Common Diseases > Depression
Depression in America
In any given 1-year period, 9.5
percent of the population, or about 18.8 million
American adults, suffer from a depressive illness5
The economic cost for this disorder is high, but the
cost in human suffering cannot be estimated.
Depressive illnesses often interfere with normal
functioning and cause pain and suffering not only to
those who have a disorder, but also to those who
care about them. Serious depression can destroy
family life as well as the life of the ill person.
But much of this suffering is unnecessary.
Most people with a depressive illness do not seek
treatment, although the great majority—even those whose
depression is extremely severe—can be helped. Thanks to
years of fruitful research, there are now medications and
psychosocial therapies such as cognitive/behavioral, "talk"
or interpersonal that ease the pain of depression.
Unfortunately, many people do not recognize that
depression is a treatable illness. If you feel that you or
someone you care about is one of the many undiagnosed
depressed people in this country, the information presented
here may help you take the steps that may save your own or
someone else's life.
WHAT IS A DEPRESSIVE DISORDER?
A depressive disorder is an illness that involves the
body, mood, and thoughts. It affects the way a person eats
and sleeps, the way one feels about oneself, and the way one
thinks about things. A depressive disorder is not the same
as a passing blue mood. It is not a sign of personal
weakness or a condition that can be willed or wished away.
People with a depressive illness cannot merely "pull
themselves together" and get better. Without treatment,
symptoms can last for weeks, months, or years. Appropriate
treatment, however, can help most people who suffer from
TYPES OF DEPRESSION
Depressive disorders come in different forms, just as is
the case with other illnesses such as heart disease. This
pamphlet briefly describes three of the most common types of
depressive disorders. However, within these types there are
variations in the number of symptoms, their severity, and
Major depression is
manifested by a combination of symptoms (see symptom list)
that interfere with the ability to work, study, sleep, eat,
and enjoy once pleasurable activities. Such a disabling
episode of depression may occur only once but more commonly
occurs several times in a lifetime.
A less severe type of depression,
dysthymia, involves long-term, chronic symptoms
that do not disable, but keep one from functioning well or
from feeling good. Many people with dysthymia also
experience major depressive episodes at some time in their
Another type of depression is
bipolar disorder, also called manic-depressive
illness. Not nearly as prevalent as other forms of
depressive disorders, bipolar disorder is characterized by
cycling mood changes: severe highs (mania) and lows
(depression). Sometimes the mood switches are dramatic and
rapid, but most often they are gradual. When in the
depressed cycle, an individual can have any or all of the
symptoms of a depressive disorder. When in the manic cycle,
the individual may be overactive, overtalkative, and have a
great deal of energy. Mania often affects thinking,
judgment, and social behavior in ways that cause serious
problems and embarrassment. For example, the individual in a
manic phase may feel elated, full of grand schemes that
might range from unwise business decisions to romantic
sprees. Mania, left untreated, may worsen to a psychotic
SYMPTOMS OF DEPRESSION AND MANIA
Not everyone who is depressed or manic experiences every
symptom. Some people experience a few symptoms, some many.
Severity of symptoms varies with individuals and also varies
- Persistent sad, anxious, or "empty" mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities
that were once enjoyed, including sex
- Decreased energy, fatigue, being "slowed down"
- Difficulty concentrating, remembering, making
- Insomnia, early-morning awakening, or oversleeping
- Appetite and/or weight loss or overeating and weight
- Thoughts of death or suicide; suicide attempts
- Restlessness, irritability
- Persistent physical symptoms that do not respond to
treatment, such as headaches, digestive disorders, and
- Abnormal or excessive elation
- Unusual irritability
- Decreased need for sleep
- Grandiose notions
- Increased talking
- Racing thoughts
- Increased sexual desire
- Markedly increased energy
- Poor judgment
- Inappropriate social behavior
CAUSES OF DEPRESSION
Some types of depression run in families, suggesting that
a biological vulnerability can be inherited. This seems to
be the case with bipolar disorder. Studies of families in
which members of each generation develop bipolar disorder
found that those with the illness have a somewhat different
genetic makeup than those who do not get ill. However, the
reverse is not true: Not everybody with the genetic makeup
that causes vulnerability to bipolar disorder will have the
illness. Apparently additional factors, possibly stresses at
home, work, or school, are involved in its onset.
