About 20 years ago, Sue gave the impression that she was the poster college girl. She was pretty, slim, in a sorority, and frequented bars and parties.

But beneath that surface was a woman in her 20s struggling with depression, a condition that she has lived with until recently.

“You can’t see depression,” she said. “It’s as if a black cloud has descended on you. It’s just kind of an overall blah feeling of no interest, no hobbies, nothing to motivate you and get you excited. Every day of your life.”

(Sue is not the patient’s real name; The Herald agreed to anonymity due to the sensitive nature of her diagnosis.)

Sue first sought medical help when she was in college. Since then it has been one medication after the other: Lexapro, Zoloft, Cymbalta, Depakote, Lithium and Ultram.

Treating depression is a trial-and-error process, said Sue, a full-time mother of two boys.

“It’s a mess,” she said. “It’s very frustrating for doctors and for patients.”

Sue is hardly an isolated case. Worldwide, women are twice as likely to develop depression than men, said Dr. Charles Nemeroff, chairman of the Department of Psychiatry and Behavioral Sciences at the University of Miami Miller School of Medicine.

In the U.S. alone, one in five women will have a major depressive episode in their life. After puberty, women are more likely to get depression than men. Particularly risky phases are after childbirth, commonly known as postpartum depression, and during menopause.

“Not any single one of these factors may be the reason why women may be more vulnerable. But when you put them together, they probably conspire to increase the risk,” Nemeroff said.

The options

Vagus nerve stimulation, repetitive transcranial magnetic stimulation and deep brain stimulation are options available for patients who have not responded to other treatments, Nemeroff said.

The vagus nerve stimulation treatment was originally approved by the Food and Drug Administration in 1997 for the treatment of epilepsy. In 2005, the FDA approved it for depression in cases where patients were not responsive to other treatments.

A battery-powered generator similar to a pacemaker is implanted in the chest. A wire connected to the generator travels to the vagus nerve in the neck, where it sends electrical impulses to mood centers in the brain.

The FDA approved repetitive transcranial magnetic stimulation in 2008. An electromagnet is placed on the scalp and magnetic pulses are sent from outside the skull to a small surface area of the brain. This type of treatment will soon be an option for patients at UM.

Case by case

Deep brain stimulation has not been FDA approved for the treatment of depression but it has been approved for Parkinson’s disease and obsessive-compulsive disorder. It is offered to UM patients on a case-by-case basis.

A hole is drilled in the skull and minuscule electrodes are lowered through a catheter into the brain area that affects mood. A generator is implanted under the chest skin to control the amount of brain stimulation. Only about 150 depression patients in the world have been treated with deep brain stimulation, Nemeroff said.

A year ago, the FDA approved Viibryd, a drug that increases serotonin levels in the brain by stimulating the brain’s serotonin receptors. Serotonin is a chemical produced by the body that allows brain cells and other nervous system cells to communicate with each other. Low serotonin levels have been linked to depression.

Studies also are under way in which patients are given ketamine intravenously, a drug originally used as a tranquilizer by veterinarians. The FDA has not approved ketamine for treating depression.

“It’s a whole new avenue of investigation,” Nemeroff said.

About four years ago Sue moved with her family to South Florida in hopes the sunny weather and outdoor lifestyle would help. She went to see Nemeroff, who prescribed Effexor and Trazodone, which boost the brain’s serotonin levels.

Trazodone is what “knocked everything back into shape,” said Sue, who now lives in South Miami. “It’s like I woke up from a 42-year-long fog.”