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Everyone feels "blue" at certain times during his or her
life. In fact, transitory feelings of sadness or discouragement are
perfectly normal, especially during particularly difficult times.
But a person who cannot "snap out of it" or get over these
feelings within two weeks may be suffering from the illness called
depression.
Depression is one of the most common and treatable of all mental
illnesses. In any six-month period, 9.4 million Americans suffer
from this disease. One in four women and one in 10 men can expect to
develop it during their lifetime. Eighty to 90 percent of those who
suffer from
depression can be effectively treated, and nearly all people who
receive treatment derive some benefit.
Unfortunately, many fail to recognize the illness and get the
treatment that would alleviate their suffering. They or their loved
ones fail to notice a pattern and instead may attribute the physical
symptoms to "the flu," the sleeping and eating problems to
"stress," and the emotional problems to lack of sleep or
improper eating.
But if people looked at all of these symptoms together and
noticed that they occur over long periods of time, they might
recognize them as signs of depression.
What Is Depression?
The term "depression" can be confusing since it's often
used to describe normal emotional reactions. At the same time, the
illness may be hard to recognize because its symptoms may be so
easily attributed to other causes. People tend to deny the existence
of depression by saying things like, "She has a right to be
depressed! Look at what she's gone through." This attitude
fails to recognize that people can go through tremendous hardships
and stress without developing depression, and that those who suffer
from depression can and should seek treatment.
Nearly everyone suffering from depression has pervasive feelings
of sadness. In addition, depressed people may feel helpless,
hopeless, and irritable. You should seek professional help if you or
someone you know has had four or more of the following symptoms
continually or most of the time for more than two weeks:
- Noticeable change of appetite, with either significant weight
loss not attributable to dieting or weight gain.
- Noticeable change in sleeping patterns, such as fitful sleep,
inability to sleep, early morning awakening, or sleeping too
much.
- Loss of interest and pleasure in activities formerly enjoyed.
- Loss of energy, fatigue.
- Feelings of worthlessness.
- Persistent feelings of hopelessness.
- Feelings of inappropriate guilt.
- Inability to concentrate or think, indecisiveness.
- Recurring thoughts of death or suicide, wishing to die, or
attempting suicide. (Note: People suffering this symptom should
receive treatment immediately!)
- Melancholia (defined as overwhelming feelings of sadness and
grief), accompanied by waking at least two hours earlier than
normal in the morning, feeling more depressed in the morning,
and moving significantly more slowly.
- Disturbed thinking, a symptom developed by some severely
depressed persons. For example, severely depressed people
sometimes have beliefs not based in reality about physical
disease, sinfulness, or poverty.
- Physical symptoms, such as headaches or stomachaches.
For many victims of depression, these mental and physical
feelings seem to follow them night and day, appear to have no end,
and are not alleviated by happy events or good news. Some people are
so disabled by feelings of despair that they cannot even build up
the energy to call a doctor. If someone else calls for them, they
may refuse to go because they are so hopeless that they think
there's no point to it.
Family, friends, and co-workers offer advice, help, and comfort.
But over time, they become frustrated with victims of depression
because their efforts are to no avail. The person won't follow
advice, refuses help, and denies the comfort. But persistence can
pay off.
Many doctors think depression is the illness that underlies the
majority of suicides in our country. Suicide is the eighth leading
cause of death in America; it is the third leading cause of death
among people aged 15 to 24. Every day 15 people aged 15 to 24 kill
themselves. One of the best strategies for preventing suicide is the
early recognition and treatment of the depression.
Depression can appear at any age. Current research suggests that
treatable depression is very prevalent among children and
adolescents, especially among offspring of adults with depression.
Depression can also strike late in life, and its symptoms--including
memory impairment, slowed speech, and slowed movement--may be
mistaken for those of senility or stroke.
Scientists think that more than half of the people who have had
one episode of major depression will have another at some point in
their lives. Some victims have episodes separated by several years
and others suffer several episodes of the disorder over a short
period. Between episodes, they can function normally. However, 20 to
35 percent of the victims suffer chronic depression that prevents
them from maintaining a normal routine.
