Depression is described as feeling sad, unhappy, miserable or unmotivated. It ranges from mild to moderate to severe. It is normal for all people to occasionally feel morose or depressed. These temporary bouts of depression are different from clinical depression, which may last for years and severely affect the quality of life. Typically, if feelings of depression last longer than two weeks, patients are encouraged to visit a physician.

Symptoms of depression include:

1. Depressed mood most of the day, nearly every day
2. Diminished interest or pleasure in activities
3. Significant weight loss or gain
4. Sleep disturbances
5. Agitation or restlessness
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Loss of concentration
9. Recurrent thoughts of death or suicide, or suicide ideation

The diagnosis of depression depends on how many of these symptoms are present and for how long. A major depressive episode may be diagnosed if at least five of the symptoms are present for more or all of the previous two weeks, and at least one of the symptoms is number one or two. If more than one major depressive episode is diagnosed in a certain time frame, then the patient may be diagnosed with a major depressive disorder.

Patients may be diagnosed with minor depression if they suffer from several of these symptoms, but not as many and not for as long. According to the main diagnostic manual used by mental health professionals, minor depression may be diagnosed if two to four of these symptoms are present most of every day, nearly every day, for at least two weeks.

Other common forms of depression include postpartum depression (after pregnancy) and seasonal affective disorder (SAD), which occurs during fall or winter and is likely due to the lack of sunlight.

If depression is diagnosed, there are many forms of therapy that may be recommended. In some cases, exercising and counseling will help ease mild depression. In other cases, the best treatment is a combination of medication (antidepressants) and psychotherapy or counseling. A number of antidepressants are available, and people are encouraged to work with their physician or a psychiatrist to find an antidepressant that works best for them. The most recent class of antidepressants is called selective serotonin reuptake inhibitors (SSRIs).

Seeking therapy as a treatment for depression involves:

• Finding a qualified professional who treats depression
• Being prepared for therapy
• Learning enough about therapy to relieve any fears that one may have about it

Most people have days when they feel sad or down. These feelings are natural. However, when these feelings are particularly severe for a significant period of time, and they interfere with a person's ability to conduct their affairs and handle daily life, they may be diagnosed as clinical depression. According to the American Psychiatry Association, major depression disorders are present in about five percent of American men and up to 10 percent of American women. This does not include lesser forms of depression, including minor depression and dysthymic disorder

This number is somewhat higher among heart patients, particularly after open-heart surgery or a heart attack. The National Mental Health Association (NMHA) estimates that depression occurs between 40 and 65 percent of patients who have had a heart attack. Similarly, up to 20 percent of heart disease patients with no history of heart attack are diagnosed with clinical depression. The depression may be a psychological reaction to the prognosis, pain, and/or incapacity caused by the disease or the treatment.

Depression among heart patients is important because it is closely associated with worse outcomes. For example, heart attack patients who suffer from clinical depression are three to four times more likely to die within six months of their heart attack than non-depressed patients. Patients who are diagnosed with clinical depression after coronary artery surgery are more likely to suffer from a cardiac-related problem in the next five years. And atherosclerosis, or “hardening of the arteries,” has been shown to progress more rapidly among depressed patients.

The problem is compounded because heart disease and clinical depression appear to cause and reinforce each other. Depressed patients are more likely to suffer heart disease, and heart patients are more likely to be depressed, thus increasing their chances of worse heart disease.

For these reasons, it is important that heart patients and their families are aware of the symptoms of depression. According to the Diagnostic and Statistical Manual of Mental Disorders IV, which is published by the American Psychiatric Association, a major depressive episode can be diagnosed if five or more of the following symptoms are present in the previous two weeks, and if at least one of the symptoms is depressed mood or loss of interest or pleasure. The nine symptoms are:

1. Depressed mood most of the day, nearly every day
2. Diminished interest or pleasure in activities
3. Significant weight loss or gain
4. Sleep disturbances
5. Agitation or restlessness
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Loss of concentration
9. Recurrent thoughts of death or suicide, or suicide ideation

For a major depressive disorder to be diagnosed, the person would have to experience one or more major depressive episodes that are not part of a larger psychiatric pattern of illness, such as manic or schizophrenic episodes. Manic episodes are characterized by elevation of mood, decreased need for sleep, inflated self-esteem, distractability and other symptoms. If a person experiences both depressive episodes and manic episodes, they may be diagnosed with a bipolar disorder. This was formally known as manic-depression.

