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Marco Pantani’s untimely death and reports about his depression highlight the important issue of depression for the cycling community. At the time of this writing, no conclusions have been reached about whether or not he committed suicide, but it is clear that he had been under tremendous stress following a string of well-documented professional setbacks. His slide from greatness was profound and relatively swift. Such a fall from grace is usually experienced by anyone as severe stress, and stress can lead to depression in those who may be predisposed to become depressed by virtue of their genetic makeup. Since one way to decrease stress, and perhaps even to decrease depression, is to exercise, the cycling community needs information about depression to be able to detect it and when necessary, refer people for appropriate treatment when cycling is not enough.
Major depressive disorder
Major depressive disorder, the formal term for clinical depression, occurs in up to 25 percent of women and 12 percent of men at some pointi n their lives. At any given time, about 9 percent of women and 3 percent of men will be depressed. Major depressive disorder is estimated by the World Health Organization to be the fourth leading cause of disability world wide, and is projected to be the second cause of disability by the year 2020. The majority of people who attempt or complete suicide have major depressive disorder. Because depression is widespread and disabling, it is a great public health problem.
An episode of major depressive disorder is defined by having a minimum of two weeks of either decreased mood (blue, down in the dumps, sad) ors ubstantially decreased interests or pleasure (no longer wanting to pursue hobbies or pleasurable activities; diminished pleasure when those activitiesa re attempted). In addition to these symptoms, people will experience changes in their sleep (either decreased or increased in duration; commonly, early morning awakening occurs and people are unable to return to sleep), feelings of guilt and self-blame, decreased energy, decreased concentration (unable to read or follow conversations), change in appetite (either increased or decreased with associated changes in weight), changes in speed of thought or movement (either increased with restlessness or decreased with actually thinking and moving more slowly), and thoughts of death or suicide. At least five symptoms are required to have the diagnosis of major depression.
Stress and depression
Not surprisingly, because life can be so stressful, many people develop depression. What is a surprise is that even under great stress, many people do not develop depression. In a key set of studies done in New Zealand, researchers followed a group of children from an early age through their middle twenties. They studied the relationship between severe stressful life events, depression, and genes. The findings were astounding: those with a particular set of genes that regulate an important neurotransmitter, serotonin, protected people from getting depressed even if they experienced severe stress; those with another set of genes became depressed under the same stressful conditions.
Another large body of research has shown that areas of the brain can be damaged by stress. Some people with depression have a decreased volume in the area of the brain called the hippocampus. Basic studies of rats show that an important protein, brain derived neurotrophic factor (BDNF), keeps nerve cells healthy and branched fully like a tree. Without BDNF, nerve cells shrivel, as if their branches were pruned. In the presence of this “nerve growth factor” nerve cells live longer, and in the absence of it they die sooner. Stressed rats produce less “nerve growth factor.” Conversely, antidepressants actually increase it, and ultimately increase the healthy branching of nerve cells. When you give a rat an antidepressant, the antidepressant will protect the stressed rat from the decrease in neurotrophicfactor and will protect its brain from the effects of stress. This is why it is not trivial to say that stress is bad for your brain (and antidepressants are actually good for your brain).
Exercise, stress and depression
Just as the antidepressants increase the neurotrophic factor and protect neurons from the damaging effects of stress, so does exercise. A large study of adults in the United States found that there is less depression and anxiety in people who engage in regular physical exercise. Other studies have found that vigorous exercise can work as an antidepressant for people who are already depressed, and active research is currently being done to find out if exercise plus antidepressants are better than antidepressants alone.
Many people who exercise (including cyclists) feel that the exercise itself decreases stress, and as discussed above, less stress is good for your brain. But if exercise is good for your brain, what happens when there is a sudden drop in exercise levels? Again, many people describe feeling worse, cranky, irritable, and moody if they don’t get their exercise –a phenomenon that, to the best of our knowledge, has not been formally examined. Is there actually an exercise withdrawal so that it is more likely that someone will get depressed after cessation of years of a vigorous exercise routine? Perhaps this is an area that should be studied and cyclists who retire should be careful to detect and treat depression should it arise.
