What Is Depression?
Depression is a serious mood disorder, which affects the way you feel, think, talk, behave, work, sleep, and eat. As someone put it, depression is the common cold of mental illnesses. It is that common, in that you will suffer from it at some point in your life or you will come across someone who does. Depression usually strikes adults, and twice as many women as men.
Who has not felt sad or lonely or even “depressed” at times or been in a low mood when you felt things could not get any worse. Almost all of us have been in such a situation. But, such feelings and moods are passing and do not last for any length of time nor do they affect our daily functioning appreciably to warrant being called depression. The symptoms that characterize depression must be present for at least two weeks before we can diagnose someone with depression.
Depression is not your “fault” or a weakness nor something you can just snap out of. It may require long-term treatment with medication, psychotherapy or both. It is also called as major depressive disorder or clinical depression. However, there are several other types, such as dysthymia, postpartum depression, psychotic depression, seasonal affective disorder, bipolar depression.
Depression Symptoms and Signs
A person with depression typically experiences quite a few of the signs and symptoms listed in Box 1 (see below), most of the day, almost every day, for at least two consecutive weeks. Not everyone who is depressed experiences all the symptoms. Some may experience only a few of these symptoms while others may experience many. The severity, frequency and duration of symptoms vary from person to person depending on his or her illness. People can have one or more episodes of depression during their lifetime.
Table 1: Signs and Symptoms of Depression
· Persistent mood of sadness, anxiety or emptiness
· Feelings of guilt, worthlessness, and helplessness
· Feelings of pessimism and hopelessness
· Irritability, frustration, or agitation even over trivial matters
· Restlessness or not able to sit still
· Tiredness and lack of energy
· Slowed down speaking or body movements
· Difficulties with concentration, memory and making decisions
· Loss of interest in things once pleasurable like TV, sex, hobbies
· Sleeplessness, early-morning wakefulness, or sleeping excessively
· Decrease or increase in appetite and weight
· Personality changes
· Unexplained physical symptoms like backache, headaches
· Digestive problems that do not improve, even if treated
· Lack of interest in socialization
· Suicide thoughts or attempts
· Poor attendance and performance at school in younger people
Causes of Depression and Risk Factors
Exact cause(s) of depression is not known. Following factors are thought to play a role:
- Depression is more common in people with a family history of depression, such as in a sibling or close relative. Search is on to find the genes involved.
- Brain structure.Physical changes in the brain are seen to be present in people with depression, particularly in areas of brain involved in mood, thinking, sleep, appetite, and behavior.
- Brain chemistry.Naturally occurring brain chemicals or neurotransmitters that play a role in mood stability and its regulation are implicated.
- Hormonal imbalance.Hormonal imbalances resulting from pregnancy, postpartum phase, thyroid problems, or menopause could be involved in causing depression.
Risk factors include:
- Family history: History of depression, bipolar disorder, alcoholism or suicide in the family or in close relatives
- Life events: Death or loss of a loved one, a difficult relationship, divorce, retirement, or loss of job
- Stress or trauma: such as physical, sexual, or emotional abuse
- Interpersonal conflicts: Personal conflicts with family members or friends, especially in those who are predisposed to depression
- Certain medications: some high BP medications, isotretinoin (used for acne), corticosteroids, oral contraceptives, statins (used to lower cholesterol), or sleeping pills
- Serious illnesses: Cancer, stroke, chronic pain or heart disease
- Certain personality traits: Low self-esteem, dependent, self-critical or pessimistic
- Being of a different sexual orientation in a hostile environment
- History of other mental health disorders: anxiety disorder, PTSD, or eating disorders
- Substance abuse: Alcohol or drugs
Types of Depression
The various types of depression are as follows:
Also referred to as “major depressive disorder.” The signs and symptoms, and causes and risk factors listed above apply to this type. To know how it is diagnosed, see under Diagnosis.
This is characterized by symptoms of major depression along with “psychotic” symptoms, such as hallucinations (seeing or hearing things that aren’t there) and delusions (false fixed beliefs). The psychotic symptoms typically have a depressive “theme,” such as delusions of guilt, poverty, or illness.
Postpartum (Peripartum) Depression
This is major depression occurring in the weeks and months following childbirth. It is much more serious than the “baby blues” (mild depressive and anxiety symptoms that last only two weeks after delivery) that many women experience after giving birth.
Premenstrual Dysphoric Disorder (PMDD)
Here the depression symptoms occur at the start of their period. Symptoms can be feeling depressed, mood swings, fatigue, alterations in appetite and sleep, irritability, anxiety, trouble concentrating, and overwhelmed feeling.
