Medically reviewed by Dr. C.H. Weaver M.D. 2/2021
Depression is quite different from having the blues. Whereas feeling sad or down on occasion is perfectly normal, depression, also called depressive disorder, is a serious illness that interferes with daily life, functioning, and relationships.
Depression in Women
Women tend to experience depression more commonly than men. In addition to postpartum depression (depression among new mothers), women may also be vulnerable to depression as a result of hormonal, biological, lifecycle, and psychological factors that differ from those of men. As well, some women experience depression as part of premenstrual syndrome (PMS), when hormonal changes occur around ovulation and before menstruation. Women may also become susceptible to depression around the time of menopause, when menstruation and the monthly menstrual cycle end, and in response to stresses associated with family, work, abuse, or hardship.
Causes of Depression
Causes of depression may be genetic, biochemical, environmental, or psychological, but there is no single known cause.
Research suggests that depression is a disorder of the brain, involving abnormal functioning of the areas that regulate mood, thinking, sleep, appetite, and behavior. In fact, MRI (magnetic resonance imaging) brain scans of people with depression appear different from those of people without depression. These findings, however, still don’t explain what causes depression.
There may be a genetic cause of depression, as it tends to run in families. But because people with no family history of the disorder also experience depression, there must be causes in addition to heredity. It’s likely a combination of genetic, environmental, and other factors.
Depression is sometimes preceded by a traumatic event—a particularly stressful and difficult situation that may be personal or job-related.
Depression and Other Illnesses
Sometimes a person with depression is also facing another significant illness. It may be not clear whether this is the result of the other illness or if depression has contributed to the development of another condition. In either case, effective treatment involves addressing both illnesses.
Several conditions that may increase a person’s risk for depression include post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia, and generalized anxiety. These are all considered anxiety disorders. Eating disorders, such as anorexia nervosa or bulimia nervosa, may also coexist with depression, particularly in women.
Depression can occur along with alcohol and substance abuse or dependence. Research indicates that there is a high rate of coexistence of depression and substance abuse in the United States.
Sometimes people facing serious medical illnesses will also experience depression. Heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s disease have all been known to coexist with depression. In such cases, treatment of depression along with the other condition is extremely important, as studies have shown that people with depression and a major medical illness tend to have more-severe symptoms of each.
Symptoms of Depression
Symptoms of depression vary from person to person and by form of depression. Signs of depression include:
- Persistent sad, anxious, or “empty” feelings
- Feelings of hopelessness and/or pessimism
- Feelings of guilt, worthlessness, and/or helplessness
- Irritability, restlessness
- Loss of interest in activities or hobbies once pleasurable, including sex
- Fatigue and decreased energy
- Difficulty concentrating, remembering details, and making decisions
- Insomnia, early-morning wakefulness, or excessive sleeping
- Overeating or appetite loss
- Thoughts of suicide, suicide attempts
- Persistent aches or pains, headaches, cramps, or digestive problems that do not ease with treatment
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Diagnosis of depression is important because it is highly treatable. An early diagnosis increases the likelihood of effective treatment and reduces the likelihood of a recurrence.
How is depression diagnosed? A visit to a primary care doctor can begin the process of diagnosing depression. The process involves a medical evaluation to rule out a medical cause of depression, such as medications, viruses, or a thyroid disorder.
If other health factors are ruled out, the doctor will conduct a psychological evaluation or refer the patient to a mental health professional, who will complete the diagnosis process. Factors including family history of depression, history of symptoms, alcohol and drug use, and thoughts of suicide will be part of the complete evaluation.
Depression is treated with psychotherapy, also called talk therapy, and with medication. Depending on the individual and the form and severity of depression, these methods may be used alone or in combination.
Psychotherapy - Psychotherapy, or talk therapy, for depression may be short- or long-term, depending on the individual and the nature of the disorder. As well, individual considerations will help determine whether a person can be treated with psychotherapy alone or also requires medication.
The two main types of psychotherapy are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). The goal of CBT is to teach new ways of thinking and behaving, which are intended to change negative thoughts and behaviors that may contribute to depression. IPT aims to address issues concerning troubled relationships that may contribute to depression.
Electroconvulsive Therapy - Electroconvulsive Therapy (ECT) may be used in patients whose depression does not improve with antidepressants and psychotherapy. Today’s ECT is greatly improved over earlier forms of “shock therapy” and can provide relief in severe cases. Side effects are generally short-term; they include confusion, disorientation, and memory loss.
Patients receiving ECT are given a muscle relaxant and then put under brief anesthesia so that they don’t feel the procedure. ECT is given only a few times or as maintenance over a longer period, depending on the individual case. Patients often also take antidepressants while undergoing ECT.
