Depression, Melancholia, Bipolar Disorders

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Differentiating Depressive Disorders to individualize therapy

Standard medicine terms the most prevalent depression diagnosis clinically as Major Depressive Disorder, which is also sometimes called unipolar depression, and defines this type of depression as a mood disorder characterized by the occurence of one or more major depressive episodes and the abscence of any history of manic, mixed, or hypomanic episodes. Minor Depressive Disorder is a term signifying a mood disorder closely resembling major depressive disorder and dysrhythmic disorder but intermediate in severity between the two. Disrhythmic Disorder is defined as a mood disorder characterized by depressed feeling, loss of interest or pleasure in one's activities, and other symptoms typical of depression but tending to be longer in duration and less severe than the episodes in Major Depressive Disorder. This was termed Melancholia in the past. Mood Disorder is defined as a group of mental disorders characterized by disturbances of mood manifested as one or more episodes of mania, hypomania (mild mania), depression, or some combination, the two main categories being bipolar disorders and depressive disorders. Hypomania is characterized by episodes of unusually excitable, energetic and productive behavior, with hyperactivity and talkativeness, increased sexual interest, quick anger, irritability, and a decreased need for sleep. All of these disorders contain a key aspect, which is an abnormality or derangement of function, and a morbid (pathological) mental or physical state. If one is becoming dysfunctional, and this may be due to a physical and/or mental disease mechanism or mechanisms, treatment is recommended, and the modern physician is looking past the standardized one-size-fits-all approach and designing individualized and integrated treatment protocols, addressing both the symptoms and the related health imbalances.

In 2009, a report by the Australian Psychiatric Drug Safety Expert Advisory Panel recommended that significant changes be introduce to prescribing guidelines for the treatment of Depressive Mood Disorders. Recommendation 1 noted that there is significant evidence that a Major Depressive Mood Disorder episode may be the initial presentation of a Bipolar Mood Disorder, and that prescription of an antidepressant alone could increase the likelihood that this could increase the likelihood of a manic episode, precipitating a worsening Bipolar Mood Disorder. Recommendation 2 noted that concurrent prescription of multiple drugs to treat Depressive Mood Disorders came with significant risk of initiating a Serotonin Syndrome of varied symptom intensity, particularly when prescribing an SSRI or SSNRI medication with an MAOI or other serotonergic agent, such as an atypical antipsychotic or medication to treat neurogenic pain.

Symptoms of Serotonin Syndrome vary widely in intensity and type, with autonomic dysfunction, altered mental status, agitation, confusion, and neuromuscular excitation, such as episodic tremors, incoordination, or hyperreflexia occurring. Recommendation 3 noted that antipsychotic medications come with considerable toxicity and the risk of developing movement disorders, or akathisia, such as bruxism, restless leg syndrome, or restless daytime movement disorders. Recommendation 4 noted that antipsychotic medications come with considerable risk of altering sugar metabolism, and glycemic monitoring be performed by the patient and changes reported to the prescribing doctor. These recommendations from an esteemed government agency show that the current standard of too easy prescription of antidepressants for episodes of depression and anxiety, and increasing multiple prescription of drugs when the effectiveness of a single drug is in question, are producing significant health risks and problems for the population.

In April of 2013, a study authored by Dr. Ramin J. Mojtabai PhD, of the Johns Hopkins Bloomberg School of Public Health, and published in the journal Psychotherapy and Psychosomatics, revealed that nearly two-thirds of a sample of 5639 patients from the 2009-10 United States Survey of Drug Use and Health, that were diagnosed with Major Depressive Mood Disorder and treated with antidepressants, did not meet the criteria for the disease. The explosive growth in the prescription of antidepressants came at the same time as a meta-review of all clinical studies of SSRI and SNRI medications showed that overall these drugs do not significantly outperform dummy pills, and the long-term adverse effects of this therapy, as well as the addictive nature of the drugs and problems with withdrawal, are serious drawbacks to therapy. Dr. Majtabai stated in an interview with the New York Times that "It's not only that physicians are prescribing more, the population is demanding more", revealing that the equation of massive advertising and the easy prescription of these drugs by medical doctors that are not specialists in the field, as well as massive monetary incentives to prescription, have resulted in most patients concerned with a mood disorder not diagnosed properly, and not treated with the best protocol.

The underlying pathophysiology of Major Depressive Disorder is still not clearly defined in standard medical theory. Theories identify imbalances of key neurotransmitters, such as serotonin (i.e. 5-HT, hydroxytryptophan), dopamine and norepinephrine (adrenaline). The links between these neurotransmitters and the disorder are still largely defined by the fact that drugs that block receptor activity for the neurotransmitters seem to alleviate symptoms for a percentage of patients. The most common drugs used to treat Major Depressive Disorder work by either inhbiting reuptake of 5-HT at the synapse, antagonizing 5-HT or norepinephrine receptor activity and enhancing neurotransmitter release, or inhibiting the enzyme monoamine oxidase (MAO) and reducing neurotransmitter breakdown. Due to the poor control of depressive symptoms in long term therapy, other classes of drugs have now been approved to also treat various types of depressive disorder, or to add to these first order drugs to increase effectiveness. Expanded research is finally linking a variety of other chemical imbalances to depressive disorders, such as adiponectin dysregulation in obesity and metabolic syndrome, and the realization that we must address a complex host of chemical imbalances to really treat these disorders is finally taking hold. Many medical experts, as well as more informed and proactive patients, are also exploring the reasons why these neurotransmitter imbalances occur, and are looking for more treatment aimed at correcting the underlying causes of neurotransmitter imbalance.

