Depression is a life-threatening disorder that seems to be triggered by stress, hormones, genetic glitches, medical conditions, medication, and maybe even the kitchen sink. Its onset is predicted by insomnia, insomnia usually accompanies it, and insomnia is usually the last symptom to disappear. Maybe that’s why, as Ruth Benca, M.D., Ph.D., and director of the sleep program at the University of Wisconsin-Madison, says, “All the things that are good sleep therapy are good depression therapy, too.” Here are the strategies that can help you beat both.
Check with your primary-care physician. Depression can be the side effect of a laundry list of illnesses — cancer, for one; sleep apnea, for another — and medications. So if you’re feeling down for any length of time, your first step is your primary-care physician.
See a psychiatrist. Depression can kill, and the medications frequently used to rebalance your brain chemicals can be tricky. So once your primary-care physician has ruled out medical conditions and medication as a cause of depression, even if you’re comfortable with your primary physician’s care, you might want to ask for a referral to a psychiatrist.
Your primary-care physician may be able to deal with depression as a temporary side effect or the everyday blues, but it’s a psychiatrist who is trained in the ins and outs of major depression and its treatment, and it’s a psychiatrist who is most able to suggest the treatment option that, tailored to your particular situation and combination of issues, is most likely to succeed.
Think about the Big 3. The three approaches doctors usually suggest for major depression are antidepressant medication and either cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT), says James P. Krainson, M.D., a sleep medicine specialist at Miami’s South Florida Sleep Diagnostic Center.
“Most depression responds to medication,” he adds. Since it’s likely to be caused by a biochemical imbalance in your brain, a chemical can frequently help. Fortunately, however, depression responds well to all three treatments.
In a review of studies conducted at Vanderbilt University, researchers found that medication had a rapid and robust effect, plus it prevented the return of symptoms for as long as it was taken.
In the review, both CBT and IPT seemed to be just as effective as medication. In particular, IPT might help the individual work out personal issues, while CBT seemed to have an enduring effect that reduced the risk of future depressive episodes — a big concern among doctors.
Combined treatment with both medication and therapy seemed the best choice, the researchers concluded, since combination therapy seemed to boost the effectiveness of each.
Try again. “Studies have shown that about half of those who start on a treatment of medication and/or therapy get some relief,” says researcher George Niederehe, Ph.D., the National Institute of Mental Health’s project officer for STAR *D, a nationwide series of studies that included more than 4,000 men and women diagnosed with major depressive disorder. But doctors weren’t sure how to help the other half once the initial therapy had failed. Common sense told them to try another medication and see what happened, which is what many doctors did. Still, they wanted some clear direction about what helped and what didn’t — or if there was another way to approach treatment altogether.
Enter the STAR *D study. Conducted in the real world among people with demanding jobs and relationships, the study has shown how to help the other half — the group science seemed to have left behind.
There were two key studies in STAR *D. “One study looked at how well people did if their original treatment was supplemented with a second one. The other looked at how well people did if their original medication was switched with another,” says Dr. Niederehe.
In the first study, in which an original antidepressant medication that hadn’t achieved complete remission of symptoms was supplemented with a second antidepressant, 1 in 3 patients achieved a remission of symptoms.
In the second study, in which patients were switched from the original antidepressant to another, 1 in 4 patients achieved a remission.
“In both cases the finding was that the move to a second treatment benefited a substantial number of patients,” says Dr. Niederehe, who further explains that when thinking about treatment for depression, there are a couple of things revealed by STAR *D to keep in mind.
One is that even though the 10 medications used in STAR *D work via different mechanisms, they all worked in the same numbers of people. In other words, no one antidepressant was more effective than any other. The other is that if you begin to take a particular medication and show even a partial benefit, you should stick with that particular medication for a full 12 weeks because you may well achieve remission in that time.
On the other hand, if you show no benefit at all after eight weeks on one medication, you should talk with your doctor about switching.
The bottom line, says Dr. Niederehe, is this: “If you fail at the first treatment, don’t give up. It may just be that you haven’t found the right approach. Another treatment is likely to help. And by giving treatment another try, you have a good chance of complete remission.”
Attack the insomnia. “You need to treat the insomnia at the same time as you treat the depression,” says Sonia Ancoli-Israel, Ph.D., a professor of psychiatry at the University of California at San Diego. “You don’t just treat the depression and then assume that the insomnia will go away on its own.”
