Depression (major depression)

Introduction

Depression is one of the most common health conditions in the world. Depression isn't a weakness, nor is it something that you can simply "snap out of." Depression, formally called major depression, major depressive disorder or clinical depression, is a medical illness that involves the mind and body. It affects how you think and behave and can cause a variety of emotional and physical problems. You may not be able to go about your usual daily activities, and depression may make you feel as if life just isn't worth living anymore.

Most health professionals today consider depression a chronic illness that requires long-term treatment, much like diabetes or high blood pressure. Although some people experience only one episode of depression, most have repeated episodes of depression symptoms throughout their life.

Effective diagnosis and treatment can help reduce even severe depression symptoms. And with effective treatment, most people with depression feel better, often within weeks, and can return to the daily activities they previously enjoyed.

Signs and symptoms

Symptoms of depression include:

• Loss of interest in normal daily activities
• Feeling sad or down
• Feeling hopeless
• Crying spells for no apparent reason
• Problems sleeping
• Trouble focusing or concentrating
• Difficulty making decisions
• Unintentional weight gain or loss
• Irritability
• Restlessness
• Being easily annoyed
• Feeling fatigued or weak
• Feeling worthless
• Loss of interest in sex
• Thoughts of suicide or suicidal behavior
• Unexplained physical problems, such as back pain or headaches

Depression symptoms can vary greatly because different people experience depression in different ways. A 25-year-old man with depression may not have the same symptoms as a 70-year-old man, for instance. For some people, depression symptoms are so severe that it's obvious something isn't right. Others may feel generally miserable or unhappy without really knowing why.

Causes

It's not known specifically what causes depression. As with many mental illnesses, it's thought that a variety of biochemical, genetic and environmental factors may cause depression:

• Biochemical. Some evidence from high-tech imaging studies indicates that people with depression have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes. The naturally occurring brain chemicals called neurotransmitters, which are linked to mood, also may play a role in depression. Hormonal imbalances also could be a culprit.
• Genes. Some studies show that depression is more common in people whose biological family members also have the condition. Researchers are trying to find genes that may be involved in causing depression.
• Environment. Environment is also thought to play a causal role in some way. Environmental causes are situations in your life that are difficult to cope with, such as the loss of a loved one, financial problems and high stress.

Risk factors

Although precise statistics aren't known, depression is considered relatively common. In any given year, about 12 million adults in the United States have depression. Depression cuts across all racial, ethnic and economic divides — no one is immune from the risk of getting depression.

Depression typically begins in the late 20s, but it can arise at any age, affecting everyone from young children to older adults. Twice as many women are diagnosed with depression as men, but this may be due in part because women are more likely to seek treatment for depression.

Although the precise cause of depression isn't known, researchers have identified certain factors that seem to increase the risk of developing or triggering depression, including:

• Having other biological relatives with depression
• Having family members who have taken their own life
• Stressful life events, such as the death of a loved one
• Having a depressed mood as a youngster
• Illness, such as cancer, heart disease, Alzheimer's or HIV/AIDS
• Long-term use of certain medications, such as some drugs used to control high blood pressure, sleeping pills or, occasionally, birth control pills
• Certain personality traits, such as having low self-esteem and being overly dependent, self-critical or pessimistic
• Alcohol, nicotine and drug abuse
• Having recently given birth
• Being in a lower socioeconomic group

When to seek medical advice

It's perfectly normal to occasionally feel sad or upset, or to be unhappy with situations in your life. But with depression, these feelings linger for weeks, months or even years. And these feelings also are much more intense than "just the blues" and can interfere with relationships, work and daily activities, and even your ability to eat and bathe.

Feelings of depression can also lead to suicide. If you have any symptoms of depression, seek medical help as soon as possible. Depression usually doesn't get better on its own, and it may even get worse if left untreated.

If you have a primary care doctor, talk to him or her about your depression symptoms. Or seek help from a mental health provider. If you're reluctant to seek treatment, try to work up the courage to confide in someone about your feelings, whether it's a friend or loved one, a health care professional, a faith leader or someone else you trust. They can help you take the first steps to successful treatment of depression.