It is important to note that postpartum depression, which occurs in about five percent of women after pregnancy, is not considered a separate diagnosis by the American Psychiatric Association. It is, however, included on the spectrum of depressive disorders.

A third form of depression is known as dysthymic disorder. A person with dysthymic disorder may be withdrawn and experience little or no joy in life. To be diagnosed with dysthymic order, the following criteria must be met:

• The person is depressed most of the time, almost every day, for at least two years. In children, the time frame is one year.
  
  
• At least two of the following symptoms are present while depressed:
  
• Overeating or lack of appetite
• Sleeping problems
• Fatigue or lack of energy
• Poor self-esteem
• Concentration problems
• Hopelessness
  
  
• There have been no major depressive episodes over the two-year time frame
  
  
• There have been no manic or mixed episodes of depression and mania
  
  
• The symptoms cannot be explained by another chronic disorder
  
  
• The symptoms cannot be explained by the use of substances, either legal or illegal
  
  
• The symptoms significantly interfere with daily function or cause great distress

The symptoms of depression may be slightly different in children and adolescents, in whom depression may be expressed as anger, irritability or temper tantrums rather than sadness. Young people may also show less interest in their friends or classmates, spending long periods of time alone in their room.

According to the National Institute of Mental Health, adolescent depression in girls is more prevalent than in boys. Parents are encouraged to consult regularly with their children’s teachers, who can be invaluable in monitoring behavioral problems and declines in academic performance. This is particularly important, as depression can give rise to self-destructive and even violent consequences. Government research has estimated that as many as half of school shooters suffer from depression. 

The diagnosis of depression, depressive episodes or manic behavior are made only by trained professionals, including psychologists, psychiatrists, social workers or physicians. Part of making a diagnosis includes ruling out physical conditions that may be causing the symptoms, such as hypothyroidism, menopause, and the side effects of prescription medications or drug abuse.

Treatment is available for depression. Strategies often include a combination of antidepressant medications and counseling or therapy to treat clinical depression. It is particularly important for heart patients to seek treatment for their depression because of the negative effects of depression on the body. By treating depression, both emotional and physical health can improve.

There appears to be a link between clinical depression and cardiovascular health. In the United States, clinical depression (defined as particularly severe depression lasting a significant amount of time) is diagnosed in roughly 10 percent of physically healthy people. By contrast, it is diagnosed in about 20 percent of heart patients with no history of heart attack, and up to 65 percent of heart patients who have had a heart attack. Research studies continue to investigate the links between clinical depression and cardiovascular health. Findings from these studies include:

• In initially healthy individuals, the onset of clinical depression can predict the development of heart disease. Even moderate levels of depression have been linked to the development of high blood pressure.
  
  
• The progress of atherosclerosis appears to be tied to clinical depression. A 2004 study found that the more severe the atherosclerosis, the more strongly it appears tied to depression later in life.
  
  
• Depression and diabetes are an especially dangerous combination. Patients who are suffering from both are 20 to 30 percent more likely to die than patients with depression alone.
  
  
• Overall mortality six months after a heart attack is higher in depressed patients than in those who are not depressed. The mortality risk is estimated to be nearly 5 times greater for depressed patients.
  
  
• Depression at one month following coronary artery bypass surgery has been seen to predict other cardiac events (e.g., angina) up to five years later.
  
  
• Among patients with heart failure, depression can increase the risk of re-hospitalization and mortality by 50 percent. This risk has shown to be independent of standard risk factors such as age, New York Heart Association Class and ejection fraction.

