Previously depressed people, what has changed


1. What is depression?

The illness depression must be distinguished from the normal emotional reaction to an emotionally negative stressful event. The foundations of today's understanding of depression were created at the end of the 19th century by the psychiatrist and founder of the current Max Planck Institute for Psychiatry, Emil Kraepelin.

Depression can take many different forms. Attempts were made to define it using certain diagnostic criteria, but the transitions between the various forms of depression are fluid and the rigid adherence to diagnostic schemes has proven to be of little use for therapy and research.

Depression can begin insidiously or occur suddenly, like a bolt from the blue. The typical symptoms are sadness, insomnia, poor concentration, tiredness, irritability, slow movement, poor appetite and weight loss, as well as hopelessness and the inability to engage emotionally in events in the immediate vicinity. Often there are daily fluctuations, typically the depression is more pronounced in the morning than in the afternoon. Interest in normally positive activities has died, and there is almost always a lack of sexual desire and even an inability to engage in sexual activity. In severe cases, the hopelessness is so pronounced that the will to live disappears and thoughts of suicide arise, up to and including planning and carrying out suicide attempts.

A relatively small number of people with depression develop unrealistic thoughts, such as: B. that depression is the just punishment for past life misconduct. These so-called delusional ideas are sometimes religiously colored and are often experienced as God's punishment. These delusional ideas can also lead to other unrealistic fears. The sick thinks that they are heavily in debt, that they cannot afford hospitalization and that they are ruining the family. In other cases, unrealistic fears about the physical condition are in the foreground, here assumptions play a major role, according to which a severe, as yet unrecognized, disease that has not yet been found would spread in the body. Such patients often consult many doctors and repeatedly undergo relatively unpleasant diagnostic procedures, e.g. B. gastroscopy because they cannot believe that their depression-related fears are unfounded.

A rare form that occurs mainly in women are the very brief acute depressive moods that often only last a day or one to two weeks and then subside by themselves. Another form that occurs rarely is chronic depression, in which, despite all therapeutic efforts, only a slight improvement can be achieved.

Another special form of depression that occurs in around 1% of the population - compared to 15% for typical severe depression - is manic-depressive illness. In addition to depressive episodes, so-called manic episodes can also be observed. In a way, these manic episodes are the opposite of the depressive episode. Here, the mood is consistently uplifted, carefree cheerful to irritable. The patient's activity is so increased that this is reflected in both social and professional areas. Patients with a mildly developed manic episode are often very efficient, perform better than usual, have a low need for sleep without having the feeling of having to exhaust themselves.

If the mania is very pronounced, however, professional overactivity often turns into an economic problem, because there is a lack of self-criticism, there is overconfidence, and it is not uncommon for a department head with a mania to feel quickly appointed head of the company, want to restructure the company or give a lot Money, including personal resources, for improper purchases (villa, luxury limousine, etc.). Problems also arise in the social area, mainly due to a lack of distance and weakness in criticism, for example towards alcohol and the tendency to sexual debauchery. In a subsequent depressive episode, the behavior during the mania is often perceived as guilty and stressful.

Depression can appear for the first time at any age, but the full picture of depression is most common in middle age. Follow-up studies have shown that the harbingers of depression can already be recognized at an early age, but not as depression, but as anxiety disorders. We now know that young people with anxiety disorders, e.g. B. panic attacks, have an increased risk of developing depression later. It is only in old age that the risk of developing depression for the first time is reduced. However, we do not know whether depression in old age is actually hiding behind some forms of dementia that are more common in old age.

2. Depression, a common illness

Depression is widespread in the population. Epidemiological studies have shown that at least 15% of the population will develop depression at some point in their life. This does not mean the slight depressive moods that could be understood as a normal emotional reaction, but those depressions that are so impairing that they have to be treated, or better said, because too often depression is not recognized.

