Depression Overview

Everyone feels "blue" at certain times during his or her life. In fact, transitory feelings of sadness or discouragement are perfectly normal, especially during particularly difficult times. But a person who cannot "snap out of it" or get over these feelings within two weeks may be suffering from the illness called depression.

Depression is one of the most common and treatable of all mental illnesses. In any six-month period, 9.4 million Americans suffer from this disease. One in four women and one in 10 men can expect to develop it during their lifetime. Eighty to 90 percent of those who suffer from

depression can be effectively treated, and nearly all people who receive treatment derive some benefit.

Unfortunately, many fail to recognize the illness and get the treatment that would alleviate their suffering. They or their loved ones fail to notice a pattern and instead may attribute the physical symptoms to "the flu," the sleeping and eating problems to "stress," and the emotional problems to lack of sleep or improper eating.

But if people looked at all of these symptoms together and noticed that they occur over long periods of time, they might recognize them as signs of depression.

What Is Depression?

The term "depression" can be confusing since it's often used to describe normal emotional reactions. At the same time, the illness may be hard to recognize because its symptoms may be so easily attributed to other causes. People tend to deny the existence of depression by saying things like, "She has a right to be depressed! Look at what she's gone through." This attitude fails to recognize that people can go through tremendous hardships and stress without developing depression, and that those who suffer from depression can and should seek treatment.

Nearly everyone suffering from depression has pervasive feelings of sadness. In addition, depressed people may feel helpless, hopeless, and irritable. You should seek professional help if you or someone you know has had four or more of the following symptoms continually or most of the time for more than two weeks:

• Noticeable change of appetite, with either significant weight loss not attributable to dieting or weight gain.
• Noticeable change in sleeping patterns, such as fitful sleep, inability to sleep, early morning awakening, or sleeping too much.
• Loss of interest and pleasure in activities formerly enjoyed.
• Loss of energy, fatigue.
• Feelings of worthlessness.
• Persistent feelings of hopelessness.
• Feelings of inappropriate guilt.
• Inability to concentrate or think, indecisiveness.
• Recurring thoughts of death or suicide, wishing to die, or attempting suicide. (Note: People suffering this symptom should receive treatment immediately!)
• Melancholia (defined as overwhelming feelings of sadness and grief), accompanied by waking at least two hours earlier than normal in the morning, feeling more depressed in the morning, and moving significantly more slowly.
• Disturbed thinking, a symptom developed by some severely depressed persons. For example, severely depressed people sometimes have beliefs not based in reality about physical disease, sinfulness, or poverty.
• Physical symptoms, such as headaches or stomachaches.

For many victims of depression, these mental and physical feelings seem to follow them night and day, appear to have no end, and are not alleviated by happy events or good news. Some people are so disabled by feelings of despair that they cannot even build up the energy to call a doctor. If someone else calls for them, they may refuse to go because they are so hopeless that they think there's no point to it.

Family, friends, and co-workers offer advice, help, and comfort. But over time, they become frustrated with victims of depression because their efforts are to no avail. The person won't follow advice, refuses help, and denies the comfort. But persistence can pay off.

Many doctors think depression is the illness that underlies the majority of suicides in our country. Suicide is the eighth leading cause of death in America; it is the third leading cause of death among people aged 15 to 24. Every day 15 people aged 15 to 24 kill themselves. One of the best strategies for preventing suicide is the early recognition and treatment of the depression.

Depression can appear at any age. Current research suggests that treatable depression is very prevalent among children and adolescents, especially among offspring of adults with depression. Depression can also strike late in life, and its symptoms--including memory impairment, slowed speech, and slowed movement--may be mistaken for those of senility or stroke.

Scientists think that more than half of the people who have had one episode of major depression will have another at some point in their lives. Some victims have episodes separated by several years and others suffer several episodes of the disorder over a short period. Between episodes, they can function normally. However, 20 to 35 percent of the victims suffer chronic depression that prevents them from maintaining a normal routine.

Sadness at the loss of a loved one or over a divorce is normal, but these losses can also be the trigger for a depressive episode. In fact, most major environmental changes can trigger depression. Job promotions, moves to new areas, changes in living space--all can bring on depressive illness. New mothers sometimes suffer with post partum depression. Birth brings dramatic changes to both their environments and bodies--a combination that can trigger a downward swing in mood. Depression also afflicts many poor single working mothers of young children. These women live with loneliness, financial stress, and the unrelieved pressure of rearing children and maintaining a household without another's help.

Types of Depression

Depression strikes in several forms. When a psychiatrist makes a diagnosis of a patient's depressive illness, he or she may use a number of terms--such as bipolar, clinical, endogenous, major, melancholic, seasonal affective or unipolar--to describe it. These labels confuse many people who don't understand that they can overlap. People with depressive illness may also receive more than one diagnosis since the illness is often linked with other problems, such as alcoholism or other substance abuses, eating disorders, or anxiety disorders.

