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Depression
medical conditions

Depression

Explore the available health information, treatment context, and integrative evidence for Depression.

Background
  • Depression or depressive disorder is an illness that involves the body, mood, and thoughts. Depression is considered a mood disorder. Imbalances in three neurotransmitters (brain chemicals), including serotonin, norepinephrine, and dopamine, are linked to depression. Depression affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about life situations. Unlike normal emotional experiences of sadness, loss, or passing mood states, depressive disorders are persistent and can significantly interfere with an individual's thoughts, behavior, mood, activity, and physical health.
  • According to the National Institute of Mental Health (NIMH), depressive disorders affect approximately 18.8 million American adults or about 9.5% of the U.S. population age 18 and older in a given year. This includes major depressive disorder (severe depression), dysthymic disorder (mild to moderate depression), and bipolar disorder (manic-depressive). Among all medical illnesses, major depression is the leading cause of disability in the U.S. and many other developed countries.
  • Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.
  • Children and teenagers can also suffer from depression. Depression in the young is defined as an illness when the feelings of depression persist and interfere with a child or adolescent's ability to function.
  • The American Academy of Child and Adolescent Psychiatry estimates that about 5% of children and adolescents in the general population suffer from depression at any given point in time. Children under stress, who experience loss, or who have trouble with attention, learning, conduct, or anxiety disorders are at a higher risk for depression.
Risk Factors and Causes
  • Neurotransmitter imbalances: Studies suggest that a low or high level of neurotransmitters such as serotonin, norepinephrine, or dopamine cause depression. Studies have found evidence that a change in the sensitivity of the receptors on nerve cells to these neurotransmitters may be one issue, along with an imbalance in the amounts of neurotransmitters. Balancing neurotransmitters with drug therapy is the current focus for treatment of major depression.
  • Heredity: Researchers have identified several genes that may be involved in bipolar disorder and are looking for genes linked to other types of depression. But not everyone with a family history of depression develops the disorder, and conversely, people with no family history of the disorder can become depressed.
  • Gender: Depression occurs twice as frequently in women as in men, for reasons that are not fully understood. Hormonal changes such as menstrual cycle changes, postpartum period, pre-menopause, pregnancy, childbirth, miscarriage, and menopause are the most likely causes of depression.
  • Although men are less likely to suffer from depression than women, six million men in the United States are affected by the illness. Men are less likely to admit to depression. The rate of suicide in men is four times that of women, though more women attempt it.
  • Stress: Stressful life events, particularly a loss or threatened loss of a loved one or a job, can trigger depression.
  • Medications: Long-term use of certain medications, such as some drugs used to control high blood pressure, sleeping pills, or birth control pills, may cause symptoms of depression in some people.
  • Illnesses: Having a chronic illness, such as heart disease, stroke, diabetes, cancer or Alzheimer's disease, puts an individual at a higher risk of developing depression. Having an underactive thyroid (hypothyroidism), even mildly, also can cause depression. Physical trauma (damage) to the brain can also trigger depression.
  • Personality: Certain personality traits, such as having low self-esteem and being overly dependent, self-critical, pessimistic and easily overwhelmed by stress, can make an individual more vulnerable to depression.
  • Postpartum depression: It is common for mothers to feel a mild form of distress that usually occurs a few days to weeks after giving birth. During this time the woman may have feelings of sadness, anger, anxiety, irritability and incompetence. A more severe form of the baby blues, called postpartum depression, also can affect new mothers.
  • Hormones: Women experience depression about twice as much as men, which leads researchers to believe hormonal factors may play a role in the development of depression.
  • Alcohol, smoking, and drug abuse: Abuse of alcohol, cigarettes, and recreational drugs such as cocaine, methamphetamine (crystal meth), ecstasy, and marijuana can lead to depression.
  • Previous depression: More than half of those who experience a single episode of depression will continue to have episodes that occur as frequently as once or even twice a year. Without treatment, the frequency of depressive illness as well as the severity of symptoms tends to increase over time. Left untreated, depression can lead to suicide.
Signs and Symptoms
  • The onset of the first episode of depression may not be obvious if it is gradual or mild. The symptoms of depression represent a significant change from how a person functioned before the illness. Symptoms of depression can either be mild, moderate or severe.
  • Loss of interest in normal daily activities: An individual may lose interest in or pleasure from activities that they used to enjoy.