A study by the World Health Organization (WHO) has shown how severe the frequent occurrence of depression affects our economic and social life, according to which depression, along with cardiovascular diseases, is the world's leading cause of the years of life impaired by disability. This calculation is based on the entire life span. If the age range is narrowed to 15 to 44 years, the great importance of these psychiatric illnesses, and here of depression, becomes particularly clear. They make up around a quarter of all disability-impaired life years in this age group.

Health insurance companies can also tell you a thing or two about this: Antidepressants are among the most widely prescribed drugs and take a top position in drug costs for all medicine. Even more serious are the high number of time spent in hospital and the costs of visits to the doctor and psychotherapy. The most serious factor, however, is the enormous amount of downtime due to sick leave and early retirement. The cost of this is a huge burden for employers, health insurers and the pension system.

Both the economic and social aspects of depression and the large number of tragic individual fates identify depression as a disease that has an enormous impact on the population. It signals to the individual affected by the disease that they are not alone with their fate. In fact, depression can affect anyone. It is not a disease of the poor, the underprivileged, those who live on the fringes of society and are in dire economic straits. The list of successful personalities from the fields of art, politics, business and science is long: Ernest Hemingway and Klaus Mann are among them, as are Ted Turner (founder of the news channel CNN), Winston Churchill, Prince Klaus of the Netherlands and Keanu Reeves. Michelangelo, Karl May, Frederic Chopin and Rudolf Diesel also suffered from depression.

3. Is depression more common today than it used to be?

If one takes the development of diagnoses, for example from health insurance statistics, as a basis, then one could actually get this impression and many would then already have the explanation ready: Because our life brings so much stress with it, more and more depression is triggered. But you should be very careful here.

In the past, when depression was supposedly rarer, the willingness was much lower than it is today to reveal symptoms of depression in an epidemiological survey. Thanks to effective educational work, I am mentioning the competence network of the Federal Ministry of Education and Research on the subject of depression, but also the good work done by numerous self-help groups, the subject of depression is less negative in public than it was 10 or 20 years ago.

If, as some think, depression were more of a kind of civilization disease or fashion disease, then the frequency of depression in industrialized countries would have to differ from those in so-called third world countries or emerging countries. However, there are strong cultural differences in the way in which patients perceive their depression and also report it in the case of an epidemiological survey. With the survey questionnaires that have been developed in Western Europe and that change from survey to survey, you cannot determine exactly whether the changes are due to the changes in the questionnaires or to the changes in the frequency of the disease, and you can do not expect that the same questionnaire - translated into the respective language - will produce the same result in Ukraine as in Colombia, southern China, Sweden or Japan.

In fact, the frequency figures vary between 10 and 25%, but not systematically, but criss-cross from country to country. If surveys are made that address the ethnic and cultural characteristics of a region, the result is always the same, namely 10-12%.

4. Do women get depression more often?

If one compares the diagnosis frequency in women with that of men, it is noticeable that women seem to be diagnosed with depression about twice as often. However, this can be an artifact, because the more severe the depression, the more similar women and men are in their frequency numbers. Manic-depressive illness occurs equally frequently in women and men. It may therefore be that the fact that women are more often diagnosed with depression can be explained primarily by the lighter forms. The possibility must be considered here that men are more reluctant to reveal symptoms of depression and to go to the doctor for treatment for depression.

However, there is one special feature that makes women more susceptible to depressive moods and even severe delusional depression: This is the increased risk of getting sick at the time of the monthly menstrual period, as well as during other hormonal changes such as childbirth and the greatly reduced production of sex hormones in women at the end of their fourth decade of life. Above all, the strong mood swings after childbirth, in which there is a massive decrease in women-specific hormones such as estrogens and progesterone, are characteristic symptoms in the puerperium. Rarely does it even lead to severe delusional depression.

5. Depression, a potentially fatal disease?

According to official statistics, 12,000 people in Germany commit suicide every year. Since attempted suicide and suicide are associated with considerable social and financial disadvantages for relatives, it is rightly assumed that the number of unreported cases is much higher. The unnatural causes of death resulting from injury and poisoning kill 35,000 people each year, including 23,000 men and 13,000 women. We have to assume that there are also many “hidden” suicides among them.

