Why is my depression worse in the morning?

FOR ten years, I have suffered with early day depression. I take the antidepressant citalopram, but it doesn’t help as far as I can tell. The depression does improve as the day wears on and is quite good by the evening, but unfortunately it’s back again next morning. I also take the occasional lorazepam (0.5mg) a sedative, but my doctor withholds them most of the time. I am 82. Pauline Andrews, London.

When I first started in general practice I was shocked to hear patients say they would rather have cancer than depression. They felt that cancer would be something more tangible and others would understand their suffering.

As it is there is still this unfortunate attitude that people who are depressed should be able to pull themselves together and get on with life — something that you will appreciate is just not possible.

Depression is not the same as feeling sad, a reaction to the pressures, tragedies, and painful dramas of life. It causes disruption to the whole body. The skin and hair can become lank, dull, and difficult to manage; the intestines stop working properly leading to bloating, constipation, halitosis, loss of appetite and nausea; the immune system also doesn’t work as well, so you’re prone to infections; many also have problems sleeping.

The symptom you describe — feeling depressed in the morning, and improving as the day wears on — is a classic one: we call it ‘diurnal variation of mood’. Along with early morning waking, lack of energy, and poor memory and concentration, it is a characteristic of depression and this symptom forms part of the diagnosis.

Depressive illness, as I prefer to call it, responds to antidepressant drugs, but a patient must take the correct drug for their situation, in the correct dose, and for an appropriate time, which can be for many weeks or months. Sometimes it’s just a question of trial and error. The drug you are taking, citalopram, is an effective antidepressant and the correct dose is 10mg or 20mg daily — probably not more in your case as higher doses can cause abnormalities of heart rhythm in older patients.

I get the sense it has improved your condition but you are not cured, and ten years is a long time to be in this state. In my view some additional medication will be needed. Lorazepam is no more than a sedative, and unlike an antidepressant, is potentially addictive. That is why your GP is limiting its use — and correctly, as it is not of value in terms of curing your condition.

What I would recommend is some basic checks. It is vital that you have a blood test to help assess your thyroid function, vitamin B12 levels, kidney function, blood sugar and liver function.

If any of these are abnormal they could cause symptoms that can be confused with depression or they can reduce the effectiveness of the antidepressant drugs.

even minor abnormalities of the thyroid gland, for example, will reduce the chance of antidepressants having their full effect. If these tests have not been done, do talk to the nurse at your practice, or raise it with your GP at your next appointment.

There are also other medicines that can be added to enhance the effect of citalopram — for example, psychiatrists do, on occasions, add l i thium — and this may be necessary in your case.

Cognitive behavioural therapy (CBT) is much talked about these days and research shows it is helpful in this type of condition. The treatment involves five to ten sessions with a psychotherapist, working at changing the way you react to your circumstances.

however, there are long waiting lists and my own view is that it must be conducted by the most skilled of practitioners. Sufficient highly trained psychotherapists are not yet available and too many inexperienced individuals are getting on the bandwagon, which worries me.

I suggest you buy a book Feeling Good: The new Mood Therapy, by David Burns. It may inspire you if you can leaf through it and may add to the sense of optimism, which I hope I am conveying to you. You can get better. MY DOCTOR recently said he would organise a ‘gynaecology MOT’, which he would be doing with his nurses. I do not mind having this type of intimate thing done by a doctor who is a stranger to me, or preferably a woman. However, I have never had a smear test done by my own GP and do not wish to start now. I need to know if I can say no. Otherwise I am afraid I will just not have this procedure. I am over 60.

Name and address withheld. To Doctors carrying out practical procedures, whether it’s a vaginal examination, or ear syringing, these things are so routine and nonemotional that on occasions they do not stop to consider their patients’ reaction.

Where s ensitive i ntimate examinations are required, not all doctors realise the difficulties that some of their patients experience when it comes to facing up to what is, essentially, an invasion of their privacy.

I can reassure you: no one can make you undergo this. It is recommended, but you can decline. however, a cervical smear test is a sensible screening measure, and can save lives, as minor abnormalities may be detected before cancer gains momentum, and early treatment stops the cancerous change long before it takes hold and spreads. AS Part of a ‘gynaecology MoT’ sometimes a pelvic examination to check for ovarian lumps or any enlargement of the uterus may be performed as well.

There is perhaps a tendency — both by doctors and patients — to ignore such screening in older women, as if somehow it no longer matters, but most of us take some trouble to persuade our patients to go ahead up to the age of 65. So I would encourage you to have the test. But you need to speak frankly about how you feel.

An involved, kind GP — and I sense that you know your doctor well — will allow you to be checked by a nurse, or even refer you to a female colleague for a cervical smear test, for that is all that’s needed.