Depression

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depression, major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and depression may make you feel as if life isn't worth living.

More than just a bout of the blues, depression isn't a weakness, nor is it something that you can simply "snap out" of. Depression may require long-term treatment. But don't get discouraged. Most people with depression feel better with medication, psychological counseling or both. Other treatments also may help.

Symptoms

Although depression may occur only one time during your life, usually people have multiple episodes of depression. During these episodes, symptoms occur most of the day, nearly every day and may include:

• Feelings of sadness, emptiness or unhappiness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in normal activities, such as sex
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so that even small tasks take extra effort
• Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and weight gain in some people
• Anxiety, agitation or restlessness — for example, excessive worrying, pacing, hand-wringing or an inability to sit still
• Slowed thinking, speaking or body movements
• Feelings of worthlessness or guilt, fixating on past failures or blaming yourself for things that are not your responsibility
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent thoughts of death, suicidal thoughts, suicide attempts or suicide
• Unexplained physical problems, such as back pain or headaches

For some people, depression symptoms are so severe that it's obvious something isn't right. Other people feel generally miserable or unhappy without really knowing why.

Types of depression

Depression affects each person in different ways, so symptoms caused by depression vary from person to person. To clarify the type of depression you have, your doctor may add information to your depression diagnosis called a specifier. Specifiers include having depression with specific features, such as:

• Anxious distress — unusual restlessness or worry about possible events or loss of control
• Mixed features — simultaneous depression and mania, which includes elevated self-esteem, talking too much, and racing thoughts and ideas
• Melancholic features — severe depression with a profound lack of response to something that used to bring pleasure, associated with early morning awakening, worsened mood in the morning, significant changes in appetite, and feelings of guilt, agitation or sluggishness
• Atypical features — ability to be cheered by happy events, increased appetite, little need for sleep, sensitivity to rejection, and a heavy feeling in arms or legs
• Psychotic features — depression accompanied by delusions or hallucinations, which may involve themes of personal inadequacy or negative themes
• Catatonia — includes motor activity that involves either uncontrollable and purposeless movement or fixed and inflexible posture
• Peripartum onset — occurs during pregnancy or in the weeks or months after delivery (postpartum)
• Seasonal pattern — related to changes in seasons and diminished exposure to sunlight

Depression symptoms in children and teens

Common symptoms of depression in children and teens are similar to those of adults, but there can be some differences.

• In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.
• In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.
• Depression may occur with other mental health conditions, such as anxiety, eating disorders, substance abuse or attention-deficit/hyperactivity disorder (ADHD).

Depression symptoms in older adults

Depression is not a normal part of growing older and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, including:

• Memory difficulties or personality changes
• Fatigue, loss of appetite, sleep problems, aches or loss of interest in sex, which are not caused by a medical condition or medication
• Often wanting to stay at home, rather than going out to socialize or doing new things
• Suicidal thinking or feelings, especially in older men

When to see a doctor

If you feel depressed, make an appointment to see your doctor as soon as you can. Depression often gets worse if it isn't treated. Untreated depression can lead to other mental and physical health problems or troubles in other areas of your life. Feelings of depression can also lead to suicide.

If you're reluctant to seek treatment, talk to a friend or loved one, a health care professional, a faith leader, or someone else you trust.

If you have suicidal thoughts

If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

• Reach out to a close friend or loved one.
• Contact a minister, a spiritual leader or someone in your faith community.
• Call a suicide hotline number 
• Make an appointment with your doctor, mental health provider or other health care provider.

When to get emergency help

If you think you may hurt yourself or attempt suicide, call  your local emergency number immediately.

If you have a loved one who is in danger of committing suicide or has made a suicide attempt, make sure someone stays with that person. Call your local emergency number immediately. Or, if you think you can do so safely, take the person to the nearest hospital emergency room.

Causes

It's not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:

• Biological differences.People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
• Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. When these chemicals are out of balance, it may be associated with depressive symptoms.
• Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result from thyroid problems, menopause or a number of other conditions.
• Inherited traits. Depression is more common in people whose biological (blood) relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.
• Life events. Traumatic events such as the death or loss of a loved one, financial problems, high stress, or childhood trauma can trigger depression in some people.

Risk factors

Depression often begins in the teens, 20s or 30s, but it can happen at any age. More women are diagnosed with depression than men, but this may be due in part because women are more likely to seek treatment.

Researchers have identified certain factors that seem to increase the risk of developing or triggering depression, including:

• Depression that started when you were a teen or child
• History of anxiety disorder, borderline personality disorder or post-traumatic stress disorder
• Abuse of alcohol or illegal drugs
• Certain personality traits, such as having low self-esteem and being overly dependent, self-critical or pessimistic
• Serious or chronic illness, such as cancer, diabetes or heart disease
• Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication)
• Traumatic or stressful events, such as physical or sexual abuse, the loss of a loved one, a difficult relationship or financial problems
• Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide

Complications

Depression is a serious disorder that can take a terrible toll on individuals and families. Untreated depression can result in emotional, behavioral and health problems that affect every area of your life. Complications associated with depression may include:

• Excess weight or obesity, which can lead to heart disease and diabetes
• Alcohol or substance abuse
• Anxiety, panic disorder or social phobia
• Family conflicts, relationship difficulties, and work or school problems
• Social isolation
• Suicidal feelings, suicide attempts or suicide
• Self-mutilation, such as cutting
• Premature death from other medical conditions

Preparing for your appointment

You may see your primary care doctor, or your doctor may refer you to a health provider who specializes in diagnosing and treating mental health conditions (psychologist or psychiatrist). Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

These steps can help you make the most of your appointment. Make a list of:

• Any symptoms you've had, including any that may seem unrelated to the reason for your appointment
• Key personal information, including any major stresses or recent life changes
• All medications, vitamins or other supplements that you're taking, including how much and how often
• Questions to ask your health provider

Take a family member or friend along, if possible, to help you remember all of the information provided during the appointment.

For problems related to depression, basic questions to ask your health provider include:

• Is depression the most likely cause of my symptoms?
• What are other possible causes for my symptoms or condition?
• What kinds of tests will I need?
• What treatment is likely to work best for me?
• What are the alternatives to the primary approach that you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a psychiatrist or other mental health provider?
• What are the main side effects of the medications you're recommending?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask questions anytime you don't understand something.

What to expect from your health provider

Be ready to answer questions from your health provider, such as:

• When did you or your loved ones first notice your symptoms of depression?
• How long have you felt depressed? Do you generally always feel down, or does your mood fluctuate?
• Does your mood ever swing from feeling down to feeling intensely happy (euphoric) and full of energy?
• Do you ever have suicidal thoughts when you're feeling down?
• How severe are your symptoms? Do they interfere with your daily life or relationships?
• Do you have any biological relatives with depression or another mood disorder?
• What other mental or physical health conditions do you have?
• Do you drink alcohol or use illegal drugs?
• How much do you sleep at night? Does it change over time?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

Tests and diagnosis

These exams and tests can help rule out other problems that could be causing your symptoms, pinpoint a diagnosis and check for any related complications:

• Physical exam. Your doctor may do a physical exam and ask in-depth questions about your health. In some cases, depression may be linked to an underlying physical health problem.
• Lab tests. For example, your doctor may do a blood test called a complete blood count (CBC) or test your thyroid to make sure it's functioning properly.
• Psychological evaluation. To check for signs of depression, your doctor or mental health provider asks about your symptoms, thoughts, feelings and behavior patterns. Your doctor may have you fill out a questionnaire to help answer these questions.

Diagnostic criteria for depression

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

For major depression, you must have five or more of the following symptoms over a two-week period, most of the day, nearly every day. At least one of the symptoms must be either a depressed mood or a loss of interest or pleasure. Other symptoms may include:

• Depressed mood, such as feeling sad, empty or tearful (in children and teens, depressed mood can appear as constant irritability)
• Significantly diminished interest or feeling no pleasure in all — or almost all — activities
• Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected)
• Insomnia or increased desire to sleep
• Either restlessness or slowed behavior that can be observed by others
• Fatigue or loss of energy
• Feelings of worthlessness, or excessive or inappropriate guilt
• Trouble making decisions, or trouble thinking or concentrating
• Recurrent thoughts of death or suicide, or a suicide attempt

Your symptoms must be severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Symptoms can be based on your own feelings or may be based on the observations of someone else.

Other conditions that cause depression symptoms

There are several other conditions with symptoms that can include depression. It's important to get an accurate diagnosis so you can get appropriate treatment. Your doctor or mental health provider's evaluation will help determine if your symptoms of depression are caused by a specific type of depression or another condition, such as:

• 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 mood disorder is characterized by mood swings that range from highs to lows. It's sometimes difficult to distinguish between bipolar disorder and depression.
• Cyclothymic disorder. Cyclothymic (sy-kloe-THIE-mik) disorder involves highs and lows that are milder than those of bipolar disorder.
• Persistent depressive disorder. Sometimes called dysthymia (dis-THIE-me-uh), this is a less severe but more chronic form of depression. While it's usually not disabling, persistent depressive disorder can prevent you from functioning normally in your daily routine and from living life to its fullest.
• Premenstrual dysphoric disorder. This involves depression symptoms associated with hormone changes that begin a week before and improve within a few days after the onset of your period, and are minimal or gone after completion of your period.
• Attention-deficit/hyperactivity disorder (ADHD). Children with ADHD can demonstrate irritability without sadness or loss of interest. However, major depression can occur with ADHD.

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

Treatments and drugs

Numerous depression treatments are available. Medications and psychological counseling (psychotherapy) are very effective for most people.

Your primary care doctor or psychiatrist can prescribe medications to relieve depression symptoms. However, many people with depression also benefit from seeing a psychologist or other mental health counselor.

If you have severe depression, you may need a hospital stay, or you may need to participate in an outpatient treatment program until your symptoms improve.

Here's a closer look at depression treatment options.

Medications

Many types of antidepressant medications are available to treat depression, including those below. Discuss possible major side effects with your doctor or pharmacist.