About 16% of all people with depression and 30% of patients with bipolar (manic-depressive) depression attempt suicide. 6% of all patients with depression die of suicide; the number is about twice as high in bipolar depression.

When you look at these numbers, you realize that depression is a potentially fatal disease. The particular tragedy is that unlike other serious illnesses, e.g. B. Cancer diseases, death by suicide would be fundamentally prevented. It is therefore all the more important to explain to patients with severe depression again and again that the current desperation and helplessness as typical signs of their illness will pass and that the desire to escape the illness by suicide will also disappear. We must not overlook the fact that the patient does not want to end life as such. Rather, the suicide happens out of an impulse, because he can no longer stand the depression.

There are also causes other than depression that can lead to suicide. A significant proportion of people who suffer from alcohol addiction or other addictive diseases attempt suicide, which leads to death, especially in older men. A certain percentage, it is estimated 8-10%, commits suicide as a result of a negative life balance, often after professional disappointment and little support in the family. There are also suicide attempts after losing a partner. Such causes lead to acts of suicide that outsiders can rarely foresee.

6. Do antidepressants increase the risk of suicide in children and adults?

In recent years it has been discussed whether children who have been diagnosed with depression have an increased risk of suicide if they are given a certain antidepressant drug. Apart from the fact that the manufacturer did not behave particularly skillfully in disclosing the study results, it can be stated that neither children nor adults are suicidal by antidepressants.

On the contrary, the thoughts of no longer wanting to live subside under these drugs. You only have to make the only restriction that in a severely depressed patient who suffers from suicidal thoughts, whenever the drive is normalized again by the drug, but the mood is still very much characterized by despair, this drive increase may result in the implementation of the Suicidal thoughts indeed aided.

Overall, however, it must be clearly stated that the main risk for attempting suicide, regardless of the age group, is the depression itself and not the drug that is given to treat the depression. In fact, some drugs that are used for other diseases, such as: B. against epilepsy, can lead to severe depressive moods. Depression can be triggered, especially in people who are prone to depression.

7. Causes of Depression

In the past, a distinction was made between neurotic and endogenous depression, on the assumption that there was an organic cause for endogenous depression, whereas neurotic depression was based on an inorganic cause that was caused by external factors such as social environment, childhood experiences, etc.

Research into the brain using methods from natural sciences, including experimental psychology, has created a new perspective here: Depression is a disease of the brain. In this organ, life influences are registered and stored in billions of small nerve cells, all of which are connected to one another in complex circuits, and the corresponding response patterns are programmed and sent to all other tissues in the body. The way in which the external influences that we absorb via sensory organs such as eyes and nose, taste buds and body touches are stored in our brain depends on our previous use of the brain, i.e. the stored information, as well as on our genetic makeup .

Almost half of all our genes are only there to create the blueprint for how our brains function. There can be larger or smaller deviations, which then make the individual susceptible to external influences. It is assumed that the genetic component for typical depression is 50%, while the genetic component for manic-depressive illness is over 80%. This genetic 'vulnerability' is not due to a single gene, but to a large number of different genes. These genes determine whether we are vulnerable to external events that trigger strong stress reactions and whether we develop depression as a result. However, it can also be the other way round, that a particular genetic predisposition means that we are more resilient to stressful situations. The question of whether we suffer from depression as a result of a stressful situation can only be answered based on the interplay between external influences and genetic predisposition.

8. How do I know if I have a predisposition to depression?

The surest indication of a predisposition is the presence of depression in family members. However, one should not be unduly alarmed by this, because the depression is not passed on after a simple inheritance process. Rather, heredity is widely spread over many genes.Each of these genes is only slightly changed and contributes to a different extent to the genetic disposition.

