Depression

Depression is a disorder of the brain. It is also called major depressive disorder or clinical depression. Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest in once enjoyable activities. It affects how you feel, think, and behave and it can lead to a variety of emotional and physical problems.

There are a variety of causes of depression, including genetic, environmental, psychological, and biochemical factors. Depression usually starts between the ages of 15 and 30, and is much more common in women than in men. Depression is one part of bipolar disorder.

Depression is more than just feeling “sad” or “blue” every once in a while. Depression may require long-term treatment, but most people with depression feel better with medication, psychological counseling, or both.

Depression may occur only one time during your life, but most people have multiple episodes of depression. During these episodes, symptoms occur most of the day, nearly every day, and may include:

• Feelings of sadness, tearfulness, emptiness or hopelessness
• Angry outbursts, irritability or frustration, even over small matters
• Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, so even small tasks take extra effort
• Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and weight gain in some people
• Anxiety, agitation, or restlessness
• Slowed thinking, speaking or body movements
• Feelings of worthlessness or guilt, fixating on past failures or blaming yourself for things that are not your responsibility
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
• Unexplained physical problems, such as back pain, headaches, or digestive disorders

For many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Other people may feel generally miserable or unhappy without really knowing why.

Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.

In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.

In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.

Children with attention-deficit/hyperactivity disorder (ADHD) can demonstrate irritability without sadness or loss of interest. However, major depression can occur with ADHD.

Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:

• Memory difficulties or personality changes
• Physical aches or pain
• Fatigue, loss of appetite, sleep problems, aches or loss of interest in sex — not caused by a medical condition or medication
• Often wanting to stay at home, rather than going out to socialize or doing new things
• Suicidal thinking or feelings, especially in older men

It is not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, including genetic, biological, environmental, and psychological factors.

Depressive illnesses are disorders of the brain, and brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain involved in mood, thinking, sleep, appetite, and behavior appear different. But these images do not reveal why the depression has occurred and they cannot be used to diagnose depression.

Neurotransmitters and hormones play a role in depression. The balance of these chemicals in the brain influence mood and mental health, and changes in levels and interactions of certain neurotransmitters and hormones can trigger depression.

Some types of depression tend to run in families. However, depression can occur in people without family histories of depression too. Scientists are studying certain genes that may make some people more prone to depression. Some genetics research indicates that risk for depression results from the influence of several genes acting together with environmental or other factors. In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Other depressive episodes may occur with or without an obvious trigger.

Risk Factors that increase the risk of developing or triggering depression include:

• Certain personality traits, such as low self-esteem and being too dependent, self-critical or pessimistic
• Traumatic or stressful events, such as physical or sexual abuse, the death or loss of a loved one, a difficult relationship, or financial problems
• Childhood trauma or depression that started when you were a teen or child
• Blood relatives with a history of depression, bipolar disorder, alcoholism or suicide
• History of other mental health disorders, such as anxiety disorder, eating disorders or post-traumatic stress disorder
• Abuse of alcohol or illegal drugs
• Serious or chronic illness, including cancer, stroke, chronic pain or heart disease

Several exams and tests can help rule out other problems that could be causing your symptoms, identify a diagnosis, and check for any related complications:

• Physical exam. Your doctor may do a physical exam and ask questions about your health. In some cases, depression may be linked to an underlying physical health problem.
• Lab tests. For example, your doctor may do a blood test called a complete blood count or test your thyroid to make sure it's functioning properly.
• Psychological evaluation. Expect your doctor or mental health provider to ask about your symptoms, thoughts, feelings and behavior patterns. You may be asked to fill out a questionnaire to help answer these questions.
• DSM-5. Your mental health professional may use the criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

If you have depression, you may feel exhausted, helpless, and hopeless. It may be extremely difficult to take any action to help yourself. But as you begin to recognize your depression and begin treatment, you will start to feel better. Depression is not a disorder that you can treat on your own, but, in addition to professional treatment, these you can take several steps to improve your symptoms and improve your chances of successful treatment:

• Do not wait too long to get evaluated or treated. There is research showing the longer one waits, the greater the impairment can be down the road. Try to see a professional as soon as possible.
• Stick to your treatment plan.
• Learn about depression so you can make informed choices about your care.
• Try to be active and exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed.
• Eat healthy and avoid drugs and alcohol, which can make depression harder to treat.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Pay attention to warning signs and learn what might trigger a depressive episode.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Depression, even the most severe cases, can be effectively treated. The earlier that treatment can begin, the more effective it is.

Medications and psychological counseling (psychotherapy) are very effective for most people with depression. Your primary care doctor or psychiatrist can prescribe medications to relieve symptoms. However, many people with depression also benefit from seeing a psychologist or other mental health professional.

Many types of antidepressant medications are available:

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often start by prescribing an SSRI. These medications are safer and generally cause fewer side effects than other types of antidepressants. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro).
• Serotonin-norepinephrine reuptake inhibitors (SNRIs). Examples of SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima).
• Norepinephrine-dopamine reuptake inhibitors (NDRIs). Bupropion (Wellbutrin, Aplenzin, Forfivo XL) falls into this category.
• Atypical antidepressants. These medications do not fit into any other antidepressant categories. Trazodone and mirtazapine (Remeron) are sedating and usually taken in the evening. Newer medications include vortioxetine (Brintellix) and vilazodone (Viibryd).
• Tricyclic antidepressants. These antidepressants, such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin, trimipramine (Surmontil), desipramine (Norpramin) and protriptyline (Vivactil), can be very effective, but tend to cause more severe side effects than newer antidepressants.
• Monoamine oxidase inhibitors (MAOIs). MAOIs such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) may be prescribed when other medications have not worked, because they can have serious side effects and multiple interactions with foods and other drugs. Selegiline (Emsam), a newer MAOI that sticks on the skin as a patch, may cause fewer side effects than other MAOIs do. MAOIs cannot be combined with SSRIs.
• Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or adding medications such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications also may be added for short-term use.

Psychotherapy is also known as talk therapy or psychological therapy. It is a general term for treating depression by talking about your condition and related issues with a mental health provider. Different types of psychotherapy can be effective for depression, such as cognitive behavioral therapy or interpersonal therapy. Psychotherapy can help you:

• Adjust to a crisis or other current difficulty
• Identify negative beliefs and behaviors and replace them with healthy, positive ones
• Explore relationships and experiences, and develop positive interactions with others
• Find better ways to cope and solve problems
• Identify issues that contribute to your depression and change behaviors that make it worse
• Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
• Learn to set realistic goals for your life
• Develop the ability to tolerate and accept distress using healthier behaviors

In some people, depression is so severe that a hospital stay is needed. This may be necessary if you cannot care for yourself properly or when you are in immediate danger of harming yourself or someone else. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves.

Partial hospitalization or day treatment programs also may help some people. These programs provide the outpatient support and counseling needed to get symptoms under control.

For some people, other procedures may be suggested:

• Electroconvulsive therapy (ECT). In ECT, electrical currents are passed through the brain. Performed under anesthesia, this procedure is thought to impact the function and effect of neurotransmitters in your brain and typically offers immediate relief of even severe depression when other treatments don't work. Physical side effects, such as headache, are tolerable. Some people also have memory loss, which is usually temporary. ECT is usually used for people who do not get better with medications, cannot take antidepressants for health reasons, or are at high risk of suicide.
• Transcranial magnetic stimulation (TMS). TMS may be an option for those who have not responded to antidepressants. During TMS, a coil sends brief magnetic pulses to stimulate nerve cells in the brain that are involved in mood regulation and depression.