  • Depressed mood: The individual may feel sad, helpless or hopeless, and may have crying spells.
  • Sleep disturbances: Sleeping too much or having problems sleeping can be a sign of depression. Waking in the middle of the night or early in the morning and not being able to get back to sleep are typical.
  • Impaired thinking or concentration: The individual may have trouble concentrating, making decisions, or have problems with memory.
  • Weight changes: An increased or reduced appetite and unexplained weight gain or loss may indicate depression.
  • Agitation: The individual may seem restless, agitated, irritable, and easily annoyed.
  • Fatigue (tiredness): Weariness and a lack of energy nearly every day are common signs of depression. The individual may feel as tired in the morning as they did when going to bed the night before.
  • Low self-esteem: Feelings of worthlessness and excessive guilt are common symptoms of depression.
  • Loss of sexual interests: If the individual was sexually active before developing depression, they may notice a dramatic decrease in the level of interest in having sexual relations.
  • Preoccupation with death: The individual may have a persistent negative view of their situation in life and the future. They may have thoughts of death, dying or suicide.
  • Other physical symptoms: Depression can also cause a wide variety of physical complaints, such as gastrointestinal problems (indigestion, constipation, or diarrhea), headache, and backache. Many people with depression also have symptoms of anxiety, including restlessness, inability to concentrate, and loss of sleep.
  • Depression in children and the elderly: Children, teens, and older adults may react differently to depression. In these groups, symptoms may take different forms or may be masked by other conditions. Kids may pretend to be sick, worry that a parent is going to die, perform poorly in school, refuse to go to school, or exhibit behavioral problems. The elderly may be more willing to discuss the physical symptoms of depression, instead of their emotional difficulties, including constant complaining about aches and pains.
  • Suicidal thoughts: Suicidal thoughts may accompany depression. Anyone who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist. Certain warning signs may indicate serious depression and the possibility of suicide. Danger signs include pacing, agitated behavior, frequent mood changes and sleeplessness for several nights, actions or threats of assault, physical harm or violence, threats or talk of death or suicide, such as "I don't care anymore," or "You won't need to worry about me much longer," withdrawal from activities and relationships, putting affairs in order, such as saying goodbye to friends, giving away prized possessions or writing a will, a sudden brightening of mood after a period of being depressed, or unusually risky behavior, such as buying or handling a gun or driving recklessly can be indicators of suicidal thinking.
Diagnosis
  • History and physical examination: To diagnosis depression the doctor must first rule out all other disease possibilities. Typically, the diagnosis begins with a medical history, including questions about the duration, severity, and characteristics of symptoms. The physician will ask about diet, stress, any medications currently being taken, and changes in sleep patterns. Questionnaires may be used to determine the level of depression.
  • Diagnosis also involves ruling out other mental health conditions that may produce symptoms similar to depression. These may include other mood disorders, such as bipolar, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), and borderline personality disorder.
  • A diagnosis of depressive disorder is based on criteria found in the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) developed by the American Psychiatric Association.
  • Laboratory tests: Blood tests can determine if the levels of neurochemicals (brain chemicals), including serotonin, dopamine, and norepinephrine, are healthy. Tests may be ordered to rule out other causes, such as blood or urine tests to determine the balance of salts and sugar in the blood, hormone function, blood cell counts, and drug and alcohol levels. Computerized tomography (CT) scan, positron emission tomography (PET), or magnetic resonance imaging (MRI) of the head may be ordered to check for blood clots, bleeding, or tumors. A spinal tap (lumbar puncture) may be ordered to get a sample of spinal fluid to determine if a brain infection, such as meningitis or encephalitis (both forms of brain inflammation), exists. These tests may rule out other conditions that may be present (such as brain tumor or other disease), and may determine if imbalances in neurochemistry are present.
Complications
  • About half of the people who have a first episode of depression will have another episode within 10 years. The risk of further bouts of depression is higher than in someone who has never been depressed.
  • Alcohol and drug abuse are very common among people with depression.
  • Depressive disorder can have devastating effects on relationships as complete isolation and withdrawal during depression are common.
  • Suicide may be a complication of untreated, mistreated, or misdiagnosed depression. Women attempt suicide more often than men do, but men are much more likely to succeed in killing themselves. The rate of suicide is four times greater for men. Men over 70 are the most likely to commit suicide.
