Tender point score and depression

Tender point scores reflect generalized pain and pain behavior in fibromyalgia patients, however, these scores are not independently related to psychological distress, according to a new study. Investigators used criteria defined by the American College of Rheumatology to assess tenderness at 18 discrete points in 111 fibromyalgia patients recruited from both private and university clinics. The patients also underwent a comprehensive evaluation of generalized pain, pain behavior, and psychological distress.


A composite index of four different measurements was used to evaluate generalized pain, while pain behaviors were determined by comparison to a videotaped index. Measured levels of stress and depression were used as assessments of generalized psychological distress. Using multiple regression analysis, the investigators found that tender point scores were independently related to the patients’ generalized pain and pain behavior. There was no relationship between tender point scores and measured depression or stress.


In addition to pain and pain behavior, a shorter duration of illness was found to be independently related to the tender point scores. A study published in the Journal of Biological Psychiatry in 1993 proved that individual’s with mood disorders are especially affected by aspartame consumption. Researchers have also singled out chronic fatigue syndrome, fibromyalgia, Alzheimer’s, brain tumors, epilepsy, Parkinson’s disease, mental retardation, lymphoma, birth defects and diabetes as being sensitive to aspartame consumption.


A study conducted by the Department of Neurology at the University of Oklahoma College of Medicine, Tulsa examined the relationship between migraine headaches and aspartame. The study confirmed that aspartame may provoke headaches in susceptible individuals. Additional studies on the topic confirmed the findings. Researchers in the Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle conducted a double-blind crossover study on 32 subjects. The study found an increased incidence of headaches reported by the participants who ingested aspartame and reported that some individuals may want to limit their aspartame consumption.


Despite the FDA’s long term hesitation to approve aspartame they are standing by their decision. The FDA responds to complaints by stating that aspartic acid and phenylalanine are amino acids and methanol is found naturally occurring in fruits. However, when aspartic acid and phenylalanine are unaccompanied by other amino acids they are neurotoxic and fruit also contains ethanol which protects against the effects of the methanol. The FDA fails to address these major differences.

Pregnancy and depression

During pregnancy, up to 70% of women experience depressive symptoms and 10% to 16% fulfill the DSM-IV diagnostic criteria for MD.[37] These prevalence rates are very similar to those in the general population, suggesting that pregnancy per se does not increase the risk of depression. A large prospective controlled study evaluated 182 pregnant and 179 nonpregnant women using Research Diagnostic Criteria for major and minor depression.[38] The rates of depression were equal in both groups, again suggesting that pregnancy does not affect the risk of depression.


In women from the second trimester through 9 weeks postpartum, the highest level of depressive symptomatology occurred at weeks 34 to 38 of gestation. As shown in Table 5, several risk factors for depression during pregnancy have been identified. Various medical disorders, such as anemia, gestational diabetes, and thyroid dysfunction, may also contribute to depressive symptoms in pregnancy.


Management of MD during pregnancy may include nonpharmacologic interventions, such as cognitive therapy or electroconvulsive therapy (ECT), and/or antidepressant medications. ECT is a relatively safe and effective treatment for MD in pregnant women, particularly in high-risk situations, such as mania and psychotic depression.[40,41] Pharmacologic interventions mainly include the use of antidepressant agents.


A meta-analysis failed to find any evidence for teratogenicity for antidepressants during pregnancy.[42] Recurrence rates for patients with MD during pregnancy are estimated to be as high as 50% within 6 months following discontinuation of antidepressant treatment.[43,44] Therefore, antidepressant prophylaxis in these patients may be reasonable. Adjustment of antidepressant dosages during pregnancy may be needed, because antidepressant levels have been reported to decrease during pregnancy, possibly as a result of pregnancy-associated altered volume of distribution.

Diagnostic criteria for depression

The diagnostic criteria for MD established in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are described in Table 2.[7] These criteria are the same for women and men. DSM-IV classifies MD as single or recurrent episodes, or dysthymia (a persistent but less severe form of MD). Clinical Features and Course of Major Depression Symptoms and Severity Depressive symptoms in men and women tend to be similar, except that women appear to be more likely to present with atypical symptoms (see Table 3), anxiety, and somatic symptoms (such as headaches and stomach upset), whereas men tend to report more weight loss.


