Depression

Definition

Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. But true clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended time.

See also depression in the elderly and adolescent depression.

Considerations

Depression is generally ranked in terms of severity -- mild, moderate, or severe. The degree of your depression, which your doctor can determine, influences how you are treated. Symptoms of depression include:

• Trouble sleeping or excessive sleeping
• A dramatic change in appetite, often with weight gain or loss
• Fatigue and lack of energy
• Feelings of worthlessness, self-hate, and inappropriate guilt
• Extreme difficulty concentrating
• Agitation, restlessness, and irritability
• Inactivity and withdrawal from usual activities
• Feelings of hopelessness and helplessness
• Recurring thoughts of death or suicide

Low self esteem is common with depression. So are sudden bursts of anger and lack of pleasure from activities that normally make you happy, including sex.

Depressed children may not have the classic symptoms of adult depression. Watch especially for changes in school performance, sleep, and behavior. If you wonder whether your child might be depressed, it's worth bringing to a doctor's attention.

The main types of depression include:

• Major depression -- five or more symptoms listed above must be present for at least 2 weeks, but major depression tends to continue for at least 6 months. (Depression is classified as minor depression if less than five depressive symptoms are present for at least 2 weeks.)
• Dysthymia -- a chronic, generally milder form of depression but lasts longer -- usually as long as two years.
• Atypical depression -- depression accompanied by unusual symptoms, such as hallucinations (for example, hearing voices that are not really there) or delusions (irrational thoughts).

Other common forms of depression include:

• Postpartum depression -- many women feel somewhat down after having a baby, but true postpartum depression is rare.
• Premenstrual dysphoric disorder (PMDD) -- depressive symptoms occur one week prior to menstruation and disappear after you menstruate.
• Seasonal affective disorder (SAD) -- occurs during the fall-winter season and disappears during the spring-summer season. Likely to be due to lack of sunlight.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Depression is more common in women than men and is especially common during the teen years. Men seem to seek help for feelings of depression less often than women. Therefore, women may only have more documented cases of depression.

Common Causes

Depression often runs in families. This may be from heredity, learned behavior, or both. Even with a genetic predisposition, it is usually a stressful or unhappy life event that triggers the onset of a depressive episode.

Depression may be brought on by:

• Disappointment at home, work, or school (in teens, this may be breaking up with a boyfriend or girlfriend, failing a class, or parents divorcing)
• Death of a friend or relative
• Prolonged pain or having a major illness
• Medical conditions such as hypothyroidism (underactive thyroid), cancer, or hepatitis
• Drugs such as sedatives and high blood pressure medications
• Alcohol or drug abuse
• Chronic stress
• Childhood events like abuse or neglect
• Social isolation (common in the elderly)
• Nutritional deficiencies (such as folate and omega-3 fatty acids)

• Sleeping problems

Home Care

If you are depressed for 2 weeks or longer, you should contact your doctor, who can offer treatment options. Regardless of whether you have mild or major depression, the following self-care steps can help:

• Get enough sleep.
• Follow a healthy, nutritious diet.
• Exercise regularly.
• Avoid alcohol, marijuana, and other recreational drugs.
• Get involved in activities that make you happy, even if you don't feel like it.
• Spend time with family and friends.
• Try talking to clergy or spiritual advisors who may help give meaning to painful experiences.
• Consider prayer, meditation, tai chi, or biofeedback as ways to relax or draw on your inner strengths.
• Add omega-3 fatty acids to your diet, which you can get from cold-water fish like tuna, salmon, or mackerel.
• Take folate (vitamin B9) in the form of a multivitamin (400 to 800 micrograms).

If your depression occurs in the fall or winter months, try light therapy using a special lamp that mimics the sun.

Many people try a popular over-the-counter herb called St. John's Wort. Some studies do suggest that this herbal remedy may be helpful for mild depression, but not moderate or severe. Be aware that St. John's Wort has potential drug interactions and should NOT be taken with prescription antidepressants, birth control pills, protease inhibitors for HIV, theophylline, warfarin, digoxin, reserpine, cyclosporine, or loperamide. Talk to your doctor if you are thinking about trying this herb for mild depression.

If you have moderate to severe depression, the most effective treatment plan will likely be a combination of counseling and medication.

Call your health care provider if

Call 911, a suicide hotline, or get safely to a nearby emergency room if you have thoughts of suicide, a suicidal plan, or thoughts of harming yourself or others.

Call your doctor right away if:

• You hear voices that are not there.
• You have frequent crying spells with little or no provocation.
• You have had feelings of depression that disrupt work, school, or family life for longer than 2 weeks.
• You have 3 or more depressive symptoms.
• You think that one of your current medications may be making you feel depressed. DO NOT change or stop any medications without consulting your doctor.
• You believe that you should cut back on drinking, a family member or friend has asked you to cut back, you feel guilty about the amount of alcohol you drink, or you drink alcohol first thing in the morning.

What to expect at your health care provider's office

A complete history, a psychiatric interview and a physical examination will be performed to try to classify your depression as mild, moderate, or severe and to see if there is an underlying, treatable cause (such as alcohol abuse or an underactive thyroid). Hospitalization is usually recommended if suicide seems possible.

Expect some exploration of the issues and events associated with your feelings of depression. Your doctor will ask you about:

• Your depressive moods and other associated symptoms (sleep, appetite, concentration, energy).
• Possible stressors in your life, and support systems in place.
• Whether thoughts about ending your life have ever crossed your mind.
• Drug and alcohol use, and about the medications you are currently taking, if any.

Treatment will vary according to the cause and severity of your depressive symptoms, as well as your personal preference. The most effective therapy for moderate or severe depression is a combination of antidepressant medication and psychotherapy.

For mild depression, counseling and self-care measures without medication may be enough.

If you are taking medications for other purposes that could cause depression as a side effect, these may need to be changed. DO NOT change or stop any of your medications without consulting your doctor.

For people who are so severely depressed as to be unable to function, or who are suicidal and cannot be safely cared for in the community, psychiatric hospitalization may be necessary.

Prevention

Healthy lifestyle habits can help prevent depression, or lessen the chances of it happening again. These habits include eating properly, sleeping adequately, exercising regularly, learning to relax, and not drinking alcohol or using drugs.

Counseling may help you through times of grief, stress, or low mood. Family therapy may be particularly important for teens who feel blue.

For elderly or others who feel socially isolated or lonely, try volunteering or getting involved in group activities.

References

Moore D, Jefferson J.  Major Depressive Disorder. In: Handbook of Medical Psychiatry. 2nd ed. Mosby, Inc., 2004; 134-141.

Screening for Depression Recommendations and Rationale. US Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services: 3rd ed. Rockville, Md. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; May 1, 2002.

World Health Organization. The World Health Report 2001 - Mental Health: New Understanding, New Hope. Geneva World Health Organization, 2001.

Guide to Clinical Preventive Services: Screening for Depression, Recommendations and Rationale. Rockville, Md. US Preventive Services Task Force, Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Ann Intern Med. 2002; 136(10): 760–764.

Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 2^nd Ed. Arlington, VA: American Psychiatric Association; 2000.

Illustrations

Depression in children

Depression and heart disease

Depression and the menstrual cycle

Depression and insomnia

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