD was recognized as a psychiatric disorder in its own right. With it came also possible therapies and treatments that can help the patients. There are those who believe, however, that grief shouldn’t be “medicalized” or “labelled as a disorder.”

The table below gives an overview of the treatment strategies for PGD (source: http://www.grief-healing-support.com):

Treatment Strategies
Learning to be mindful	Buddhist teachings and meditations talk of mindfulness and how we can pay attention to our life in the moment, with intention and without judgement. Echhart Tolle teaches us to have a pain free life by living fully in the present -The Power of Now - a guide to spiritual enlightenment
Managing Stress	Managing the fight-or-flight response. As we have to deal with one of life’s greatest stress events we are aslo encountering other grief related as well as normal life stressful events and situations
Solving Problems	A simple yet structured approach to identifying issues, searching for options and working on possible solutions
Setting Goals	Even at times of great pain there are things we may want or need to achieve in life. It may be to reduce our current levels of pain, or to become financially secure
Managing Emotions and Anger	We may feel that our emotional responses are out of our control. However, there are some strategies we can use to control emotions and make life easier for ourselves and for others
Relaxation Techniques	Some of these ideas may help you to relax. How relaxed are you at the moment? What is your mind doing? Where are your thoughts? What is your body doing?
Dealing with Conflict	There are different levels and degrees of conflict. The grief period is a time of mixed and difficult emotions, consequently we may become more susceptible to conflict situations
Scheduling Enjoyable activities	We have just lost someone very close to us, perhaps our partner or companion. It is important that we now schedule to do something that will bring us joy and fill some of the space
Improving Sleep	A good sleeping pattern is crucial for normal healthy functioning. Are you getting adequate and restful sleep?
Understanding Anxiety	A feeling of dread, fear, or worry. We all experience anxiety at some time or another, but when anxiety becomes too severe it can interfere with everyday functioning

 Remember, it is normal to grieve but when grief becomes prolonged and rules your life, then it’s time to seek professional help.

 

Photo credit: stock.xchng

               

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Fighting depression with exercise

Many children and adolescents suffer from clinical depression. That is why experts have recently come up with guidelines that recommended routine screening for depression in the younger segment of the population. The guidelines also recommended psychotherapy or psychotropic drugs or both in the management of clinical depression in adolescents. But aren’t there other ways - especially non-pharmacological approaches to manage depression?

Researchers at the Medical College of Georgia looked at the effect of exercise on depressive kids. The participants were 207 weight children aged 7 to 11 years old. The participants were tested for depressive symptoms using the Reynolds Child Depression scale as well as the Self-Perception Profile for Children, a test which measures childrens’ perception of themselves before (at baseline) and after the study. The children were randomly assigned to three different physical exercise regime which lasted for 13 weeks

• Group one: a “low-dose” exercise group which was physically active20 minutes each day
• Group two: a “high-dose” exercise group which was physically active for 40 minutes each day
• Group three: a control group which consisted of sedentary children.

Exercises consisted of activities which were fun but maximized for intensity and designed so that the participants’ heart rates exceeded more than 150 beats per minute.

The study results showed that depressive symptoms improved significantly with increasing exercise time even though no noticeable weight increase was observed. It seems that exercise has a positive impact on the children’s self-esteem. However, this positive effect was only observable in white but black participants.

Physical activity has been shown to greatly help in managing depression in adults. In patients who suffered from stroke or cardiac events, exercise helps in improving health outcomes. In patients with primarily clinical depression, exercise leads to release of the hormone endorphin which induces positive feeling. The study results here suggest that physical exercise can positively affect children’s self-worth should therefore be considered as intervention against depressive symptoms.

This is very relevant considering the results of another study last year which showed that American children take more psychotropic medications that their counterpart in Western Europe. Comparing the US with two European countries, the annual prevalence of use of psychotropic medications is:

• US  - 6.7%
• The Netherlands - 2.9%
• Germany - 2.0%

The most common of these psychotropic drugs were antidepressants and stimulants and there was a tendency for multiple drug therapy among US kids. There is some indication that Europeans tend to use alternative ways of managing depression - including exercise.

               

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The depressive brain: it’s in the family

The depressive brain is structurally different compared to a non-depresssive brain. And it seems to run in the family. This is reported by scientists at Columbia University. Those with a family history of depression have brains which are, on average, 28% thinner in the area of the right cortex compared to those with out familial history of depression. This difference seems to be evident long before depressive symptoms, if ever, come up. The cortex is the outermost layer of the brain and this thinning of the cortex is also somewhat similar to those observed in patients with schizophrenia or Alzheimer’s disease.

According to Dr. Peter Bradley, lead researcher:

The greater the anatomical differences seen in patients, on average, the more severe were their symptoms of cognitive impairment. Subjects who showed cortical thinning in the left hemisphere of the brain went on to develop the hallmark symptoms of clinical depression or anxiety.

The most common symptom of depression is sadness. However, it goes far beyond than just feeling down or having the blues. Researchers have long identified that clinical depression comes with a wide range of neurological and cognitive problems including:

• Problems with concentration
• Problems with visual memory
• Failure to pick up on social and emotional stimuli

These symptoms cannot be attributed to emotional and psychological problems alone. The current study published in the Proceedings of the National Academy of Sciences, indicate that there is a physiological and anatomical side to depression.

The study looked at the brains of 131 people using functional magnetic resonance imaging (fMRI) technique. The study participants were aged 6 to 54 years old “who were biological descendants (children or grandchildren) of individuals identified as having either moderate to severe, recurrent, and functionally debilitating depression or as having no lifetime history of depression.” The cortical thinning was observed to correlate well with severity of depression and the symptoms listed above.

The findings suggest that the cognitive problems may not be due to depression but may actually be the cause of the depressive symptoms. The thinning of the right cortical region suggest that an individual is at risk of developing depressive symptoms. If the thinning spreads to the left cortex, the cognitive weakness can lead to full-blown depression.

“…the cortical thinning in the right hemisphere produces disturbances in arousal, attention, and memory for social stimuli, which in turn may increase the risk of developing depressive illness.” The findings may have some major implication in the screening for depression. When signs of right cortical thinning are detected early, certain therapies can be used to help patients compensate for their cognitive problems and thus minimize depressive symptoms.

               

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Experts: routine depression screening for teenagers

It is a problem that many parents face: clinical depression among teenagers.

As many as two million American teenagers suffer from depression and most go undiagnosed, thus untreated according to the United States Preventive Services Task Force. The task force has recently came up with guidelines recommending primary health care practitioners to routinely screen teenage patients for clinical depression. The new recommendations have been published in the April issue of the journal Pediatrics.

The guidelines apply to adolescents aged 12 to 18 years old. However, the task force found there is insufficient evidence to show the benefits of screening younger children for clinical depression

Depression in young people can lead to

• poor health outcomes
• difficulties in school
• disruptions of family and social relationships
• lowerquality of life
• self-destructive behavior/suicide
• depression in adulhood

It is therefore necessary that clinical depression be diagnosed as early as possible.

“Depression in adolescents has a significant impact on both mental and physical health, and adolescents with depression have more hospitalizations for psychiatric and medical issues than adolescents who are not depressed,” said Task Force Chair Ned Calonge, M.D., who is also chief medical officer for the Colorado Department of Public Health and Environment. “It is important that adolescents are diagnosed and treated for clinical depression in order to improve their health and quality of life, especially if they have a family history of depression.”

However, screening for clinical depression should only be done “when appropriate systems are in place to ensure accurate diagnosis, treatment and follow-up care.” Treatment of clinical depression among teenagers can be through by psychotherapy or by pharmacological means using selective serotonin reuptake inhibitors (SSRIs), or combined therapy (SSRIs plus psychotherapy). However, the prescription of anitdepressants SSRIs should be done with care as this class of drugs is associated with an increased risk of suicidality.

The new guidelines go further than the previous guideline issued by the Academy of Pediatrics which recommended pediatricians to ask their young patients questions about depression.

The new recommendarions cited using “two questionnaires that focus on depression tip-offs, like mood, anxiety, appetite and substance abuse.” The screening should be done by the family doctor or pediatrician who is known to the family and the patient.

Almost 6% of Amrican teenagers aged 13 to 18 are clinically depressed. A lot of cases do not show over symptoms and are therefore easily overlooked by parents and teachers. Suicide due to clinical depression is the 3^rd leading cause of death in US adolescents in the age range 15 to 24 years old.

Photo credit: stock.xchng

               

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Depressed? Check your blood pressure!

The link between depression and cardiovascular health is well-known although the mechanism behind the relationship is not well-understood.

A study by Dutch researchers may just give us an idea of the complexity of that link. For one thing, contrary to the common perception that depression can lead to hypertension, depression, is, in fact, associated with low blood pressure. However, medications against depression - the so-called anti-depressants can increase blood pressure. In particular, tricyclic antidepressants (TCAs) can increase the risk for hypertension.

According lead author Carmilla Licht

“Doctors should at least be aware of a potential blood-pressure rise that could be linked to TCA use, especially for patients with cardiovascular disease or high blood pressure or others who are at risk for hypertension…They may consider meticulously monitoring these patients’ blood pressure when they prescribe one of these antidepressants or consider prescribing another antidepressant medication.”

The results of the study are somewhat controversial because they contradict the current “depression-hypertension theory.”

