Unipolar depressive disorder is a mood disorder state where life experiences
of loss, anger, upset, and frustration outweigh a person's ability to
effectively cope with daily experiences. It is characterized by one or more
major depressions (requiring at least four or more additional symptoms) without
mania and lasting at least two weeks (but typically longer). It involves
emotional, cognitive, behavioral, and somatic disturbances. Depression is rated
in terms of severity (mild, moderate, severe) and is classified by frequency
(single episode, recurrent, or chronic [i.e., lasting more than two years]).
There are three subtypes.
- Major depressive disorder—one or more major
depressions with or without interepisodic recovery
- Dysthymic disorder—chronic (at least two
years), low-grade depression without a major depressive episode
- Depression not otherwise specified—PMS;
depressions with psychotic, melancholic, catatonic, or atypical features; and
depressions that briefly recur or with postpartum or seasonal
Psychodynamic influences (e.g., chronic stress, especially early childhood
loss or deprivation), biologic factors (e.g., alteration of neurotransmitters),
and genetic predisposition are factors in the etiology of
- Prior episodes of depression
- Family history of depression
- Prior suicide attempt(s)
- Female gender (lifetime risk, 20% to 25% for women and 7% to 12% for
- Age (rate of occurrence is highest from age 25 to 44)
- Postpartum period
- Medical comorbidity
- Stressful life events, especially loss
- Lack of social support system
- Current or past alcohol or drug
|Signs and Symptoms|
Significantly depressed mood, diminished interest or pleasure in activities
(including reduced sexual functioning), and at least four of the
- Feelings of worthlessness, self-reproach, inappropriate
- Significant weight loss or weight gain
- Insomnia or hypersomnia (especially early morning
- Hyperactivity or inactivity
- Fatigue/loss of energy
- Poor concentration, restlessness, irritability, withdrawal
- Recurrent thoughts of death or
- Bipolar I and II mood disorders (manic or hypomanic)
- Schizoaffective disorder
- Substance abuse or withdrawal (e.g., cocaine, amphetamines,
- Medical illness (e.g., endocrine dysfunctions such as hypothyroidism,
pancreatic cancer, other malignant neoplasms, central nervous system lesions,
diabetes mellitus, vitamin deficiency)
- Normal life stress (e.g., bereavement)
- Delusional, adjustment, or anxiety disorder
- Dementia or malnutrition in the
The facial expression and demeanor may appear withdrawn, sad, exhausted, or
agitated. The physical appearance may include weight loss or
A variety of laboratory tests can be abnormal with
- Determine underlying medical conditions.
- Screen for biologic abnormalities (e.g., the dexamethasone
suppression test to differentiate psychotic depression from schizophrenia; sleep
EEG to differentiate sleep apnea from depression).
- Blood tests (e.g., measure neurotransmitter levels; screen for amino
acid or folate deficiency).
The Hamilton Rating Scale for Depression (HAM-D) or Beck's Depression
Inventory (BDI) are used to assess symptoms and severity of
- Assess symptoms/degree of severity. This may include a
clinician-completed rating scale, such as the HAM-D; a psychological test, such
as the Minnesota Multiphasic Personality Inventory (MMPI); or a mental status
examination, such as the Global Assessment Functioning Scale.
- Evaluate for concurrent substance abuse, medical conditions, or
nonmood psychiatric conditions.
- Self-reported questionnaire, e.g., Beck Depression Inventory
Depending on the type, number, severity, and duration of episodes one or more
of the following are recommended.
- Psychotherapy, including interpersonal and
- Bright light treatment, for seasonal depression
- Nutritional support
- Yoga, exercise, meditation, massage, and tai chi may be
- Hospitalization if suicide is
- Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine
(Prozac; 10 to 80 mg once a day) or sertraline (Zoloft; 50 to 200 mg once a day)
block serotonin reuptake. Side effects are generally fewer than for MAOIs and
tricyclic antidepressants but can include gastrointestinal upset, sedation,
sexual dysfunction, and headache with a three day to two-week onset. SSRIs can
be combined with tricyclics.
- Monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil; 15
to 90 mg once a day) increase intrasynaptic norepinephrine levels. Severe side
effects (e.g., hypertension) require a tyramine-free diet. Use of other
antidepressants is contraindicated.
- Tricyclic antidepressants such as amitriptyline (Elavil; 50 to 300 mg
once a day) increase the activity of norepinephrine. Side effects include
xerostomia, constipation, and orthostatic hypotension with a two-week
- Atypical antidepressants include drugs such as bupropion (Wellbutrin;
200 to 450 mg bid), a dopamine reuptake blocker; heterocyclics; and newer
medications, such as venlafaxine (Effexor; 75 to 375 mg bid or tid), or
mirtazapine (Remeron; 15 to 45 mg once a
|Complementary and Alternative
Usually a combination of relaxation techniques, nutrition, and herbs provide
the greatest relief.
