More than just a bad day
Depression isn't the blues or feeling glum. Rather, depression is a clinical term referring to an illness of the central nervous system that actually alters brain chemistry. Depression is agonizing, debilitating, and potentially fatal. One study shows that depressed patients are socially and physically impaired at the same level as patients with chronic heart disease.
A depressed person struggles with intense sadness and feelings of helplessness and hopelessness. He or she may find it difficult or impossible to enjoy anything that was once pleasurable. Working, eating, or sleeping may be hard. While such feelings may have their roots in a sad event a death or job loss, for instance the symptoms may grow out of proportion to the event or last beyond a normal recovery period. Some types of depression are not spurred by a traumatic event. Others result from different illnesses, certain prescription drugs, or substance abuse.
However, depression even in severe cases is treatable.
Although even severe depression is quite treatable, it often goes untreated. Many of those suffering depression are uninformed or misinformed about the disease and do not know they can be helped. Others fear the stigma of mental illness and feel they should be able to "snap out of it." Yet a depressed person is no more capable of snapping out of it than a person with diabetes is capable of suddenly having normal blood sugar levels.
It's normal for brain chemistry to change in response to life's disappointments, traumas, and grief. At such times, the levels of the molecules that act as messengers to your brain and nerves (neurotransmitters) drop. Since these brain chemicals relate to our feelings of happiness and well-being, depression may occur. Normally, when the event that caused the depression passes, brain chemistry returns to normal. In depressive illness, however, the altered brain chemistry persists.
Fortunately, several drugs can successfully treat depression, such as the newer selective serotonin reuptake inhibitors (SSRIs), Prozac being the most well known. Psychotherapy alone is often successful in treating certain depressions. At other times, psychotherapy is best used along with antidepressant drugs.
Depressive illness is the fourth most likely reason for visiting one's family physician. It is usually diagnosed when five or more symptoms persist throughout the day for at least two weeks. Some symptoms include feelings of hopelessness, loss of interest in previously pleasurable activities, and fatigue.
The following are some principal features of the five major types of depression:
- Situational depression (exogenous depression). Results from an understandably upsetting event, such as a death, divorce, or job loss. Sadness and fretfulness often characterize such depressions. They are considered mild to moderate depressions and usually last a few weeks a few months at the most.
- Dysthymia. A chronic, mild form of depression that leaves people with the disorder feeling persistently sad or down in the dumps. Dysthymia sufferers also lose interest in their daily affairs and/or activities they once found pleasurable. It is diagnosed only when symptoms have persisted for two or more years. Dysthymic disorder, despite its "mild" characteristics, can be as debilitating as major depression, because of its chronic, persistent nature.
- Seasonal affective disorder (SAD). Mild to moderate depression caused by a disturbance of our body's internal waking-and-sleeping clock (circadian rhythm). This disturbance occurs from lack of enough exposure to the sun's full-spectrum light, usually in the winter months.
- Major depression. The most severe form of depression. It may cause extreme impairment and even death, in some cases. This form of depression has its roots in biology rather than external events. It is marked by a profound lack of energy, a distorted, negative self-image, and deep sadness or hopelessness. It can be moderate to severe and pass in months or last for years without treatment.
- Bipolar disorder (manic-depression). People with this illness alternate between the "highs" of mania and the "lows" of depression. Either extreme may be severe.
How Common Is Depression?
More than 19 million American adults suffer from depressive illnesses. At some time in their lives, about 10% of all people will have a depressive disorder serious enough to require medical attention, with an average age of 40. Twice as many women are affected by depression than men.
What You Can Expect
Many depressive episodes can pass without treatment, usually within six to nine months. However, in 15% to 20% of depressed people, the illness may linger for two years or more. Depression tends to come back an average of four to five times during a lifetime.
That depressions may pass doesn't minimize the depths of despair a depressed person may feel. Depression is a serious, treatable illness that left untreated can result in suicide. About 15% of severely depressed people commit suicide.
ALERT! Any person who talks of making a specific plan for suicide is at great risk for carrying it out. This is an emergency. If you or someone you know is considering suicide, contact your local suicide prevention hotline and your doctor immediately. Help and hope is available for those with even the most severe depression.
Goals of Treatment
Currently there is no cure for depression, but researchers are looking for better treatments, as well as for the cause of the illness. Depression even the most severe forms can be treated effectively in 80%-90% of people suffering from it. If you are depressed, your doctor's immediate goal will be to relieve the symptoms of your depression and return you to your normal mood. In addition, you and your doctor can work together to prevent the depression from happening again.