Medications - Medications used to treat depression are known as antidepressants. They work by normalizing naturally occurring brain chemicals called neurotransmitters, which appear to be involved in regulating mood. Three neurotransmitters targeted by antidepressants include serotonin, norepinephrine, and dopamine. Classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) and the older tricyclics and monoamine oxidase inhibitors (MAOIs).
The two newer, more-popular classes of antidepressants are SSRIs— including Prozac® (fluoxetine), Celexa® (citalopram), Zoloft® (sertaline), and several others—and SNRIs— including Effexor® (venlafaxine) and Cymbalta® (duloxetine). They tend to have fewer side effects that tricyclics and MAOIs, though some people have better outcomes with the older classes.
Taking Antidepressants - Before they start to work, antidepressants need to be taken at regular doses for at least three to four weeks. A patient should continue to take antidepressant medication for the prescribed time—even when feeling better—to prevent a relapse. Medication should only be stopped (if appropriate to stop—some individuals with chronic or recurrent depression stay on medication indefinitely) under a doctor’s supervision; even though antidepressants are non-habit-forming, the body will still need to adjust.
Side Effects of Antidepressants
Side effects vary by the type of antidepressant and are generally mild and often temporary. Sometimes, however, more-severe side effects that interfere with normal functioning occur. These should be discussed with a doctor.
Side Effects of SSRIs and SNRIs:
- Headache—usually temporary and will subside
- Nausea—temporary and usually short-lived
- Insomnia and nervousness (trouble falling asleep or waking often during the night)—may occur during the first few weeks but often subside over time or if the dose is reduced
- Agitation (feeling jittery)
- Sexual problems—both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.
Side Effects of Tricyclic Antidepressants:
- Dry mouth
- Bladder problems
- Sexual problems—Sexual functioning may change, and side effects are similar to those of SSRIs.
- Blurred vision (often passes soon and usually will not require a new corrective lens prescription)
- Drowsiness during the day— Driving or operating heavy machinery should be avoided when drowsiness occurs. Antidepressants that cause drowsiness are generally taken at bedtime to help sleep and minimize daytime drowsiness.
Side Effects of MAOIs:
- Significant food restrictions—Foods containing certain levels of the chemical tyramine must be avoided (wine, cheese, and pickles, for example); a doctor can provide a complete list.
- Medical restrictions—Serious interactions with other medications can occur.
FDA Warning on Antidepressants
Antidepressants are relatively safe, but studies do suggest that some people may experience unintentional effects. Adolescents and young adults (up to age 24) in particular may experience an increase in suicidal thoughts or suicide attempts while taking antidepressants. To address this issue, the FDA had adopted a “black box” warning label on antidepressants that alerts the public of this risk.
With the risk of suicidal thinking—and other side effects associated with antidepressant medication—it’s very important that these medicines are only taken under a doctor’s supervision and that warning signs (worsening depression, suicidal thinking or behavior, sleeplessness, agitation, or withdrawal from normal social situations) are watched for and immediately addressed with a doctor or by dialing 911 or the National Suicide Prevention Lifeline at 1-800-TALK (8255).
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Taking Antidepressants During Pregnancy and Breastfeeding
Research into the effect of antidepressants on the fetus and baby are inconclusive, though some studies suggest potential risks. It’s therefore very important that pregnant women and women thinking about becoming pregnant discuss antidepressant use with their doctors. Breastfeeding is associated with few problems, but risks and benefits of antidepressants while breastfeeding should still be discussed.
St. John’s Wort
The herbal remedy St. John’s Wort is sometimes used to treat mild or moderate depression. Research into its effectiveness is inconclusive, but the significant concern about St. John’s Wort is that it may interact badly with other medications. These include medicines used to treat heart disease, depression, seizures, certain cancers, and organ transplant, as well as oral contraceptives. It’s always important to consult with a doctor before taking St. John’s Wort or any herbal supplement.
Living with Depression
In addition to medical treatment and psychotherapy, you can take personal measures to manage your depression and improve your well-being. Taking action will certainly require effort—especially in the early stages of treatment—but you’ll be well rewarded as you feel better and begin to again enjoy things that were once pleasurable.
Try, for example, mild activity or exercise—something you once enjoyed. Get involved in your community and with your friends. Set realistic goals and tackle large tasks in small steps. Remember that it may take time for your mood to improve; enjoy the gradual progress. Don’t make major decisions until you are feeling better. Focus on the positive!