Not only can clinical depression increase the likelihood of developing or dying from a heart problem, but a heart problem can also increase the likelihood of clinical depression. Many patients feel sadness, a loss of control, insecurity about scars from a heart-related surgery, a loss of youth and other feelings that spiral into clinical depression. These feelings are real and in no way reflect weakness or failure. Depressed patients are urged to seek treatment as soon as possible.

Researchers are investigating a number of theories to explain how clinical depression affects the body. A leading area of research focuses on the levels of certain chemicals in the brain that regulate mood, especially the neurotransmitters norephinephrine and serotonin. People with depression may have reduced levels of these neurotransmitters, or be unable to properly utilize them. Currently, drug therapy for depression focuses on boosting levels of these mood-enhancing neurotransmitters, especially serotonin.

Another idea from Duke University Medical Center is that depression interferes with the body’s natural baroreflex sensitivity (BRS). When functioning properly, BRS helps the body to adjust to the common changes in blood pressure that occur throughout the day. For example, pressure rises when the heart increases its pumping activity. This causes arteries to dilate and special nerve receptors to stretch. The stretching of these receptors then signals the heart to decrease pumping activity so pressure will not get too high. Without properly adjusting to changes in blood pressure, the heart is working harder and is more at risk of heart disease.

A reduction in BRS has been found to occur in people diagnosed with clinical depression, as well as in people who have experienced a heart attack or who have been diagnosed with an abnormal heart rhythm (arrhythmia). Moreover, reduced BRS can be a harbinger of future life-threatening arrhythmias, such as ventricular tachycardia.

A third theory is based on the finding that clinically depressed people have higher levels of stress hormones (e.g., adrenaline and cortisol) than do people without clinical depression, and their sympathetic nervous system, which controls the “fight or flight” response, is activated. This may help explain why the hearts of clinically depressed people beat faster, even during sleep. It is also consistent with studies showing that people with both heart disease and clinical depression have reduced heart rate variability – the heart’s ability to handle stress.

Frequent or consistently high levels of stress hormones have also been linked to:

• Certain types of chest pain (angina) and abnormal heart rhythms 
  
  
• Increased risk of blood clots and high blood pressure (hypertension)
  
  
• Cardiac ischemia (a condition in which the heart does not get enough blood)
  
  
• Higher cholesterol and higher risk of hardening of the arteries (atherosclerosis)
  
  
• Reduced effectiveness of some heart medications

Another theory is that depressed heart patients are less likely to exercise, spend time with family and friends, participate in rehabilitation, or follow their medication plans. They may also be more likely to “self-medicate” their depression by smoking, drinking alcohol or eating unhealthy “comfort foods.” Because they are more likely to experience chest pain, the pain may also further their isolation and inactivity.

Although studies have established links between depression and heart disease, much more research must be done to reveal the actual mechanism behind this link. For instance, researchers discovered that it is possible to predict the risk of depression by measuring the severity of atherosclerosis. However, they do not know if atherosclerosis causes depression or whether both conditions are symptoms of some other underlying process.

According to the National Institute of Mental Health (NIMH), more than 80 percent of people with major depression can be treated successfully with psychotherapy, medical therapy or a combination of both. However, up to 50 percent may not respond to initial treatment. The treatment options available for depression are quite varied and individualized. Mild forms of the disorder may respond well to psychotherapy alone, whereas moderate to severe forms typically require medication treatment (e.g., antidepressants). The outcome of treatment is generally best with a combination of psychotherapy and medication. During treatment, the patient’s mood will improve gradually, with the patient feeling a little better each day.

Some forms of psychotherapy that may be effective in the treatment of major depression include:

• Cognitive behavioral therapy. Attempts to change negative patterns of thought or behavior that are associated with depression and teach the patient to achieve more satisfaction and rewards from their own actions.
  
  
• Interpersonal therapy. Focuses on the patient’s personal relationships and the problems in these relationships that cause or worsen depression. A form of interpersonal therapy, family therapy, involves the entire family and may be particularly helpful when there are specific family-related stresses.
  