Current treatment methods such as new drugs, exposure to bright light, psychotherapy, and physical exercise have done wonders for the treatment of depression. Your treatment probably won't require a hospital stay; you'll be treated in your doctor's office and go home the same day. But if you suffer from severe depression, you may need to stay in the hospital at some point during the illness.
Your treatment can vary widely depending upon the type of depression you are diagnosed with:
- Situational depression. Your doctor may not prescribe drugs to treat your depression. This is usually mild and responds well to counseling. Should depression persist, your doctor may look for progression to a major depression and then prescribe an antidepressant drug for treatment.
- Dysthymia. Your doctor may suggest psychotherapy alone or in combination with an antidepressant.
- Major depression. This illness is often treated effectively with an antidepressant drug. If you have had depression before, your doctor may suggest a maintenance dose of the drug once the episode has passed, to protect against future relapses of the illness.
- Seasonal affective disorder (SAD). Your doctor may suggest light therapy in addition to an antidepressant. In light therapy, you spend from 30 minutes to several hours a day in front of special, extra-bright, full-spectrum fluorescent lights.
Antidepressant drug therapy is remarkably successful for treating depression. The chances that any given antidepressant will work for a particular person are about 65%, while the chances that at least one antidepressant will work for a particular person are 80%-90%.
|Selective serotonin reuptake inhibitors (SSRIs)|
|Serotonin–norepinephrine reuptake inhibitors (SNRIs)|
|Tricyclic antidepressants (TCAs)|
|Monoamine oxidase inhibitors (MAOIs)|
Psychotherapy and drug therapy in combination often produce the best results. In mild cases, psychotherapy alone can be just as effective as drug therapy. Forms of psychotherapy for relieving depression include:
- Interpersonal therapy. Supporters believe that depression results from flawed personal relationships, which in turn perpetuate the depression. Interpersonal therapists focus on relationship issues, helping the patient to understand his or her feelings about them and finding ways to address them.
- Cognitive/behavioral therapy. This helps depressed people recognize and change the negative thinking and behavior that may lead to and perpetuate depression.
- Psychodynamic therapy. This focuses on resolving deep internal conflicts that depressed people may have carried from childhood to adulthood.
Electroconvulsive therapy (ECT)
ECT, previously known as "shock treatment," is reserved for severe depression, such as when a patient becomes suicidal or psychotic. Doctors place electrodes on the patient's head and deliver a mild shock, inducing a brain seizure. Doctors give the treatment under general anesthesia, in five to seven treatments, one treatment every other day. It may cause temporary memory loss, but it can deliver almost immediate relief from a severe depressive episode. Why ECT works is still a mystery.
Healthcare Professionals Who May Be Involved in Treatment
Many types of doctors treat depression, including:
- Family physicians
Considerations When Selecting Treatment
Some types of depression medication may be less suited for those with other health problems. For instance, if you have heart rhythm disturbances you should generally avoid tricyclic antidepressants (TCAs). These drugs may also cause blurred vision, dry mouth, and constipation. Another class of antidepressants, selective serotonin reuptake inhibitors (SSRIs), may decrease your sex drive. Ask your doctor about side effects of any medication you're prescribed.
Activity & Diet Recommendations
People who are depressed do best when their routine is as normal as possible. Even if you don't feel up to it, continue daily personal care, work, normal meals, and outings with friends and family. Also, get regular exercise, which can greatly improve your mood.
Even if your appetite is suppressed, you should make sure you get enough calories, protein, and nutrients. Avoid alcohol because it may interfere with the effectiveness of certain antidepressants as well as worsen depression. Some nutritional therapists promote a sugar-free diet high in complex carbohydrates and protein.
Your physician will probably want to see you within two weeks of starting your medication and every two weeks thereafter until you feel an improvement. He or she will also want to evaluate side effects and effectiveness of the treatment. If the medication works for you at the right dosage you should see results within a month or so. You will probably want to see your doctor once every three months after you improve. Your treatment may last anywhere from six months to two years.
The complications of depression include continuing misery and other symptoms. If a person does not respond to medication, suicide is a possibility in some cases. Ongoing depression occurring simultaneously with another major or chronic illness can make recovery from the second illness more difficult.
Quality of Life
Living with depression can profoundly affect the quality of your life. Even mild depression can steal months or years of happiness from your life if it goes untreated. And sadly, many depressed people struggle through their depressions without medical help. If you have friends or family members who are depressed, you would do them a great service by letting them know about their treatment options.
Considerations for Women
You should avoid many antidepressant drugs during pregnancy. Check with your physician about treatment alternatives.
