In any given 1-year period, 9.5% of the
population, or about 19 million American adults, suffer from a
depressive illness. The economic cost is estimated at $30.4
billion a year, but the cost in human suffering cannot be
estimated. Depressive illnesses often interfere with normal
functioning and cause pain and suffering not only to those who
have a disorder, but also to those who care about them. Serious
depression can destroy family life as well as the life of the ill
person. But much of this suffering is unnecessary.
Most people with a depressive illness do not
seek treatment, although the great majority--even those whose
depression is extremely severe--can be helped. Thanks to
years of fruitful research, the medications and psychosocial
therapies that ease the pain of depression are at hand.
Unfortunately, many people do not recognize
that depression is a treatable illness. If you feel that you or
someone you care about is one of the many undiagnosed depressed
people in this country, the information presented here may help
you take the steps that may save your own or someone else's life.
A depressive disorder is an illness that involves
the body, mood, and thoughts. It affects the way a person eats and
sleeps, the way one feels about oneself, and the way one thinks
about things. A depressive disorder is not the same as a passing
blue mood. It is not a sign of personal weakness or a condition
that can be willed or wished away. People with a depressive
illness cannot merely "pull themselves together" and get
better. Without treatment, symptoms can last for weeks, months, or
years. Appropriate treatment, however, can help most people who
suffer from depression.
Depressive disorders come in different forms, just
as in the case with other illnesses such as heart disease. This
pamphlet briefly describes three of the most common types of
depressive disorders. However, within these types there are
variations in the number of symptoms, their severity, and
Major depression is manifested by a
combination of symptoms (see symptom list) that interfere with the
ability to work, study, sleep, eat, and enjoy once pleasurable
activities. Such a disabling episode of depression may occur
only once but more commonly occurs several times in a lifetime.
A less severe type of depression, dysthymia,
involves long-term, chronic symptoms that do not disable, but keep
one from functioning well or from feeling good. Many people with
dysthymia also experience major depressive episodes at some time
in their lives.
Another type of depression is bipolar disorder,
also called manic-depressive illness. Not nearly as prevalent as
other forms of depressive disorders, bipolar disorder is
characterized by cycling mood changes: severe highs (mania)
and lows (depression). Sometimes the mood switches are
dramatic and rapid, but most often they are gradual. When in the
depressed cycle, an individual can have any or all of the symptoms
of a depressive disorder. When in the manic cycle, the individual
may be overactive, overtalkative, and have a great deal of energy.
Mania often affects thinking, judgment, and social behavior in
ways that cause serious problems and embarrassment. For example,
the individual in a manic phase may feel elated, full of grand
schemes that might range from unwise business decisions to
romantic sprees. Mania, left untreated, may worsen to a
Not everyone who is depressed or manic experiences
every symptom. Some people experience a few symptoms, some many.
Severity of symptoms varies with individuals and also varies over
Persistent sad, anxious, or "empty"
Feelings of hopelessness, pessimism
Feelings of guilt, worthlessness, helplessness
Loss of interest or pleasure in hobbies and
activities that were once enjoyed, including sex
Decreased energy, fatigue, being "slowed
Difficulty concentrating, remembering, or
Insomnia, early-morning awakening, or
Appetite and/or weight loss or overeating and
Thoughts of death or suicide; suicide attempts
Persistent physical symptoms that do not
respond to treatment, such as headaches, digestive disorders,
and chronic pain
Abnormal or excessive elation
Decreased need for sleep
Increased sexual desire
Markedly increased energy
Inappropriate social behavior
Some types of depression run in families,
suggesting that a biological vulnerability can be inherited. This
seems to be the case with bipolar disorder. Studies of families in
which members of each generation develop bipolar disorder found
that those with the illness have a somewhat different genetic
makeup than those who do not get ill. However, the reverse is not
true: Not everybody with the genetic makeup that causes
vulnerability to bipolar disorder will have the illness.
Apparently additional factors, possibly stresses at home, work, or
school, are involved in its onset.
In some families, major depression also seems to
occur generation after generation. However, it can also occur in
people who have no family history of depression. Whether inherited
or not, major depressive disorder is often associated with changes
in brain structures or brain function.