Sadness at the loss of a loved one or over a divorce is normal,
but these losses can also be the trigger for a depressive episode.
In fact, most major environmental changes can trigger depression.
Job promotions, moves to new areas, changes in living space--all can
bring on depressive illness. New mothers sometimes suffer with post
partum depression. Birth brings dramatic changes to both their
environments and bodies--a combination that can trigger a downward
swing in mood. Depression also afflicts many poor single working
mothers of young children. These women live with loneliness,
financial stress, and the unrelieved pressure of rearing children
and maintaining a household without another's help.
Types of Depression
Depression strikes in several forms. When a psychiatrist makes a
diagnosis of a patient's depressive illness, he or she may use a
number of terms--such as bipolar, clinical, endogenous, major,
melancholic, seasonal affective or unipolar--to describe it. These
labels confuse many people who don't understand that they can
overlap. People with depressive illness may also receive more than
one diagnosis since the illness is often linked with other problems,
such as alcoholism or other substance abuses, eating disorders, or
anxiety disorders.
When you hear the term clinical depression, it merely means the
depression is severe enough to require treatment. When a person is
badly depressed during a single severe period, he or she can be said
to have had an episode of clinical depression. More severe symptoms
mark the period as an episode of major depression. Many mental
health experts say the key to judging this gradation lies in the
amount of change a person undergoes in his or her normal patterns
along with a loss of interest and a lack of pleasure in them. An
almost-daily tennis player, for instance, who began to break her
court dates frequently, or a regular bridge player who lost interest
in weekly games, might be edging into an episode of major
depression. The more severe the depression, the more it is likely to
affect its sufferer's life.
While many people have single or infrequent episodes of severe
depression, some suffer with recurrent or long-lasting depression.
For these people, who almost always seem to have symptoms of a mild
form of the illness, the diagnosis is dysthymia. A major depressive
episode can hit the dysthymic person, too, causing double
depression, a condition that demands careful treatment and close
follow-up.
In bipolar depression, the lows alternate with terrible highs in
an often bewildering oscillation. Scientists now believe this
up-and-down mood rollercoaster is the product of an imbalance in the
brain chemistry which can be treated successfully about 80 percent
of the time with balance-restoring medications.
Recent research has also found that a subtype of depression
called seasonal affective disorder (SAD) exists. Research suggests
that SAD arises from some people's sensitivity to seasonal changes
in the amount of available daylight.
Theories About Causes
Medical research has contributed much to our understanding of
depression. However, scientists do not know the exact mechanism that
triggers depressive illness. Probably no single cause gives rise to
the illness, and researchers continue to piece the puzzle together.
Scientists now believe genetic factors play a role in some
depressions. Researchers are hopeful, for instance, that they are
closing in on genetic markers for susceptibility to manic-depressive
disorder [see APA's Let's Talk Facts About Manic-Depressive/Bipolar
Disorder].
Recent genetic research also supports earlier studies reporting
family links in depression. For example, if one identical twin
suffers from depression or manic-depressive disorder, the other twin
has a 70 percent chance of also having the illness. Other studies
that looked at the rate of depression among adopted children
supported this finding. Depressive illnesses among adoptive family
members had little effect on a child's risk of depression; however,
the disorder was three times more common among adopted children
whose biological relatives suffered depression.
Additional research data indicate that people suffering from
depression have imbalances of neurotransmitters, natural substances
that allow brain cells to communicate with one another. Two
transmitters implicated in depression are serotonin and
norepinephrine. Scientists think a deficiency in serotonin may cause
the sleep problems, irritability, and anxiety associated with
depression. Likewise, a decreased amount of norepinephrine, which
regulates alertness and arousal, may contribute to the fatigue and
depressed mood of the illness.
Other body chemicals also may be altered in depressed people.
Among them is cortisol, a hormone that the body produces in response
to stress, anger, or fear. In normal people the level of cortisol in
the bloodstream peaks in the morning, then decreases as the day
progresses. In depressed people, however, cortisol peaks earlier in
the morning and does not level off or decrease in the afternoon or
evening.