When you have suicidal thoughts
Suicidal thoughts and behavior are common among people with depression. If you're considering suicide right now and have the means available, talk to someone now. The best choice is to call 911 or your local emergency services number. If you simply don't want to do that, for whatever reason, you have other choices for reaching out to someone:

• Contact a family member or friend
• Contact a doctor, mental health provider or other health care professional
• Contact a minister, spiritual leader or someone in your faith community
• Go to your local hospital emergency room
• Call a crisis center or hot line

Helping a loved one with depression symptoms
If you have a loved one who you think may have symptoms of depression, have an open and honest discussion about your concerns. You may not be able to force someone to seek professional care, but you can offer encouragement and support.

You can also help your loved one find a qualified doctor or mental health provider and make an appointment. You may even be able to go to an appointment with him or her. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, take him or her to the hospital or call for emergency help.

Screening and diagnosis

Some doctors and health care providers may ask you questions about your mood and thoughts during routine medical visits. They may even ask you to fill out a brief questionnaire to help screen, or check, for depression symptoms.

When doctors suspect someone has depression, they typically run a battery of medical and psychological tests and exams. These can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and also check for any related complications. These exams and tests generally include:

• Physical exam. This may include measuring height and weight; checking vital signs, such as heart rate, blood pressure and temperature; listening to the heart and lungs; and examining the abdomen.
• Laboratory tests. These may include a complete blood count (CBC), screening for alcohol and drugs, and a check of your thyroid function.
• Psychological evaluation. A doctor or mental health provider will talk to you about your thoughts, feelings and behavior patterns. He or she will ask about your symptoms, including when they started, how severe they are, how they affect your daily life and whether you've had similar episodes in the past. You'll also discuss any thoughts you may have of suicide or self-harm.

Diagnostic criteria for depression
There are several other conditions whose symptoms may include depression. It's important to get an accurate diagnosis so you can get the appropriate treatment. Your doctor or mental health provider's evaluation will help determine if you have major depression or one of these other conditions that can sometimes resemble major depression:

• Adjustment disorder. An adjustment disorder is a severe emotional reaction to a difficult event in your life. It's a type of stress-related mental illness that may affect your feelings, thoughts and behavior.
• Bipolar disorder. This type of depression is characterized by mood swings that range from highs to lows. It's sometimes difficult to distinguish between bipolar disorder and depression, but it's very important to get the right diagnosis so that you can get the proper treatment and medications.
• Cyclothymia. Cyclothymia, or cyclothymic disorder, is a milder form of bipolar disorder.
• Dysthymia. Dysthymia (dis-THI-me-uh) is a less severe but more chronic form of depression. While it's usually not disabling, dysthymia can prevent you from functioning normally in your daily routine and from living life to its fullest.
• Postpartum depression. This is depression that occurs in a new mother usually within a month of having a baby.
• Psychotic depression. This is severe depression accompanied by psychosis, such as delusions or hallucinations.
• Schizoaffective disorder. Schizoaffective disorder is a condition in which a person meets the criteria for both schizophrenia and a mood disorder.
• Seasonal affective disorder. This type of depression is related to changes in seasons and a lack of exposure to sunlight.

Major depression is distinguished from these other conditions by its symptoms and their severity. To be diagnosed with major depression, you must meet the symptom criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Diagnostic criteria for depression include:

• Symptoms that occur nearly every day for two or more weeks
• A depressed mood
• Loss of interest or pleasure in most activities
• Significant unintentional weight loss or weight gain
• Sleeping difficulties, whether sleeping too much, too little or frequent waking episodes while trying to sleep
• Feelings of restlessness and agitation
• Feelings of sluggishness
• Fatigue or lack of energy
• Feelings of worthlessness or guilt
• Problems thinking, concentrating or making decisions
• Thoughts of death or suicide
• Your symptoms cause you distress or impair your ability to function in your daily life

Make sure you understand what type of depression you have so that you can learn more about your specific situation and its treatments.

Complications

Depression is a serious illness that can take a terrible toll on individuals and families. Untreated, depression can lead to a downward spiral of disability, dependency and suicide. Depression can result in severe emotional, behavioral, health and even legal and financial problems that affect every area of your life. Complications that depression may cause or be associated with include:

• Suicide
• Alcohol abuse
• Substance abuse
• Anxiety
• Heart disease and other medical conditions
• Work or school problems
• Family conflicts
• Relationship difficulties
• Social isolation

Treatment

Numerous treatments for depression are available. Standard depression treatment options include:

• Medications
• Psychotherapy
• Electroconvulsive therapy (ECT)

Emerging and less-studied treatments for depression include:

• Brain stimulation
• Complementary and alternative treatments

In some cases, your primary care doctor can treat your depression. In other cases, you may benefit from treatment with a qualified mental health provider, such as a psychiatrist, psychologist or social worker.