Most antidepressant drugs are passed through breast milk. Talk to your doctor about any medicines you may be taking if you are considering breastfeeding.
Considerations for Older People
Nearly one in six Americans over age 65 more than five million has serious symptoms of depression. Another one million have clinical depression. But other serious physical problems that an older person may have often overshadow the depression. Also, the usual symptoms of depression may not show up in older people. Instead, the person may be irritable and apathetic, have difficultly concentrating, memory lapses, and decreased energy symptoms that are often mistaken for normal signs of aging. Because adverse reactions to antidepressant drugs are more common in older people, doctors start their medications at a low dosage.
Considerations for Children and Adolescents
Some perfectly healthy children and teens are, on occasion, moody, withdrawn, and sullen. Such behavior is normal. When a child is clinically depressed, symptoms such as these become exaggerated, persist, and do not respond to parental counseling or intervention. In addition, children and adolescents may not appear "depressed" as an adult would, but instead may be more angry, irritable, or complain of vague physical symptoms. Depressed children need medical help and can benefit from the same treatments as adults. Here's what to look for if you are worried that your child may be depressed:
- Social isolation
- Anger and irritability
- Poor school performance
- Withdrawal from parents and family
- Unexplained crying
- Insomnia or excessive sleepiness
- Guilty feelings
- Unexplained physical pains
- Loss of appetite or overeating
- Neglect of personal appearance
ALERT! Children who ponder suicide, threaten it, or make a suicide plan should be taken seriously. Suicide rates among the young have increased and such threats represent a true emergency. Contact your suicide prevention hotline and your primary care doctor immediately if you worry that your child is at risk. Hope and help are available for anyone who is depressed.
Last updated 25 May 2012
- Major depressive disorder
- Unipolar affective disorder (depression)
- Bipolar affective disorder (manic-depression)
- Dysthymic disorder
Depression does not have any proven cause. However, some medical illnesses, such as pancreatic cancer, adrenal dysfunction, and stroke, can lead to depression. But researchers have not determined a common final pathway to depression symptoms.
Researchers believe that depression has no one single cause; a combination of biological and psychosocial factors may be responsible. Manic-depression often runs in families, meaning it has a genetic predisposition. However, just because you have it in your family doesn't mean you will get it. A decrease in certain molecules that act as messengers to your brain and nerves (neurotransmitters) can trigger some types of depression. Depression can also be spurred by a medical illness such as AIDS or long-term use of some medications, particularly treatments for high blood pressure. Environmental factors and personality seem to be very important as well.
Components of your personality, health, personal life, financial situation, and occupation may all make it more likely you will get a depressive illness. Common risk factors include:
- Family history of depression, suicide, alcoholism, or other substance abuse
- Major illness or disability
- Certain anxiety disorders
- Being a woman
- Failed marriage or relationship
- Death or loss of loved one
- Repressed anger or other strong emotion
- Job change or loss
- Stressful situations
- A compulsive, rigid, perfectionist, or highly dependent personality
Symptoms & Diagnosis
Different kinds of depression share features of "down" symptoms. In bipolar disorder (manic-depression), there is also an "up" phase of mania. Features of a depressed mood include:
- Feeling sad, hopeless, pessimistic, unnecessarily guilty, worthless, unneeded, and/or helpless
- Anxiety, restlessness, unremitting worries
- Rumination about death or suicide
- Poor self-image
- Loss of interest in previously pleasurable activities, including sex
- Diminished energy or fatigue
- Sleep disorder: sleeping too much or too little insomnia
- Difficulty remembering things, making decisions, or concentrating
- Change in appetite (either up or down) nearly every day
- Weight loss (without dieting) or weight gain
- Chronic physical symptoms like headaches, digestive problems, and/or pain
- Delusions or hallucinations
The phase of mania in bipolar disorder appears very different from the depressed phase. In mania there may be:
- An inflated view of oneself (grandiosity)
- Decreased need for sleep, increased "energy"
- Increased speech, faster or louder speech, or feeling pressure to keep talking
- Racing and erratic thoughts (flight of ideas)
- Inappropriate behavior
Despite these symptoms, many people do not realize that they have the condition.