What’s more, she adds, “There have been studies on depression that show that if you treat both the depression and the insomnia at the same time, concurrently, you’ll get a better, faster response not only to the insomnia, but to the depression as well.”
So put the basic insomnia-fighting strategies to work: Go to bed at the same time every night. Get up at the same time every morning. Walk in the noonday sun without sunglasses. Each of these strategies uses the presence or absence of light to set off a chemical reaction in your brain that ultimately affects the neurotransmitters involved in depression. It’s no coincidence that light therapy alone is used to treat a specific form of depression called “winter depression”
If you’re still not sleeping after a few days, ask your health-care provider to give you a hand, says Dr. Ancoli-Israel. “And don’t let her dismiss the idea that sleep is important,” she adds. “If necessary, make a separate appointment to discuss your insomnia with her.”
Report thoughts of suicide immediately. The idea of suicide is common in severe depression. If the thought even passes through your mind, call your doctor or 911 immediately. Severely depressed people do commit suicide.
See a sleep specialist. If you have severe depression and you can’t sleep, you may want to ask your doctor for a referral to a sleep center, suggests Dr. Benca. A sleep center’s specialized testing and trained scientists may be able to give you some help.
Practice your faith. A study at Duke University found that severely depressed people who put their faith at the center of their lives recovered 70 percent faster than those who did not.
Sweat. Another Duke University study found that 30 minutes of exercise, in which you work up a sweat, is just as effective as antidepressants in reducing major depression. What’s more, another study found that exercise is key to preventing relapses — a serious problem in those who have had more than one episode of depression.
Hang out with friends. In a British study, hanging out with a friend on a regular basis lifted the spirits of those with mild depression.
Structure your day. People who have depression frequently lead unstructured lives, says Ruth Benca, M.D., P.h.D. Unfortunately, it contributes to both depression and insomnia. So put yourself on a schedule and stick to it. Eating, sleeping, working, exercising, socializing — figure out what times work for you and then carve them in stone.
If it swims, eat it. Those who consume diets rich in omega-3 fatty acids, a type of fat found in cold-water fish such as salmon, are less likely to experience depression than others, reports a Dutch study. And a study in England found that pregnant women who ate 10 ounces of fish a day had half the rate of depression as women who didn’t. In fact, some researchers think that the amount of depression in America is directly related to a lack of fish in our diet.
Enlist your partner. A study of 84 depressed pregnant women found that those who were given two 20-minute massages a week from their partners reduced their incidence of depression by 70 percent. The researchers suspect massage boosts serotonin levels and reduces levels of stress hormones.
Stay out all night. But only once, and only with your doctor’s approval and support. This is a bit tricky, since it can make depression worse. But the odd thing is that depriving yourself of sleep for one night — and no more than that — has been shown to lift depression for as long as a month. Researchers don’t know how it works, but they suspect that one night of sleep deprivation may reset your sleep clock.
Take care of business. In London, researchers at King’s College have spent three decades looking into the effect of workloads, deadlines, and other job-related stressors on nearly a thousand young working adults. They’ve found that these types of jobs demand nearly double the risk of depression in women.
If you find yourself getting depressed at the thought of going in to work because of the workload or time demands, talk to your employer and try to negotiate a saner workload, more realistic deadlines, or assistance from other colleagues. If your boss isn’t interested, put the word out to friends: You’re looking for a new job.
A woman’s best friend, too. When people without pets played with a dog for just a few minutes a day as part of a University of Missouri study, levels of the brain chemicals serotonin and oxytocin — both mood elevators — rose. You don’t have to own a dog to get these benefits, either. Volunteer at an animal shelter to walk a dog, or just pet your neighbor’s whenever it trots by.
Eat a bowl of fortified cereal every day. Or take a multivitamin. Either will provide you with 400 micrograms of folate, a B vitamin that is known to lift depression. Folate and other vitamins help maintain nerve and blood cells, which are used in brain reactions and are essential for the production and function of a number of mood-boosting brain chemicals. And a study published in the Annals of Clinical Psychiatry found that folate actually helps enhance the effectiveness of antidepressants.
Stay on meds. Depressive episodes tend to recur. To reduce the risk of relapse, doctors recommend that you stay on medication for six months to a year even though you may be feeling normal again.
Stay alert. Insomnia can herald the return of depression before you’re even aware of it. If you start having sleep problems again, schedule an appointment with your doctor. Early detection and treatment can minimize its effect on your life — and even head it off.