Researchers don't know if these imbalances cause the disease or
if the illness gives rise to the imbalances. They do know that
cortisol levels will increase in anyone who must live with long-term
stress.
Treatments
Depression is one of the most treatable mental illnesses. Between
80 and 90 percent of all depressed people respond to treatment and
nearly all depressed people who receive treatment see at least some
relief from their symptoms. Along with the great strides made in
understanding the causes of depression, scientists are closer to
understanding how treatment of the illness works.
Before any treatment program begins, however, a complete
evaluation is essential. Depression is a complex illness, and many
factors in a depressed person's life may feed into their condition.
For example, a number of prevalent illnesses (such as hypothyroidism
or hypertension) and commonly used medications can bring on
depression. An evaluation will reveal the presence of these
conditions or medicines to the psychiatrist. The evaluation will
also include a medical/psychiatric history that will outline the
patient's physical and emotional background, and a mental status
examination, to uncover changes in the patient's mood, thoughts,
patterns of speech, and memory that are manifestations of
depression. The psychiatrist may also perform or order a physical
exam for the patient to rule out undiagnosed medical problems that
might be related to depressive illness.
Medication Therapy
Since the 1950s, physicians have learned much more about the
effects of medication on depression. The effectiveness of a drug
depends on a person's general health, weight, metabolism, and other
characteristics unique to that patient. Medication must be used at
an adequate dosage level and for a long enough time. If one form
doesn't work, the psychiatrist may prescribe another, or may try a
combination of medications to determine what works best. Generally,
antidepressant drugs become fully effective within three to six
weeks after a person begins taking them.
Physicians generally prescribe one of four major types of
medication used to treat depression: heterocyclics, serotonin
reuptake inhibitors, monoaminine oxidase inhibitors (MAOIs) and
lithium.
The oldest of the heterocyclics, the tricyclics, and the
serotonin reuptake inhibitors are most often prescribed for people
whose depressions are characterized by fatigue; feelings of
hopelessness, helplessness and excessive guilt; inability to feel
pleasure; and loss of appetite with resulting weight loss.
MAO inhibitors may be prescribed for people whose depressions are
characterized by increased appetite; excessive sleepiness; and
anxiety, phobic, and obsessive-compulsive symptoms in addition to
the depression. These medications may also be prescribed for people
whose depression has not been reached by other drugs.
Lithium is used for people who have manic-depressive (bipolar)
illness. It is also prescribed for people suffering from recurrent
depression without mania.
Newer antidepressants, such as the serotonin reuptake inhibitors,
have recently become available, and more are being developed. The
newer drugs can help patients who either do not respond to the more
traditionally prescribed medications or have trouble with those
medications' side effects.
Like medications for any other illness, antidepressants can have
side effects. With tricyclic antidepressants, for instance, these
may include dry mouth, blurred vision, drowsiness, lowered blood
pressure, and constipation, and tend to lessen as the body adjusts
to the medication.
Psychotherapies
Psychotherapy involves the verbal interaction between a trained
professional and a patient with emotional or behavioral problems.
The therapist applies techniques based on established psychological
principles to help the patient gain insights about him or herself
and thus change his or her maladaptive thoughts, feelings, and
behavior. There are several forms of this "talk treatment"
that have proven useful in helping the depressed person.
In the spring of 1986, scientists announced results of research
into the effectiveness of short-term psychotherapy in treating
depression. Their findings indicated that for some categories of
patients and under certain circumstances, some types of
cognitive/behavioral therapy and interpersonal therapy were as
effective as medications for depressed patients. Medications
relieved the symptoms more quickly, but patients with moderately
severe depression who received psychotherapy instead of medicine had
as much relief from symptoms after 16 weeks.
The data from this study will help scientists better identify the
depressed patients who will do best with psychotherapy alone and
which patients may benefit from medications. In general,
psychiatrists agree that severely depressed patients do best with a
combination of medication and psychotherapy.