- B12 and folate: Even with normal serum values, some patients respond
well to supplementation. Particularly the elderly are at risk for deficiency,
since proper digestion is required for good utilization. Dose is 800 mcg/day for
folate and 100 to 500 mcg/day for B12.
- Other vitamins shown to be low in depression are vitamin C (1,000 mg
tid), biotin (300 mcg), B1 (50 to 100 mg), B2 (50 mg), B6 (50 to 100
mg). Minerals shown to be deficient are calcium (800 to 1,200 mg), iron (15 to
30 mg), magnesium (400 to 800 mg). A good multi-vitamin can efficiently address
these deficiencies. In addition, chromium (200 to 500 mcg) helps to stabilize
mood changes associated with hypoglycemia.
- Essential fatty acids: depleted in depression (1,000 to 1,500 IU/day)
- Vanadium: Excess vanadium is associated with
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
- St. John's wort (Hypericum perforatum): Numerous studies
support its use in mild to moderate depression; side effects may include
photosensitization, gastric upset, headaches, and rash. Dose is 1 to 4 ml
tincture/day, or 250 mg tid when taken as the only herb. It may take four to six
weeks to become effective. Do not use concomitantly with an antidepressant
- Valerian (Valeriana officinalis): sedative, with digestive
- Black cohosh (Cimicifuga racemosa): chronic depression,
especially with a hormonal component
- Ginkgo (Ginkgo biloba): circulatory stimulant, especially with
decreased circulation and/or memory loss
- Oatstraw (Avena sativa): nerve tonic, gentle, slow
- Siberian ginseng (Eleutherococcus senticosus): improves
ability to withstand stress
- Licorice (Glycyrrhiza glabra): antidepressant, especially for
long-term stress with a digestive and/or hormonal component. (Contraindicated in
- Passionflower (Passiflora incarnata): especially for emotional
upheaval with nervousness and insomnia
- Lemon balm (Melissa officinalis): mild sedative and
spasmolytic, especially with a "nervous stomach"
A combination of equal parts of four to six herbs (1 cup tea tid, or 30 to 60
drops tincture) listed above can be very helpful.
Although homeopathics can be very helpful, an experienced homeopath should be
consulted for appropriate treatment based on constitutional
Recent studies show that acupuncture can be effective at relieving symptoms,
at times statistically comparable to antidepressants or
Therapeutic massage has been shown to be effective in increasing circulation
and promoting general well-being.
Patients should be closely monitored for compliance, comorbidity, and side
effects. Concurrent psychotherapy should be
Education that compliance with regimen decreases the chance of relapse.
Cognitive or psychotherapy directed at coping skills may help prevent relapses.
Sleep, exercise, and good diet are important self-care steps that should be
encouraged. Biofeedback, meditation, visualization techniques, and tai chi are
effective ways to prevent or reduce the symptoms associated with
- Drug interactions (e.g., combining of MAOIs and SSRIs) or drug
overdose (e.g., tricyclics) can be severe or fatal.
- 20% to 25% rate of associated medical problems with
- 15% of patients with major depressive disorder die from
The course of recurrence is variable. Fifty percent of patients who have
suffered an initial episode suffer a second major depressive disorder, 70% of
those suffer a third, and 90% of those suffer a fourth episode. Twenty-five
percent of patients with depression develop a bipolar disorder. Untreated
episodes of depression last 6 to 24 months. The need for pharmacologic and
psychologic treatment is greater with subsequent episodes.
Preschool children whose mothers took tricyclic antidepressant drugs or
fluoxetine during pregnancy showed no significant difference in global IQ or
language and behavioral development.
American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:422, 425.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:967-968, 1015.
Hippius H. St John's wort (Hypericum
perforatum)—a herbal antidepressant. Curr Med
Res Opin. 1998;14:171-184.
Kaplan HW, ed. Comprehensive Textbook of Psychiatry. 6th ed.
Baltimore, Md: Williams & Wilkins; 1995.
Linde K, Ramirez G, Mulrow CD, et al. St. John's wort for
depression—an overview and meta-analysis of randomized
clinical trials. Br Med J. 1996;313:253-258.
Rakel RE, ed. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB
Saunders Co; 1998.
Reuter HD. St. John's wort as a herbal antidepressant. Eur J Herbal
Med. Part 1. 1995;1(3):19-24. Part 2.
Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein.