Summary: The following Frequently-Asked-Questions (FAQ) attempts to impart an understanding of depression including its causes; its symptoms; its medication and treatments--including professional treatments as well as things you can do to help yourself. In addition, information on where to get help, books to read, a list of famous people who suffer from depression, internet resources, instructions for posting anonymously, and a list of the many contributors is included.

Part 3 of 5 ===========

**Medication** (cont.) - If an antidepressant has produced a partial response, but has not fully eliminated depression, what can be done about it?

**Electroconvulsive Therapy** - What is electroconvulsive therapy (ECT) and when is it used? - Exactly what happens when someone gets ECT? - How do individuals who have had ECT feel about having had the treatments? - How long do the beneficial effects of ECT last? - Is it true that ECT causes brain damage? - Why is there so much controversy about ECT?

**Substance Abuse** - May I drink alcohol while taking antidepressants? - If I plan to drink alcohol while on medication, what precautions should I take? - What's the relationship between depression and recovery from substance abuse? - What does the term "dual-diagnosis" mean? - Is it safe for a person recovering from substance abuse to take drugs? - How do you know when depression is severe enough that help should be sought?

**Getting Help** -Where should a person go for help? -Where can I find help in the United Kingdom? -Where can I find out about support groups for depression? -How can family and friends help the depressed person?

**Choosing A Doctor** -What should you look for in a doctor? How can you tell if he/she really understands depression?

**Self-care** - How may I measure the effects my treatment is having on my depression?

Medication (cont.) ------------------ Q. If an antidepressant has produced a partial response, but has not fully eliminated depression, what can be done about it?

There are many techniques to help an antidepressant work more completely. The simplest is to increase the dose until relief is experienced or side- effects are severe. If the dose can not be increased, lithium can be added to any antidepressant to augment its effect. With all antidepressants it is possible to add small doses of stimulants such as pemoline (Cylert), methylphenidate (Ritalin), or dextroamphetamine (Dexedrine) to augment the antidepressant effect. Selective serotonin re-uptake inhibitors often work better when small doses of desipramine (Norpramin) or nortriptyline (Aventyl and Pamelor) are co-administered. Thyroid hormones (Synthroid or Cytomel) may be used to augment any antidepressant. At times combinations of these techniques may be utilized.

Electroconvulsive Therapy -------------------------

Q. What is electroconvulsive therapy (ECT) and when is it used?;

ECT is an effective form of treatment for people with depressions and other mood disorders. ECT may be used when a severely depressed patient has not responded to antidepressants, is unable to tolerate the side effects of antidepressants, or must improve rapidly. Some depressed people simply do not respond to antidepressants or mood controlling drugs, and ECT is a way for such people to be effectively treated. ECT is utilized in the treatment of both mania and depression. There are some people who because of severe physical illness are unable to tolerate the side-effects of the medications used to treat mood disorders. Many of these people can be successfully be treated with ECT. Pregnant women and people who have recently had heart attacks can be safely treated with ECT. Because of time pressure regarding occupational, social, or family events, some people do not have the time to wait for antidepressants or mood regulating medications to become effective. As ECT quite regularly brings about improvement within two or three weeks, people who are under such time pressure are also excellent candidates for ECT.

Q. Exactly what happens when someone gets ECT?

The physician must fully explain the benefits and dangers of ECT, and the patient give consent, before ECT can be administered. The patient should be encouraged to ask questions about the procedure and should be told that consent for treatments can be withdrawn at any time, and in the event that this happens, the treatments will be stopped. After giving consent, the patient undergoes a complete physical examination, including a chest x-ray, electrocardiogram, and blood and urine tests. A series of ECTs usually consists of six to twelve treatments. Treatments can be administered to either in-patients or out-patients. Nothing should be taken by mouth for 8-hours prior to a treatment. An intravenous drip is started and through it medications to induce sleep, relax the muscles of the body, and reduce saliva are given. Once these medications are fully effective, an electrical stimulus is administered through electrodes to the head. The electrical stimulus produces brain wave (EEG) changes that are characteristic of a grand mal seizure. It is believed that this seizure activity leads to the clinical improvement seen after a series of ECT. About 30-minutes after the treatment the patient awakens from sleep. While confused at first, the patient is soon oriented enough to eat breakfast, and return home if the treatments are being done in an outpatient setting.

