Depression

What is depression?

Depression is more than just a passing blue mood, a "bad day," or temporary sadness. The most common symptom is a low mood that can sometimes appear as irritability. Often the person with depression is not able to enjoy activities that he or she normally enjoys.

There are several types of depression, including:

Major depression. With major depression, there is a profound sadness or a sense of despair. The symptoms of major depression are defined as lasting at least two weeks, but usually they go on much longer.

Bipolar disorder (previously called manic depression or manic depressive illness). Bipolar disorder is a mental disorder characterized by wide mood swings from high (manic) to low (depressed). It is commonly divided into two subtypes (bipolar I and bipolar II) based on the dividing line between mania and hypomania.

• Bipolar I disorder is the classic form where a person has had at least one manic episode.
• In bipolar II disorder, the person has never had a manic episode, but has had at least one hypomanic episode and at least one period of significant depression.

Most people who have manic episodes also experience periods of depression. In fact, there is some evidence that the depression phase is much more common than periods of mania in this illness. Bipolar depression can be much more distressing than mania and, because of the risk of suicide, is potentially more dangerous.

Persistent depressive disorder (previously called dysthymia). Persistent depressive disorder is less severe than an episode of major depression, but lasts longer. Many people with this disorder describe having been depressed as long as they can remember, or feeling as though they go in and out of depression all the time.

Postpartum depression. A major depressive episode may occur within the first two to three months after giving birth to a baby. In that case, it may be called major depressive disorder with peripartum onset. Most people refer to it as postpartum depression.

Seasonal affective disorder. Depression that occurs mainly during the winter months is usually called seasonal affective disorder, or SAD. It also may be called major depressive disorder with seasonal pattern.

A variety of symptoms usually accompany the low mood of any type of depression. And the symptoms can vary significantly among different people.

Many people with depression also have anxiety. They may worry more than average about their physical health. They may have excessive conflict in their relationships, or function poorly at work. Sexual functioning may be a problem. People with depression are also at more risk for abusing alcohol or other substances.

Depression probably involves changes in the areas of the brain that control mood. The nerve cells may be functioning poorly in certain regions of the brain. Altered communication between nerve cells or nerve circuits can make it harder for a person's brain to regulate his or her mood.

Hormone changes may also negatively affect mood. An individual's life experiences can affect these biological processes. And a person's genetic makeup influences how vulnerable he or she is to experiencing depression.

An episode of depression can be triggered by a stressful life event. But in many cases, depression does not appear to be related to a specific event.

Episodes of depression can occur at any age. Depression is diagnosed in women twice as often as in men. People who have a family member with major depression are more likely to develop depression or drinking problems.

What are the main depression symptoms?

A depressed person may gain or lose weight, eat more or less than usual, have difficulty concentrating, and have trouble sleeping or sleep more than usual. He or she may feel tired and have no energy for work or play. Small burdens or obstacles may appear impossible to manage. The person can appear slowed down, or agitated and restless. The symptoms can be quite noticeable to others.

A particularly painful symptom of this illness is an unshakable feeling of worthlessness and guilt. The person may feel guilty about a specific life experience, or may feel general guilt not related to anything in particular.

If pain and self-criticism become great enough, they can lead to feelings of hopelessness, self-destructive behavior, or thoughts of death and suicide. The vast majority of people who suffer severe depression do not attempt or commit suicide, but they are more likely to do so than people who are not depressed.

Symptoms of major depression include:

• distinctly depressed or irritable mood
• loss of interest or pleasure
• decreased or increased weight or appetite
• decreased or increased sleep
• appearing slowed or agitated
• fatigue and loss of energy
• feeling worthless or guilty
• poor concentration or indecisiveness
• thoughts of death, or suicide plans or attempts.

People with persistent depressive disorder may have many of the same symptoms. While the symptoms tend to be less severe, they are long-lasting.

How is depression diagnosed?

A primary care physician or a mental health professional usually can diagnose depression by asking questions about a person's medical history and symptoms.

The simplest screening tool to help determine if a person may be depressed is the PHQ-2. Over the last two weeks, how often have you experienced:

• little interest or pleasure in doing things
• feeling down, depressed, or hopeless.

If it is more than several days over the past two weeks, your doctor will pursue additional questions. There are no specific tests for depression.

Many people with depression do not seek evaluation or treatment because of society's attitudes about depression. The person may feel the depression is his or her fault, or may worry about what others will think. Also, the depression itself may distort a person's ability to recognize the problem. Therefore, family members or friends may need to encourage someone showing symptoms of depression to seek help.

Also, it is important to be evaluated by a primary care physician to make sure the symptoms are not being caused by a medical condition or medication.

How is depression treated?

No single treatment, whether it's a drug or a style of therapy, can ease depression in every case. However, research suggests you will improve your chances of getting relief if you combine antidepression medication and therapy. One report that pooled findings from 25 studies found that adding psychotherapy to an antidepressant drug was more helpful than medication alone in treating major depression. Earlier research suggested that one reason therapy and medication may complement each other is that they have different effects on the brain.