Depression in women may be more severe than in men and associated with increased functional impairment.[25] However, most studies have not documented gender-specific differences in severity of depression, except for higher scores of self-reported atypical symptoms in women.[24,26] In general, anxiety or suicidal thoughts accompanying depression indicate a more severe disorder. Women are more likely to attempt suicide, but the rate of fatalities from suicide is higher in men, probably because men tend to use more lethal methods, such as guns or hanging, whereas women more often take medication overdoses or drown.


Also, men are less likely to seek psychiatric help that may prevent suicide. Age at Onset Some studies have noted an earlier age at onset of MD in women.[11,25,27] In the National Comorbidity Survey, this difference was most pronounced in early adolescence, with age at onset of the first MD beginning as early as age 10 in females.


Whereas men more commonly become symptomatic in their twenties, women often become symptomatic in mid-adolescence.[28] A peak in first onsets of MD also has been reported in women during their childbearing years, with a decrease in first onsets after age 45 These findings led to the proposal that two forms of MD occur in women: early onset (10 to 14 years) and adult onset.

Major depression in women

Major depression (MD) is the most common of all psychiatric disorders. According to the National Comorbidity Survey,[1] 17.1% of the general population in the United States have a lifetime history of a major depressive episode and 10.3% have had an episode in the past 12 months. With the exception of hypertension, MD is more commonly encountered than any other condition in the primary care setting.[2] MD is also associated with markedly higher health care costs than other common disorders seen in primary care.


Additionally, MD is one of the 15 leading causes of disability in developed countries and will become the second leading cause of disability worldwide by 2020.[3,4] The Global Burden of Disease Study[3,4] reported that MD-related disability is equivalent to that caused by blindness or paraplegia, and the World Health Organization deemed the degree of disability to be greater than that associated with other chronic conditions, such as hypertension, diabetes, arthritis, and back pain.


Finally, MD is associated with high morbidity and mortality[6]; up to 15% of individuals with more severe forms of this disorder die by suicide.[7] Thus, the prevalence, disability burden, economic toll, morbidity, and mortality associated with MD call for increased attention to this disorder among pharmacists and other health care providers.


The aim of this article is to promote awareness of this debilitating psychiatric illness among pharmacists, focusing on the disproportionate burden of depression in women and ways to reduce it. In this article the term “gender” is used to connote broad psychosocial and cultural differences between men and women; the term “sex” is used to refer to only biological and physiological differences.

Women’s higher depression rate

Depression is twice as common among adolescent and adult females as among their male counterparts, but the reason why has not yet been fully explained. Now after reviewing various studies on the topic, a Michigan researcher reports that the gender difference is probably due to an interaction between biological, psychological and social factors. “There is no single reason for women’s greater vulnerability (to depression),” Dr. Susan Nolen-Hoeksema of the University of Michigan-Ann Arbor, told Reuters Health.


Biological and psychological reactions to stress, as well as social factors, like oppression, all work together to promote higher levels of depression among females, she said. Her findings are based on a review of more than 10 studies on the topic. Women may be more vulnerable than men to stressful life events that can contribute to depression, such as victimization, sexual harassment on the job, and “burn-out” due to numerous family and workplace responsibilities, Nolen-Hoeksema reports in the October issue of Current Directions in Psychological Science.


In adolescence, girls’ increased depression may be caused by intensified social pressure to conform to their gender role, Nolen-Hoeksema notes. This pressure includes a real or perceived reduction in opportunities and choices, tighter restriction on behavior than faced by their male peers, and lowered expectations in comparison with adolescent boys, studies suggest. Besides this increased vulnerability to particular stressors, study findings suggest that females may also react differently than men to common stressors.