When you hear the term clinical depression, it merely means the depression is severe enough to require treatment. When a person is badly depressed during a single severe period, he or she can be said to have had an episode of clinical depression. More severe symptoms mark the period as an episode of major depression. Many mental health experts say the key to judging this gradation lies in the amount of change a person undergoes in his or her normal patterns along with a loss of interest and a lack of pleasure in them. An almost-daily tennis player, for instance, who began to break her court dates frequently, or a regular bridge player who lost interest in weekly games, might be edging into an episode of major depression. The more severe the depression, the more it is likely to affect its sufferer's life.

While many people have single or infrequent episodes of severe depression, some suffer with recurrent or long-lasting depression. For these people, who almost always seem to have symptoms of a mild form of the illness, the diagnosis is dysthymia. A major depressive episode can hit the dysthymic person, too, causing double depression, a condition that demands careful treatment and close follow-up.

In bipolar depression, the lows alternate with terrible highs in an often bewildering oscillation. Scientists now believe this up-and-down mood rollercoaster is the product of an imbalance in the brain chemistry which can be treated successfully about 80 percent of the time with balance-restoring medications.

Recent research has also found that a subtype of depression called seasonal affective disorder (SAD) exists. Research suggests that SAD arises from some people's sensitivity to seasonal changes in the amount of available daylight.

Theories About Causes

Medical research has contributed much to our understanding of depression. However, scientists do not know the exact mechanism that triggers depressive illness. Probably no single cause gives rise to the illness, and researchers continue to piece the puzzle together.

Scientists now believe genetic factors play a role in some depressions. Researchers are hopeful, for instance, that they are closing in on genetic markers for susceptibility to manic-depressive disorder [see APA's Let's Talk Facts About Manic-Depressive/Bipolar Disorder].

Recent genetic research also supports earlier studies reporting family links in depression. For example, if one identical twin suffers from depression or manic-depressive disorder, the other twin has a 70 percent chance of also having the illness. Other studies that looked at the rate of depression among adopted children supported this finding. Depressive illnesses among adoptive family members had little effect on a child's risk of depression; however, the disorder was three times more common among adopted children whose biological relatives suffered depression.

Additional research data indicate that people suffering from depression have imbalances of neurotransmitters, natural substances that allow brain cells to communicate with one another. Two transmitters implicated in depression are serotonin and norepinephrine. Scientists think a deficiency in serotonin may cause the sleep problems, irritability, and anxiety associated with depression. Likewise, a decreased amount of norepinephrine, which regulates alertness and arousal, may contribute to the fatigue and depressed mood of the illness.

Other body chemicals also may be altered in depressed people. Among them is cortisol, a hormone that the body produces in response to stress, anger, or fear. In normal people the level of cortisol in the bloodstream peaks in the morning, then decreases as the day progresses. In depressed people, however, cortisol peaks earlier in the morning and does not level off or decrease in the afternoon or evening.

Researchers don't know if these imbalances cause the disease or if the illness gives rise to the imbalances. They do know that cortisol levels will increase in anyone who must live with long-term stress.

Treatments

Depression is one of the most treatable mental illnesses. Between 80 and 90 percent of all depressed people respond to treatment and nearly all depressed people who receive treatment see at least some relief from their symptoms. Along with the great strides made in understanding the causes of depression, scientists are closer to understanding how treatment of the illness works.

Before any treatment program begins, however, a complete evaluation is essential. Depression is a complex illness, and many factors in a depressed person's life may feed into their condition. For example, a number of prevalent illnesses (such as hypothyroidism or hypertension) and commonly used medications can bring on depression. An evaluation will reveal the presence of these conditions or medicines to the psychiatrist. The evaluation will also include a medical/psychiatric history that will outline the patient's physical and emotional background, and a mental status examination, to uncover changes in the patient's mood, thoughts, patterns of speech, and memory that are manifestations of depression. The psychiatrist may also perform or order a physical exam for the patient to rule out undiagnosed medical problems that might be related to depressive illness.

Medication Therapy

Since the 1950s, physicians have learned much more about the effects of medication on depression. The effectiveness of a drug depends on a person's general health, weight, metabolism, and other characteristics unique to that patient. Medication must be used at an adequate dosage level and for a long enough time. If one form doesn't work, the psychiatrist may prescribe another, or may try a combination of medications to determine what works best. Generally, antidepressant drugs become fully effective within three to six weeks after a person begins taking them.

Physicians generally prescribe one of four major types of medication used to treat depression: heterocyclics, serotonin reuptake inhibitors, monoaminine oxidase inhibitors (MAOIs) and lithium.

The oldest of the heterocyclics, the tricyclics, and the serotonin reuptake inhibitors are most often prescribed for people whose depressions are characterized by fatigue; feelings of hopelessness, helplessness and excessive guilt; inability to feel pleasure; and loss of appetite with resulting weight loss.

MAO inhibitors may be prescribed for people whose depressions are characterized by increased appetite; excessive sleepiness; and anxiety, phobic, and obsessive-compulsive symptoms in addition to the depression. These medications may also be prescribed for people whose depression has not been reached by other drugs.

Lithium is used for people who have manic-depressive (bipolar) illness. It is also prescribed for people suffering from recurrent depression without mania.