In some families, major depression also seems to occur
generation after generation. However, it can also occur in
people who have no family history of depression. Whether
inherited or not, major depressive disorder is often
associated with changes in brain structures or brain
People who have low self-esteem, who consistently view
themselves and the world with pessimism or who are readily
overwhelmed by stress, are prone to depression. Whether this
represents a psychological predisposition or an early form
of the illness is not clear.
In recent years, researchers have shown that physical
changes in the body can be accompanied by mental changes as
well. Medical illnesses such as stroke, a heart attack,
cancer, Parkinson's disease, and hormonal disorders can
cause depressive illness, making the sick person apathetic
and unwilling to care for his or her physical needs, thus
prolonging the recovery period. Also, a serious loss,
difficult relationship, financial problem, or any stressful
(unwelcome or even desired) change in life patterns can
trigger a depressive episode. Very often, a combination of
genetic, psychological, and environmental factors is
involved in the onset of a depressive disorder. Later
episodes of illness typically are precipitated by only mild
stresses, or none at all.
Depression in Women
Women experience depression about twice as often as men.1
Many hormonal factors may contribute to the increased rate
of depression in women—particularly such factors as
menstrual cycle changes, pregnancy, miscarriage, postpartum
period, pre-menopause, and menopause. Many women also face
additional stresses such as responsibilities both at work
and home, single parenthood, and caring for children and for
A recent NIMH study showed that in the case of severe
premenstrual syndrome (PMS), women with a preexisting
vulnerability to PMS experienced relief from mood and
physical symptoms when their sex hormones were suppressed.
Shortly after the hormones were re-introduced, they again
developed symptoms of PMS. Women without a history of PMS
reported no effects of the hormonal manipulation.6,7
Many women are also particularly vulnerable after the
birth of a baby. The hormonal and physical changes, as well
as the added responsibility of a new life, can be factors
that lead to postpartum depression in some women. While
transient "blues" are common in new mothers, a full-blown
depressive episode is not a normal occurrence and requires
active intervention. Treatment by a sympathetic physician
and the family's emotional support for the new mother are
prime considerations in aiding her to recover her physical
and mental well-being and her ability to care for and enjoy
Depression in Men
Although men are less likely to suffer from depression
than women, 3 to 4 million men in the United States are
affected by the illness. Men are less likely to admit to
depression, and doctors are less likely to suspect it. The
rate of suicide in men is four times that of women, though
more women attempt it. In fact, after age 70, the rate of
men's suicide rises, reaching a peak after age 85.
Depression can also affect the physical health in men
differently from women. A new study shows that, although
depression is associated with an increased risk of coronary
heart disease in both men and women, only men suffer a high
Men's depression is often masked by alcohol or drugs, or
by the socially acceptable habit of working excessively long
hours. Depression typically shows up in men not as feeling
hopeless and helpless, but as being irritable, angry, and
discouraged; hence, depression may be difficult to recognize
as such in men. Even if a man realizes that he is depressed,
he may be less willing than a woman to seek help.
Encouragement and support from concerned family members can
make a difference. In the workplace, employee assistance
professionals or worksite mental health programs can be of
assistance in helping men understand and accept depression
as a real illness that needs treatment.
Depression in the Elderly
Some people have the mistaken idea that it is normal for
the elderly to feel depressed. On the contrary, most older
people feel satisfied with their lives. Sometimes, though,
when depression develops, it may be dismissed as a normal
part of aging. Depression in the elderly, undiagnosed and
untreated, causes needless suffering for the family and for
the individual who could otherwise live a fruitful life.
When he or she does go to the doctor, the symptoms described
are usually physical, for the older person is often
reluctant to discuss feelings of hopelessness, sadness, loss
of interest in normally pleasurable activities, or extremely
prolonged grief after a loss.
