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A cyclist’s guide to depression
Written on a note found at Marco Pantani’s
bedsideat the time of his death.
Marco Pantani’s untimely death and reports about his depression highlightthe important issue of depression for the cycling community. At the timeof this writing, no conclusions have been reached about whether or nothe committed suicide, but it is clear that he had been under tremendousstress following a string of well-documented professional setbacks. Hisslide from greatness was profound and relatively swift. Such a fall fromgrace is usually experienced by anyone as severe stress, and stress canlead to depression in those who may be predisposed to become depressedby virtue of their genetic makeup. Since one way to decrease stress, andperhaps even to decrease depression, is to exercise, the cycling communityneeds 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 pointin their lives. At any given time, about 9 percent of women and 3 percentof men will be depressed. Major depressive disorder is estimated by theWorld Health Organization to be the fourth leading cause of disabilityworld wide, and is projected to be the second cause of disability by theyear 2020. The majority of people who attempt or complete suicide havemajor depressive disorder. Because depression is widespread and disabling,it is a great public health problem.
Depression defined
An episode of major depressive disorder is defined by having a minimumof two weeks of either decreased mood (blue, down in the dumps, sad) orsubstantially decreased interests or pleasure (no longer wanting to pursuehobbies or pleasurable activities; diminished pleasure when those activitiesare attempted). In addition to these symptoms, people will experience changesin their sleep (either decreased or increased in duration; commonly, earlymorning awakening occurs and people are unable to return to sleep), feelingsof guilt and self-blame, decreased energy, decreased concentration (unableto read or follow conversations), change in appetite (either increasedor decreased with associated changes in weight), changes in speed of thoughtor movement (either increased with restlessness or decreased with actuallythinking and moving more slowly), and thoughts of death or suicide. Atleast five symptoms are required to have the diagnosis of major depression.
Stress and depression
Not surprisingly, because life can be so stressful, many people developdepression. What is a surprise is that even under great stress, many peopledo not develop depression. In a key set of studies done in New Zealand,researchers followed a group of children from an early age through theirmiddle twenties. They studied the relationship between severe stressfullife events, depression, and genes. The findings were astounding: thosewith a particular set of genes that regulate an important neurotransmitter,serotonin, protected people from getting depressed even if they experiencedsevere stress; those with another set of genes became depressed under thesame stressful conditions.
Another large body of research has shown that areas of the brain canbe damaged by stress. Some people with depression have a decreased volumein the area of the brain called the hippocampus. Basic studies of ratsshow 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 presenceof this “nerve growth factor” nerve cells live longer, and in the absenceof it they die sooner. Stressed rats produce less “nerve growth factor.”Conversely, antidepressants actually increase it, and ultimately increasethe 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 whyit is not trivial to say that stress is bad for your brain (and antidepressantsare actually good for your brain).
Exercise, stress and depression
Just as the antidepressants increase the neurotrophic factor and protectneurons from the damaging effects of stress, so does exercise. A largestudy of adults in the United States found that there is less depressionand anxiety in people who engage in regular physical exercise. Other studieshave found that vigorous exercise can work as an antidepressant for peoplewho are already depressed, and active research is currently being doneto find out if exercise plus antidepressants are better than antidepressantsalone.
Many people who exercise (including cyclists) feel that the exerciseitself decreases stress, and as discussed above, less stress is good foryour brain. But if exercise is good for your brain, what happens when thereis a sudden drop in exercise levels? Again, many people describe feelingworse, cranky, irritable, and moody if they don’t get their exercise –a phenomenon that, to the best of our knowledge, has not been formallyexamined. Is there actually an exercise withdrawal so that it is more likelythat someone will get depressed after cessation of years of a vigorousexercise routine? Perhaps this is an area that should be studied and cyclistswho retire should be careful to detect and treat depression should it arise.
Treatments for depression
Antidepressants work for a majority of patients with major depressivedisorder. They are effective for the range of depression, from the mildestto the most severe, but are most effective for moderate to severe depression.The stigma associated with antidepressant medications is decreasing, andthe newest antidepressant medications are safe to use (even in high performanceathletes), but can cause side effects (that should be discussed with yourtreater). The most common antidepressants are in the same category as Prozac(fluoxetine). These are called “selective serotonin reuptake inhibitors”(SSRIs), and include Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram),Lexapro (escitalopram), and Luvox (fluvoxamine). Other antidepressantseffect different chemicals in the brain. These include Wellbutrin (bupropion),Effexor (venlafaxine), and Remeron (mirtazapine).
Older antidepressants include tricyclics (including trimipramine whichwas found by Pantani’s bedside) and monoamine oxidase inhibitors and generallycause more side effects than the newer generation of antidepressants. Tricyclicantidepressants are frequently lethal when taken as an overdose while thenewer antidepressants are generally safe in overdose. Some herbal treatmentssuch as St. John’s Wort (which contains the chemical hypericum) may alsobe 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 formajor depressive disorder. Cognitive Behavioral Therapy (CBT) helps peoplechange thought patterns and reduces depression. It may also prevent episodesfrom returning. Another type of talk therapy, called Interpersonal Psychotherapy(IPT), also reduces depression and prevents it from coming back. For peoplewho have many episodes of depression or who have a long-lasting kind ofdepression called chronic depression seem to do best when they receiveboth medication and one of these psychotherapies. The addition of exercisecan also help, as mentioned above. Of course, if you are already exercisingregularly and you are still depressed, other treatments may bring relief.
All antidepressants take at least 6 to 12 weeks to help people feelbetter so it is essential to not give up too early. After people feel betterwith treatment, they should continue their treatment for at least fourto nine months. People who stop their treatment too soon are likely tohave the depression return. Many people think that because they are feelingbetter that they don’t need treatment anymore and then stop their treatmenttoo soon. Finally, if treatments don’t seem to be helping, it is worthwhileto get a consult.
When to seek help
If your mood is down or things just aren’t enjoyable anymore for morethan two weeks in a row, and you have some of the other symptoms of depressionsuch as low energy and activity, loss or increase in appetite, problemssleeping, low self-esteem, problems concentrating, and agitation or fidgetiness,it is worth getting a consultation from a physician. General medical professionalssuch as internists, primary care doctors, and nurse practitioners as wellas psychiatrists, of course, evaluate, diagnose, and treat depression.If you have suicidal thoughts or thoughts that it is no longer worth goingon, it is essential that you get help immediately.
Major depression is a serious, but highly treatable condition. Treatmentsare safe, effective, and readily available. It is not necessary to justgrit 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) (www.mghmadi.org), the Depression and Bipolar Support Alliance (www.dbsalliance.org)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, MPHDoctors 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 CyclingAssociation. He usually advises them to go faster.