Depression Occurs More in Women than In Men

The short answer is “yes.” A woman is approximately twice as likely to have a major depressive disorder or dysthymia (a less severe, more chronic depression) than a man. In bipolar, or manic-depressive, disorder, however, the sex ration is about the same. The preponderance of women among the ranks of the depressed is well studied and repeatedly demonstrated. In a large 1991 study, 7 percent of women had major depression in their lifetimes as opposed to 2.6 percent of men.


The difference appears to hold in other cultures as well and begins to assert itself around puberty. However, when depression occurs, the severity or course of the illness does not appear to be different between the sexes. The next question is, Is this apparent difference in rates of depression a real one? Are there differences in the way women express emotions and seek and accept help that falsely makes them appear to have more depression? Men, we have reason to think, conceal their depressions. (See Terrence Real’s new book I Don’t Want to Talk About It.)


So are the rates of women’s “depressions” inflated by women’s emotional availability and men’s reduced by their concealment? The big survey studies, which use diagnostic methods that penetrate these disguises, indicate that the difference between men and women appears to be real. What accounts for the difference?


There have been possible biological explanations — most prominently, the role of female hormones and hormone-intensive events, such as menses, pregnancy and childbirth, and menopause, which are known to be associated with emotional changes and depression. Many women have premenstrual sadness and irascibility; some have frank and significant depression. Postpartum depression is a well-known event, and menopause, in the popular mind, is linked to depression and emotional upheaval.

Suffering with depression

Being in hospital helped me because ME can be affected by mood, and I felt it was time to strike out on my own and fend for myself, otherwise I would always be dependent on my parents,’ she says. ‘Being away from home allowed me to do that.’ Because Emily’s recovery really started after her treatment for depression, it might be tempting for some people to presume that her condition really was all in the mind. That being the daughter of such high-profile and successful television personalities took its toll on a rather fragile psyche.


However, Emily, who developed ME after contracting glandular fever at the age of 14, insists not. ‘The only person who ever told me it was all in the mind was me. I was anxious to snap out of it, but I couldn’t. Anyone who saw me could see there was something very physically wrong,’ she says. ‘It was the ME that caused the depression, not the other way around. ‘After I caught glandular fever I pushed myself on. Both my parents are passionate about their work and will not stop until exhaustion forces them to, and I was such a perfectionist I was the same. ‘I went to North London Collegiate School, which has high standards and is very competitive, and my whole life was geared up to emulating my mother to go to Oxford to read English or French.


I convinced everyone that I was OK when I should have perhaps slowed down a bit.’ When Emily was found weeping in despair in the library at school after her fatigue had left her virtually on the point of collapse, her parents and the head-mistress agreed she should take a year out to recover. In 1995, her GP referred her to Essex based consultant neurologist Professor Leslie Findley, who, after a battery of medical tests, diagnosed ME. It was a relief to the whole family to finally know what Emily was suffering from and that it was not life-threatening.


But the impact on them all has been devastating. Sister Rebecca, 20, now studying English at Oxford and Joshua, 18, in his final year at Winchester, were a tower of strength, but Emily often felt guilty about the way her condition affected the dynamic of the family. ‘My family were wonderful to me, they all put on a brave face. But now I am getting better they admit what a huge strain it was at times for them. Mum and Dad wept many tears because they felt so helpless,’ says Emily. ‘There were a lot of tensions. They could see Rebecca going out and having a great life with her friends and then they would look at me and feel desperate over the unfairness of it all. Mum felt terrible guilt about being a working mother. But as far as I’m concerned she is the best mother in the world.’

Fibromyalgia can cause depression

Fibromyalgia, a chronic condition characterized by widespread persistent musculoskeletal pain, fatigue and multiple tender points, can be difficult to diagnose and treat because it is so poorly understood. Part of the problem is that its symptoms–which include headaches or facial pain, sleep disturbances, head-to-toe aching or burning, body stiffness, muscle spasms, gastrointestinal complaints, depression and anxiety–are similar to those presented by other illnesses. And in many of the 4 million Americans with fibromyalgia, the pain is so diffuse that they can’t even describe where it hurts.