Try to be an active participant in your depression treatment. Working together, you and your doctor or therapist can decide which treatment options may be best for your situation, depending on your symptoms and their severity, your personal preferences, insurance coverage, affordability, treatment side effects and other factors. In some cases, though, depression is so severe that a doctor, loved one or guardian may need to guide your care until you're well enough to participate in decision making.

Here's a closer look at your depression treatment options.

Medications
Dozens of medications are available to treat depression. Most people find the best relief of depression symptoms by combining medications and psychotherapy. Some medications for depression are antidepressants that have been specifically approved by the Food and Drug Administration (FDA) to treat depression. Doctors also can use their medical judgment to prescribe other medications that haven't been FDA approved to treat depression but that may be effective anyway — a common and perfectly legal practice called off-label use.

There are several different types of antidepressants. Antidepressants are generally categorized by how they affect the naturally occurring biochemicals in your brain to change your mood. To determine which antidepressant may be best for you, doctors typically follow general practice guidelines. They may also ask you to take a blood test called the cytochrome P450 test, which can help identify genetic factors that influence your response to certain antidepressants (as well as some other medications).

Other factors that are considered when choosing an antidepressant are your symptoms, your family history of depression, and other conditions you may have. Don't give up until you find an antidepressant or medication that's suitable for you — you have a good chance of finding one that works and that doesn't have intolerable side effects, even if it takes a few tries.

Most antidepressants are equally effective. But some pose a higher risk of serious side effects. Here's how antidepressants and other medications are generally considered when you're starting treatment for depression:

• Typical first choices. Many doctors start treatment with antidepressants by prescribing an antidepressant known as an SSRI — a selective serotonin reuptake inhibitor. This is because the side effects of the medications in the SSRI class of antidepressants are generally more tolerable than are those of other types of antidepressants, and they also generally work well. SSRIs include fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).

  Other common first choices for antidepressants include serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), combined reuptake inhibitors and receptor blockers, and tetracyclic antidepressants.

• Typical second choices. The class of antidepressants called tricyclic antidepressants (TCAs) has been around longer than has the SSRI class, and TCAs are still effective. But because TCAs tend to have more numerous and more severe side effects, they're often not prescribed until you've tried SSRIs first without an improvement in your depression.
• Typical last choices. The class of antidepressants called monoamine oxidase inhibitors (MAOIs) is often prescribed as a last resort, when other medications haven't worked. That's because MAOIs, while generally effective, can have serious harmful side effects. They also require strict dietary restrictions because of rare but potentially fatal interactions with certain foods. Newer versions of MAOIs that you stick on your skin as a skin patch rather than swallowing may have fewer side effects.
• Other medication strategies. Your doctor may also suggest other medications to treat your depression. These may include stimulants, mood-stabilizing medications, anti-anxiety medications or antipsychotic medications. In some cases, your doctor may recommend combining two or more antidepressants or other medications for better effect, which is sometimes called augmentation.

Side effects of antidepressants
All antidepressants can cause unwanted side effects. Not everyone experiences the same number or intensity of side effects, though. You may find that your side effects are so mild that you don't need to stop taking the antidepressant. Coping strategies also can help you manage side effects. In addition, side effects often go away or lessen within several weeks of starting an antidepressant.

If you experience unpleasant or intolerable side effects, don't just stop taking an antidepressant without consulting your doctor first. Some antidepressants can cause withdrawal-like symptoms unless you slowly taper off your dose.

Precautions when taking antidepressants
Although studies have shown that antidepressants are generally safe, some precautions are in order when taking them. The FDA now requires that all antidepressant medications carry black box warnings. These are the strictest warnings that the FDA can issue for prescription medications.

The antidepressant warnings note that in some cases, children, adolescents and young adults ages 18 to 24 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting an antidepressant or when the dose is changed. Because of this risk, people in these age groups must be closely monitored by loved ones, caregivers and health care providers while taking antidepressants.