Often, treatment is divided into three phases. Keep in mind, though, that there are no sharp lines dividing the phases, and very few people take a straight path through them.

1. In the initial phase, the aim is to relieve symptoms. Generally, this occurs within four to eight weeks, but it may take longer depending on your response to the first treatments you try.
2. In the continuation phase, you work with your doctor to maximize your improvements. Further treatment adjustments, such as modifying the dosage of a depression medication and sometimes adding a second drug, can help. This period may take another four to five months.
3. In the maintenance phase, the aim is to prevent relapse. Ongoing treatment is often necessary, especially if you have already experienced several depressive episodes, have chronic low mood, or have risk factors that make a recurrence more likely.

If your symptoms are mild or moderate, it is often reasonable to start with either an antidepressant medication or psychotherapy. If your depression is mild, there is a greater chance that you will respond well to psychotherapy alone. Generally, as symptoms become more severe, it is more important to consider medication earlier in your treatment.

Of course, consider all your options carefully, and discuss them with the professionals you are consulting. If one type of treatment alone isn't helping you — and especially if your depression is getting worse — you can always try combination treatment.

A medication from a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) is often prescribed first. These medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). They are not without problems, but they are fairly easy to take and relatively safe compared with previous generations of antidepressants.

SSRIs are known to cause problems with sexual functioning, some nausea, and an increase in anxiety in the early stages of treatment.

Other effective antidepressants include bupropion (Wellbutrin), venlafaxine (Effexor), mirtazapine (Remeron), and duloxetine (Cymbalta).

It usually takes at least two to six weeks of taking an antidepressant to see improvement. It may take several attempts to find the medication that works best. Once the right medication is found, it may take up to a few months to find a proper dose and for the full positive effect to be seen.

A number of different psychotherapy techniques have been demonstrated to be helpful, depending on the causes of the depression, the availability of family and other social support, and an individual's personal style and preference. A technique called cognitive behavioral therapy can help a depressed person recognize negative thinking and teach techniques for controlling symptoms. Other types of therapy, including psychodynamic, insight-oriented, and interpersonal psychotherapy, can help depressed people to sort out conflicts in important relationships or explore the history behind symptoms.

If you suffer from depression, you will benefit from learning all you can about the illness. You can also make use of any support networks that may be available in your community.

Does taking an antidepressant increase suicide risk?

The FDA still requires manufacturers of antidepressants to include a so-called "black box warning" on their product labeling. The warning is intended to address the concern that antidepressants may increase the risk of suicide in children, adolescents, and young adults. This problem has remained a focus of research, but the evidence surrounding it remains hard to interpret.

A small number of young people taking these medications probably do have an unusual reaction and end up feeling much worse, rather than better. Any medication that affects mood can have an unexpected negative effect in some people.

However, some experts worry that this warning has had too much of a chilling effect on the use of antidepressants for treatment. It is potentially dangerous for both doctors and patients to be too cautious about using a helpful intervention. When depression goes untreated, the risk of suicide goes up. Paradoxically, it is possible that the labeling puts more people at risk for suicide if it means that some people do not receive the treatment they need.

Therefore, independent of this debate, it is always important to monitor your treatment closely. No matter what age you are or what treatment you're getting, report any troubling symptoms or worsening mood to your doctor immediately.

How to help someone with depression

Like a pebble thrown into a pond, depression creates ripples that spread far from their immediate point of impact. Those closest to people who have these illnesses often suffer alongside them. It's upsetting and often frustrating to deal with the inevitable fallout. But you can do a lot to help a loved one and yourself handle this difficult period.

Encourage him or her to get treatment and stick with it. Remind the person about taking antidepressant medication or keeping therapy appointments.

Don't ignore comments about suicide. If you believe your loved one is suicidal, call his or her doctor or therapist. Mental health professionals can't divulge information about a patient without permission, but it is not a violation of confidentiality for them to listen to you. In urgent situations, if you can't reach the doctor or therapist, you may want to call a local crisis hotline for advice or bring the person to a local ER.

Care for yourself. Being a caregiver is a difficult job. You may want to seek individual therapy or join a support group. Numerous mental health organizations sponsor such groups, and can also provide you with information on the illness and the latest treatments.

Offer emotional support. Your patience and love can make a huge difference. Ask questions and listen carefully to the answers. Try not to brush off or judge the other person's feelings, but do offer hope. Suggest activities that you can do together, and keep in mind that it takes time to get better. Don't worry if you don't know what to say; it takes a great deal of training (such as that received by therapists) to advise people in emotional distress.

Recognize that depression may manifest as irritability or anger, which is often directed toward family and other loved ones. Remind yourself that a disease is causing your loved one to act differently or perhaps be difficult. Do not blame him or her, just like you wouldn't if it were chronic physical pain that caused the person to change in certain ways.

Many participants said they kept trying different combinations of these specific strategies, and learned what helped through trial and error.