Depression Guide

Your complete guide to the mental disorder that produces extreme feelings of sadness or hopelessness.


What is depression?

Depression (also called clinical depression, major depression, or major depressive disorder) is a mental disorder that is characterized by feelings of sadness or hopelessness, loss of interest in normal activities, and an inability to experience happiness or pleasure. While everyone experiences periods of sadness in their lives, or days when they are "feeling blue" or feeling down, such instances are not the same thing as depression. Depression is a medical illness that affects both the mind and the body. The feelings of sadness that occur with depression tend to persist for weeks, months, or sometimes longer and the person who is suffering cannot simply "snap out" of it.

Depression is very common in the United States. It is hard to know for sure how many people are affected by depression because many people never seek treatment for their illness. Nonetheless, the National Institute of Mental Health (NIMH) estimates that depression affects close to 15 million American adults (about 7 percent) each year. Some of these people experience an episode of depression only once, while others may continue to have recurrent episodes for many years. Depression can occur at any age but most commonly arises in the 20s or early 30s. The disorder is about twice as frequent in women as it is in men.

Children can also experience depression. It is estimated that approximately 2.5% of children in the United States (one in every 40 children) suffer from depression. Depression is more common in boys under the age of ten, but in the teens, the disorder is more common in girls. Depression in children is just as serious as it is in adults. If you suspect your child (or any child) or teenager is depressed or if they are talking about suicide, get them to a health professional as soon as possible.

Not everyone with depression experiences the same symptoms to the same degree. Sometimes the symptoms are mild, such as when a person experiences general malaise or unhappiness with no apparent cause that will not go away. In other cases the symptoms can be severe such as when a person feels so hopeless they can't even get out of bed in the morning. Officially, depression is characterized by the presence of the majority of the following symptoms nearly all day on most days for two or more weeks:

-- Persistent feelings of sadness or anxiousness.

-- Feelings of guilt, worthlessness, helplessness, or hopelessness.

-- Irritability or restlessness.

-- Loss of interest in normal activities.

-- Inability to enjoy normally-pleasurable activities, including sex.

-- Fatigue and decreased energy.

-- Difficulty focusing or concentrating, problems remembering details.

-- Problems sleeping, including insomnia or excessive sleeping.

-- Overeating, or loss appetite, with accompanying weigh gain or loss.

-- Thoughts of suicide, suicide attempts.

-- Unexplained aches or pains, headaches, cramps, or digestive problems.

-- Crying for no apparent reason.

-- Difficulty making decisions.

-- Feeling fatigued or weak.

In young children, depression may be harder to identify. Common symptoms include frequent vague physical complaints such as headaches, body aches, stomachaches or tiredness, irritability, "moping around," social withdrawal, persistent fear of dying or that loved ones will abandon them, and changes in eating habits. In adolescents, common symptoms include sad mood, sleep disturbances, difficulty with relationships, feeling shunned or socially isolated, and substance abuse. Other symptoms in both children and teens; include unexplained anger, vocal outbursts, and failure to engage in or attend normal activities such as school, after-school activities or even playing with friends.

While the exact cause of depression remains elusive, research suggests that, as with other mental disorders, it likely results from an interaction of several factors including genetics, environmental aspects, and brain biochemistry.

It is unlikely that people are born with a single gene that causes depression, but instead they may have a genetic makeup that predisposes them to developing depression, if other factors are also present. This is sometimes called the diathesis-stress model of mental disease and it explains why mental disorders tend to run in families but do not seem to be associated with any particular gene: for example, identical twins (who have all the same genes) commonly have one twin affected by depression but not the other. It is also common for depression to occur in people with no family history of the disease.

In addition, any trauma or severe stress, such as the loss of a loved one or experiencing a divorce, tends to make depression more likely to occur. These environmental factors may play a huge role in some cases of depression and a lesser role in others. After an initial episode of depression in some people subsequent episodes may occur without any precipitating event.

In addition to the genetic and environmental factors mentioned above, changes in brain biochemistry may be an important cause of depression. Research indicates that people who are depressed have different patterns of brain activation and show alterations in the levels of certain brain chemical messengers (neurotransmitters). It may be the case that people with an imbalance in their neurotransmitter levels due to genetics and/or environment are more likely to become depressed, or it may be that depression is caused by some other factor entirely and the changes in neurotransmitter levels are simply another consequence or by-product of the disorder.

Anyone of any race can experience depression at any time in their life but the disorder arises most commonly in the late twenties or early thirties. About twice as many women are diagnosed with depression as men, but this may reflect a difference in the willingness of women and men to seek treatment. Other risk factors for depression include:

-- Having a close relative with depression.

-- Having family members who have committed suicide.

-- Stressful life events, such as the death of a loved one.

-- Having had a depressive episode in the past.

-- Chronic illness, such as cancer, heart failure, Alzheimer's or HIV/AIDS.

-- Long-term use of certain medications including some blood pressure medicines.

-- Having certain personality traits, such as having low self-esteem.

-- Abusing alcohol, nicotine, or drugs.

-- Being in a lower socioeconomic group.