People who have low self-esteem, who consistently
view themselves and the world with pessimism or who are readily
overwhelmed by stress, are prone to depression. Whether this
represents a psychological predisposition or an early form of the
illness is not clear.
In recent years, researchers have shown that
physical changes in the body can be accompanied by mental changes
as well. Medical illnesses such as stroke, a heart attack,
cancer, Parkinson's disease, and hormonal disorders can cause
depressive illness, making the sick person apathetic and unwilling
to care for his or her physical needs, thus prolonging the
recovery period. Also, a serious loss, difficult relationship,
financial problem, or any stressful (unwelcome or even desired)
change in life patterns can trigger a depressive episode. Very
often, a combination of genetic, psychological, and environmental
factors is involved in the onset of a depressive disorder.
Depression in Women
Women experience depression about twice as often
as men. Many factors may contribute to depression in
women--particularly such factors as menstruation, pregnancy,
miscarriage, postpartum period, and menopause. Many women
also face additional stresses such as responsibilities both at
work and home, single parenthood, and caring for children and for
A recent NIMH study showed that in the case of
premenstrual syndrome (PMS), women with a preexisting
vulnerability to PMS experienced relief from mood and physical
symptoms when their sex hormones were suppressed. Shortly
after the hormones were re-introduced, they again developed
symptoms of PMS. Women without a history of PMS reported no
effects of the hormonal manipulation.
Many women are also particularly vulnerable after
the birth of a baby. The hormonal and physical changes, as
well as the added responsibility of a new life, can be factors
that lead to postpartum depression in some women. Treatment
by a sympathetic physician and the family's emotional support for
the new mother are prime considerations in aiding her to recover
her physical and mental well-being and her ability to care for and
enjoy the infant.
Depression in the Elderly
Some people have the mistaken idea that it is
normal for the elderly to feel depressed. On the contrary,
most older people feel satisfied with their lives.
Sometimes, though, when depression develops, it may be dismissed
as a normal part of aging. Depression in the elderly,
undiagnosed and untreated, causes needless suffering for the
family and for the individual who could otherwise live a fruitful
life. When he or she does go to the doctor, the symptoms
described are usually physical, for the older person is often
reluctant to discuss feelings of hopelessness, sadness, loss of
interest in normally pleasurable activities, or extremely
prolonged grief after a loss.
Recognizing how depressive symptoms in older
people are often missed, many health care professionals are
learning to identify and treat the underlying depression. They
recognize that some symptoms may be side effects of medication the
older person is taking for a physical problem, or they may be
caused by a co-occurring illness. If a diagnosis of
depression is made, treatment with medication and/or psychotherapy
will help the depressed person return to a happier, more
fulfilling life. Recent research suggests that brief psychotherapy
(talk therapies that help a person in day-to-day relationships or
in learning to solve problems of everyday life) is effective in
reducing symptoms in short-term depression in older persons who
are medically ill. Psychotherapy is also useful in older
patients who cannot or will not take medication. Efficacy
studies show that late-life depression can be treated with
Improved recognition and treatment of depression
in late life will make those years more enjoyable and fulfilling
for the depressed elderly person, the family, and caretakers.
Depression in Children
Only in the past two decades has depression in
children been taken very seriously. The depressed child may
pretend to be sick, refuse to go to school, cling to a parent, or
worry that the parent may die. Older children may sulk, get
into trouble at school, be negative, grouchy, and feel
misunderstood. Because normal behaviors vary from one
childhood stage to another, it can be difficult to tell whether a
child is just going through a temporary "phase" or is
suffering from depression. Sometimes the parents become
worried about how the child's behavior has changed, or a teacher
mentions that "Johnny doesn't seem to be himself."
In such a case, if a visit to the child's pediatrician rules out
physical symptoms, the doctor will probably suggest that the child
be evaluated, preferably by a psychiatrist who specializes in the
treatment of children. If treatment is needed, the doctor
may suggest that another therapist, a social worker or a
psychologist, provide therapy while the psychiatrist will oversee
medication if it is needed. Parents should not be afraid to
ask questions: What are the therapist's qualifications?
