Depression awareness — understanding the factors that contribute to it
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Yesterday was National Depression Screening Day, a day we look  deeper for those subtle and not-so-subtle signs of depression in ourselves and those around us.  

However, we shouldn’t dedicate only one day to depression screenings and awareness since it’s so common and strikes approximately 350 million people worldwide. 

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It affects our thoughts, feelings, behaviors, daily activities such as sleep, energy level, interests, and the everyday lives of many people, all in a negative way.  Screening for depression is effective in identifying those who require further evaluation and treatment. It is designed to pick up on the signals of what might be depression and lead us to further evaluation by a medical or mental health provider.

Screening occurs in a variety of ways around the country, from our family doctor's or primary care physician's offices to our schools and universities, medical specialty clinics such as dialysis centers and pain clinics, churches, community centers, the YMCA, and even online.  

There has been an effort to bring depression screening into the general practitioner's office and other non-mental health settings. Along with this has been the use of briefer screening tools such as the PHQ-9 (Patient Health Questionnaire-9), which asks only nine questions, to make it easier to complete the screening questionnaire and capture those at risk without over-diagnosing others.  

There has also been great interest in developing screening tools for specific populations, such as postpartum women, people on dialysis, those with cardiac disease, stroke or cancer, and children and adolescents. This is because depression has been found to be highly co-morbid with these other medical conditions.  For example, the National Cancer Institute (NCI) reports that approximately 15-25% of persons who have cancer also experience depression.

So who should we screen?  Everyone, or those who are most at risk for developing depression?  There is some divided opinion around this, as the goal of screening is to identify those who require further evaluation and treatment and avoid stigmatizing those who are not in need of mental health treatment, particularly the teens and young adults who are most sensitive to peer pressure.  So who is at risk for depression?

First are those who have already had one or more episodes of depression or bipolar disorder, or a history of anxiety or PTSD.  Experience shows that sixty percent of those who have had one episode of depression and recover will have a second one; seventy percent of those with two episodes will experience a third, and ninety percent of those with three episodes will have a fourth.

Anxiety and depression are often linked, and approximately half of those who have depression experience anxiety at the same time.  Those who have a family history of depression, particularly in a twin or parent, are at risk.  The current thinking of depression is a "gene x environment" theory which involves an interaction between our genes, inherited from our parents, and the events in our life.  

Some genes are thought to be associated with psychiatric illnesses such as schizophrenia, bipolar disorder, and depression. And depression is thought to “run” in some families. This means that a person can inherit genetic factors that make him or her more likely to experience depression, but it does not guarantee that he will have the illness.  He may not have an episode of depression unless he experiences certain stressful life events during a vulnerable period in his life, when the genes affect brain functioning. 

Those who have had recent traumatic or stressful life event, such as the loss of a job, divorce, moving to a new home, the birth of a baby (postpartum women) or those who have a history of childhood abuse or trauma are all at increased risk.Any person who has a serious or chronic illness such as cancer, stroke, or chronic pain is also at increased risk for depression.

Certain medications can increase the chance of depression, such as some blood pressure medications, steroids used for chronic medical conditions or as sports performance enhancement drugs, and other meds.  

Women have more frequent episodes of depression than men, and it is not clear whether this is due to the impact of reproductive hormones cycling, such as estrogen and progesterone, or if we are not capturing all of the instances of depression in men, who tend to tough it out and not disclose. The age distribution of depression follows a bell curve, with middle-aged people at the peak, and adolescents and the elderly at each end.  

Teens are at risk for depression because of the pressure to succeed in school and from their peers. The elderly are at risk as they face loneliness, loss of friends and family, physical impairments that limit their lifestyle, medical problems, chronic pain, or loss of independence and purpose.

A family history of bipolar disorder, suicide, or alcoholism also places a person at risk for developing depression. A personal history of alcoholism or substance abuse may be a risk factor for developing depression.  In addition, the Center for Disease Control and Prevention (CDC) reports that those who are less educated, have economic instability, and less insurance coverage may be significantly stressed as to have these life conditions trigger depression.  

Susan J. Noonan MD, MPH is a physician and Certified Peer Specialist, is the author of When Someone You Know Has Depression: Words to say and things to do (JHUP 2016), and Managing Your Depression: What you can do to feel better (JHUP 2013). For more info please visit susannoonanmd.com.


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