Depression.
A syndrome that typically consists of a constellation of low mood, low energy, low motivation, loss of interest, impaired concentration, negative or unpleasant ruminative thoughts, and disturbed sleep and appetite. One quote captures this difficulty well:
“Depression is being colorblind and constantly told how colorful the world is.”
Signs and Symptoms of Depression.
The syndrome of depression can be captured by the acronym SIGECAPS:
S: Sleep disturbances
I: Interest decreased, referred to as anhedonia
G: Guilt and/or perceptions of worthlessness
E: Energy decreased
C: Concentration (or focus) problems
A: Appetite and weight changes
P: Psychomotor agitation or sluggishness (i.e., changes in activity levels and movement)
S: Suicidal ideation or death preoccupation
Screening and Diagnosis of Depression.
The most widespread tool used for screening depression symptoms is the PHQ-9. This 9-item questionnaire explores the major symptoms of depression and allows for the generation of a score to rate the severity of depression. The score is interpreted as follows:
5-9, Mild
10-14, Moderate
15-19, Moderately Severe
20-27, Severe
If the score is greater than 10, it may be beneficial to explore further investigation and treatment.
The presence of depression symptoms can be used to diagnose the form of depression using the Diagnostic and Statistical Manual of Mental Disorders (DSM). Some diagnostic labels for depression include Major Depressive Disorder, Bipolar Depression, Post-Partum Depressive Disorder, and Persistent Depressive Disorder, among others.
While the diagnosis tells us what constellation of symptoms best matches your experience, psychiatric diagnoses do not explain your symptoms. Unfortunately, this is a trap that many clinicians fall into. To explain your symptoms, we must explore the underlying causes and contributing factors.
Causes and Contributing Factors.
Depression is a complex experience that likely includes a combination of underlying causes and contributing factors. Some of these include the following:
Biological Factors:
Genetic abnormalities (e.g., MTHFR or COMT abnormalities)
Impaired immunity (i.e., inflammatory depression)
Altered endocrine function (e.g., hypothyroid, hypercortisolemic/adrenal, and glycemic dysregulation depression)
Post-partum and peri-menopausal changes
An imbalance of key brain chemicals (serotonin, norepinephrine, and dopamine)
An imbalance of brain growth and development hormone (e.g., neurotrophins such as brain-derived neurotrophic factor).
Imbalanced cofactors, methylation, and nutritional factors (e.g., vitamins and minerals)
Impaired receptor responsiveness (i.e., reception and response to brain chemicals)
Impaired gut health (i.e., gut dysbiosis)
Substance-induced dysregulation (e.g., downers such as alcohol, benzodiazepines, and opioid,s as well as withdrawal from uppers such as cocaine and methamphetamine)
Medication-induced depression (certain medications can cause depression, such as steroids, contraceptives, and beta blockers)
Lifestyle/Environmental Factors: traumatic experiences (single incident, multiple incidents, developmental, or transgenerational), adverse childhood experiences, stressful events (accumulation of small stressors and/or large stressors), socioeconomic strain, impaired or dysfunctional relationships, separation or loss, sedentary lifestyle or impaired ability to exercise, nutritional imbalances and food intolerances/sensitivities, inadequate or impaired sleep, substance use at al. addictions, seasonal changes and nature deficit (Remes et al., 2021).
Psychological Factors: coping skills and resources, stress responsivity, perception of self (including a mismatch between ability and performance), sensitivity to rejection, interpretation bias, rumination, negative emotionality, attachment style, and personality structure (including personality disorder) (Remes et al., 2021).
The Integrative (Holistic) Psychiatry Approach.
Through an Integrative Psychiatry lens, we conduct a thorough examination of underlying causes and contributing factors. As these underlying causes and contributing factors are identified, we guide you through personalized treatment considerations that will meet your specific needs. We want to help you get to the root of your experiences. Below, you’ll find some of the treatment considerations for depression.
Treatments for Depression.
Medications. Common medications used in the treatment of depression include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), bupropion (Wellbutrin), tricyclic antidepressants (TCAs), second-generation antipsychotics (SGAs), and several adjunctive treatments.
Nutraceuticals. There are several nutraceutical options that will help with depression. Unlike pharmacologic approaches, nutraceutical approaches are a little more differentiated in terms of subtypes of depression. Some nutraceutical products are better for endocrine-related (stress-related) depression, anxious depression, agitated depression, inflammatory depression, etc. Common nutraceuticals used for depression include Rhodiola, Saffron, Curcumin, SAMe, 5HTP, L-methyl folate, and Saint John's Wort, among others.
The Body. The brain and body are not separate entities. In Integrative Psychiatry, we explore and treat causes and contributing factors such as the adrenal glands, gut, thyroid, immune system, metabolism, mitochondrial functioning, epigenetic factors, B complex levels, iron, and vitamin D. These considerations are based on a comprehensive evaluation of these systems through laboratory and diagnostic testing.
Lifestyle. Several lifestyle modifications can help improve depressive symptoms:
Habits: Reducing and eliminating substance use and other addictions. Although easier said than done, this often involves multimodal treatment and exploration of root causes.
Sleep: Stabilization of sleep routines and patterns (e.g., reducing blue light exposure from screens 4 hours prior to bed, avoiding stimulating activity prior to bed, etc.) with a goal of 6-7 hours per night (sometimes medication or nutraceutical options are helpful here).
Exercise: Moderate intensity exercise (e.g., walking) with a goal of 3-4 times per week has the best evidence basis for improving upon depression, though any activity is better than none. It’s recommended to start with something you enjoy and build upon a routine and habit from there.
Nutrition: Dietary adjustments such as sugar reduction (<10% added sugar in products) and a goal of a Mediterranean diet with healthy fats and high fiber have been shown to improve depressive symptoms.
Therapy. Therapy approaches help to develop strategies and techniques to influence your experiences AND/OR involve depth-oriented work to get to the root causes of symptoms. Common therapy modalities used in the treatment of depression include cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), psychodynamic psychotherapy (PDT), positive psychotherapy (PPT), and solution-focused or problem-solving therapy (SFT/PST), among others. While there are several psychotherapy modalities used for depression, at the core is the relationship between the individual and therapist.
Additional Treatments. Transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT) have also been used in depression. A more novel treatment in psychedelic-assisted and psychedelic integration therapy for depression. Several studies out of Johns Hopkins surrounding the use of psilocybin for depression have been promising.
Our clinicians can help you navigate these options safely and effectively to determine the best course of action for you.
Get to the Roots of Depression!
-
Li, B., Friston, K., Mody, M., Wang, H., Lu, H., & Hu, D. (2018). A brain network model for depression: From symptom understanding to disease intervention. CNS Neuroscience and Therapeutics, 24(11), 1004-1019.
Remes, O., Mendes, J. F., & Templeton, P. (2021). Biological, psychological, and social determinants of depression: A review of recent literature. Brain Science, 11(12), 1633.
