Jay R. Cavanaugh, Ph.D.

Depression is actually a variety of disorders that affect approximately 18 million Americans. Women are twice as likely as men to suffer from some form of depression. Acuity, or seriousness, of depressive disorders ranges from mild to severe. Depression can be episodic, short lived or chronic. Depression is the leading cause of disability in America today costing the nation in excess of $47 billion dollars a year in lost productivity and health costs. Depression is a serious medical illness that can have numerous physical complications.

Depression may manifest as major depression, dysthymic disorder (a less severe form of major depression), or bipolar disorder (a type of depression that involves cycling between depressive and manic states). A host of factors are responsible for depression including:

• Biological- a chemical imbalance of neurotransmitters and/or certain types of brain cell receptor sites is often seen in depression. Hormonal disorders including PMS (premenstrual syndrome) and PMDD (premenstrual dysthymic disorder) may influence or trigger depression. Depression may be linked to key biological events (i.e. post-partum depression or menopause).
• Genetic- Twin studies indicate that depression is often found grouped in families. Scientists have not isolated a single "depression" gene but feel a relatively small grouping of genes are involved in depression.
• Situational- Loss of a job, change in status, moving, divorce, and other major life stressors. Over use and chronic stimulation of the hypothalamic/pituitary/adrenal system (stress axis) has been implicated in depression.
• Chronic Illness and Disability- Depression occurs in the large majority of patients with long- term disease and disability. A traumatic diagnosis (i.e. cancer) may trigger depression.
• Personal Losses- The death of an immediate family member, close friend, or colleague.
• Medications- Many commonly prescribed medications may have depression as a side effect. Certainly tranquillizing medications including the Benzodiazapams may cause or deepen depression.
• Seasonal changes- Seasonal affective disorder (SAD) is sometimes seen where depressive episodes are related to winter or overcast weather.
• Alcohol and other drug abuse- Rates of depression in substance abusers are three times higher than the normal population. While many substance abusers are self-medicating a depression, studies show that chronic substance abuse itself leads to brain changes and depression.

Some recent studies have linked depression to chronic use of cannabis (several times/day for several years). This idea remains controversial. A current Australian study reviewed thousands of such cannabis users and found normal rates of depression once other factors such as alcohol use, gender, illness, etc., were accounted for.

Single agent prescription drugs called SSRI’s (Selective Serotonin Reuptake Inhibitors) are the most common form of treatment. Drugs like Prozac, Zoloft, and Paxil are in this category. These medications usually begin to work in one to four weeks. Side effects of SSRI’s can include sleeplessness, sexual dysfunction, and agitation. Older drugs called tricyclic antidepressants (i.e. Elavil) are also still used although their rate and severity of side effects is much higher than the SSRI’s. A new class of "bimodal" agents have recently been introduced (i.e. Serzone) that act on both the neurotransmitters serotonin and dopamine. Some of these agents such as Paxil and Serzone are also used in panic disorders and obsessive-compulsive disorders.

Individual psychotherapy and cognitive-behavioral therapy (CBT) in particular are often helpful in mild to moderate depression. Often a combination of CBT and a short course of medication are sufficient to relieve moderate depression.

Severe forms of depression with psychotic symptoms sometimes respond to today’s modified ECT therapy (electro-convulsive therapy) but the track record of this formerly brutal treatment clouds use and analysis of this controversial treatment.

Bipolar disorders are often treated with lithium carbonate a so called "mood stabilizer" lithium can lessen manic episodes but must be closely monitored as this metallic salt is highly toxic with side effects that include nausea, vomiting, and tremor. Patients undergoing lithium treatment require frequent blood tests to insure the correct blood level is maintained. Recently anti-seizure drugs such as Valproate and Neurontin have been used alone or in combination with lithium. These powerful drugs may help but can produce mental dullness. Neither lithium nor anti-seizure medications seem to help the symptoms associated with the depressive cycle of bipolar disease. The SSRI’s and tricyclic drugs are usually avoided in fear of aggravating manic symptoms. When manic episodes include psychotic delusions an anti-psychotic medication is often added. Anti-anxiety drugs of the Benzodiazapam class may be added where agitation is a prominent feature. The medication management of bipolar disease is complex and can be hazardous.

In evaluating the efficacy of prescription medications in depression it is important to remember that many of the current clinical studies have been financed largely or wholly by the pharmaceutical industry.

Symptoms of depression include:

• Sadness for prolonged periods. Fits of crying
• Sleeplessness or excessive sleeping
• Loss of appetite or excessive overeating
• Sexual dysfunction
• Anhedonia or the loss of pleasure in normal activities
• Feelings of despair or hopeless
• Feelings of low self esteem, guilt, or self loathing
• Ideas of hurting oneself or thoughts of suicide
• Unexplained lack of energy
• Chronic pain that doesn’t respond to treatment
• Anxious mood and irritability
• Trouble concentrating

In bipolar disease the above noted symptoms may be present during the depressive cycle while the "manic" cycle may include features such as:

• Excitability
• Rapid thoughts
• A reduced "need" for sleep
• Inflated self esteem or personal delusions
• Irritable mood
• Hyperactivity

Even a few of the preceding symptoms can indicate what is called a "clinical" depression if they persist for more than just a few weeks. A clinical depression rarely improves without a medical intervention and some combination of treatment.

Suicidal thoughts or impulses should always be taken seriously. The "truism" that suicidal patients won’t disclose their suicidal thoughts and that those who do are simply seeking attention is absolutely false. Seriously depressed patients may lack the "energy" for suicide, which is why the initial treatment and lifting of depression can be a particularly hazardous time. Patients who have a "plan" and the means to suicide are most likely to actually attempt harming themselves. One in every eight patients hospitalized for depression actually commits suicide.

Numerous patients report significant improvement and stabilization with their bipolar disorder when they utilize adjunctive therapy with medical cannabis. While some mental health professionals worry about the impact of cannabis on aggravating manic states, most bipolar patients trying cannabis find they "cycle" less often and find significant improvement in overall mood. Bipolar disorders vary tremendously in the time spent in the depressive versus manic states. Those who experience extended depressive episodes are more likely to be helped with cannabis.

Patients who use cannabis to "relax" may be treating the anxiousness sometimes associated with depression. Cannabis aids the insomnia sometimes present in depression and can improve appetite. Better pain control with cannabis can reduce chronic pain related depression. While cannabis cannot yet be considered a primary treatment of major depression it may improve mood when used under physicians supervision and in combination with therapy and/or SSRI’s.

There is currently a debate as to which "strain" of cannabis is most appropriate for the adjunctive treatment of depression. Since symptoms are so individualistic it is hard to determine what strain is right expect empirically. In general Sativa dominant strains tend to be more "up" and Indica dominant strains more relaxing.

Patients themselves are often the best judges of whether or not cannabis helps relieve the symptoms of depression. A poorly educated or narrow-minded physician may think any use of cannabis to be a substance abuse related aspect of depression. More enlightened psychiatrists (i.e. Lester Grinspoon of Harvard Medical School) appreciate the often beneficial aspects of cannabis therapy.

Perhaps the most reliable yardstick of the efficacy of medical cannabis in the treatment of depression is whether or not specific aspects of functionality improve. Functionality includes aspects such as self-care ability, job or school attendance, social interaction, normal sleeping, and cognitive skills.