External influencing factors can change the gene activity acutely and only temporarily or permanently, so that clinical symptoms can manifest themselves spontaneously or only gradually. It is important to know that there is a genetic risk from family history and then to be aware of early signs of illness, such as B. to pay attention to sleep disorders, vegetative changes, anxiety attacks and to take countermeasures early.

9. Cognitive impairments in depression: memory, attention and concentration

In depression, in addition to the brain regions that are responsible for feelings and emotions, those that are responsible for attention and concentration, memory, i. H. the ability to learn and remember, the mental speed and the so-called executive functions are responsible. The latter concern skills such as planning and performing actions, multi-tasking or mental arithmetic.

It often happens that even simple activities such as reading or listening to the news, which can otherwise be routinely done, are extremely difficult or even impossible. In about half of the cases, these deficits, some of which are serious, can also be resolved after the acute episode of illness, i.e. H. after the actual core symptoms of depression (e.g. depressed mood, joylessness, sleep disorders) have regressed.

This not only makes psychotherapeutic treatment more difficult, but also plays a major role in the ongoing impairment of social and professional functionality and quality of life. Therefore, the exact diagnosis of the deficits at the start of treatment and during the course of treatment is of great importance for the tailored planning of neuropsychological, behavioral and occupational therapy interventions to improve cognitive abilities.

10. How is depression treated?

All of our body processes, our thinking, feeling, acting and willing are influenced by certain circuits in our brain via chemical processes. In depression, the biochemical balance of signal transmission is disturbed. The therapy aims to correct this metabolic disorder in the nerve cells with medication.

If one compares a large number of patients with depression, then there is a clear connection between genetic disposition and external stress, perceived as stressful situations, which can trigger depression. In individual cases it often looks different: Such a stressful situation, which is perceived as stressful for the individual, cannot always be identified as the trigger of a depressive episode, just as most people who experience a stressful situation do not fall ill with depression as a result.

Due to the clear connection between stressful life events, or stressors for short, and the development of depression, stress research has also played a central role in the treatment of depression.

Stressful situations are answered in the brain by the production of various protein molecules. These increase the concentration of stress hormones in the brain and in the rest of the body. However, these stress hormones also attack the so-called messenger substances in the brain. These are small chemical molecules that act as signal mediators between the billions of nerve cells in the brain. These signal molecules are the starting point of the drugs against depression that are commercially available today, the so-called antidepressants. This class of drugs is made up of very different chemical compounds. What all antidepressants have in common, however, is that they intervene in the metabolism or in the function of the signal-transmitting neurotransmitters.

You have to imagine it like this: The neurotransmitter is released from the terminal of a nerve cell in order to transmit the signal from one nerve cell to the other. There is a small gap between the ends of two nerve cells, into which the messenger substance is released. Basically, two reactions can now set in: Either the neurotransmitter is taken up again by the nerve cell that released it, or it binds to a structure on the surface of the neighboring nerve cell and triggers a signal there that is passed on inside the cell.

The effect of today's antidepressants is based on an amplification of this form of signal transmission. The antidepressants differ, however, in what kind of messenger substances are strengthened in their effect. We differentiate between serotonin and norepinephrine. The antidepressants most widely used today strengthen the signaling effect of serotonin. Our knowledge of the effects of antidepressants is already very extensive, but we are constantly discovering new effects that these drugs can exert on the cell surface or inside the cell.

Many clinical studies on patients with depression have clearly shown that antidepressants are effective. Occasionally one also hears voices that antidepressants should not have the effect attributed to them. These statements are wrong, cynical and dangerous, because they can lead one to refrain from using this therapy on the patients who urgently need it. The impression that antidepressants do not have the expected effect stems from studies in which patients with mild depression were examined and in which it was found that there was no advantage here compared to placebo (i.e. a non-effective dummy drug). However, it is the case that mild depression very often goes away without specific treatment, so that the equivalence of antidepressants and placebo in such studies should not lead to the conclusion that antidepressants are ineffective in severe depression.