  • Calling a local suicide hotline, such as the National Suicide Prevention Lifeline at 1-800-273-8255, can be help for someone thinking of suicide.
Treatment
  • Treatment for depression usually involves a combination of drug and psychological therapies.
  • Psychotherapy: Psychotherapy involves talking to a healthcare professional about one's problems and life situation. There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.
  • Cognitive-behavioral therapy (CBT): CBT helps to change the negative thinking and unsatisfying behavior associated with depression, while teaching individuals how to unlearn the behavioral patterns that contribute to their depression.
  • Interpersonal therapy (IPT): IPT focuses on improving troubled personal relationships and on adapting to new life roles that may have been associated with a person's depression.
  • Medications: Drugs used for depression often take two to four weeks to start having an effect, and 6-12 weeks to have their full effect. The first antidepressant medications were introduced in the 1950s. Research has reported that imbalances in neurotransmitters like serotonin, dopamine, and norepinephrine can be improved with antidepressant use.
  • Selective serotonin reuptake inhibitors (SSRIs): SSRIs act specifically on the neurotransmitter (brain chemical) serotonin. Serotonin is mainly involved with mood balance. SSRIs are the most common agents prescribed for depression worldwide. These agents increase the amount of serotonin that is available for use by the brain. SSRIs include fluoxetine (Prozac®), sertraline (Zoloft®), paroxetine (Paxil®), citalopram (Celexa®), escitalopram (Lexapro®), and fluvoxamine (Luvox®).
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs): SNRIs are the second-most popular antidepressants worldwide. These agents increase the amount of both serotonin and norepinephrine. SNRIs include venlafaxine (Effexor®) and duloxetine (Cymbalta®). SSRIs and SNRIs tend to have fewer side effects than other types of antidepressants. Side effects include nausea, nervousness, insomnia, diarrhea, rash, agitation, or sexual side effects (problems with arousal or orgasm).
  • Norepinephrine-dopamine reuptake inhibitor (NDRI): NDRIs acts by increasing the amounts of dopamine and norepinephrine available to the brain. Bupropion (Wellbutrin®) is commonly used as an antidepressant in this class.
  • Tricyclic antidepressants (TCAs): TCAs are older antidepressants that are not used as frequently now. They work similarly to the SNRIs, but have other properties that result in very high side effect rates, as compared to almost all other antidepressants. They are sometimes used in cases where other antidepressants have not worked. TCAs include amitriptyline (Elavil®), desipramine (Norpramin®), doxepin (Sinequan®), imipramine (Norpramin®, Tofranil®), nortriptyline (Pamelor®, Aventyl®), and protriptyline (Vivactil®). TCAs cause side effects that include dry mouth, constipation, bladder problems, sexual problems, blurred vision, dizziness, drowsiness, skin rash, and weight gain or loss.
  • Monoamine oxidase inhibitors (MAOIs): MAOs are seldom used now for depression. They also increase amounts of serotonin, norepinephrine, and dopamine for the brain to use in mood stabilization. They can sometimes be effective for people who do not respond to other medications or who have atypical depression with marked anxiety, excessive sleeping, irritability, hypochondria (health anxiety), or phobic (obsessive) characteristics. However, they are the least safe antidepressants to use, as they have important medication interactions, including causing dangerously high blood pressure, and require adherence to a diet free of tyramines, chemicals found in certain foods such as fish (especially dried and salted), chocolate, alcoholic beverages (chianti wine), and fermented foods such as cheese and soy sauce, sauerkraut, and processed meat. MAOIs include phenelzine (Nardil®), isocarboxazid (Marplan®), and tranylcypromine sulfate (Parnate®). A range of other, less serious side effects occur including weight gain, constipation, dry mouth, dizziness, headache, drowsiness, insomnia, and sexual side effects (problems with arousal or satisfaction).
  • Other: Mirtazapine (Remeron®) is an antidepressant used commonly in the elderly that helps cause weight gain. A common side effect is drowsiness. Often psychiatrists will combine antidepressants with each other or with agents that are not antidepressants themselves. A class of drugs called atypical antipsychotic agents, including aripiprazole (Abilify®), olanzapine (Zyprexa®), quetiapine (Seroquel®), ziprasidone (Geodon®), and risperidone (Risperdal®) may be used. Side effects for these drugs are high, including excessive sedation and tardive dyskinesia (a nervous system disorder causing facial grimaces, lip smacking, and uncontrollable shaking). According to the American Diabetes Association (ADA), certain antipsychotic drugs may increase the risk of diabetes, obesity and high blood pressure.
