C.Strange

Q: My wife is 37 years old and has started to slip into depression. She cries and gets anxious, also hides away from her friends and cannot see her way out of it. My worry is: She is being treated for anxiety and I fear she is still slipping. We are both desperate for an answer to her problem. Her period has been irregular recently and I wondered if this could be hormonal and whether HRT would help.

A: As painful as this must be for both of you now, your wife has at least two important things in her favor. She has sought help, and she has the support of a significant loved one — you.

        Depression, the most common serious psychiatric problem, affects nearly 20 million Americans every year. The majority never seek help, which is a shame because 80 percent to 90 percent of people with depressive illness get better with treatment, whether that's medication, psychotherapy or a combination.
      One in four women is likely to experience severe depression, according to the American Psychological Association, and it's about twice as common in women as men. While experts debate just why that is, they suspect it's caused by a combination of biological, psychological and social factors that play out differently in men's and women's lives.
      You didn't mention what sort of treatment your wife is receiving, nor how long she's been treated and by whom. But it sounds like time for a re-evaluation and perhaps a second opinion. A complete and careful history by a mental health professional is critical for proper diagnosis and treatment. "It's very multifactorial, what goes into creating depression," says Dr. Marlene Casiano, a psychiatrist in private practice near Chicago. "You have to really look at a lot of different things."
      As your question suggests, it's important to rule out potential underlying physical causes. Thyroid imbalance, crash diets, certain cold and allergy drugs, high blood-pressure medications, herbal remedies and, yes, hormones are among the things that can contribute to mood swings and depression. But it's important not to jump to conclusions about causes and effects.
      “There’s still a stigma attached to having a diagnosis of depression,” Dr. Casiano says, and people have a tendency to want to attribute it to things like hormonal changes.
But even if a contributing medical condition is discovered and treated, "You still do have to treat the depression itself," she says.
      At 37, your wife is younger than average for perimenopause, but it's possible. Her irregular periods could be the result of perimenopause, or of the depression. "When people are depressed they're real stressed and that could throw off their periods, too," Dr. Casiano says. Your wife could ask her mom at what age she reached perimenopause, and blood tests of her hormone levels could help clarify the picture. If she's perimenopausal, hormone therapy might help some but, "That probably would not be enough if she has the full criteria for depression," Dr. Casiano says.
      Which brings us back to the importance of proper diagnosis and treatment. Depression and anxiety often coexist, but anxiety has more outward, physical symptoms such as heart-pounding panic attacks and insomnia. A family doctor may see just that part of it and not ask further questions designed to reveal depression. The problem is that sleeping pills, tranquilizers and other anti-anxiety drugs can make depression worse.
      "I tell patients, if they want to start out with a family doctor because they have a lot of faith, that's fine," Dr. Casiano says. "But if they don't see improvement within a month, they really, really should see a specialist."
      Any doctor can prescribe antidepressants and other psycho-active drugs. As long as they truly understand the psychopharmacology of what they're prescribing, that's fine. "Modern drugs are getting more complex in terms of drug interactions and which types are most appropriate for which individuals," Dr. Casiano says. "If you don't do well on one drug, there are plenty of others out there that we could try you on."
      It's important to remember that many antidepressants don't take effect for a few weeks. Sometimes the depressed person doesn't notice, and loved ones may see slight improvements first. No one should go off these drugs without discussing it with their doctor. The usual advice is to wait several months after feeling better before tapering off. Slow tapering is important to avoid side effects and return of depressive symptoms.
      Some people may be shy about discussing their life with a stranger or simply don't want to pursue therapy into personal issues, and settle for a prescription. But generally, most people do better with combination therapy, Dr. Casiano says. During "talk" therapy, people can learn to change or at least recognize triggering situations and destructive thought patterns that contribute to depression. With psychotherapy, recovery is often quicker and relapses fewer — or at least caught earlier on. That's important, because as with other types of illness, the earlier you catch and treat depression, quite often, the quicker the recovery.
      “It’s such a waste of human potential,” Dr. Casiano says, “Sometimes people feel this is how life is going to be and it’s not really true once they’ve seen better.”
She works with women suffering postpartum depression who often look back and regret delaying treatment because their mental state made them miss the first precious, fleeting months of their babies' lives. And there's some evidence that the babies of depressed mothers don't do as well, and even experience developmental lags.
      The point is not to load yet more guilt on already overburdened new moms or anyone else. The point is to encourage people to get help as soon as possible to minimize any negative consequences in their lives and relationships.
      Living with a depressed person can be difficult as you tiptoe on eggshells wondering what to say or do, desperately hoping not to make things worse. Gently ask your wife how she feels. Find out what you can do around the house to lighten her load until she feels better. Cultivate your listening skills, and resist the urge to jump into active problem-solving. Recovery takes time and pressuring the person doesn't help. Meanwhile make sure your needs, and the needs of other family members, are getting met. Remember that with proper treatment people can and do get better.

                                                                               
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