The frequency figures of around 10-12% risk for each individual to develop depression in life do not include mild depression that does not require drug therapy. In severe depression there is no alternative to influencing the metabolic disorder with antidepressants. These drugs are not sedative, do not induce habituation or addiction, and have no serious side effects.

The time between taking an antidepressant and the onset of first symptom improvement varies widely. It often takes two or more weeks for the patient to feel an improvement in their symptoms. It is therefore important not to lose patience and accept that the healing process is slow, step by step and that sometimes, after an initial therapeutic success, it can temporarily deteriorate again.

11. The journey of antidepressants to the brain

Antidepressants have to travel a complicated path before they can work in the brain. First they are taken as tablets, rarely also as drops, and travel through the esophagus to the stomach and from there to the intestines. There they are absorbed by the blood, enter the great circulation and, after they have managed to survive their stay in the stomach and intestines intact and not be broken down by the liver, are released from the blood to the brain.

The way the stomach and intestines handle the drug varies widely. Medicines also suffer a different fate in the liver, because every person there has a slightly different mixture of such enzymes, the main task of which is to break down medicines. This means that in one person a drug will pass from the gastrointestinal tract into the blood and will only be broken down to a small extent by the liver, so that in this case there is already a sufficient concentration of the antidepressant in the blood even though the amount taken was small. In another case, however, the passage from the gastrointestinal tract can be more difficult and the drug can be broken down very intensively in the liver, so that only a small amount circulates into the bloodstream at the same dose as before. In order to avoid the risks of too high or too low a dose, the plasma concentrations of the antidepressants in the blood are measured.

Since the brain is protected from the blood circulation by a so-called blood-brain barrier so that our most valuable organ is not flooded with substances that are incompatible with the brain, we also have to be sure that the drug is actually passed from the blood through this blood-brain barrier. Barrier enters the brain. To check this, after the start of therapy we have to measure the brain waveform (EEG), among other things, in order to be able to estimate the adequate dosage with its help.

12. Do antidepressants have side effects?

Substances of the first generation of antidepressants, which were discovered in their basic chemical structure in the fifties of the last century, actually had unpleasant side effects in many people, affecting the autonomic nervous system and occasionally leading to sweats, dry mouth, blurred vision and seizures .

The new antidepressants that we use today do not show these side effects or they show them very much less, but others that are less unpleasant, but with which we cannot be satisfied either. These include restlessness, sweating, weight gain and occasionally sexual dysfunction, especially at the beginning of treatment.

All of these symptoms caused by antidepressants - and this must be emphasized again and again - are minor compared to the symptoms of depression, which is also associated with cardiovascular problems, gastrointestinal problems, sexual dysfunction, insomnia and restlessness. It is important to know that antidepressants are not addictive, so you don't get “addicted” to them.

13. How do I know if I am getting the right medication?

There are a large number of different antidepressants on the market today (around 40) without us being able to say with certainty which one is right for the patient in question. Different drugs have different main and side effect profiles.

Some drugs have a more activating effect. These are particularly appropriate in patients who have poor psychological drive. Other medications tend to have a calming effect and are particularly suitable when the patient is plagued by strong inner restlessness and sleep disorders.

Science is currently trying to identify the most suitable drug for the individual patient on the basis of biochemical and genetic data. This tailor-made form of therapy is also called "personalized medicine". The first results from the Max Planck Institute for Psychiatry allow the conclusion that this will actually become a feasible and, for the patient, a considerably better way than with today's therapies.

14. Are only antidepressants given as medication for depression?

In fact, antidepressants are at the heart of any therapy for depression. At the beginning of treatment, however, it may be necessary to give a so-called benzodiazepine for one or two weeks. This alleviates agonizing states of fear, especially thoughts of suicide. Today, however, we are extremely cautious about prescribing benzodiazepines. They are only prescribed in selected cases because prolonged use can lead to dependence.