Recognizing how depressive symptoms in older people are
often missed, many health care professionals are learning to
identify and treat the underlying depression. They recognize
that some symptoms may be side effects of medication the
older person is taking for a physical problem, or they may
be caused by a co-occurring illness. If a diagnosis of
depression is made, treatment with medication and/or
psychotherapy will help the depressed person return to a
happier, more fulfilling life. Recent research suggests that
brief psychotherapy (talk therapies that help a person in
day-to-day relationships or in learning to counter the
distorted negative thinking that commonly accompanies
depression) is effective in reducing symptoms in short-term
depression in older persons who are medically ill.
Psychotherapy is also useful in older patients who cannot or
will not take medication. Efficacy studies show that
late-life depression can be treated with psychotherapy.4
Improved recognition and treatment of depression in late
life will make those years more enjoyable and fulfilling for
the depressed elderly person, the family, and caretakers.
Depression in Children
Only in the past two decades has depression in children
been taken very seriously. The depressed child may pretend
to be sick, refuse to go to school, cling to a parent, or
worry that the parent may die. Older children may sulk, get
into trouble at school, be negative, grouchy, and feel
misunderstood. Because normal behaviors vary from one
childhood stage to another, it can be difficult to tell
whether a child is just going through a temporary "phase" or
is suffering from depression. Sometimes the parents become
worried about how the child's behavior has changed, or a
teacher mentions that "your child doesn't seem to be
himself." In such a case, if a visit to the child's
pediatrician rules out physical symptoms, the doctor will
probably suggest that the child be evaluated, preferably by
a psychiatrist who specializes in the treatment of children.
If treatment is needed, the doctor may suggest that another
therapist, usually a social worker or a psychologist,
provide therapy while the psychiatrist will oversee
medication if it is needed. Parents should not be afraid to
ask questions: What are the therapist's qualifications? What
kind of therapy will the child have? Will the family as a
whole participate in therapy? Will my child's therapy
include an antidepressant? If so, what might the side
The National Institute of Mental Health (NIMH) has
identified the use of medications for depression in children
as an important area for research. The NIMH-supported
Research Units on Pediatric Psychopharmacology (RUPPs) form
a network of seven research sites where clinical studies on
the effects of medications for mental disorders can be
conducted in children and adolescents. Among the medications
being studied are antidepressants, some of which have been
found to be effective in treating children with depression,
if properly monitored by the child's physician.8
Depression a Holistic View
DIAGNOSTIC EVALUATION AND TREATMENT
The first step to getting appropriate treatment for
depression is a physical examination by a physician. Certain
medications as well as some medical conditions such as a
viral infection can cause the same symptoms as depression,
and the physician should rule out these possibilities
through examination, interview, and lab tests. If a physical
cause for the depression is ruled out, a psychological
evaluation should be done, by the physician or by referral
to a psychiatrist or psychologist.
A good diagnostic evaluation will include a complete
history of symptoms, i.e., when they started, how long they
have lasted, how severe they are, whether the patient had
them before and, if so, whether the symptoms were treated
and what treatment was given. The doctor should ask about
alcohol and drug use, and if the patient has thoughts about
death or suicide. Further, a history should include
questions about whether other family members have had a
depressive illness and, if treated, what treatments they may
have received and which were effective.
Last, a diagnostic evaluation should include a mental
status examination to determine if speech or thought
patterns or memory have been affected, as sometimes happens
in the case of a depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the
evaluation. There are a variety of antidepressant
medications and psychotherapies that can be used to treat
depressive disorders. Some people with milder forms may do
well with psychotherapy alone. People with moderate to
severe depression most often benefit from antidepressants.
Most do best with combined treatment: medication to gain
relatively quick symptom relief and psychotherapy to learn
more effective ways to deal with life's problems, including
depression. Depending on the patient's diagnosis and
severity of symptoms, the therapist may prescribe medication
and/or one of the several forms of psychotherapy that have
proven effective for depression.
Electroconvulsive therapy (ECT) is useful, particularly
for individuals whose depression is severe or life
threatening or who cannot take antidepressant medication.3
ECT often is effective in cases where antidepressant
medications do not provide sufficient relief of symptoms. In
recent years, ECT has been much improved. A muscle relaxant
is given before treatment, which is done under brief
anesthesia. Electrodes are placed at precise locations on
the head to deliver electrical impulses. The stimulation
causes a brief (about 30 seconds) seizure within the brain.