Conditions That May Be Mistaken for Depression
Many disorders can be mistaken for depression. Because the diagnosis of depression is done mostly on the basis of symptoms, your doctor should perform a thorough evaluation to rule out other underlying disorders. In addition, your doctor must rule out other psychological disorders. For example, your doctor may look for:
- Organic brain diseases
- Other neurological conditions such as stroke, head injury, tumor, or infection
- Endocrine diseases (diseases involving hormones such as thyroid, parathyroid, or adrenal gland dysfunction)
- Liver failure
- Kidney failure
- Chronic fatigue syndrome
- Vitamin deficiency
- Partial complex seizures
- Panic and anxiety disorders
- Medication side effects
- Heart disease
- Lung disease
- Substance abuse
How Depression Is Diagnosed
Since there are no reliable laboratory tests to diagnose depression, your doctor makes the diagnosis based primarily on signs and symptoms of depression. If you have had symptoms for two or more weeks in a row, the case for a diagnosis of depression is strengthened. Your doctor may also use mental status testing and standardized questionnaires to measure the severity of the depression.
Your doctor may run certain tests, including:
- Electrocardiogram (ECG), which measures heart rhythm
- Electroencephalogram (EEG), which measures brain waves
- Complete blood count (CBC)
- Sedimentation rate (ESR)
- Thyroid function test
- Liver function test
- RPR and HIV titers
- Urine toxicology screen
- Kidney function test
If your doctor is trying to rule out an organic brain syndrome, he or she may order the following brain imaging scans:
- CT: computed tomography
- MRI: magnetic resonance imaging
- Vitamin B. The B vitamins play an important role in mood and mental health. At the University of Arizona, researchers gave 14 depressed elderly people either antidepressant drugs plus a placebo, or antidepressant drugs plus vitamins B-1, B-2, and B-6 (10 mg a day of each). A month later, the supplement group showed greater relief.
- Fish oil. In a small but pioneering new study, capsules of the fatty oil found in salmon and other cold-water fish have been shown to significantly improve symptoms of bipolar disorder, popularly known as manic depression. Researchers at Harvard's Pharmacology Research Laboratory at McLean Hospital gave 30 bipolar patients either a placebo or fish oil capsules. They all were evaluated every two weeks for four months. The fish-oil group showed marked improvement in the highs and lows of bipolar disorder. Fish oil is rich in omega-3 fatty acids. Most experts recommend four to 12 standard fish-oil capsules a day.
- St. John's wort. A very popular herbal treatment for depression, "wort, " is Old English for "plant." St. John's wort is a natural form of selective serotonin reuptake inhibitor (SSRI), the class of antidepressants that includes Prozac.
Recently, American and German researchers analyzed 23 studies comparing St. John's wort and a placebo for depression. In the placebo group, 22% reported benefit. In the herb group, 55% obtained significant relief. Among those who responded to St. John's wort, the relief obtained was similar to that experienced from pharmaceutical antidepressants.
St. John's wort is less likely to cause side effects than pharmaceutical antidepressants. Possible side effects may include fatigue, restlessness, stomach distress, and allergic reactions. Don't mix St. John's wort with pharmaceutical antidepressants. And don't take this herb if you are pregnant or nursing.
- Ginkgo: also recommended to treat depression.
- Kava kava: recommended for treating depression accompanied by anxiety.
Meditation, visualization (imagining pleasant scenes), and similar therapies can be deeply relaxing. And deep relaxation often improves mood. British researchers gave one of three treatments to 154 breast cancer patients who felt depressed: face-to-face meetings (control group), meditation instruction with visualization exercises, or progressive muscle relaxation, a technique similar to meditation. The control group remained depressed, but both relaxation therapies helped lift the women's depression.
Bright light is the treatment of choice for the type of depression that develops in winter from lack of sunlight, called seasonal affective disorder, or SAD. For other types of depression, the effectiveness is less clear.
Self care & Prevention
Preventing Recurrences of Depression
Depression cannot be cured, but it can be successfully treated. To prevent recurrence, a maintenance dose of an antidepressant drug may be helpful. Continued counseling, regular aerobic exercise, and a healthy diet may also help prevent recurrences.
Cognitive therapy is a powerful self-care approach to treating depression by changing the way you think, helping you shed unrealistic attitudes and perceptions that may be making you unhappy. In an analysis of 28 studies, a University of Calgary psychologist determined that for mild to moderate depression, cognitive therapy is as effective as drug treatment or psychotherapy.
Exercise relieves depression, although the mechanism is not known. It does reduce blood levels of cortisol, a hormone associated with stress; increase levels of endorphin, the body's own internal antidepressant; and boost levels of serotonin, as do the SSRIs.
At the University of Illinois, researchers surveyed 401 adults about their health, mental health, and lifestyle. The more time the subjects spent in strenuous exercise, the less depression, anxiety, and insomnia they reported.
Researchers at the University of California-Berkeley have followed the mental health of 6,000 local residents since 1965. The more sedentary the participants are, the more likely they are to suffer depression.