Newer antidepressants, such as the serotonin reuptake inhibitors, have recently become available, and more are being developed. The newer drugs can help patients who either do not respond to the more traditionally prescribed medications or have trouble with those medications' side effects.

Like medications for any other illness, antidepressants can have side effects. With tricyclic antidepressants, for instance, these may include dry mouth, blurred vision, drowsiness, lowered blood pressure, and constipation, and tend to lessen as the body adjusts to the medication.

Psychotherapies

Psychotherapy involves the verbal interaction between a trained professional and a patient with emotional or behavioral problems. The therapist applies techniques based on established psychological principles to help the patient gain insights about him or herself and thus change his or her maladaptive thoughts, feelings, and behavior. There are several forms of this "talk treatment" that have proven useful in helping the depressed person.

In the spring of 1986, scientists announced results of research into the effectiveness of short-term psychotherapy in treating depression. Their findings indicated that for some categories of patients and under certain circumstances, some types of cognitive/behavioral therapy and interpersonal therapy were as effective as medications for depressed patients. Medications relieved the symptoms more quickly, but patients with moderately severe depression who received psychotherapy instead of medicine had as much relief from symptoms after 16 weeks.

The data from this study will help scientists better identify the depressed patients who will do best with psychotherapy alone and which patients may benefit from medications. In general, psychiatrists agree that severely depressed patients do best with a combination of medication and psychotherapy.

Interpersonal Psychotherapy: This therapy is based on the theory that disturbed social and personal relationships can cause or precipitate depression. The illness, in turn, may make these relationships more problematic. The therapist helps the patient understand his or her illness and how depression and interpersonal conflicts are related.

Cognitive/Behavioral Therapy: This treatment approach is based on the theory that people's emotions are controlled by their views and opinions of the world. Depression results when patients constantly berate themselves, expect to fail, make inaccurate assessments of what others think of them, feel hopeless, and have a negative attitude toward the world and the future. The therapist uses various techniques of talk therapy and behavioral prescriptions to alleviate the negative thought patterns and beliefs.

Psychoanalysis: This therapy is based on the concept that depression is the result of past conflicts which patients have pushed into their unconscious. The therapist meets 3 to 5 times a week with the patient to identify and resolve the patient's past conflicts that have given rise to depression in later years.

Psychodynamic Psychotherapy: Based on the principles of psychoanalysis, this therapy is less intense and often is provided once or twice a week over a shorter span of time. It is based on the premise that human behavior is determined by one's past experience, genetic endowment, and current reality. It recognizes the significant effects that emotions and unconscious motivation can have on human behavior.

Electroconvulsive Therapy (ECT): Scientists believe ECT works by affecting the same transmitter chemicals in the brain that are affected by medications. As more effective medications have been developed, the use of ECT for the treatment of depression has decreased. However, ECT is very effective for treating patients who cannot take medications due to heart conditions, old age, severe malnourishment, or for patients who do not respond to antidepressant medication. It can be a life-saving treatment technique that is considered when other therapies have failed or when a person is very likely to commit suicide.

Before ECT is administered, patients receive anesthesia and a muscle relaxant to protect them from physical harm and pain. Electrodes are placed on the head and a small amount of electricity is applied. This procedure is repeated two or three times a week until the patient improves or it becomes evident that further treatment will be ineffective.

Side effects of ECT are largely transitory. Some people may experience mild problems with memory of events that occurred within several months of the therapy.

Light therapy: Researchers have found that people suffering with seasonal affective disorder can be helped with the symptoms of their illness if they spend a therapeutic session bathed in light from a special full-spectrum light source, called a "light box." In summary, medication or psychotherapy, or a combination of the two treatment methods, usually relieves symptoms of depression in weeks. Even the most severe forms of depression can respond to treatment rapidly.

(c) Copyright 1988 American Psychiatric Association
Revised 1994

Produced by the APA Joint Commission on Public Affairs and the Division of Public Affairs. This document contains the text of a pamphlet developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association.

Additional Resources

Burns, D. Feeling Good: The New Mood Therapy. New York: Morrow, 1980.

Greist, J. and Jefferson, J. Depression and Its Treatment. Washington, DC: American Psychiatric Press, Inc., rev. ed. 1992.

Morrison, J.M. Your Brother's Keeper. Chicago: Nelson-Hall, 1981.

Sargent, M. Depressive Illnesses: Treatments Bring New Hope. U.S. Dept. of Health & Human Services (ADM 89-1491), 1989.

Winokur, G. Depression: The Facts. New York: Oxford University Press, 1981.

Technical Books

Deakin, J.F.W. (Ed.): The Biology of Depression. Washington, DC: American Psychiatric Press, Inc., 1986.

Klein, D. and Wender, P. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment. New York: Oxford University Press, 1993.

Klerman, G. (Ed.): Suicide and Depression Among Adolescents and Young Adults. Washington, DC: American Psychiatric Press, Inc., 1986.

Other Resources

National Alliance for the Mentally Ill
(703) 524-7600

National Depressive and Manic Depressive Association
(312) 939-2442

National Foundation for Depressive Illness
(800) 248-4344

National Institute of Mental Health Public Information Branch
(301) 443-4536

National Mental Health Association
(703) 684-7722