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often start by prescribing an SSRI. These medications are safer and generally cause fewer bothersome side effects than do other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
• Serotonin and norepinephrine reuptake inhibitors (SNRIs).Examples of SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR) and desvenlafaxine (Pristiq).
• Norepinephrine and dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin) falls into this category. It's one of the few antidepressants not frequently associated with sexual side effects.
• Atypical antidepressants. These medications don't fit neatly into any of the other antidepressant categories. They include trazodone and mirtazapine (Remeron). Both are sedating and usually taken in the evening. A newer medication called vilazodone (Viibryd) is thought to have a low risk of sexual side effects.
• Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil) and nortriptyline (Pamelor) — tend to cause more severe side effects than do newer antidepressants. So tricyclics generally aren't prescribed unless you've tried an SSRI first without improvement.
• Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate) and phenelzine (Nardil) — may be prescribed, typically when other medications haven't worked, because they can have serious side effects. Using MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods ― such as certain cheeses, pickles and wines ― and some medications including birth control pills, decongestants and certain herbal supplements. Selegiline (Emsam), a newer MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs do. These medications can't be combined with SSRIs.
• Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or medications such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications might also be added for short-term use.

Finding the right medication

If a family member has responded well to an antidepressant, it may be one that could help you. Or you may need to try several medications before you find one that works. This requires patience, as some medications need several weeks or longer to take full effect and for side effects to ease as your body adjusts.

Don't stop taking an antidepressant without talking to your doctor first. Antidepressants aren't considered addictive, but sometimes physical dependence, which is different from addiction, can occur. Stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, and quitting suddenly may cause a sudden worsening of depression. Work with your doctor to gradually and safely decrease your dose.

Inherited traits play a role in how antidepressants affect you. In some cases, where available, results of genetic tests (done by blood test or cheek swab) may offer clues about how your body may respond to a particular antidepressant. The study of how genes affect a person's response to drugs is called pharmacogenomics. However, other variables besides genetics can affect your response to medication.

Antidepressants and pregnancy

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 if you become pregnant or are planning on becoming pregnant.

Antidepressants and increased suicide risk

Most antidepressants are generally safe, but the FDA requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

Psychotherapy

Psychotherapy is a general term for treating depression by talking about your condition and related issues with a mental health provider. Psychotherapy is also known as talk therapy, counseling or psychosocial therapy.

Different types of psychotherapy can be effective for depression, such as cognitive behavioral therapy, interpersonal therapy, dialectic behavioral therapy, acceptance and commitment therapy, and mindfulness techniques. These therapies can help you:

• Adjust to a crisis or other current difficulty
• Identify negative beliefs and behaviors and replace them with healthy, positive ones
• Explore relationships and experiences, and develop positive interactions with others
• Find better ways to cope and solve problems
• Identify issues that contribute to your depression and change behaviors that make it worse
• Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
• Learn to set realistic goals for your life
• Develop the ability to tolerate and accept distress using healthier behaviors

Hospitalization and residential treatment programs

In some people, depression is so severe that a hospital stay is needed. Inpatient hospitalization may be necessary if you can't care for yourself properly or when you're in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling you need while you get symptoms under control.

Other treatment options

For some people, other procedures may be suggested:

• Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. This procedure is thought to affect levels of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who don't get better with medications, can't take antidepressants for health reasons or are at high risk of suicide.
• Transcranial magnetic stimulation (TMS). TMS may be an option for those who haven't responded to antidepressants. During TMS, you sit in a reclining chair with a treatment coil placed against your scalp. The coil sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Typically, you'll have five treatments each week for up to six weeks.

Lifestyle and home remedies

Depression generally isn't a disorder that you can treat on your own. But in addition to professional treatment, these self-care steps can help:

• Stick to your treatment plan. Don't skip psychotherapy sessions or appointments. Even if you're feeling well, don't 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. Encourage your family to learn about depression to help them understand and be more supportive of you.
• Pay attention to warning signs. Work with your doctor or therapist to learn what might trigger your depression symptoms. Make a plan so you know what to do if your symptoms get worse. Contact your doctor or therapist if you notice any changes in symptoms or how you feel. Ask family members or friends to help watch for warning signs.
• Get exercise. Physical activity reduces depression symptoms. Consider walking, jogging, swimming, gardening or taking up another activity that you enjoy.
• Avoid alcohol and illegal drugs. It may seem like alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or substance abuse.
• Get plenty of sleep. Sleeping well is important for both your physical and mental well-being. If you're having trouble sleeping, talk to your doctor about what you can do.

Alternative medicine

Make certain you understand the risks as well as possible benefits if you pursue alternative or complementary therapy. Don't replace conventional medical treatment or psychotherapy with alternative medicine. When it comes to depression, alternative treatments aren't a substitute for medical care.

Mind-body connections

Complementary and alternative medicine practitioners believe the mind and body must be in harmony for you to stay healthy. Examples of mind-body techniques that may be helpful for depression include:

• Acupuncture
• Yoga or tai chi
• Meditation
• Guided imagery
• Massage therapy
• Relaxation techniques
• Music or art therapy
• Spirituality
• Exercise

Relying solely on these therapies is generally not enough to treat depression. They may be helpful when used in addition to medication and psychotherapy.