Some antidepressants have the potential of causing serious or even life-threatening health problems, such as liver failure or a dangerous drop in white cell count. While such cases are rare, it's important to get blood work or other tests on schedule and stick to your treatment regimen. Make sure you understand the risks of the medications you're taking and that you're being properly monitored.

In addition, if you're pregnant or breast-feeding, some antidepressants may pose an increased health risk to your unborn child or nursing child. Talk to your doctor about any concerns you have. Again, make sure you understand the risks of the various antidepressants. Working together, you and your doctor can explore options to get your depression symptoms under control.

Waiting for antidepressants to work
It can take as long as eight to 12 weeks to gain the full benefits of an antidepressant, although you may notice some improvements in your mood before that. Certain genetic factors may influence whether or not an antidepressant works for you and how long it takes for symptoms to improve. (DHF review) If you haven't had improvements in your mood and thoughts, your doctor may suggest either increasing your dose, combining medications or switching to a new medication.

Psychotherapy
Psychotherapy is another key depression treatment. It's often used along with medication treatment. Psychotherapy is a general term for a way of treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as therapy, talk therapy, counseling or psychosocial therapy.

Through these talk sessions, you learn about the causes of depression so that you can better understand it. You also learn how to identify and make changes in unhealthy behavior or thoughts, explore relationships and experiences, find better ways to cope and solve problems, and set realistic goals for your life. Psychotherapy can help you regain a sense of happiness and control in your life and help alleviate depression symptoms, such as hopelessness and anger. It also may help you adjust to a crisis or other current difficulty.

There are several types of psychotherapy that are effective for depression. Cognitive behavioral therapy is one of the most commonly used talk therapies for depression. This type of therapy helps you identify pessimistic, negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that your own thoughts — not other people or situations — determine how you behave. Even if an unwanted situation doesn't change, you can change the way you think and behave in a positive way. Interpersonal therapy and psychodynamic psychotherapy are other types of therapy commonly used to treat depression.

Electroconvulsive therapy
In electroconvulsive therapy (ECT), electrical currents are passed through the brain to trigger a seizure. Although many people are leery of ECT and its side effects, it typically offers fast, effective relief of depression symptoms. Experts aren't sure how this therapy relieves the signs and symptoms of depression. The procedure may affect levels of neurotransmitters in your brain. The most common side effect is confusion, which can last from a few minutes to several hours. Some people also experience partial memory loss, but memory often returns.

ECT is usually used for people who don't get better with medications and for those at high risk of suicide. It may be the only treatment available for older adults with severe depression who can't take medications because of heart disease.

Hospitalization and residential treatment programs
It's not often that depression becomes so severe that you require psychiatric hospitalization. And even when depression is severe, it still may not be easy to decide if hospitalization is appropriate. If you can be treated just as effectively or better outside of the hospital, your doctor probably won't recommend hospitalization.

Psychiatric hospitalization is generally recommended only when you aren't able to care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric hospitalization options include 24-hour inpatient care, partial or day hospitalization, or residential treatment, which offers a supportive place to live.

Nontraditional depression treatment options
If standard depression treatment hasn't been effective, you may want to try nontraditional depression treatments. These options, sometimes called neurotherapeutic treatments, involve direct stimulation of your brain. They include:

• Vagus nerve stimulation (VNS). VNS uses electrical impulses with a surgically implanted pulse generator to affect mood centers of the brain. The FDA approved this treatment in July 2005 for certain cases of severe or chronic, treatment-resistant depression.
• Transcranial magnetic stimulation (TMS). TMS is an experimental procedure that uses magnetic fields to alter brain activity. A large electromagnetic coil is held against your scalp near your forehead to produce an electrical current in your brain.
• Deep brain stimulation. This is a highly experimental treatment for depression in which the brain is stimulated with surgically implanted electrodes.

Prevention

There's no sure way to prevent depression. However, taking steps to control stress, to increase your resilience and to boost low self-esteem may help. Friendship and social support, especially in times of crisis, can help you weather rough spells. In addition, treatment at the earliest sign of a problem can help prevent depression from worsening. Long-term maintenance treatment also may help prevent a relapse of depression symptoms.