What kind of therapy will the child have? Will the family as
a whole participate in therapy? Will my child's
therapy include an antidepressant? If so, what might the
side effects be?
The National Institute of Mental Health (NIMH) has
identified the use of medications for depression in children as an
important area to learn more about. The NIMH-supported
Research Units on Pediatric Psychopharmacology (RUPPs) form a
network of seven research sites where clinical studies on the
effects of medications for mental disorders can be conducted
in children and adolescents. Among the medications being
studied are antidepressants which can be effective in treating
children with depression, if properly monitored by the child's
The first step to getting appropriate treatment
for depression is a complete physical examination by a family
physician or internist. Certain medications as well as some
medical conditions such as a viral infection can cause the same
symptoms as depression, and the physician should rule out these
possibilities through examination, interview, and lab tests.
If a physical cause for the depression is ruled out, a
psychological evaluation should be done, usually by a psychiatrist
A good diagnostic evaluation will include a
complete history of symptoms, i.e., when they started, how long
they have lasted, how severe they are, whether the patient had
them before and, if so, whether the symptoms were treated and what
treatment was given. The doctor should ask about alcohol and drug
use, and if the patient has thoughts about death or suicide.
Further, a history should include questions about whether other
family members have had a depressive illness and, if treated, what
treatments they may have received and which were effective.
Last, a diagnostic evaluation should include a
mental status examination to determine if speech or thought
patterns or memory have been affected, as sometimes happens in the
case of a depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the
evaluation. There are a variety of antidepressant medications and
psychotherapies that can be used to treat depressive disorders.
Some people with milder forms may do well with psychotherapy
alone. People with moderate to severe depression often benefit
from antidepressants. Most do best with combined treatment:
medication to gain relatively quick symptom relief and
psychotherapy to learn more effective ways to deal with life's
problems, including depression. Depending on the patient's
diagnosis and severity of symptoms, the therapist may prescribe
medication and/or one of the several forms of psychotherapy that
have proven effective for depression.
Electroconvulsive therapy (ECT) is useful,
particularly for individuals whose depression is severe or life
threatening or who cannot take antidepressant medication. ECT
often is effective in cases where antidepressant medications do
not provide sufficient relief of symptoms. In recent years, ECT
has been much improved. A muscle relaxant is given before
treatment, which is done under brief anesthesia. Electrodes
that deliver electrical impulses are placed at precise locations
on the head to deliver electrical impulses. The stimulation
causes a brief (about 30 seconds) seizure within the brain.
The person receiving ECT does not consciously experience the
electrical stimulus. For full therapeutic benefit, at least
several sessions of ECT, typically given at the rate of three per
week, are required.
There are several types of antidepressant
medications used to treat depressive disorders. These include
newer medications--chiefly the selective serotonin reuptake
inhibitors (SSRIs)--the tricyclics, and the monoamine oxidase
inhibitors (MAOIs). The SSRIs--and other newer medications that
affect neurotransmitters such as dopamine or
norepinephrine--generally have fewer side effects than tricyclics.
Sometimes your doctor will try a variety of antidepressants before
finding the medication or combination of medications most
effective for you. Sometimes the dosage must be increased to be
effective. Antidepressant medications must be taken
regularly for as many as 8 weeks before the full therapeutic
Patients often are tempted to stop medication too
soon. They may feel better and think they no longer need the
medication. Or they may think the medication isn't helping
at all. It is important to keep taking medication until it
has a chance to work, though side effects may appear before
antidepressant activity does. Once the individual is feeling
better, it is important to continue the medication for 4 to 9
months to prevent a recurrence of the depression. Some
medications must be stopped gradually to give the body time to
adjust. For individuals with bipolar disorder or chronic major
depression, medication may have to be maintained indefinitely.
Antidepressant drugs are not habit-forming.
However, as is the case with any type of medication prescribed for
more than a few days, antidepressants have to be carefully
monitored to see if the correct dosage is being given. The
doctor will check the dosage and its effectiveness regularly.