Seasonal Affective Disorder (SAD)
It is a periodic major depression that occurs when you get less sunlight, such as in the winter months. You recover from it in the spring and summer. It is accompanied by social withdrawal, increased sleep, and weight gain, and predictably returns every year in the winter.
In this there can be mood episodes that range from an “up” mood with extremes of high energy to low “depressive” periods. In the low phase, you’ll have the symptoms of major depression.
Persistent Depressive Disorder
This is depression that lasts for 2 years or longer, and is used to describe two conditions previously known as dysthymia and chronic major depression. Person may have may have episodes of major depression along with periods of less severe symptoms.
In this the sadness is not persistent as in typical depression. Here, a positive or happy event can temporarily improve your mood, but you also feel hungrier, need to sleep a lot, feel a heaviness in arms or legs, and are sensitive to criticism.
Diagnosis of Depression
There is no specific test for diagnosing depression, so it is largely based on signs and symptoms. As per DSM-5 (American Psychiatric Association, 2013, pp. 160-161), to pronounce that someone has major depression, they need to have five or more of these symptoms nearly every day for at least 2 weeks:
- A depressed mood most of the day, either self-reported or observed by others
- No interest or pleasure in many activities nearly every day
- Decrease or increase in appetite and weight
- Lack of sleep or too much sleep every day
- Restlessness or slowing down, observable by others
- Fatigue or loss of energy
- Feelings of worthless or excessive or inappropriate guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts about death or plans and attempts to commit suicide
- The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The episode is not attributable to the physiological effects of a substance or to another medical condition.
- Plus, other mental disorders should be ruled out as causes, and there is no episode of mania or hypomania.
Treatment of Depression
(Harrison, et al., 2018, pp. 218-224)
Unfortunately, about half the people with depression never get it diagnosed or treated. Untreated, it can last for months, even years. Treatment is usually effective with medications (antidepressants), or psychotherapy, or both. If these treatments do not work (treatment-resistant depression), electroconvulsive therapy (ECT) and other brain stimulation therapies can be explored.
Depression Medications (Antidepressants)
Antidepressants are used in depression, though other medicines may also be given to cover for other symptoms like anxiety. There is no “one-size-fits-all” when it comes to treatment. Some trial and error is needed to find the treatment that works best for you. An antidepressant that has worked for you or a family member in the past will often be the go-to medication. If an antidepressant doesn’t work well, the doctor might try changing the dose, try another antidepressant, or recommend taking more than one medication.
Antidepressants usually take 1 to 2 months to work, although sleep, appetite, and concentration problems improve before mood lifts. So, one should give the medication a chance before considering it ineffective. Antidepressants can have side effects, such as insomnia, sleepiness, nausea, weight loss or gain, and sexual problems.
Some of the commonly used antidepressants are as follows:
- Selective serotonin reuptake inhibitors (SSRIs).An SSRI is quite often prescribed first. They cause fewer bothersome side effects than other types of antidepressants. SSRIs include fluoxetine, sertraline, citalopram, escitalopram, paroxetine, and vilazodone.
- Tricyclic antidepressants.These are an older group of antidepressants and tend to cause more-severe side effects, but can be effective. They are imipramine, trimipramine, desipramine, amitriptyline, nortriptyline, doxepin, and protriptyline. So they are reserved for those patients in whom SSRIs do not work.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs).Examples of SNRIs are venlafaxine, levomilnacipran, duloxetine, and desvenlafaxine.
- Monoamine oxidase inhibitors (MAOIs).MAOIs can have serious side effects, so they are tried in the end. They include tranylcypromine, phenelzine and isocarboxazid. MAOIs can have dangerous or deadly interactions with certain foods like cheese, pickles and wine, and some medications and herbal supplements. Selegiline is a newer MAOI that can be used as a patch on the skin, and causes fewer side effects than other MAOIs do. They should not be combined with SSRIs.
- Atypical antidepressants.These antidepressants don’t fit into any of the other antidepressant categories. They include bupropion, mirtazapine, nefazodone, trazodone and vortioxetine.
Usually, a course of 6 to 12 months is needed, before the doctor will slowly decrease your dose. Sometimes people stop taking the medication on their own when they start to feel better, which usually leads to a relapse. Stopping treatment abruptly or missing several doses can cause withdrawal-like symptoms, and quitting suddenly may cause a sudden worsening of depression. If you’re pregnant or breast-feeding, talk to your doctor about the safety of the antidepressants to your unborn child or nursing child.
In some cases, children, teenagers and young adults under age 25 may have an increase in suicidal thoughts or behavior in the first few weeks after starting antidepressants or when the dose is changed. So, watch closely for worsening depression or unusual behavior. However, note that antidepressants are more likely to reduce suicide risk in the long run by improving mood.