Treatments for depression
Antidepressants work for a majority of patients with major depressive disorder. They are effective for the range of depression, from the mildest to the most severe, but are most effective for moderate to severe depression.The stigma associated with antidepressant medications is decreasing, and the newest antidepressant medications are safe to use (even in high performance athletes), but can cause side effects (that should be discussed with your treater). The most common antidepressants are in the same category as Prozac(fluoxetine). These are called “selective seroton uptake inhibitors” (SSRIs), and include Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), Lexapro (escitalopram), and Luvox (fluvoxamine). Other antidepressant seffect different chemicals in the brain. These include Wellbutrin (bupropion), Effexor (venlafaxine), and Remeron (mirtazapine).
Older antidepressants include tricyclics (including trimipramine which was found by Pantani’s bedside) and monoamine oxidase inhibitors and generally cause more side effects than the newer generation of antidepressants. Tricyclic antidepressants are frequently lethal when taken as an overdose while the newer antidepressants are generally safe in overdose. Some herbal treatments such as St. John’s Wort (which contains the chemical hypericum) may also be effective for milder depression, but the efficacy and safety of St. John’s Wort is not as well established as it is for the prescribed antidepressants.
Two types of psychotherapy have been shown to work especially well for major depressive disorder. Cognitive Behavioral Therapy (CBT) helps people change thought patterns and reduces depression. It may also prevent episodes from returning. Another type of talk therapy, called Interpersonal Psychotherapy(IPT), also reduces depression and prevents it from coming back. For people who have many episodes of depression or who have a long-lasting kind of depression called chronic depression seem to do best when they receive both medication and one of these psychotherapies. The addition of exercise can also help, as mentioned above. Of course, if you are already exercising regularly and you are still depressed, other treatments may bring relief.
All antidepressants take at least 6 to 12 weeks to help people feel better so it is essential to not give up too early. After people feel better with treatment, they should continue their treatment for at least four to nine months. People who stop their treatment too soon are likely to have the depression return. Many people think that because they are feeling better that they don’t need treatment anymore and then stop their treatment too soon. Finally, if treatments don’t seem to be helping, it is worth while to get a consult.
When to seek help
If your mood is down or things just aren’t enjoyable anymore for more than two weeks in a row, and you have some of the other symptoms of depression such as low energy and activity, loss or increase in appetite, problems sleeping, low self-esteem, problems concentrating, and agitation or fidgetiness,it is worth getting a consultation from a physician. General medical professionals such as internists, primary care doctors, and nurse practitioners as well as psychiatrists, of course, evaluate, diagnose, and treat depression. If you have suicidal thoughts or thoughts that it is no longer worth going on, it is essential that you get help immediately.
Major depression is a serious, but highly treatable condition. Treatments are safe, effective, and readily available. It is not necessary to just grit your teeth will yourself to get better. Help is available.
Where to get more information
Several organizations can provide reliable information about depression. The Massachusetts General Hospital Mood and Anxiety Disorders Institute (MADI), the Depression and Bipolar Support Alliance are dedicated to improving the lives of people with mood disorders. Beginning in March of 2004, the MADI resource center will also offer a web site at www.moodandanxiety.org.
Andrew A. Nierenberg, MD and Michael Ostacher, MD, MPH Doctors Nierenberg and Ostacher (the one with the hair) are experts in the evaluation and treatment of mood disorders. They collaborate through the Depression Clinical and Research Program in addition to the Harvard Bipolar Research Program at Massachusetts General Hospital and Harvard Medical School. They are avid cyclists (the famed Crack O’Dawn Riders) and VeloNews readers. Dr. Nierenberg is also a faculty advisor to the Harvard University Cycling Association. He usually advises them to go faster.