You may want to find support beyond your healthcare providers, therapist, and family to help you manage your depression and its impact on your life. Here is a list of possibilities:
- Social workers
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and outpatient clinics
- Mental health programs at universities or medical schools
- State hospital outpatient clinics
- Family services, social agencies, or clergy
- Peer support groups
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
- Also, check your local phone book for listings under “mental health,” “health,” “social services,” and “hotlines.”
If you are thinking about harming yourself, get help immediately. Call 911 or go to the emergency room. Call your doctor or therapist. You can also speak to a trained counselor at the the National Suicide Prevention Lifeline at 1-800-TALK (8255).
If Your Loved One Has Depression—How to Help
How do you help a friend or family member who has depression? Remember, depression is highly treatable, so the most important thing you can do is help your loved one get treatment. This may involve making a doctor’s appointment for your friend and accompanying him or her to the doctor’s office. Once he or she begins treatment, you can continue to help by encouraging your friend to stay on treatment.
Importantly, your personal support can also help your friend or family member confront depression. Offer emotional support and encouragement and listen thoughtfully. Invite him or her to enjoy fun activities with you. Focus on the positive but take seriously comments about suicide and warning signs that depression is worsening; notify your loved one’s therapist or doctor immediately in such an event.
What if my loved one is thinking about harming him- or herself?
Get help immediately. Call 911 or take your friend to an emergency room as soon as possible. Call his or her doctor or therapist. You can also speak to a trained counselor by calling the National Suicide Prevention Lifeline at 1-800-TALK (8255). The suicidal person should never be left alone, so ask friends and family for assistance. Also, make sure that he or she has no access to weapons, firearms, pills, or other means of self-injury.
Types of Depression
There are several forms of depression, and the way that a person experiences this illness will depend on what kind of depression he or she has. The most commons forms are major depressive disorder and dysthymic disorder.
Major Depressive Disorder or Major Depression. Individuals with this form of depression are likely to have trouble working, sleeping, and studying, and will no longer enjoy activities they once did. An episode of major depression, which may occur once in a person’s lifetime or more frequently, prevents normal functioning so much so that it’s disabling.
Dysthymic Disorder or Dysthymia. Individuals with dysthymia don’t experience symptoms that are as severe as those of major depression, but their depression lasts for two years or longer. They may also experience one or more episodes of major depression during their lifetime. Though dysthymia isn’t disabling, it can interfere with normal functioning and prevent a person from feeling well.
Other forms of depression include:
Psychotic Depression. A person suffering from psychotic depression will experience severe depression along with some form of psychosis, such as a break with reality, hallucinations, and delusions.
Postpartum Depression. This form of depression affects an estimated 10 to 15 percent of new mothers. A depressive episode is considered postpartum when it occurs within one month after giving birth.
Seasonal Affective Disorder (SAD). Depression that occurs during winter months, when there is less natural sunlight, is considered SAD. Some people with SAD try treatment with light therapy. But because many do not respond to light therapy alone, SAD may also be treated with antidepressant medications and psychotherapy. In general, this form of depression lessens during spring and summer months.
Bipolar Disorder or Manic-depressive Illness. People with bipolar disorder experience severe mood changes that go from extreme highs (mania) to extreme lows (depression). In addition to mood, these dramatic swings affect energy and ability to function. Long-term treatment, including medication and psychotherapy, can help stabilize mood swings.
Depression is a risk factor for suicide. Suicide occurs when a person ends his or her own life. According to the Centers for Disease Control and Prevention, it is the eleventh cause of death among Americans. Understanding the risk factors for suicide and learning to recognize early warning signs are important steps in prevention.
Risk Factors for Suicide:
- A previous suicide attempt.
- A history of depression or other mental illness
- Alcohol or drug abuse
- A family history of suicide or other violence
- Serious medical illness
- Feeling alone
- Dramatic mood changes
- Rage and anger
- Feelings of hopelessness
- Withdrawing from friends, family, and society
- Reckless behavior
- Family history of child abuse
- Local epidemics of suicide
- Loss (relational, social, work, or financial)
Warning Signs of Suicide:
- Changes in mood, diet, or sleeping pattern
- Discussing or writing about suicide or threatening to harm oneself
- Looking for ways to harm oneself and seeking access to means to do so (weapons, firearms, or pills)
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- Seasonal Affective Disorder
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The National Suicide Prevention Lifeline
- Depression. The National Institute of Mental Health Web site. http://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed May, 2020.
- Know the Warning Signs. The American Association of Suicidology Web site. http://www.suicidology.org/web/guest/stats-and-tools/warning-signs. Accessed May, 2020.
- Suicide. The Centers for Disease Control and Prevention Web site. http://www.cdc.gov/ViolencePrevention/suicide/index.html. Accessed May, 2010.