For the small number of people for whom MAO
inhibitors are the best treatment, it is necessary to avoid
certain foods that contain high levels of tyramine, such as many
cheeses, wines, and pickles, as well as medications such as
decongestants. The interaction of tyramine with MAOIs can bring on
a hypertensive crisis, a sharp increase in blood pressure that can
lead to a stroke. The doctor should furnish a complete list of
prohibited foods that the patient should carry at all times. Other
forms of antidepressants require no food restrictions.
Medications of any kind--prescribed,
over-the counter, or borrowed--should never be mixed without
consulting the doctor. Other health professionals who may
prescribe a drug--such as a dentist or other medical
specialist--should be told that the patient is taking
antidepressants. Some drugs, although safe when taken alone can,
if taken with others, cause severe and dangerous side effects.
Some drugs, like alcohol or street drugs, may reduce the
effectiveness of antidepressants and should be avoided. This
includes wine, beer, and hard liquor. Some people who have
not had a problem with alcohol use may be permitted by their
doctor to use a modest amount of alcohol while taking one of the
Antianxiety drugs or sedatives are not
antidepressants. They are sometimes prescribed along with
antidepressants; however, they are not effective when taken alone
for a depressive disorder. Stimulants, such as amphetamines, are
not first-line antidepressants and share the habit-forming risks
of antianxiety medications and sleeping pills.
Questions about any antidepressant prescribed,
or problems that may be related to the medication, should be
discussed with the doctor.
Lithium has for many years been the treatment of
choice for bipolar disorder, as it can be effective in smoothing
out the mood swings common to this disorder. Its use must be
carefully monitored, as the range between an effective dose and a
toxic one is small. If a person has pre-existing
thyroid, kidney, or heart disorders or epilepsy, lithium may not
be recommended. Fortunately, other medications have been
found to be of benefit in controlling mood swings. Among
these are two mood-stabilizing anticonvulsants, carbamazepine
(Tegretol®) and valproate (Depakote®). Both of these
medications have gained wide acceptance in clinical practice, and
valproate has been approved by the Food and Drug Administration
for first-line treatment of acute mania. Other
anticonvulsants that are being used now include lamotrigine
(Lamictal®) and gabapentin (Neurontin®).
Most people who have bipolar disorder take more
than one medication including, along with lithium and/or an
anticonvulsant, a medication for accompanying agitation, anxiety,
or insomnia. Finding the best possible combination of these
medications is of utmost importance to the patient and requires
close monitoring by the physician.
Antidepressants may cause mild and, usually,
temporary side effects (sometimes referred to as adverse effects)
in some people. Typically these are annoying, but not serious.
However, any unusual reactions or side effects or those that
interfere with functioning should be reported to the doctor
immediately. The most common side effects of tricyclic
antidepressants, and ways to deal with them, are:
Dry mouth--it is helpful to drink lots
of water; chew sugarless gum; clean teeth daily.
Constipation--bran cereals, prunes,
fruit, and vegetables should be in the diet.
Bladder problems--emptying the bladder
may be troublesome, and the urine stream may not be as strong
as usual; the doctor should be notified if there is any pain.
Sexual problems--sexual functioning may
change; if worrisome, it should be discussed with the doctor.
Blurred vision--this will pass soon and
will not necessitate new glasses.
Dizziness--rising from the bed or chair
slowly is helpful.
Drowsiness as a daytime problem--this
usually passes soon. A person feeling drowsy or sedated
should not drive or operate heavy equipment. The more
sedating antidepressants are generally taken at bedtime to
help sleep and minimize daytime drowsiness.
The newer antidepressants have different types of
Headache--this will usually go away.
Nausea--even when it occurs, it is
transient after each dose.
Nervousness and insomnia (trouble falling
asleep or waking often during the night)--these may occur
during the first few weeks; dosage reductions or time will
usually resolve them.
Agitation (feeling jittery)--if this
happens for the first time after the drug is taken and is more
than transient, the doctor should be notified.
Sexual problems--the doctor should be
consulted if the problem is persistent or worrisome.