Having recently given birth puts you at risk for a different type of depression called postpartum depression or the "baby blues." This condition can be seriously debilitating and often requires treatment, but is considered distinct from major depression because it is caused by the hormonal changes that occur after childbirth. In addition, living in a temperate or arctic environment where the sun angle is low in the winter puts people at risk for seasonal affective disorder (SAD), also distinct from major depression due to its situational nature.

If you are having several of the symptoms mentioned above and they last for longer than a week or two, you may be depressed. See your doctor to be evaluated so you can begin treatment.

Diagnosing depression often begins with a screening questionnaire that asks questions about your outlook, mood, and attitude in the recent past. Examples of these types of questions include:

-- Do you feel sad, blue, unhappy or "down in the dumps"?

-- Do you feel tired, having little energy, unable to concentrate?

-- Do you feel inadequate, like a failure or that nobody likes you anymore?

-- Do you feel guilty without a rational reason, or put yourself down?

-- Do you feel that things always go or will go wrong no matter how hard you try?

The doctor will also do a physical examination and ask about your personal and family medical history. He or she may also do blood tests to rule out other disorders such as thyroid problems, diabetes, or viral infections. There is no concrete test for depression and so its diagnosis depends on how well your symptoms conform to the guidelines laid out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The diagnostic criteria for depression include the presence of the majority of the following symptoms lasting nearly all day on most days for two or more weeks:

-- A depressed mood, as indicated either by subjective report or observation made by others.

-- Loss of interest or pleasure in most activities.

-- Significant unintentional weight loss or weight gain.

-- Sleeping difficulties, either sleeping too much or too little.

-- Feelings of restlessness and agitation.

-- Feelings of sluggishness.

-- Fatigue or lack of energy.

-- Feelings of worthlessness or guilt.

-- Problems thinking, concentrating, or making decisions.

-- Recurrent thoughts of death or suicide.

-- Symptoms that cause distress or impair your ability to function in your daily life.

The most common treatments for depression are medications and psychotherapy. Medications include three broad classes of antidepressant drugs:

-- SSRIs: Selective serotonin reuptake inhibitors work by increasing the activity of a neurotransmitter called serotonin. These drugs are usually the first to be prescribed if depression is suspected because they have the least bothersome side-effects. They include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Lexapro). Related dugs include the SNRIs¿ -- ¿such as venlafaxine (Effexor) -- ¿that increase the activity of both serotonin and another neurotransmitter called norepinephrine; the NDRIs -- ¿such as Bupropion (Wellbutrin) -- which increase brain levels of norepinephrine and another neurotransmitter called dopamine.

-- TCAs: The tricyclic antidepressants have been around longer than the SSRIs but they are still commonly prescribed. They work by increasing the levels of serotonin, norepinephrine and dopamine in the brain. Because they tend to have more troublesome side effects, TCAs are usually a secondary choice that may be prescribed if the SSRIs do not provide relief from symptoms. Examples of TCAs include: amitriptyline (Elavil) and imipramine (Tofranil).

-- MAOIs: The monoamine oxidase inhibitors are rarely prescribed unless other edications have failed, in part because they interact with many other medications and with certain foods. They work by inhibiting an enzyme that breaks down serotonin, norepinephrine, and dopamine, thus increasing their levels in the brain. Examples include phenelzine (Nardil) and isocarboxazid (Marplan). The FDA recently approved selegiline (Emsam) which is an MAOI applied as a patch to the skin, a method of administration with fewer side effects.

Several herbal remedies for depression are on the market, some of which have proved to be effective in controlled studies and many others that have not. Talk to a doctor or a trusted health care professional before trying these treatments. All herbs and supplements carry a risk of interaction with other drugs so it is important to let your doctor know what you are taking and in what amount.

Psychotherapy, alone or in combination with medications, has been shown to help many people with depression. Psychotherapy or "talk therapy" is a general term for treatment that is focused on talking about your condition and related issues in your life with a mental health professional such as a counselor, psychiatrist, or clinical psychologist. The goal is to help you gain insight into your own feelings so you can better understand them and perhaps make changes in your life to feel empowered or find more effective ways to cope with stress. There are several different types of psychotherapy so talk to a mental health professional about which one might be right for you.

Since the root cause of depression is unknown, there is no reliable way to prevent it from occurring. Since you cannot do anything to change your genetics and science is still learning about ways to influence brain biochemistry, that leaves the environment as the one factor in depression that you can control. Taking steps to limit stress in your life or learning new strategies for coping with stress and trauma may help lower the chances of your becoming depressed. Building a support system of friends and relatives that you can rely on during a crisis may also help. Getting treatment as early as possible after symptoms appear can help reduce the impact of a depressive episode. Finally, if you have been depressed in the past, maintenance treatment in the form of medication or psychotherapy may help lower the chances of depressive symptoms recurring.

If you have the majority of the symptoms listed above and they last for most of the day on all days for two weeks or more, see the doctor right away. Also, if you are having thoughts of suicide you should talk to someone right away. If you recognize symptoms of depression in a loved one, they may be reluctant to get help. The best way to deal with this is often to discuss the situation with them in a frank and open manner. If necessary, you may want to consult a health care or mental health professional about how to approach such a situation. Regardless of whether it is you or a loved one who is depressed, the sooner treatment is started, the more likely there will be a quick and complete recovery.

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