The person receiving ECT does not consciously experience the
electrical stimulus. For full therapeutic benefit, at least
several sessions of ECT, typically given at the rate of
three per week, are required.
There are several types of antidepressant medications
used to treat depressive disorders. These include newer
medications—chiefly the selective serotonin reuptake
inhibitors (SSRIs)—the tricyclics, and the monoamine oxidase
inhibitors (MAOIs). The SSRIs—and other newer medications
that affect neurotransmitters such as dopamine or
norepinephrine—generally have fewer side effects than
tricyclics. Sometimes the doctor will try a variety of
antidepressants before finding the most effective medication
or combination of medications. Sometimes the dosage must be
increased to be effective. Although some improvements may be
seen in the first few weeks, antidepressant medications must
be taken regularly for 3 to 4 weeks (in some cases, as many
as 8 weeks) before the full therapeutic effect occurs.
Patients often are tempted to stop medication too soon.
They may feel better and think they no longer need the
medication. Or they may think the medication isn't helping
at all. It is important to keep taking medication until it
has a chance to work, though side effects (see section on
Side Effects on page 13) may appear before antidepressant
activity does. Once the individual is feeling better, it is
important to continue the medication for at least 4 to 9
months to prevent a recurrence of the depression. Some
medications must be stopped gradually to give the body time
to adjust. Never stop taking an
antidepressant without consulting the doctor for
instructions on how to safely discontinue the medication.
For individuals with bipolar disorder or chronic major
depression, medication may have to be maintained
Antidepressant drugs are not habit-forming. However, as
is the case with any type of medication prescribed for more
than a few days, antidepressants have to be carefully
monitored to see if the correct dosage is being given. The
doctor will check the dosage and its effectiveness
For the small number of people for whom MAO inhibitors
are the best treatment, it is necessary to avoid certain
foods that contain high levels of tyramine, such as many
cheeses, wines, and pickles, as well as medications such as
decongestants. The interaction of tyramine with MAOIs can
bring on a hypertensive crisis, a sharp increase in blood
pressure that can lead to a stroke. The doctor should
furnish a complete list of prohibited foods that the patient
should carry at all times. Other forms of antidepressants
require no food restrictions.
Medications of any kind—prescribed,
over-the counter, or borrowed—should
never be mixed without consulting the doctor. Other
health professionals who may prescribe a drug—such as a
dentist or other medical specialist—should be told of the
medications the patient is taking. Some drugs, although safe
when taken alone can, if taken with others, cause severe and
dangerous side effects. Some drugs, like alcohol or street
drugs, may reduce the effectiveness of antidepressants and
should be avoided. This includes wine, beer, and hard
liquor. Some people who have not had a problem with alcohol
use may be permitted by their doctor to use a modest amount
of alcohol while taking one of the newer antidepressants.
Antianxiety drugs or sedatives are not antidepressants.
They are sometimes prescribed along with antidepressants;
however, they are not effective when taken alone for a
depressive disorder. Stimulants, such as amphetamines, are
not effective antidepressants, but they are used
occasionally under close supervision in medically ill
Questions about any antidepressant
prescribed, or problems that may be related to the
medication, should be discussed with the doctor.
Lithium has for many years been the treatment of choice
for bipolar disorder, as it can be effective in smoothing
out the mood swings common to this disorder. Its use must be
carefully monitored, as the range between an effective dose
and a toxic one is small. If a person has preexisting
thyroid, kidney, or heart disorders or epilepsy, lithium may
not be recommended. Fortunately, other medications have been
found to be of benefit in controlling mood swings. Among
these are two mood-stabilizing anticonvulsants,
carbamazepine (Tegretol®) and valproate (Depakote®).
Both of these medications have gained wide acceptance in
clinical practice, and valproate has been approved by the
Food and Drug Administration for first-line treatment of
acute mania. Other anticonvulsants that are being used now
include lamotrigine (Lamictal®) and gabapentin (Neurontin®):
their role in the treatment hierarchy of bipolar disorder
remains under study.
Most people who have bipolar disorder take more than one
medication including, along with lithium and/or an
anticonvulsant, a medication for accompanying agitation,
anxiety, depression, or insomnia. Finding the best possible
combination of these medications is of utmost importance to
the patient and requires close monitoring by the physician.