Interpersonal Psychotherapy: This therapy is based on the
theory that disturbed social and personal relationships can cause or
precipitate depression. The illness, in turn, may make these
relationships more problematic. The therapist helps the patient
understand his or her illness and how depression and interpersonal
conflicts are related.
Cognitive/Behavioral Therapy: This treatment approach is
based on the theory that people's emotions are controlled by their
views and opinions of the world. Depression results when patients
constantly berate themselves, expect to fail, make inaccurate
assessments of what others think of them, feel hopeless, and have a
negative attitude toward the world and the future. The therapist
uses various techniques of talk therapy and behavioral prescriptions
to alleviate the negative thought patterns and beliefs.
Psychoanalysis: This therapy is based on the concept that
depression is the result of past conflicts which patients have
pushed into their unconscious. The therapist meets 3 to 5 times a
week with the patient to identify and resolve the patient's past
conflicts that have given rise to depression in later years.
Psychodynamic Psychotherapy: Based on the principles of
psychoanalysis, this therapy is less intense and often is provided
once or twice a week over a shorter span of time. It is based on the
premise that human behavior is determined by one's past experience,
genetic endowment, and current reality. It recognizes the
significant effects that emotions and unconscious motivation can
have on human behavior.
Electroconvulsive Therapy (ECT): Scientists believe ECT
works by affecting the same transmitter chemicals in the brain that
are affected by medications. As more effective medications have been
developed, the use of ECT for the treatment of depression has
decreased. However, ECT is very effective for treating patients who
cannot take medications due to heart conditions, old age, severe
malnourishment, or for patients who do not respond to antidepressant
medication. It can be a life-saving treatment technique that is
considered when other therapies have failed or when a person is very
likely to commit suicide.
Before ECT is administered, patients receive anesthesia and a
muscle relaxant to protect them from physical harm and pain.
Electrodes are placed on the head and a small amount of electricity
is applied. This procedure is repeated two or three times a week
until the patient improves or it becomes evident that further
treatment will be ineffective.
Side effects of ECT are largely transitory. Some people may
experience mild problems with memory of events that occurred within
several months of the therapy.
Light therapy: Researchers have found that people
suffering with seasonal affective disorder can be helped with the
symptoms of their illness if they spend a therapeutic session bathed
in light from a special full-spectrum light source, called a
"light box." In summary, medication or psychotherapy, or a
combination of the two treatment methods, usually relieves symptoms
of depression in weeks. Even the most severe forms of depression can
respond to treatment rapidly.
(c) Copyright 1988 American Psychiatric Association
Revised 1994
Produced by the APA Joint Commission on Public Affairs and the
Division of Public Affairs. This document contains the text of a
pamphlet developed for educational purposes and does not necessarily
reflect opinion or policy of the American Psychiatric Association.
Additional Resources
Burns, D. Feeling Good: The New Mood Therapy. New York: Morrow,
1980.
Greist, J. and Jefferson, J. Depression and Its Treatment.
Washington, DC: American Psychiatric Press, Inc., rev. ed. 1992.
Morrison, J.M. Your Brother's Keeper. Chicago: Nelson-Hall, 1981.
Sargent, M. Depressive Illnesses: Treatments Bring New Hope. U.S.
Dept. of Health & Human Services (ADM 89-1491), 1989.
Winokur, G. Depression: The Facts. New York: Oxford University
Press, 1981.
Technical Books
Deakin, J.F.W. (Ed.): The Biology of Depression. Washington, DC:
American Psychiatric Press, Inc., 1986.
Klein, D. and Wender, P. Understanding Depression: A Complete
Guide to Its Diagnosis and Treatment. New York: Oxford University
Press, 1993.
Klerman, G. (Ed.): Suicide and Depression Among Adolescents and
Young Adults. Washington, DC: American Psychiatric Press, Inc.,
1986.
Other Resources
National Alliance for the Mentally Ill
(703) 524-7600
National Depressive and Manic Depressive Association
(312) 939-2442
National Foundation for Depressive Illness
(800) 248-4344
National Institute of Mental Health Public Information Branch
(301) 443-4536
National Mental Health Association
(703) 684-7722
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