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Neurology Now:
doi: 10.1097/01.NNN.0000511232.97266.78
Departments: The Waiting Room

Questions to Ask About Depression: Feeling low? Your physician can help.

Kritz, Fran

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Too often people with neurologic conditions think depression is something they just have to live with or can “shake off” without help from their doctor, says Melissa Armstrong, MD, FAAN, a movement disorders specialist at the Center for Movement Disorders and Neurorestoration at the University of Florida in Gainesville. Neither is true, she says. First, depression is sometimes caused by the illness itself. And second, depression is treatable. But many patients are uncomfortable talking about depression with their doctor and may miss out on a chance to feel much better. Here's how—and why—to get the conversation started.

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1. HOW DO I KNOW IF I'M DEPRESSED? If you have persistent feelings of sadness and lose interest in activities you previously enjoyed, if you have trouble concentrating or sleep too much or too little, or if you have thoughts of death almost every day for a couple weeks, speak to your doctor about depression, says Dr. Armstrong. Untreated, it can interfere with daily living and may contribute to suicidal thoughts.

2. DOES DEPRESSION AFFECT MORE THAN JUST MOOD? Yes, says Scott Hirsch, MD, assistant professor of neurology, psychiatry, and child and adolescent psychiatry at the New York University School of Medicine in New York City. If you're depressed, you may not take your medication as directed or you may miss doctor's appointments, he says. You also may avoid people or stop exercising—all of which makes it harder to manage a chronic condition.

3. SHOULD I WAIT FOR MY DOCTOR TO BRING IT UP? No. But you may not have to, says Dr. Hirsch. Most doctors use screening questions to evaluate for depression either at the time of a diagnosis or soon after. You should also tell your primary care physician if you're feeling down, especially if you see your neurologist only occasionally. Your primary care doctor can start helping you manage depression as soon as symptoms appear. Family members can also bring up depression or mood changes, especially for patients in advanced stages of illness who may not be able to speak for themselves.

4. WHAT SORTS OF MEDICATIONS CAN HELP? The most commonly prescribed medications for depression are selective serotonin reuptake inhibitors (SSRIs), but doctors will consider each patient's situation when selecting a treatment. For example, if patients have pain, doctors may prescribe duloxetine (Cymbalta), which can help both depression and pain. For people who have trouble sleeping and have lost their appetite, physicians might prescribe mirtazapine (Remeron), an antidepressant that stimulates appetite and promotes sleep.

5. HOW LONG DOES IT TAKE FOR DRUGS TO WORK? Some antidepressants can take a few weeks to kick in, says Dr. Hirsch, so check in with your doctor, even by phone, to let him or her know how you're doing. An early change to a more effective medication can make a big difference, he says. You and your doctor or psychiatrist will have to work together to find drugs that are effective but that don't interfere with other medication you may be taking.

6. ARE DRUGS THE ONLY WAY TO TREAT DEPRESSION? No. Talk therapy, support groups, and adopting healthy habits such as exercising, sleeping, and eating well are all helpful in treating depression, says Dr. Hirsch. When Chuck McClatchy, 63, of Chicago, was diagnosed with early-stage Alzheimer's disease two years ago, he talked about depression with his doctor at his next visit. “My doctor asked if I wanted to consider antidepressant medicines, but I decided I wanted to work it out on my own and was able to find a therapist who specialized in age-related issues,” says McClatchy. “That was the right choice for me, but it was so helpful to talk it through with my doctor.”

7. CAN EXERCISE HELP? Definitely, says Dr. Armstrong. “We're learning more and more about the positive effects of exercise on people with brain disease and depression.” A 2015 study in the Archives of Physical Medicine and Rehabilitation, for example, reviewed 23 randomized controlled trials of more than 1,300 patients with seven different neurologic conditions. The studies compared groups of people with neurologic conditions who exercised with those who did not and found that exercise can improve depressive symptoms in adults with neurologic disorders. Exercise has been crucial for McClatchy, who calls yardwork and gardening “dirt therapy.” He also plays golf and spends time with people he knows well. He keeps busy, he says, “so my brain doesn't just dwell on what is going to happen.”

8. WHAT IF I'M NOT DEPRESSED? Not everyone with a neurologic condition is depressed, says Dr. Hirsch, a fact he acknowledges in conversations with his patients. “I tell patients everyone is a little different, not everyone will feel depressed, and I explain what changes to look for so that we can intervene early on.” The goal, he says, is to make daily life as good as possible.

© 2016 American Academy of Neurology

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