Q. How do individuals who have had ECT feel about having had the treatments?

In studies of people treated with ECT it has been found that 80% of such people report that they were helped by the treatments. About 75% say that ECT is no more frightening than going to the dentist.

Q. How long do the beneficial effects of ECT last?;

While ECT is a highly successful way of helping people come out of depressions, it has to be followed by antidepressant therapy. If antidepressants are not administered after a series of ECTs, there is a 50% relapse rate within 6-months.

Q. Is it true that ECT causes brain damage?;

There is no scientific evidence that ECT causes brain damage. A woman who had over 1,000 ECT died of natural causes, and her brain was examined for evidence of ECT-induced brain damage. None was found. ECT does cause memory problems. These memory problems may take a number of months to clear. A small number of people who have received ECT complain of longer lasting memory problems. Such problems do not show up on psychological tests, it is not clear what causes them.

Q. Why is there so much controversy about ECT?

There is little controversy about ECT among psychiatrists. Much of the opposition to ECT seems political in nature and originates in the anti-psychiatry groups that oppose the use of Ritalin for the treatment of children with attention deficit disorder, and who oppose the use of Prozac for the treatment of depressed people.

Substance Abuse ---------------

Q. May I drink alcohol while taking antidepressants?

There are a number of problems with the mixture of alcohol and antidepressants. First, antidepressants may make you especially susceptible to the intoxicating effects of alcohol. Second, if you drink more than three or four drinks a week, the effects of alcohol may prevent the antidepressants from working. Many people who seem not to benefit from antidepressants, do so, if they reduce or eliminate their intake of alcohol. Third, you may be taking along with the antidepressant a drug such as clonazepan (Klonopin) with which one should not drink at all.

Q. If I plan to drink alcohol while on medication, what precautions should I take?

There is much misinformation about drinking while on anti- depressants. Alcohol can prevent antidepressants from being effective. This is not so much because it interferes with the absorption of antidepressants, it is because of the effects of alcohol upon brain chemistry. Antidepressants can also increase one's susceptibility to the intoxicating effects of alcohol. Also, both alcohol and some anti- depressants (especially Wellbutrin) increase the possibility of seizures.

If you are determined to drink despite taking antidepressants you should discuss the matter with your psychiatrist. If you get permission you might want to determine the extent to which the medication has made you more sensitive to the alcohol. You might start by seeing what are the effects of half a glass of wine. You might then experiment with a full glass. Remember, a 4 oz glass of wine, a 12 oz bottle of beer, and 1 oz of "hard stuff" all contain the same amount of alcohol.

Q. What's the relationship between depression and recovery from substance abuse?

It is not unusual for people who have recently been withdrawn from alcohol, or other abusable drugs to become depressed. These depressions are often self-limited, and clear in about 8-weeks. If depression has not cleared by the end of that period, anti-depressant therapy should be started.

Q. What does the term "dual-diagnosis" mean?

Dual-diagnosis is a phrase used to indicate the combination of substance abuse and a psychiatric disorder. A path to alcohol or other substance abuse is an attempt to self- medicate uncomfortable symptoms such as depression, anxiety, agitation or feelings of emptiness. The psychiatric disorders that cause such symptoms are often diagnosed in substance abusers.

Q. Is it safe for a person recovering from substance abuse to take drugs?

People recovering from substance abuse can safely take many kinds of psychiatric drugs. Most psychiatric drugs are unable to be abused. The best evidence for this is that there are not street markets for such drugs. On the other hand, The benzodiazepines (diazepam [Valium], lorazepam [Ativan], alprazolam [Xanax], etc.) and the psycho-stimulants (dextroamphetamine [Dexedrine], methamphetamine [Desoxyn], and Ritalin [methylphenidate]) are quite abusable.

For people active in AA please read the pamphlet "The AA Member--Medications & Other Drugs." This outlines AA's official attitude toward medication--that it is necessary for certain illnesses including depression. Too many depressed people who have been talked out of taking antidepressants by members of their AA groups have killed themselves as a result.