Another class of substances that is occasionally combined with antidepressants are the so-called neuroleptics. These drugs are particularly useful in the treatment of mania. They are also given to those depressed patients who have unrealistic negative ideas (e.g. delusional thoughts of guilt, etc.). If sleep disorders are particularly distressing, one will first try to treat them with a particularly suitable antidepressant. If this is not enough, sleeping pills or neuroleptics are also temporarily prescribed.

15. What role does psychotherapy play?

Psychotherapeutic accompaniment of a patient is urgently needed in the majority of cases. An understanding and supportive medical discussion with the creation of an overall treatment plan is the basis of any depression treatment and can be sufficient as the only therapeutic method for mild depressive moods.

The most important form of psychotherapy is what is known as cognitive behavioral therapy. It includes the correction of negative reality and self-assessment, the step-by-step development of activities according to the reinforcement principle, the promotion of self-confidence and social competence as well as coping with everyday problems. Psychoanalysis, named after its founder Sigmund Freud, has no relevance for the treatment of severe depression, although this is still by far the method for which the most money is spent (75% of the total health insurance budget for individual therapeutic procedures).

The aim of any depression therapy is always the complete restoration of the psychological well-being. Due to the increasing economic pressure from the cost bearers to shorten the length of inpatient stay, this goal often cannot be achieved. It is therefore necessary to interlink inpatient and outpatient care so that the deficits remaining after inpatient therapy are eliminated by outpatient treatment and the risk of relapse is thus reduced.

16. Can Depression Be Cured?

If healing is understood to mean restoration of the state of health by reaching the initial state, then we can say with certainty that after a treatment of about six weeks between 50 and 60% of the patients are healed again. Another 20-30% of patients require more complicated therapies, in which several drugs have to be combined and, in any case, intensive psychotherapy has to be used. In about 5-10% of patients, the healing is not complete; residual symptoms remain, ranging from listlessness to sleep disorders and other complaints. These figures correspond roughly to those of a therapy for high blood pressure, here too 5-10% of the patients remain therapy-resistant.

In connection with depression therapy, the term healing is discussed controversially again and again. It must be made clear here that depression is curable, but that someone who has already suffered a depressive episode has an increased risk of experiencing another depressive episode later. This is not surprising because he has an increased risk of disease. He must have had this increased risk of illness before the first episode, otherwise he would not have got it.

Precisely because every depressive episode increases the risk of a new episode, it is so important that the early episodes are treated effectively and that this treatment is not ended after the main symptoms have subsided, but rather continued for six to twelve months, if possible, in order to ensure a high level of stability to reach. Antidepressant therapy as prophylaxis should be continued for a long time, especially in older people.

17. What should be done to prevent relapse?

If a depressive episode is cured, there is still a risk of getting the disease again, and more likely than someone who has not had a depressive episode. It is therefore necessary that all possible means are used to prevent depression from recurring.

Further treatment with an antidepressant after the depressive episode - for about a year - can prevent such a relapse. Have depressive episodes occurred more frequently in the past or was the first depressive episode characterized by particularly severe symptoms, e. B. through thoughts of suicide or delusional ideas, then preventive therapy must be considered after the first episode of illness.

In addition to passing on the most recently effective antidepressant, long-term therapy can also be used to prevent medication that was originally developed to treat seizures. These are mainly carbamazepine and lamotrigine. The latter in particular has proven itself in the past few years for the almost side-effect-free prevention of new episodes. In the case of manic-depressive illness, the best-established form of prevention to date is the administration of lithium salts or valproic acid.

18. What can relatives contribute?

In the past few years there has been some improvement in public attitudes towards patients with depression. Nevertheless, there are still a number of prejudices and misconceptions in the population and many people still believe that depression is a fashionable disease and reflects character defects or weak will. It can be countered by the fact that depression is just as common in remote villages in Africa or South America as it is in Shanghai or Los Angeles.