  • Stimulants, such as methylphenidate (Ritalin®) or dextroaphetamine (Dexedrine®) can be added. Stimulants may cause dry mouth, disturbances in sleep patterns, nervousness, anxiousness, and weight loss.
  • Lithium and mood-stabilizing medications may be prescribed, including lithium (Eskalith®, Lithobid®), valproic acid (Depakene®), divalproex (Depakote®), and carbamazepine (Tegretol®) to treat bipolar depression. Medications called atypical antipsychotics such as olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) were initially developed for treatment of psychotic disorders.
  • Hormone therapy: For women with postpartum depression or premenstrual dysphoric disorder (PMDD), hormonal replacement with estrogen and/or progesterone may help with depression. However, there is an increased risk of heart disease and cancer (breast and ovarian) with the use of these medications.
  • Electroconvulsive therapy: Electroconvulsive therapy (ECT) involves the use of electrical current to stimulate various parts of the brain, and is used mainly in people who have episodes of major depression associated with suicidal tendencies, or in people whose medication has proved to be ineffective. ECT profoundly affects brain metabolism and blood flow to various areas of the brain. How that correlates to easing depression remains unknown, but this therapy is often highly effective. Safety of ECT is controversial, and adverse effects such as confusion, memory loss, headache, hypotension (low blood pressure), and tachycardia (increased heart rate) may occur.
  • Light therapy: This therapy may help if the individual has seasonal affective disorder (SAD). This disorder involves periods of depression that recur at the same time each year, usually when days are shorter in the fall and winter. Scientists believe fewer hours of sunlight may increase levels of melatonin, a brain hormone thought to induce sleep and depress mood. Treatment in the morning with a specialized type of bright light, which suppresses production of melatonin, may help with this disorder. Melatonin is a hormone for the sleep-wake cycle and may be decreased during depression.
  • Mild depression: If mild depression is diagnosed, antidepressant drugs are not usually recommended as a first treatment. Exercise seems to help some people with depression. Talking through feelings using counselling may also be helpful for mild depression. Talking to a friend or relative, self-help reading material, or a local self-help group are good choices. If the depression is mild but there is a past history of depression, antidepressants may be used.
  • Chronic (long term) mild depression or dysthymia (present for two or more years) is more likely in people over 55 years and can be difficult to treat. Individuals diagnosed with dysthymia are usually started on a course of antidepressants.
  • Moderate depression: If mild depression does not improve, antidepressants or talking treatments are generally used. Research has shown that antidepressants and psychological therapies are equally effective in treating mild or moderate depression but having the two types of treatment together does not seem to offer any extra benefits.
  • Severe depression: If severe depression is diagnosed, both antidepressant therapy together with psychotherapy are usually used in combination.
  • Although major depression can be a devastating illness, it is highly treatable. Between 80-90% of individuals diagnosed with major depression can be effectively treated and return to their usual daily activities and feelings.
  • Hospitalization: Depression is a serious medical illness. Urgent care and hospitalization may be necessary when someone seems to be a danger to themselves or others, or if they are psychotic. A person experiencing extreme major depression should be brought to the hospital immediately to prevent suicide or possible violence to another person. An acute episode is treated with medications and a low-stimulation environment. Depending on the individual's symptoms and history, longer-term hospitalization may be required.
Prevention
  • Healthcare providers recommend that an individual suffering from depression reduce stress and try to develop regular sleep patterns. Sleep disturbances may signal the early phase of a depressive episode.
  • Learn to recognize the early warning signs and triggers of depression. Warning signs of relapse vary from patient to patient, and may include thoughts of death, or slight changes in sleep patterns (a common indicator), mood, energy, self-esteem, sexual interest, concentration, and willingness to take on new projects, and dress or grooming.
References

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

  • American Academy of Child and Adolescent Psychiatry. . Accessed March 15, 2009.
  • American Academy of Family Physicians. . Accessed March 15, 2009.
  • American Psychiatric Association. . Accessed March 15, 2009.
  • Mental Health America.
  • National Alliance on Mental Illness. . Accessed March 15, 2009.
  • National Institute of Mental Health. . Accessed March 15, 2009.
  • Natural Standard: The Authority on Integrative Medicine. Copyright © 2009. . Accessed March 15, 2009.