Major Depressive Disorder (MDD) is diagnosed in approximately twice as many women as men in the United States. The underlying causes and contributors are linked to a variety of female hormonal imbalances in most cases. Women with bipolar disorder tend to be more prone to a rapid cycling of depressive and manic mood, and women are vulnerable to a variety of hormonally influenced psychological disorders, including premenstrual dysophoric disorder (PDD), premenstrual syndrome (PMS), postpartum depression, and perimenopausal mood disorders. Pharmaceutical medications for mood disorders have been more frequently prescribed for women, often without a proper assessment of these female hormone imbalances, and without adequate therapy to correct the underlying causes or contributors to mood disorders. By seriously considering the effects of synthetic hormones on hormonal imbalance and mood disorder, by integrating Complementary Medicine to achieve better hormonal health, and by educating the female patient to the physiology of neurohormonal mechanisms, we will be able to resolve many of these mood disorders without the dependence on drugs.

Overall, the focus on the pathology of Major Depressive Disorder has not been neurohormonal, though, but limited to the contribution of imbalances of neurotransmitters, especially serotonin (5HT) and norepinephrine (adrenalin). The underlying causes of these neurotransmitter imbalances usually relate to neurohormonal dysfunction, though. One of the most significant reasons why we have so little research success in discovering the underlying causes for imbalances of 5-HT and norepinephrine is that the pharmaceuticals that block these neurotransmitter reuptakes are so profitable. A time will come when the world directs more research into the mechanisms that precede these neurotransmitter imbalances, and at that time, the profits of pharmaceutical companies will drop dramatically. The relatively little research now being conducted to discover these imbalances has uncovered the more complex role of receptors in the disease mechanism, leading to a current drive to promote drugs that affect a large array of neurotransmitter receptors, called antipsychotics. This strategy still fails to understand and correct the underlying homeostatic failures and their causes. This type of research has uncovered the complexity of receptors in the brain, though, and revealed that many, if not most, receptors are triggered by more than just one type of neurotransmitter chemical. These receptors are usually stimulated by more than one neurotransmitter, and by hormones, and potentially by lesser signaling chemicals as well, such as immune cytokines. Research is also discovering that there is a complex quantum effect in the receptor functions as well, and that when there is a change in neurotransmitter concentration, a change in quantity of variants of a neurotransmitter, hormonal changes, and metabolic changes, that these receptors exhibit altered function and reactivity. In effect, there is a complex balance of chemistry that is needed to insure the healthy function of neurotransmitter receptors, and since the receptors are doing the work, not the neurotransmitters and hormones directly, this is where more advanced research is directed.

Recent theories have led to the belief that reduced nerve cell volume and size in the hippocampus is a key to mood disorders (reduced neurogenesis or neurodegeneration). Neurodegeneration is now a very important focus in discovering the underlying health problems in depressive disorders. Reduced neurogenesis, or neurodegeneration, in patients suffering from chronic depression is now found in the hippocampus, lateral ventricles, and neocortex, which is small in cell number and size but very important to cortical function. The dual role of neurotransmitter chemicals as both hormones and neurotransmitters is also a focus of modern study once again, and subclinical hormone imbalances may be integral to depressive syndromes in a large percentage of patients. The body's intrinsic regulation of mood is also of prime importance, and such mechanisms as GABA modulation may be significantly improved with herbal and nutrient therapies. While recent studies have shown that there may not be a GABA deficiency per se in Major Depressive Mood Disorders, all studies have revealed a consistent glutamate deficiency, the precursor to GABA, and it is certain that the homeostatic function of glutamate receptors, the regulation of GABA metabolism, and other modulating factors are related to mood disorders and erratic symptoms. The persistence in standard medicine to treat these homeostatic feedback mechanisms as just a deficiency of one molecule is a hallmark of the allopathic approach. All of this research points to the need to develop a more complex and multifaceted approach to therapy in depressive disorders, and a more complex and individualized way to diagnose that reveals the differences between one patient and another. In recent years, it has been discovered that electroacupuncture and manual acupuncture at common points, such as ST36 and DU20, stimulates neurogenesis in the hippocampus (see study link below in Additional Information).

Adherence to the standardized treatment of all of these depressive disorders has been much studied, and non-adherence to this simplified treatment protocol of single drug therapy has been a common problem across the world. Non-adherence to this drug regimen presents problems beyond poor effect of treatment, as intermittent use and dose variance is shown to create many physiological problems and side effects itself. Withdrawal from SSRI and SSNRI medication is also problematic, as neurochemical changes from sudden withdrawal have been show to have negative effects that are quite dramatic. Many books have now been written on the subject of this withdrawal syndrome and the subsequent addiction to these medications. With the promotion of these drugs as a standardized therapy, integration of a multifaceted treatment protocol declined, and depressive disorders that were less severe, such as Minor Depressive Disorder, Disrhythmic Disorder, minor Mood Disorders, and even situational depression and depression related to chronic health problems such as hormonal imbalance, subclinical hypothyroidism, obesity, etc. were all treated the same, with exactly the same drug protocol. The creation of dozens of different names for slight variations of the same drug has given the public the impression that there are significanct choices in treatment, but this aspect is finally being realized as false. The public is now looking to an evolved treatment standard that utilizes a variety of treatment tools and integrates them with an individualized approach.