In hardly any other area of ​​medicine does the layman appear as competent as an expert than when it comes to explaining where a depression comes from and what you have to do about it to make it go away again. The consequences are the blossoming of obscure ineffective forms of therapy, up to and including the use of herbal extracts instead of effective drugs, which is particularly popular in Germany (see question 21).

With all these interrelationships, it is important that an understanding of the disease is built up in the patient's immediate environment, especially so that the patient comes into an environment after his discharge that supports him and is not perplexed, reproachful or critical.

It is therefore important to win over relatives or confidants to work together at an early stage. They need to be introduced to the biological basis of depression and made aware that depression is not something that can be overcome by willpower or following advice.

Symptoms such as negativity and irritability or inactivity and alleged self-centeredness on the part of the patient must not lead to the relatives losing understanding and patience and turning away from the “ungrateful” patient. The relatives and friends must learn to develop an understanding of the patient's inability to achieve something on their own and not to misinterpret the emotional distance or a reduced need for tenderness and sexuality as an emotional aversion.

It is also important that the patient is not overwhelmed by "good advice" and, conversely, relatives are not pushed into a kind of co-therapist status in which they are in turn overwhelmed. Since the pressure increases after the inpatient stay has been shortened, it is important that patients are released into an environment that carefully takes all of these things into account: where both specialists in psychiatry and psychotherapy, but also neurologists and internists, together with clinical psychologists Carefully coordinate efforts so that the patient does not have to be hospitalized for relapse a few weeks or months after discharge.

19. What is burnout syndrome?

Burnout syndrome is a diagnosis that patients often make themselves, especially when they are in a state of total exhaustion. The typical symptoms are reduced performance, emotional and physical exhaustion, an indifferent negative and sometimes cynical attitude towards work and colleagues and the conviction that you have failed professionally. In addition, there are symptoms that we are also familiar with with depression, such as sleep disorders, joylessness, concentration disorders and a variety of physical complaints such as back pain, headaches and the like.

Basically, it can be said here that patients who diagnose themselves with burnout syndrome sometimes already meet the criteria of a depression requiring treatment. Often the long-lasting stressful situation is likely to trigger it in those who are predisposed to depression.

However, a distinction must be made between the situation of exhaustion, which is caused by prolonged exertion, a lack of recovery, and above all a lack of sleep. In this case, it makes sense to talk to the patient about their lifestyle, performance limits, career expectations and social network. If the patient succeeds in making it clear to the patient that a compression of the task management that goes beyond his own abilities and performance reserves must be avoided, then the first step in the right direction has already been taken.

If this is not possible right away, relaxation procedures and cognitive behavioral training also seem appropriate. The rapid use of antidepressants does not seem advisable, nor does the prescription of sedatives (benzodiazepines of the Valium type) or stimulants (dexidrine, modafinil).

20. Does depression itself affect health?

Patients with depression are at increased risk of cardiovascular and metabolic diseases, especially diabetes mellitus.

A study published by the University College London shows that severe depressive symptoms can trigger an acute hypoperfusion of the heart. Severe depression is a risk factor for cardiovascular disease, both for its onset and for its recurrence: for example, the risk of having another heart attack within six months after a heart attack is three in patients who are depressed up to four times higher than in those who are depression-free after the heart attack. Depression is seen as a risk factor for cardiovascular diseases that is equivalent to increased blood lipids.

Another problem is that patients with depression often develop diabetes mellitus. The cause of this is the so-called metabolic syndrome. It consists, among other things, of a sugar metabolism disorder, high blood pressure, a change in fat metabolism and an accumulation of fatty tissue inside the abdomen. Metabolic syndrome is a major risk factor for cardiovascular disease and diabetes. These two diseases are the most common diseases of the elderly. If you look at the age development in our society, then you can see from this alone how important it is to reduce the risks for these two widespread diseases. This also includes the early detection and treatment of depression, which, if left untreated, has a tendency to become chronic in old age.