Q. How do you know when depression is severe enough that help should be sought?

Professional help is needed when symptoms of depression arise without a clear precipitating cause, when emotional reactions are out of proportion to life events, and especially when symptoms interfere with day-to-day functioning.. Professional help should definitely be sought if a person is experiencing suicidal thoughts.

Getting Help ------------

Q. Where should a person go for help?

If you think you might need help, see your internist or general practitioner and explain your situation. Sometimes an actual physical illness can cause depression-like symptoms so that is why it is best to see your regular physician first to be checked out. Your doctor should be able to refer you to a psychiatrist if the severity of your depression warrants it.

Other sources of help include the members of the clergy, local suicide hotline, local hospital emergency room, local mental health center.

Q. Where can I find help in the United Kingdom?

The following are places one might find help in Great Britain:

Depressives Associated PO Box 1022 London SE1 7QB

Depressives Anonymous 36 Chestnut Avenue Beverley Humberside HU17 9QU

MIND (National association for mental health) 22 Harley Street London W1N 2ED

To find a psychiatrist/ psychologist near you, call or write: Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG

Q. Where can I find out about support groups for depression?

The following is a list of national organizations dealing with the issues of depression. Please note: Model groups are not national organizations and should be contacted primarily by persons wishing to start a similar group in their area. Also, please enclose a self-addressed stamped envelope when requesting information from any group. When calling a contact number, remember that many of them are home numbers, so be considerate of the time you call. Keep in mind the different time zones.

[Reprinted from The Self-Help Sourcebook, 4th Edition, 1992. American Self-Help Clearinghouse, St.Clares' Riverside Medical Center, Denville, New Jersey 07834]

**Depressed Anonymous** Int'l. 8 affiliated groups. Founded 1985. 12-step program to help depressed persons believe & hope they can feel better. Newsletter, phone support, information & referrals, pen pals, workshops, conference & seminars. Information packet ($5), group starting manual ($10.95).Newsletter. Write: 1013 Wagner Ave., Louisville, KY 40217. Call Hugh S. 502-969-3359.

**Depression After Deliver** National. 85 chapters. Founded 1985. Support & Information for women who have suffered from post-partum depression. Telephone support in most states, newsletter, group development guidelines, pen pals, conferences. Write: PO. Box 1281, Morrisville, PA 19067. Call 215-295-3994 or 800-944-4773 (to leave name & address for information to be sent).

**Emotions Anonymous** National. 1200 chapters. Founded 1971. Fellowship sharing experiences, hopes & strengths with each other, using the 12-step program to gain better emotional health. Correspondence program for those who cannot attend meetings. Chapter development guidelines. Write: PO. Box 4245, St. Paul, MN 55104. Call 612-647-9712.

**National Depressive & Manic-Depressive Association** National. 250 chapters. Founded 1986. Mutual support & information for manic-depressives, depressives & their families. Public education on the biochemical nature of depressive illnesses. Annual conferences, chapter development guidelines. Newsletter. Write: NDMDA, 730 Franklin, 501, Chicago, IL 60610. Call 800-82-NDMDA or 312-642-0049.

**National Foundation for Depressive Illness**. An informational service, which provides a recorded message of the clear warning signs of depression and manic-depression, and instructs how to get help and further information. Call 1-800-239-1295. For a bibliography and referral list of physicians and support groups in your area, send $5 (if you can afford it) and a self-addressed, stamped business-size envelope with 98 cents postage to, NAAFDI, PO. Box 2257, New York, NY 100116.

NOSAD (**National Organization for Seasonal Affective Disorder**) National. groups. Founded 1988. Provides information & education re: the causes, nature & treatment of Seasonal Affective Disorder. Encourages development of services to patients & families, research into causes & treatment. Newsletter. Write: PO. Box 451, Vienna, VA 22180. Call 301-762-0768.

(Model) **Helping Hands** Founded 1985. A comfortable & homey atmosphere for people with manic-depression, schizophrenia or clinical depression who seek an environment that makes them more aware of themselves & eliminates a negative attitude. Group development guidelines. Write: c/o Rita Martone, 86 Poor St, Andover, MA 01810. Call 508-475-3388.