The study was part of the Netherlands Study of Depression and Anxiety, and followed up 2618 participants aged 18 to 65 years old. The study participants were divided into 3 groups:

• Control group without history of anxiety or depression
• Patient group with a major depressive disorder (MDD) but not on antidepressants
• Patients with MDD and on antidepressants

Patients were monitored for systolic blood pressure (SBP) and diastolic blood pressure (DBP) and distinction was made between different types of antidepressants, e.g. selective serotonin-reuptake inhibitors (SSRIs) vs tricyclic antidepressants (TCAs).

The study also observed that a typical patient with psychiatric disorder “were a little older, more likely to be female, less educated, less physically active, smoked more, and had a higher body-mass index and more diseases.”

The study results showed that compared with health controls, MDD patients have significantly lower blood pressure. However, MDD patients on TCA had significant higher blood pressure. The use of SSRIs doesn’t seem to be associated with blood pressure measurements.

So the next question is

Is it the depression that lowers the blood pressure or is it the low blood pressure that causes the depression?

The authors speculate that three things might influence the depression-low blood pressure link.

• Use of anti-hypertensive drugs
• Common causes of depression and low blood pressure, e.g. fluctuations in metabolites, hormones or neurotransmitters
• Low blood pressure can cause depressive symptoms, e.g. fatigue, dizziness, low tolerance to cold temperatures, and concentration problems.

While depression is associated with low blood pressure, the study shows that anxiety is linked to high blood pressure. This, the authors say, might be due to continuous stress associated with anxiety.

Photo credit: stock.xchng

               

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Shaking off the winter blues (SAD!)

The groundhog was right earlier this month - winter in the northern hemisphere is taking longer than usual this year. And the winter blues will take longer to shake off as well. But winter blues is not just a state of mind. It’s for real and in doctor speak it’s called seasonal affective disorder (SAD - what an apt abbreviation!), a psychiatric condition characterized by depressive symptoms during the long, dark, winter months. SAD is said to affect about 2 to 5% of Americans. The incidence is higher as one goes north, where the winters are colder and the daylight hours are less. No wonder the suicide rates are high in winter time in these regions.

Other symptoms include:

• Mood disturbances
• Chronic fatigue and need for more sleep
• Cravings for carbs, leading to increase in weight

Health experts at the University of California at Davis give us some tips on how to survive the winter blues or SAD.

Go outside, go for the light.

A major characteristic of SAD is that it usually goes away with the coming of spring the sun shines more and the days get longer. But in the midst of the winter, we have to find our own source of light, be it normal or artificial.

UC Davis experts recommends a daily walk outside, preferable at midday, to get the most of whatever daily is available. Another way is to adjust our sleeping patterns by going to bed early and waking up early to take advantage of the short daytime. This is one of the reasons why we have daylight savings time.

In Switzerland where I am residing, the gloominess of winter is worsened by the fog and low clouds that are produced by the big lakes in the lowlands even if the sun can be blinding up in the mountains. To help people escape the blues, they are given daily tips as which is the closest hilltop or mountain to go to see the sun. You will even see these tips on the train schedule boards. Great service, eh?

Sun exposure also has the additional benefit of getting Vitamin D!

Use artificial light if you must.

Now, while sunlight may be the best cure for SAD, it may not be available all the time. Think of all those living in the winter darkness up north. Well the UC Davis experts recommend artificial light therapy.

The standard medical treatment for SAD is a TV-sized light box, containing fluorescent bulbs behind a protective filter. These boxes, which cost in the range of $200 to $500 (and are sometimes available to rent), are covered by an increasing number of insurance companies. They emit 2,500 to 10,000 lux (a term used to quantify brightness), which is about equivalent to the outdoor light of dawn or dusk. Illumination in homes and offices is about 500 lux. Treatment for SAD typically involves daily sessions in front of a light box for a period of 15 minutes to 2 hours.

Counselling and medications

Artificial light therapy is said to be work better and faster than drugs. But in cases where light alone doesn’t help, this can be combined with anti-depressants and counselling. Selective serotonin reuptake inhibitors (SSRIs) such as Prozac seem to work best.

Think positive!

This one is from me. Isn’t it great to know that even if we are sad with SAD, the treatment may just be right outside our front door, and relief is just a couple of weeks away? Spring, here I come!

               

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Expert recommendations:heart patients should be screened for depression

Background

Time and time again, studies have shown that many patients become depressed after suffering from major cardiac events. This occurs even after successful surgery and interventions. The reasons for this depression are many and may differ depending on the age of the patients (see previous post).

With this knowledge in mind, the American Heart Association (AHA) issued a new science advisory endorsed by the American Psychiatric Association which recommends that primary health care physicians should routinely screen their cardiac patients for signs of clinical depression. This would include referring suspected cases to mental health specialists for assessment, monitoring, and therapy.