Antidepressants may cause mild and, usually, temporary
side effects (sometimes referred to as adverse effects) in
some people. Typically these are annoying, but not serious.
However, any unusual reactions or side effects or those that
interfere with functioning should be reported to the doctor
immediately. The most common side effects of tricyclic
antidepressants, and ways to deal with them, are:
- Dry mouth—it is helpful to drink sips of water;
chew sugarless gum; clean teeth daily.
- Constipation—bran cereals, prunes, fruit, and
vegetables should be in the diet.
- Bladder problems—emptying the bladder may be
troublesome, and the urine stream may not be as b as
usual; the doctor should be notified if there is marked
difficulty or pain.
- Sexual problems—sexual functioning may change;
if worrisome, it should be discussed with the doctor.
- Blurred vision—this will pass soon and will not
usually necessitate new glasses.
- Dizziness—rising from the bed or chair slowly
- Drowsiness as a daytime problem—this usually
passes soon. A person feeling drowsy or sedated should not
drive or operate heavy equipment. The more sedating
antidepressants are generally taken at bedtime to help
sleep and minimize daytime drowsiness.
The newer antidepressants have different types of side
- Headache—this will usually go away.
- Nausea—this is also temporary, but even when it
occurs, it is transient after each dose.
- Nervousness and insomnia (trouble falling asleep or
waking often during the night)—these may occur during
the first few weeks; dosage reductions or time will
usually resolve them.
- Agitation (feeling jittery)—if this happens for
the first time after the drug is taken and is more than
transient, the doctor should be notified.
- Sexual problems—the doctor should be consulted
if the problem is persistent or worrisome.
In the past few years, much interest has risen in the use
of herbs in the treatment of both depression and anxiety.
St. John's wort (Hypericum perforatum), an herb used
extensively in the treatment of mild to moderate depression
in Europe, has recently aroused interest in the United
States. St. John's wort, an attractive bushy, low-growing
plant covered with yellow flowers in summer, has been used
for centuries in many folk and herbal remedies. Today in
Germany, Hypericum is used in the treatment of depression
more than any other antidepressant. However, the scientific
studies that have been conducted on its use have been
short-term and have used several different doses.
Because of the widespread interest in St. John's wort,
the National Institutes of Health (NIH) conducted a 3-year
study, sponsored by three NIH components—the National
Institute of Mental Health, the National Center for
Complementary and Alternative Medicine, and the Office of
Dietary Supplements. The study was designed to include 336
patients with major depression of moderate severity,
randomly assigned to an 8-week trial with one-third of
patients receiving a uniform dose of St. John's wort,
another third sertraline, a selective serotonin reuptake
inhibitor (SSRI) commonly prescribed for depression, and the
final third a placebo (a pill that looks exactly like the
SSRI and the St. John's wort, but has no active
ingredients). The study participants who responded
positively were followed for an additional 18 weeks. At the
end of the first phase of the study, participants were
measured on two scales, one for depression and one for
overall functioning. There was no significant difference in
rate of response for depression, but the scale for overall
functioning was better for the antidepressant than for
either St. John's wort or placebo. While this study did not
support the use of St. John's wort in the treatment of major
depression, ongoing NIH-supported research is examining a
possible role for St. John's wort in the treatment of milder
forms of depression.
The Food and Drug Administration issued a Public Health
Advisory on February 10, 2000. It stated that St. John's
wort appears to affect an important metabolic pathway that
is used by many drugs prescribed to treat conditions such as
AIDS, heart disease, depression, seizures, certain cancers,
and rejection of transplants. Therefore, health care
providers should alert their patients about these potential
Some other herbal supplements frequently used that have
not been evaluated in large-scale clinical trials are
ephedra, gingko biloba, echinacea, and ginseng. Any herbal
supplement should be taken only after consultation with the
doctor or other health care provider.
Depression a Holistic View
Many forms of psychotherapy, including some short-term
(10-20 week) therapies, can help depressed individuals.
"Talking" therapies help patients gain insight into and
resolve their problems through verbal exchange with the
therapist, sometimes combined with "homework" assignments
between sessions. "Behavioral" therapists help patients
learn how to obtain more satisfaction and rewards through
their own actions and how to unlearn the behavioral patterns
that contribute to or result from their depression.