Other medications may be added to an antidepressant such as mood stabilizers, antipsychotics, and anti-anxiety medications, depending on your symptoms.
Natural remedies: St. John’s wort is a top-selling botanical product, but the FDA has not approved its use for depression, and its safety and effectiveness are under doubt. It should not be combined with a prescription antidepressant. Dietary supplements, such as omega-3 fatty acids and S-adenosylmethionine (SAMe), have not yet been proven to be safe and effective.
Psychotherapy is also known as talk therapy or psychological therapy because it involves talking about your condition and related issues with a mental health professional. Examples of evidence-based approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy.
Psychotherapy can help you:
- Adjust to a crisis or difficulty
- Cultivate healthy, positive beliefs and behaviors
- Develop positive interactions with others
- Cope with and solve problems
- Identify and change issues that contribute to your depression
- Neutralize hopelessness and anger
- Set realistic goals
- Tolerate and accept distress using healthier behaviors
Alternative Formats of Therapy for Depression
Therapy can be provided as a computer program, by online sessions, or using videos or workbooks. Programs can be partially or totally independent or guided by a therapist.
In severe cases of depression, a hospital stay is needed to help keep you calm and safe until your mood improves. Partial hospitalization or day treatment programs also may help some people, which involve outpatient support and counseling.
Brain Stimulation Therapies
In treatment-resistant depression, brain stimulation therapies such as the following can be tried:
- ECT (electroconvulsive therapy):It uses electric impulses to trigger controlled seizures in the brain and to impact the function and effect of neurotransmitters in your brain to relieve depression. A series of such treatments (usually 6-12) may be needed over a few weeks. In some severe cases where a rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention. Nowadays, ECT is often performed on an outpatient basis. ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, anesthesia and a muscle relaxant may be given. The procedure takes only a few minutes. Within one hour after the treatment, the patient is awake and alert.
- VNS (vagus nerve stimulation):Like ECT, it uses electrical stimulation to relieve the symptoms of depression. The difference is that the device is surgically implanted in your body. Its effects may take up to 9 months to appear and it may be effective only in about 1 in 3 people.
- Transcranial magnetic stimulation (TMS):This also uses electrical stimulation, but side effects are fewer than in the previous two therapies. During TMS, a treatment coil placed against your scalp sends brief magnetic pulses to stimulate nerve cells in your brain that are involved in mood regulation and depression. Treatment is done on an outpatient basis four to five days a week for four or more weeks. It is not as effective as ECT.
- Techniques under trial:Deep brain stimulation and MST (magnetic seizure therapy).
How to Cope With Depression?
Here are some tips that may help you cope during treatment for depression:
- Inform your doctor about other medications you may be taking because they can interfere with medications for depression.
- Stick to the prescribed treatment and do not stop it on your own.
- Don’t ignore side effects of medications and contact the doctor immediately should they occur.
- Monitor your moods and behavior from time to time to observe any patterns of mood swings and call your doctor if you notice a worsening.
- Have a social support system, such as family members and close circle of friends and co-workers you can turn to in times of need.
- Socialize with other people and confide in someone you trust.
- Exercise patience because your mood will improve only gradually, and not immediately.
- Discuss your decisions with others who know you well and have a more objective view of your situation.
- Postpone important decisions, such as getting married or divorced, or changing jobs until you feel better.
- Educate yourself about depression.
Table 2: Prognosis for Depression (Harrison, et al., 2018, p. 217)
· The average length of a depressive episode is about 6 months, but around 25% of patients have episodes that last for more than 1 year, and around 10–20% develop a chronic unremitting course.
· About 80% of patients with major depression will experience further episodes (i.e., have recurrent major depression).
· Over a 25-year follow-up, patients with recurrent major depression experience on average about four further episodes.
· The interval between episodes becomes progressively shorter.
· About 50% of depressed patients do not achieve complete symptom remission between episodes, and experience continuing subsyndromal depressive symptomatology of fluctuating severity.
· The longer-term prognosis of recurrent major depression is modest. For example, only about 25% of patients with recurrent depression achieve a period of 5 years of clinical stability with good social and occupational performance.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
Harrison, P., Cowen, P., Burns, T. & Fazel, M., 2018. Shorter Oxford Textbook of Psychiatry. 7 ed. Oxford: Oxford University Press.
Mayo Clinic, n.d. Depression (major depressive disorder). [Online]
Available at: https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007
[Accessed 24 August 2019].
National Institute of Mental Health, n.d. Depression. [Online]
Available at: https://www.nimh.nih.gov/health/topics/depression/index.shtml
[Accessed 24 August 2019].
WebMD, n.d. What Is Depression?. [Online]
Available at: https://www.webmd.com/depression/guide/what-is-depression#1
[Accessed 24 August 2019].