Depression in heart patients

According to Dr Viola Vaccarino

“Despite a long-standing popular belief that stress and emotions affect the cardiovascular system, it was not until the mid-1980s that the first studies linking depression to higher mortality after a myocardial infarction (MI) began to appear in the medical literature. Since then, scientific interest in the link between depression and heart disease has grown steadily over time, with an increasing number of research studies addressing depression as a prognostic factor in cardiac patients. There is now a sufficient consensus that depression is a risk factor for coronary heart disease (CHD), as well as an important prognostic factor in cardiac patients. It is also recognized that depression is a growing global problem. By 2030, depression is projected to be the second leading cause of disability worldwide (after HIV/AIDS) and the number one cause of disability in high-income countries.“

Screening methods

The recommended assessment for depression in cardiac patients is fast and easy. The patients only have to initially answer 2 questions. Longers questionnaires may be needed when further assessment is deemed necessary.

Experts believe that the recommended questionnaires

“are validated tools and an efficient, evidence-based way of finding possible cases and referring them on for further assessment and treatment.”

However, a big problem would be how the patients would accept the recommendations for screening and the diagnosis of depression. People with heart disease would not necessarily be happy (and they are already unhappy) when they hear they have another clinical problem to face.

Treatments

The AHA advisory recommends pharmacological treatment of depression. As first line of treatment, the selective serotonin reuptake inhibitors (SSRIs) sertraline and citalopram are recommended. Furthermore, AHA cautions that some antidepressant drugs may have some cardiotoxic effects that can worsen existing cardiovascular conditions.

For those who cannot tolerate antidepressant medications or prefer nonpharmacological treatments, cognitive behavior therapy is recommended. A combination of both psychotherapy and medications may also work for some patients. The important thing is to find the right therapeutic approach for patients.

               

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Don’t Pretend! It Doesn’t Help!

By M Walker

I think for most of my post-natal depression I felt as if I was permanently constrained by chains and that someone else had control of my life. It was as if even though I desperately wanted to break free, I just didn’t know how to.

The funny thing is too, I love writing and I love to keep a diary on my children when I remember, but in the throws of my depression I just didn’t know how to even pick up a pen, let alone describe what I was going through. How could I tell others what I was experiencing when I didn’t even know myself? How could I tell people that I wasn’t enjoying motherhood? Needless to say my diary during my thickest bout of depression was quite slim and in fact only 2 lines were taken up to discuss months of torment and anguish and the confusion that I felt at that time in my life.

How could I write when I could barely sit still for longer than 2 minutes? I was way too agitated to sit down, to type at a computer, analyse me thoughts and put them to paper in a logical fashion. Infact I was way too agitated to barely do anything. For me, everything at this time was a real struggle.

Infact it was at least 12 months later that I was able to write about my experiences with post-natal depression and start telling more people about my time back then. I was so ashamed that I had failed in my parenting duties, that I just didn’t want anyone to know the truth. So emotionally I guess it took quite some time before I could accept the illness as a part of me, without me having to have been the cause of it. In time I eventually learnt to come to terms with what went on at that time in my life and how to move forward.

I remember telling everyone I was exhausted and that the exhaustion and anxiety only lasted 2-3 weeks, but the reality is that it lasted for 2-3 months, if not longer. There were still times in January when I fretted if I was left alone or around too many people-but I think by the time we got into mid February I was almost back to normal. I know 2-3 months is not very long at all compared to what some women have been through, but for me it was still a very frightening and uncertain time in my life.

I tell everyone now that that was when I had my little breakdown-trying to make light of it-and you know what, I feel like I did. I was at the lowest point that I had been since I had Abbey and I guess from there the only way was up-mind you it took me a long time to figure out which way was up.

In my diary I say Christmas came and went without too much hassle-what a lie that was. I was at a Christmas party over the road and had to leave early as I started freaking out with so many people around-I made a very quick exit and a feeble excuse about a bad headache. Christmas day with my family was okay, but I hated every minute with Paul’s family-there were so many adults and kids there and I felt so claustrophobic that I just needed to run and scream. None of Paul’s family knew so I had to continue on as best as I could-god I hated that day and quite possibly myself for having to pretend.

We then went to Adelaide for a 2 week holiday and I also started freaking out-I desperately wanted to be left alone but just couldn’t stand to be on my own-it was such a weird time. I think for Paul (my husband), he felt like he couldn’t ever do or say the right thing. We also had Paul’s 10 year old son (Taylor) on holiday with us for the first time-so it was even extra trying than it would normally have been. I remember thinking I just want to go home and see Mum. Eventually I was able to settle down a bit and we moved onto a beautiful spot in the country where we had our own house and plenty of room to move. There I felt at peace, at least for a little while anyway.

From M.Walker. For more information on post-natal depression and where you can go to get help, please visit my website at www.mothersinneed.com

Article Source: EzineArticles.com/?expert=M_Walker

               

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