21. What will depression therapy look like in the future?

Today we have drugs that basically all have a similar profile of action and also a similar clinical effect. We have to find out that it takes too long for them to work, often after four to six weeks, sometimes even later. In about 5-10% of patients, they have no or only very unsatisfactory effects and have too many side effects.

However, depression is not a disease that is triggered by a specific bacterium or a severed tendon, but rather by a multitude of very complex, interlocking mechanisms. These mechanisms are partly based on peculiarities in our genetic make-up, but partly also on the changes in our brain function that have occurred as a result of biographical events. Here experiences in childhood are meaningful, but so are acute life events.

This interaction of genetic and external factors differs from person to person. Therefore, in the future, we will create an individual risk profile for each individual patient and then apply a tailor-made treatment that is appropriate to this risk profile. The aim should be not to wait until the disease occurs, but rather to establish a kind of early warning system based on the risk profile, with the help of which one can always intervene if the disease has not yet occurred in its full spectrum of symptoms. If our growth in knowledge from research continues at the same pace as in the last five to ten years, then this is not a utopia.

22. What do I get with St. John's wort, Bach flowers, gingko and other herbal products?

We must first understand that those substances that are derived from plants are also chemical compounds that cause desirable and undesirable effects in the body. In fact, chemical compounds from natural products are not fundamentally different from the chemical compounds that we ingest as tablets and that were developed in chemical laboratories. Pharmaceutical science eventually developed from the chemical substances found in natural products. The aim of the pharmaceutical industry is to modify chemical molecules in their laboratories in such a way that the desired effect is optimized and the undesired side effects are minimized.

This can be illustrated using the example of St. John's wort, which is extremely popular in Germany: Various chemicals are extracted from the petals of this plant, the most important of which are hypericin and hyperforin. Just like commercial antidepressants, these chemical substances increase the effectiveness of the neurotransmitters serotonin and norepinephrine in the brain by, like Prozac or Trevilor, inhibiting the reuptake of these neurotransmitters into the nerve endings. In addition, the chemicals contained in St. John's wort extracts have an effect on other neurotransmitters, for example gamma-aminobutyric acid, dopamine and glutamate.

Even if the last word about the effectiveness of St. John's wort has not yet been spoken (the more recent scientific publications that report positive results often come from the manufacturer himself or his contractors), according to the current state of knowledge, one can say that in milder depression against there is nothing wrong with attempting therapy.

However, some side effects must be taken into account, which can be serious: For example, St. John's wort leads to diarrhea and an increased tendency to severe sunburn. The use of St. John's wort is problematic if other medications are also taken, as St. John's wort activates some metabolic processes in the liver that lead to the undesirably rapid breakdown of drugs. The contraceptive pill often no longer works and some drugs that are prescribed for AIDS or infections (antibiotics) are limited in their effectiveness if St. John's wort is taken at the same time.

Medicines that are given for cardiovascular diseases (e.g. digitalis, anticoagulants and antihypertensive agents) or convulsions (epilepsy) can become less effective if St. John's wort is taken at the same time.

If standard antidepressants are given, not only are their effects increased, but also the number and extent of side effects. Therefore, simultaneous use of St. John's wort under standard therapy with antidepressants should be avoided.

I advise against using Bach flower extracts, gingko preparations and other herbal products for the treatment of depression. It must be borne in mind that inadequate therapy increases the risk of depression becoming chronic. Therefore, moderate and severe depression should be treated consistently with the well-established antidepressants under the guidance of a specialist.

23. Is the industry trying to invent our indications for their products?

Of course, the pharmaceutical industry is keen to market its drugs well. In fact, of the four million people currently suffering from depression in Germany, only about 10% receive adequate therapy. So it is a mistake to believe that the antidepressant market is already saturated for those suffering from depression. Exactly the opposite is the case.

At the same time, today's tendency to "talk ill" to people because they only have one or the other symptom due to special living conditions is a negative development, because it distracts from the actual big problem, namely the inadequate recognition and treatment of severe depression.