  
• Psychodynamic therapy. Focuses on resolving the conflict in a patient’s feelings, such as the desire for praise coupled with feelings of worthlessness. This therapy is often reserved until symptoms are significantly improved.

Antidepressants can be a valuable treatment option that, in combination with counseling, may provide significant relief of depression. Most antidepressants exert their effect on brain chemicals known as neurotransmitters. Healthy brain function depends on a certain chemical balance of these neurotransmitters.

Two such neurotransmitters are serotonin and noradrenaline, which play roles in the regulation of emotions, behavior, appetite and sleep. A decrease in these neurotransmitters is associated with depressive symptoms. However, it is not known for certain whether an imbalance can be brought on by a traumatic life event, and/or if the threshold for depression is lower due to a pre–existing imbalance.

Antidepressants (which are neither stimulants nor sedatives) work toward restoring and maintaining that balance. This begins immediately, although it may be a number of weeks before individuals see improvement in their symptoms.

The main classes of antidepressants are:

• Tricyclic and tetracyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)
• Monoamine oxidase inhibitors (MAOIs)

Tricyclics (e.g., amitriptyline, nortriptyline, desipramine) have been a mainstay in the treatment of severe depression. As with any medication, there is a risk of side effects. Common side effects with tricyclics include dry mouth, fatigue, constipation and difficulty urinating. There is also a risk of increased blood pressure and heart rate.

MAOIs (e.g., phenelzine, isocarboxazid, tranylcypromine) are generally reserved for depression that does not improve with other classes of antidepressants. MAOIs can provide benefit to individuals with severe anxiety or phobias. Possible side effects include dizziness, headache and muscle tremors.

Antidepressants not falling in the above classes include bupropion, nefazodone, venlafaxine, trazodone and mirtazapine. Possible side effects include weight loss, sexual dysfunction, and increased blood pressure, heart rate and cholesterol levels.

The most recent class of antidepressants is SSRIs, which have found use in mild to moderate depression and tend to cause fewer side effects than the tricyclics. In heart patients, success has been reported with sertraline, a type of SSRI. Early studies demonstrated that the antidepressant was a safe and effective therapy in patients having a recent heart attack or unstable angina (more frequent angina attacks, occurring even at rest). Follow–ups to those studies showed that sertraline also had anti–platelet (anti–clotting) properties. Acting alongside patients’ standard regimen of anti-platelet heart drugs, sertraline further reduced the number of adverse vascular events (e.g., heart attack, stroke). Possible side effects with SSRIs include decreased appetite, insomnia, nervousness and sexual dysfunction.

Combining antidepressants with prescription drugs, over–the–counter remedies, other antidepressants, and even some foods or alcohol, may cause serious adverse reactions. Individuals should talk to their physician and pharmacist about possible interactions between medications. Because many medications cross the placenta, women should confirm the safety of a particular antidepressant during pregnancy or breastfeeding.

The safety and effectiveness of antidepressants not only requires the right dosage, but also involves how the medication is stopped. Abruptly discontinuing antidepressants can result in a relapse of depressive symptoms. This is why antidepressants are typically withdrawn gradually, with a stepwise lowering of the dose.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to depression:

1. Am I suffering from depression?
   
   
2. Do you think it would be appropriate to treat my depression with medication? Which medication would you recommend?
   
   
3. Could my antidepressants interact with any of my other medications?
   
   
4. Could I experience any side effects from the antidepressants you are recommending? Could the medication cause my cholesterol to rise?
   
   
5. Do you think therapy could help improve my depression? Can you recommend anyone?
   
   
6. Do you think group therapy could help me to feel better?
   
   
7. How often will I need to attend therapy?
   
   
8. Can you recommend a group that might help me deal with my recent stroke, heart attack or cardiovascular diagnosis?
   
   
9. Are there any lifestyle changes I can make that might help me to feel better?
   
   
10. How long may it take for my treatment to begin to work?