Self-care

Depression generally isn't an illness that you can treat on your own. But you can do some things for yourself that will build on your treatment plan. In addition to professional treatment, follow these self-care steps for depression:

• Stick to your treatment plan. Don't skip therapy sessions, even if you don't feel like going.
• Take your medications as directed. Even if you're feeling well, resist any temptation to skip your medications. If you stop, depression symptoms may come back, and you could also experience withdrawal-like symptoms.
• Learn about depression. Education about your condition can empower you and motivate you to stick to your treatment plan.
• Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so that you know what to do if symptoms return. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Consider involving family members or friends in watching for warning signs.
• Get active. Physical activity and exercise have been shown to reduce depression symptoms. Consider walking, jogging, swimming, gardening or taking up another form of exercise you enjoy.
• Avoid drugs and alcohol. Alcohol and illicit drugs can worsen depression symptoms.

Coping skills

Coping with depression can be challenging. Depression makes it hard to engage in the behavior and activities that may help you feel better. Talk to your doctor or therapist about improving your coping skills, and consider these tips to cope with depression:

• Simplify your life. Cut back on obligations when possible, and set reasonable schedules for goals.
• Consider writing in a journal to express pain, anger, fear or other emotions.
• Read reputable self-help books and consider talking about them to your doctor or therapist.
• Don't become isolated. Try to participate in normal activities and get together with family or friends regularly.
• Take care of yourself by eating a healthy diet and getting sufficient sleep.
• Join a support group for people with depression so that you can connect to others facing similar challenges.
• Stay focused on your goals. Recovery from depression is an ongoing process. Stay motivated by keeping your recovery goals in mind. Remind yourself that you're responsible for managing your illness and working toward your goals.
• Learn relaxation and stress management. Try such stress reduction techniques as meditation, yoga or tai chi.
• Structure your time. Plan your day and activities. Try to stay organized. You may find it helpful to make a list of daily tasks.
• Don't make important decisions when you're in the depths of depression, since you may not be thinking clearly.

Complementary and alternative medicine

You may be interested in trying to relieve depression symptoms with complementary or alternative medicine strategies. These include nutritional and dietary supplements and mind-body techniques.

Keep in mind that nutritional and dietary products aren't regulated. The Food and Drug Administration doesn't test them for safety, purity or effectiveness. You can't always be sure of what you're getting and if it's safe. Also, be aware that herbal and dietary supplements can interfere with the way certain prescription medications work or cause dangerous interactions that can harm your health. Talk to your doctors and other health care providers before taking any herbal or dietary supplements.

While some researchers are studying the effectiveness of complementary and alternative medicine, the jury's still out. Make certain you understand possible risks as well as benefits before pursuing them. Complementary and alternative treatments generally aren't a good substitute for traditional medical care.

Nutritional and dietary supplements
Here's a look at some nutritional supplements commonly used for depression:

• St. John's wort. Known scientifically as Hypericum perforatum, this is an herb that's been used for centuries to treat a variety of ills, including depression. It's not approved by the Food and Drug Administration to treat depression in the United States. Rather, it's classified as a dietary supplement. However, it's a popular depression treatment in Europe. Some studies show it may be helpful if you have mild or moderate depression.
• SAM-e. Pronounced "sammy," this is a synthetic form of a chemical that occurs naturally in the body. The name is short for S-adenosyl-methionine. It's not approved by the FDA to treat depression in the United States. Rather, it's classified as a dietary supplement. However, it's used in Europe as a prescription drug to treat depression.
• Omega-3 fatty acids. These are polyunsaturated fats found mostly in seafood. Good sources of omega-3s include fatty, cold-water fish, such as salmon, mackerel and herring. Flaxseed, flax oil and walnuts also contain omega-3 fatty acids, and small amounts are found in soybean and canola oils.

Mind-body connections
The connection between mind and body has been studied for centuries. And with depression, some people experience physical symptoms even more than mood-related symptoms. For instance, they may experience frequent fatigue, headache, backache, or vague aches and pains.

Mind-body techniques are thought to strengthen the communication between your mind and your body. Complementary and alternative medicine practitioners believe these two systems must be in harmony for you to stay healthy or to heal.

Mind-body techniques used to improve depression symptoms include:

• Acupuncture
• Yoga
• Meditation
• Guided imagery
• Massage therapy

As with dietary supplements, take care in using these techniques. Although they may pose less of a risk, relying solely on these to treat depression may not be effective enough. If you try mind-body techniques first to treat your depression but your symptoms worsen or don't improve, be sure to consult your health care providers.