Depression or depressive disorders (unipolar depression) are mental illnesses characterized by a profound and persistent feeling of sadness or despair and/or a loss of interest in things that once were pleasurable. Disturbance in sleep, appetite, and mental processes are a common accompaniment.
Everyone experiences feelings of unhappiness and sadness occasionally. But when these depressed feelings start to dominate everyday life and cause physical and mental deterioration, they become what are known as depressive disorders. Each year in the United States, depressive disorders affect an estimated 17 million people at an approximate annual direct and indirect cost of $53 billion. One in four women is likely to experience an episode of severe depression in her lifetime, with a 10-20% lifetime prevalence, compared to 5-10% for men. The average age a first depressive episode occurs is in the mid-20s, although the disorder strikes all age groups indiscriminately, from children to the elderly.
There are two main categories of depressive disorders: major depressive disorder and dysthymic disorder. Major depressive disorder is a moderate to severe episode of depression lasting two or more weeks. Individuals experiencing this major depressive episode may have trouble sleeping, lose interest in activities they once took pleasure in, experience a change in weight, have difficulty concentrating, feel worthless and hopeless, or have a preoccupation with death or suicide
. In children, the major depression may appear as irritability.
While major depressive episodes may be acute (intense but short-lived), dysthymic disorder is an ongoing, chronic depression that lasts two or more years (one or more years in children) and has an average duration of 16 years. The mild to moderate depression of dysthymic disorder may rise and fall in intensity, and those afflicted with the disorder may experience some periods of normal, non-depressed mood of up to two months in length. Its onset is gradual, and dysthymic patients may not be able to pinpoint exactly when they started feeling depressed. Individuals with dysthymic disorder may experience a change in sleeping and eating patterns, low self-esteem, fatigue
, trouble concentrating, and feelings of hopelessness.
Depression also can occur in bipolar disorder
, an affective mental illness that causes radical emotional changes and mood swings, from manic highs to depressive lows. The majority of bipolar individuals experience alternating episodes of mania and depression.
Causes and symptoms
The causes behind depression are complex and not yet fully understood. While an imbalance of certain neurotransmitters—the chemicals in the brain that transmit messages between nerve cells—is believed to be key to depression, external factors such as upbringing (more so in dysthymia than major depression) may be as important. For example, it is speculated that, if an individual is abused and neglected throughout childhood and adolescence, a pattern of low self-esteem and negative thinking may emerge. From that, a lifelong pattern of depression may follow. A 2003 study reported that two-thirds of patients with major depression say they also suffer from chronic pain
. A 2004 study linked severe obesity
with major depression. Another study showed a strong relationship between smoking
and depression among teens.
Heredity seems to play a role in who develops depressive disorders. Individuals with major depression in their immediate family are up to three times more likely to have the disorder themselves. It would seem that biological and genetic factors may make certain individuals pre-disposed or prone to depressive disorders, but environmental circumstances often may trigger the disorder.
External stressors and significant life changes, such as chronic medical problems, death
of a loved one, divorce or estrangement, miscarriage
, or loss of a job, also can result in a form of depression known as adjustment disorder. Although periods of adjustment disorder usually resolve themselves, occasionally they may evolve into a major depressive disorder.
Major depressive episode
Individuals experiencing a major depressive episode have a depressed mood and/or a diminished interest or pleasure in activities. Children experiencing a major depressive episode may appear or feel irritable rather than depressed. In addition, five or more of the following symptoms will occur on an almost daily basis for a period of at least two weeks:
- Significant change in weight.
- Insomnia or hypersomnia (excessive sleep).
- Psychomotor agitation or retardation.
- Fatigue or loss of energy.
- Feelings of worthlessness or inappropriate guilt.
- Diminished ability to think or to concentrate, or indecisiveness.
- Recurrent thoughts of death or suicide and/or suicide attempts.