(Model) MDSG-NY (**Mood Disorders Support Group, Inc.**) Founded 1981. Support & education for people with manic-depression or depression & their families & friends. Guest lectures, newsletter, rap groups, assistance in starting groups. Write: PO. Box 1747, Madison Square Station, New York, NY 10159. Call 212-533-MDSG.

Q. How can family and friends help the depressed person?

The most important things anyone can do for depressed people is to help them get appropriate diagnosis and treatment. This may involve encouraging a depressed individual to stay with treatment until symptoms begin to abate (several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication.

The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always report them to the doctor. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon.

The depressed person needs diversion and company. but too many demands can increase feelings of failure. Do not accuse the depressed person of faking illness or laziness or expect him or her to "snap out of it." Eventually, with treatment, most depressed people do yet better. Keep that in mind, and keep reassuring the depressed person that with time and help, he or she will feel better.

Choosing A Doctor -----------------

Q. What should you look for in a doctor? How can you tell if he/she really understands depression?

If you are looking for a psychopharmacologist to prescribe medications to help control your depression there are a number of things to check. If you are in psychotherapy, it is important to ask prospective doctors about their opinions on the psychotherapeutic treatment of depression. Psychopharmacologists who are hostile to psychotherapy are difficult to deal with while you are in therapy.

It is always legitimate to ask any professionals you are thinking about seeing regularly about their understanding of depression, their beliefs about the causes of depression and their philosophy of treatment. You might ask about how often the prospective doctor has worked with people who have had your particular variety of depression. If you have a rapidly cycling Bipolar depression, for example, you should seek a doctor who has much experience dealing with people who have this problem. Prior to the first visit it is important to clarify with the doctor or the secretary the fee of the initial and subsequent visits, the doctor's policy regarding missed and changed appointments, whether the doctor will accept assignment from insurance companies. If you have Medicare or Medicaid it is important to make sure that the doctor sees people with these forms of medical coverage.

Another aspect of the style of doctors is the extent to which they include their patients in the decision-making process. You might ask "How do you go about deciding which treatment is right for me?" See if you are comfortable with the method the doctor describes. Much can also be learned from how doctors respond to questions such as these. There is much difference between a doctor who welcomes such questions and answers them fully and one who is annoyed by them and answers them superficially.

Self-care ---------

Q. How may I measure the effects my treatment is having on my depression?

If one completes the following scale each week, and keeps track of the scores, one would have a detailed record of one's progress.

Name _________________________ Date _________

The items below refer to how you have felt and behaved **during the past week.** For each item, indicate the extent to which it is true, by circling one of the numbers that follows it. Use the following scale:

0 = Not at all 1 = Just a little 2 = Somewhat 3 = Moderately 4 = Quite a lot 5 = Very much _______________________

1. I do things slowly............................0 1 2 3 4 5

2. My future seems hopeless......................0 1 2 3 4 5

3. It is hard for me to concentrate on reading...0 1 2 3 4 5

4. The pleasure and joy has gone out of my life..0 1 2 3 4 5

5. I have difficulty making decisions............0 1 2 3 4 5

6. I have lost interest in aspects of life that used to be important to me...................0 1 2 3 4 5

7. I feel sad, blue, and unhappy.................0 1 2 3 4 5

8. I am agitated and keep moving around..........0 1 2 3 4 5 9. I feel fatigued...............................0 1 2 3 4 5

10. It takes great effort for me to do simple things.......................................0 1 2 3 4 5

11. I feel that I am a guilty person who deserves to be punished......................0 1 2 3 4 5

12. I feel like a failure.........................0 1 2 3 4 5

13. I feel lifeless--more dead than alive.........0 1 2 3 4 5

14. My sleep has been disturbed: too little, too much, or broken sleep........0 1 2 3 4 5

15. I spend time thinking about HOW I might kill myself..................................0 1 2 3 4 5

16. I feel trapped or caught......................0 1 2 3 4 5

17. I feel depressed even when good things happen to me.................................0 1 2 3 4 5

18. Without trying to diet, I have lost, or gained, weight............................0 1 2 3 4 5

Note: This scale is designed to measure changes in the severity of depression and it has been shown to be sensitive to the changes that result from psychotherapeutic or psychopharmacologic treatment. These scales are not designed to diagnose the presence or absence of either depression or mania.