Two of the short-term psychotherapies that research has
shown helpful for some forms of depression are interpersonal
and cognitive/behavioral therapies. Interpersonal therapists
focus on the patient's disturbed personal relationships that
both cause and exacerbate (or increase) the depression.
Cognitive/behavioral therapists help patients change the
negative styles of thinking and behaving often associated
Psychodynamic therapies, which are sometimes used to
treat depressed persons, focus on resolving the patient's
conflicted feelings. These therapies are often reserved
until the depressive symptoms are significantly improved. In
general, severe depressive illnesses, particularly those
that are recurrent, will require medication (or ECT under
special conditions) along with, or preceding, psychotherapy
for the best outcome.
HOW TO HELP YOURSELF IF YOU ARE DEPRESSED
Depressive disorders make one feel exhausted, worthless,
helpless, and hopeless. Such negative thoughts and feelings
make some people feel like giving up. It is important to
realize that these negative views are part of the depression
and typically do not accurately reflect the actual
circumstances. Negative thinking fades as treatment begins
to take effect. In the meantime:
- Set realistic goals in light of the depression and
assume a reasonable amount of responsibility.
- Break large tasks into small ones, set some
priorities, and do what you can as you can.
- Try to be with other people and to confide in someone;
it is usually better than being alone and secretive.
- Participate in activities that may make you feel
- Mild exercise, going to a movie, a ballgame, or
participating in religious, social, or other activities
- Expect your mood to improve gradually, not
immediately. Feeling better takes time.
- It is advisable to postpone important decisions until
the depression has lifted. Before deciding to make a
significant transition—change jobs, get married or
divorced—discuss it with others who know you well and have
a more objective view of your situation.
- People rarely "snap out of" a depression. But they can
feel a little better day-by-day.
- Remember, positive thinking will replace the
negative thinking that is part of the depression and will
disappear as your depression responds to treatment.
- Let your family and friends help you.
How Family and Friends Can Help the Depressed Person
The most important thing anyone can do for the depressed
person is to help him or her get an appropriate diagnosis
and treatment. This may involve encouraging the individual
to stay with treatment until symptoms begin to abate
(several weeks), or to seek different treatment if no
improvement occurs. On occasion, it may require making an
appointment and accompanying the depressed person to the
doctor. It may also mean monitoring whether the depressed
person is taking medication. The depressed person should be
encouraged to obey the doctor's orders about the use of
alcoholic products while on medication. The second most
important thing is to offer emotional support. This involves
understanding, patience, affection, and encouragement.
Engage the depressed person in conversation and listen
carefully. Do not disparage feelings expressed, but point
out realities and offer hope. Do not ignore remarks about
suicide. Report them to the depressed person's therapist.
Invite the depressed person for walks, outings, to the
movies, and other activities. Be gently insistent if your
invitation is refused. Encourage participation in some
activities that once gave pleasure, such as hobbies, sports,
religious or cultural activities, but do not push the
depressed person to undertake too much too soon. The
depressed person needs diversion and company, but too many
demands can increase feelings of failure.
Do not accuse the depressed person of faking illness or
of laziness, or expect him or her "to snap out of it."
Eventually, with treatment, most people do get better. Keep
that in mind, and keep reassuring the depressed person that,
with time and help, he or she will feel better.
WHERE TO GET HELP
If unsure where to go for help, check the Yellow Pages
under "mental health," "health," "social services," "suicide
prevention," "crisis intervention services," "hotlines,"
"hospitals," or "physicians" for phone numbers and
addresses. In times of crisis, the emergency room doctor at
a hospital may be able to provide temporary help for an
emotional problem, and will be able to tell you where and
how to get further help.
Listed below are the types of people and places that will
make a referral to, or provide, diagnostic and treatment
- Family doctors
- Mental health specialists, such as psychiatrists,
psychologists, social workers, or mental health counsellors
- Health maintenance organizations
- Community mental health centres
- Hospital psychiatry departments and outpatient clinics
- University- or medical school-affiliated programs
- State hospital outpatient clinics
- Family service, social agencies, or clergy
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
US Organizations that focus on depression.
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