Dysthymia commonly occurs in tandem with other psychiatric and physical conditions. Up to 70% of dysthymic patients have both dysthymic disorder and major depressive disorder, known as double depression. Substance abuse, panic disorders, personality disorders, social phobias
, and other psychiatric conditions also are found in many dysthymic patients. Dysthymia is prevalent in patients with certain medical conditions, including multiple sclerosis
, AIDS, hypothyroidism, chronic fatigue syndrome, Parkinson's disease, diabetes, and post-cardiac transplantation. The connection between dysthymic disorder and these medical conditions is unclear, but it may be related to the way the medical condition and/or its pharmacological treatment affects neurotransmitters. Dysthymic disorder can lengthen or complicate the recovery of patients also suffering from medical conditions.
Along with an underlying feeling of depression, people with dysthymic disorder experience two or more of the following symptoms on an almost daily basis for a period for two or more years (most suffer for five years), or one year or more for children:
- under or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or trouble making decisions
- feelings of hopelessness
In addition to an interview, several clinical inventories or scales may be used to assess a patient's mental status and determine the presence of depressive symptoms. Among these tests are: the Hamilton Depression Scale (HAM-D), Child Depression Inventory (CDI), Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), and the Zung Self-Rating Scale for Depression. These tests may be administered in an outpatient or hospital setting by a general practitioner, social worker, psychiatrist, or psychologist.
Recent scientific research has indicated that the size of the subgenual prefrontal cortex of the brain (located behind the bridge of the nose) may be a determining factor in hereditary depressive disorders.
(Illustration by Electronic Illustrators Group.)
Major depressive and dysthymic disorders are typically treated with antidepressants or psychosocial therapy. Psychosocial therapy focuses on the personal and interpersonal issues behind depression, while antidepressant medication is prescribed to provide more immediate relief for the symptoms of the disorder. When used together correctly, therapy and antidepressants are a powerful treatment plan for the depressed patient.
Selective serotonin reuptake inhibitors
(SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft) reduce depression by increasing levels of serotonin, a neurotransmitter. Some clinicians prefer SSRIs for treatment of dysthymic disorder. Anxiety
, diarrhea, drowsiness, headache
, sweating, nausea, poor sexual functioning, and insomnia all are possible side effects of SSRIs. In early 2004, a joint panel of the U.S. Food and Drug Administration (FDA) issued stronger warnings to physicians and parents about increased risk of suicide among children and adolescents taking SSRIs.
Tricyclic antidepressants (TCAs) are less expensive than SSRIs, but have more severe side-effects, which may include persistent dry mouth
, sedation, dizziness, and cardiac arrhythmias
. Because of these side effects, caution is taken when prescribing TCAs to elderly patients. TCAs include amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor). A 10-day supply of TCAs can be lethal if ingested all at once, so these drugs may not be a preferred treatment option for patients at risk for suicide.
Monoamine oxidase inhibitors
(MAOIs) such as tranylcypromine (Parnate) and phenelzine (Nardil) block the action of monoamine oxidase (MAO), an enzyme in the central nervous system. Patients taking MAOIs must cut foods high in tyramine (found in aged cheeses and meats) out of their diet to avoid potentially serious hypertensive side effects.
Heterocyclics include bupropion (Wellbutrin) and trazodone (Desyrel). Bupropion should not be prescribed to patients with a seizure disorder
. Side effects of the drug may include agitation, anxiety, confusion, tremor, dry mouth, fast or irregular heartbeat, headache, low blood pressure, and insomnia. Because trazodone has a sedative effect, it is useful in treating depressed patients with insomnia. Other possible side effects of trazodone include dry mouth, gastrointestinal distress, dizziness, and headache. In 2003, Wellbutrin's manufacturer released a once—daily version of the drug that offered low risk of sexual side effects or weight gain.
