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Recognizing Signs of Depression and When It May Be Time to Start Medication

Dr. Tal Weinberger, an adult psychiatrist, discusses symptoms of depression and how she approaches diagnosis and medication management with her patients.

Some depressive symptoms are a normal part of the human experience, says adult psychiatrist Dr. Tal Weinberger. Experiencing great sadness is normal and expected under circumstances that are difficult or painful. “Even if somebody’s really grieving a very serious loss, what we do expect is some degree of recovery with time,” she explains. “It may not be linear, and it may take a very long time, but we do expect as more time elapses since the stressor—even, for example, a serious loss—people will recover and feel somewhat better to some extent.”

People with depression, Dr. Weinberger says, tend to feel sad persistently and this sadness may not get better with time—it can become pervasive and chronic.

Major depression is one of the most common mental disorders in the United States, according to The National Institute of Mental Health. We recently sat down with Dr. Weinberger to better understand how depression is diagnosed, its signs and symptoms and medication management.

What are some criteria or symptoms of depression you look for as an adult psychiatrist?

I look for people who tend to feel sad most of the time or every day. They often are not able to enjoy other aspects of their life that are unrelated to the thing that’s making them sad, as opposed to somebody who’s sad or grieving who generally, at some point, would be able to find joy in other aspects of their life.

Other associated symptoms of depression that we often see are difficulties with sleep. Often people with depression will either sleep too much or more commonly will have a lot of difficulties sleeping. Other symptoms that we see are changes in appetite, energy levels, and motivation. People may feel like they just really don’t feel like doing anything or that nothing is worth doing. They may have an exaggerated sense of guilt about past perceived mistakes. They may be quite self-critical in a way that might be distorted. People can feel hopeless and think that things will never get better. And in more extreme or severe situations they can even have thoughts of harming themselves.

Is depression something that can be passed down genetically?

Yes. Definitely. However, it’s not always that straightforward. In other words, if you struggle with depression or anxiety, that doesn’t guarantee that your child will. But certainly yes, relatives of people with depression or anxiety are at somewhat higher risk, and first-degree relatives are likely at even higher risk.

The silver lining here is that for those people that are aware and mindful of their illness, they can be more likely to pay attention and be more vigilant and therefore be able to intervene appropriately when their children are struggling.

Should people discontinue or not take antidepressants if they are pregnant, postpartum or breastfeeding?

There’s unfortunately a lot of misinformation about treatment during pregnancy and postpartum. As a general statement, most of the medications that we use to treat depression have reassuring data on their use during pregnancy

However, often the conversation around medication and pregnancy is framed as, “Are you going to choose to take this medication and expose your baby?” When the question is framed in this way, most women decline medication, regardless of how much they are suffering. But the fact is that that’s not a fair or accurate way of framing the issue.

What we’ve seen over the course of decades of research is that we need to look at depression during pregnancy and postpartum in a similar way to the way we look at other illnesses during pregnancy and postpartum. For example, if somebody has high blood pressure during pregnancy, we weigh the risks of exposing the baby to uncontrolled high blood pressure to the risks of medications used to treat high blood pressure. Those risks come out in favor of treatment, as the risks of exposure to untreated illness are much greater. Then, we choose the safest and most effective treatment. Similarly, when we think about depression treatment, we also need to consider the impact of untreated illness on the baby, and there are very clear developmental risks associated with exposure to untreated depression have been demonstrated. In general, the risks to the baby of not treating depression during pregnancy are much more significant than the risks of treatment with well-studied medications.

If you start taking a long-term anti-depressant medication, do you stay on it for the rest of your life?

It really depends a lot on the circumstances. The short answer is often no, but there are some individual considerations that would guide how long I would recommend that you would stay on medication. If somebody has had multiple episodes of depression over the course of their life, that’s a different situation than somebody who’s had one episode in the context of a significant stressor.

Another important factor when considering how long someone should stay on medication is whether they’ve also been in psychotherapy. What we see in our data is that when we compare the effects of medication and psychotherapy, medication tends to work faster, but psychotherapy tends to be longer lasting. In other words, people who have a good response to psychotherapy and stop psychotherapy stay well longer than people who have a good response to medication and stop medication.

Someone who’s had a single episode of depression, possibly triggered by a stressor that’s resolved, or someone who’s made significant progress in psychotherapy may be a good candidate to try to stop their medication if they choose to. However, I’ve also had patients in this situation choose not to stop medication and that’s a reasonable decision as well. The caveat here is that what we do see is that the highest period of the risk of relapse is the first year, so I ideally wouldn’t even start the conversation about stopping medications until someone’s been well for a year.

Somebody else who’s had recurrent episodes of depression throughout their life may not be a good candidate to stop their medication. And somebody who’s had three or more episodes of depression is somebody who should probably consider staying on medication indefinitely because their risk of relapse is quite high.

I think the other important factors that we need to take into consideration are the strength of a person’s support system and the severity of their past episodes. In other words, if somebody has had an episode that was very severe, where they were very depressed and impaired and may have even been suicidal, we want to think longer and harder about whether to stop medication, as opposed to somebody who had a milder episode. Additionally, I might consider whether someone has people in their life who might notice if they’re starting to do poorly off medication. Sometimes when people start to have mild, subtle symptoms, they may not notice right away and other people in their life may notice and bring this to their attention before the symptoms progress and become more severe.

If someone is ready to stop their antidepressants, how would they go about doing that?

Like some other long-term medications, you can’t withdraw them abruptly. If a medication that your body is used to seeing is stopped abruptly, your body responds to the fact that something it’s used to seeing has been quickly withdrawn. Many of the symptoms people experience when stopping antidepressants are related to them being withdrawn too abruptly. We need to withdraw them slowly and carefully under the guidance of your doctor. In most circumstances, when the medication is tapered gradually, we can get the person off the medication without significant problems.

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