As recently as a decade ago, fibromyalgia “was considered a wastebasket type of diagnosis for any patient with chronic musculoskeletal pain” that couldn’t otherwise be explained, according to rheumatologist Russell Rothenberg, assistant professor of medicine at George Washington University Hospital. Before the American College of Rheumatology issued its diagnostic criteria for fibromyalgia in 1990, Rothenberg says, “doctors either didn’t believe their patients or knew that they had pain but didn’t know how to treat it.”


A diagnosis of fibromyalgia requires a thorough evaluation, including a complete medical history and physical examination to rule out diseases with similar symptoms, such as systemic lupus, thyroid disease and rheumatoid arthritis. Further complicating matters is the fact that fibromyalgia–in a form known as secondary fibromyalgia–may occur alongside other illnesses. For example, one-third of patients with systemic lupus also have fibromyalgia, as do one-third of those with irritable bowel syndrome.


The condition also appears in some people with rheumatoid arthritis. (Fibromyalgia unaccompanied by other diseases is primary fibromyalgia.) While its cause is unknown, fibromyalgia often develops in the wake of physical trauma. The condition can be latent until triggered by any of several factors: changes in the weather, lack of sleep or physical overexertion. The pain can range from mild discomfort to severe enough to interfere with daily activities, and it can change location, centering in overused parts of the body, such as the neck, shoulders and feet.

Studies on CFS related depression

We found that CFS and depression are associated with increased blood flow in the right thalamus. In support of previous ROI studies (Goldstein et al, 1995; Fischler et al, 1996) we found little difference between the two groups, other than the pattern of perfusion in the left prefrontal cortex on SPM analysis. This is in keeping with previous reports of decreased left prefrontal perfusion in depression (Goodwin, 1997). In agreement with the work of Fischler et al (1996) which, like our own, normalized regional activity to total brain perfusion, we did not replicate reports of global or localized cerebral hypo-perfusion in CFS.


We believe that this is most likely to be explained by the fact that our CFS patients had been carefully screened for comorbid psychiatric disorders (especially depression) and were well matched for potential confounders, as well as by our use of the more robust whole-brain normalisation of cerebral perfusion. We were not able to address the possibility of reduced perfusion of the brain-stem (Costa et al, 1995), mainly because of the lack of reliable data from an area whose size lies at the spatial resolution limit of SPECT. Limitations


The main limitation of the present study is that our CFS subjects had high levels of depression: almost half were on psychotropic medication and five had a previous history of depression. This reflects the rarity of CFS without comorbid psychiatric disturbance, and is only evident because we characterised our subjects so carefully. Our rigorous screening and inclusion of self-help group members may, of course, mean that our CFS subjects are not representative of people with CFS in clinics and in the community.


Almost all our depressed subjects were medicated, and psychotropic medication may well alter cerebral perfusion, although the findings in our CFS subjects do not appear to be explained by medication effects. It should also be noted that our controls were recruited as staff or friends and may not therefore be representative of the ‘normal’ population.

Relationship between CFS and Depression Studied

A recent study set out to identify the relationship between CFS and depression. Researchers at Edinburgh University in the UK evaluated brain scans from 30 people with CFS, 12 diagnosed with depression, and 15 healthy subjects. They concluded that both CFS and depression may be neurological and due primarily to increased blood flow in the right thalamus, which is responsible for processing sight, sound, touch, and more importantly, pain. However, there is one detail that separates CFS from depression – CFS sufferers also have an increase in blood flow to the left thalamus.


The researchers believe that this lack of activity in the left thalamus may have something to do with the fact that depression alone involves more psychological problems than does CFS. Past studies have indicated that the onset of CFS is not related to depression, and that increased depression can reactivate latent viruses, decrease the body’s immune response, and stimulate the production of certain cytokines linked to some CFS-like symptoms.


Dr. Jacob Teitelbaum, author of From Fatigued to Fantastic, states “Although many CFS patients feel depressed because of their illness, only a small minority have depression causing their fatigue. Findings from this most recent study may bring a sense of relief to CFS sufferers who often have to convince people that their disorder is real and that their symptoms are not just in their minds. The discovery of the increased blood flow unique to CFS patients may potentially lead to the discovery of additional physical changes responsible for developing CFS.