Psychotherapy explores an individual's life to bring to light possible contributing causes of the present depression. During treatment, the therapist helps the patient to become self-aware of his or her thinking patterns and how they came to be. There are several different subtypes of psychotherapy, but all have the common goal of helping the patient develop healthy problem solving and coping skills.
assumes that the patient's faulty thinking is causing the current depression and focuses on changing the depressed patient's thought patterns and perceptions. The therapist helps the patient identify negative or distorted thought patterns and the emotions and behavior that accompany them, and then retrains the depressed individual to recognize the thinking and react differently to it.
ECT, or electroconvulsive therapy
, usually is employed after all therapy and pharmaceutical treatment options have been explored. However, it is sometimes used early in treatment when severe depression is present and the patient refuses oral medication, or when the patient is becoming dehydrated, extremely suicidal, or psychotic.
The treatment consists of a series of electrical pulses that move into the brain through electrodes on the patient's head. ECT is given under general anesthesia and patients are administered a muscle relaxant to prevent convulsions. Although the exact mechanisms behind the success of ECT therapy are not known, it is believed that the electrical current modifies the electrochemical processes of the brain, consequently relieving depression. Headaches, muscle soreness, nausea, and confusion are possible side effects immediately following an ECT procedure. Memory loss, typically transient, also has been reported in ECT patients.
St. John's wort (Hypericum perforatum) is used throughout Europe to treat depressive symptoms. Unlike traditional prescription antidepressants, this herbal antidepressant has few reported side effects. Despite uncertainty concerning its effectiveness, a 2003 report said acceptance of the treatment continues to increase. A poll showed that about 41% of 15,000 science professionals in 62 countries said they would use St. John's wort for mild to moderate depression. Although St. John's wort appears to be a safe alternative to conventional antidepressants, care should be taken, as the herb can interfere with the actions of some pharmaceuticals. The usual dose is 300 mg three times daily.
Homeopathic treatment also can be therapeutic in treating depression. Good nutrition, proper sleep, exercise, and full engagement in life are very important to a healthy mental state.
In several small studies, S-adenosyl-methionine (SAM, SAMe) was shown to be more effective than placebo and equally effective as tricyclic antidepressants in treating depression. The usual dosage is 200 mg to 400 mg twice daily. In 2003, a U.S. Department of Health and Human Services team reviewed 100 clinical trials on SAMe and concluded that it worked as well as many prescription medications without the side effects of stomach upset and decreased sexual desire.
In 2003, a report from Great Britain emphasized that more physicians should encourage alternative treatments such as behavioral and self-help programs, supervised exercise
programs, and watchful waiting before subscribing antidepressant medications for mild depression.
Untreated or improperly treated depression is the number one cause of suicide in the United States. Proper treatment relieves symptoms in 80-90% of depressed patients. After each major depressive episode, the risk of recurrence climbs significantly—50% after one episode, 70% after two episodes, and 90% after three episodes. For this reason, patients need to be aware of the symptoms of recurring depression and may require long-term maintenance treatment of antidepressants and/or therapy.
Research has found that depression may lead to other problems as well. Increased risk of heart disease has been linked to depression, particularly in post-menopausal women. And while chronic pain may cause depression, a 2004 study in Canada revealed that depression also may lead to back pain.
Patient education in the form of therapy or self-help groups is crucial for training patients with depressive disorders to recognize symptoms of depression and to take an active part in their treatment program. Extended maintenance treatment with antidepressants may be required in some patients to prevent relapse. Early intervention for children with depression is effective in arresting development of more severe problems.
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American Psychiatric Association. 1400 K Street NW, Washington DC 20005. (888) 357-7924. http://www.psych.org.
American Psychological Association (APA). 750 First St. NE, Washington, DC 20002-4242. (202) 336-5700. http://www.apa.org.
National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. http://www.nami.org.
National Depressive and Manic-Depressive Association (NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL 60610. (800) 826-3632. http://www.ndmda.org.
National Institute of Mental Health. Mental Health Public Inquiries, 5600 Fishers Lane, Room 15C-05, Rockville, MD 20857. (888) 826-9438. http://www.nimh.nih.gov.