In the past few years, much interest has risen in
the use of herbs in the treatment of both depression and anxiety.
John's wort (Hypericum perforatum), an herb used
extensively in the treatment of mild to moderate depression in
Europe, has recently aroused interest in the United States.
St. John's wort, an attractive bushy, low-growing plant covered
with yellow flowers in summer, has been used for centuries in many
folk and herbal remedies. Today in Germany, Hypericum
is used in the treatment of depression more than any other
antidepressant. However, the scientific studies that have
been conducted on its use have been short-term and have used
several different doses.
Because of the widespread interest in St. John's
wort, the National Institutes of Health (NIH) is conducting a 3-year
study, sponsored by three NIH components--the National
Institute of Mental Health, the National Institute for
Complementary and Alternative Medicine, and the Office of Dietary
Supplements. The study is designed to include 336 patients
with major depression, randomly assigned to an 8-week trial with
one-third of patients receiving a uniform dose of St. John's wort,
another third receiving a selective serotonin reuptake inhibitor
(SSRI) commonly prescribed for depression, and the final third
receiving a placebo (a pill that looks exactly like the SSRI and
the St. John's wort, but has no active ingredients). The
study participants who respond positively will be followed for an
additional 18 weeks. After the 3-year study has been completed,
results will be analyzed and published.
Many forms of psychotherapy, including some
short-term (10-20 weeks) therapies, can help depressed
individuals. "Talking" therapies help patients gain
insight into and resolve their problems through verbal
"give-and-take" with the therapist.
"Behavioral" therapies help patients learn how to obtain
more satisfaction and rewards through their own actions and how to
unlearn the behavioral patterns that contribute to or result from
Two of the short-term psychotherapies that
research has shown helpful for some forms of depression are
interpersonal and cognitive/behavioral therapies. Interpersonal
therapists focus on the patient's disturbed personal relationships
that both cause and exacerbate (or increase) the depression.
Cognitive-behavioral therapists help patients change the negative
styles of thinking and behaving often associated with depression.
Psychodynamic therapies, which are sometimes used
to treat depressed persons, focus on resolving the patient's
internal conflicts. These therapies are often reserved until the
depressive symptoms are significantly improved. In general, severe
depressive illnesses, particularly those that are recurrent, will
require medication (or ECT under special conditions) along with,
or preceding, psychotherapy for the best outcome.
Depressive disorders make one feel exhausted,
worthless, helpless, and hopeless. Such negative thoughts and
feelings make some people feel like giving up. It is important to
realize that these negative views are part of the depression and
typically do not accurately reflect the situation. Negative
thinking fades as treatment begins to take effect. In the
Set realistic goals and assume a reasonable
amount of responsibility.
Break large tasks into small ones, set some
priorities, and do what you can as you can.
Try to be with other people and to confide in
someone; it is usually better than being alone and secretive.
Participate in activities that may make you
Mild exercise, going to a movie, a ballgame,
or participating in religious, social, or other activities may
Expect your mood to improve gradually, not
immediately. Feeling better takes time.
It is advisable to postpone important
decisions until the depression has lifted. Before
deciding to make a significant transition--change jobs, get
married or divorced--discuss it with others who know you well
and have a more objective view of your situation.
People rarely "snap out of" a
depression. But they can feel a little better day by
Remember, positive thinking will
replace the negative thinking that is part of the depression
and will disappear as your depression responds to treatment.
Let your family and friends help you.
How Family and Friends Can Help the Depressed
The most important thing anyone can do for the
depressed person is to help him or her get an appropriate
diagnosis and treatment. This may involve encouraging the
individual to stay with treatment until symptoms begin to abate
(several weeks), or to seek different treatment if no improvement
occurs. On occasion, it may require making an appointment and
accompanying the depressed person to the doctor. It may also mean
monitoring whether the depressed person is taking medication.
The depressed person should be encouraged to obey the doctor's
orders about the use of alcoholic products while on medication.
The second most important thing is to offer emotional support.
This involves understanding, patience, affection, and
encouragement. Engage the depressed person in conversation and
listen carefully. Do not disparage feelings expressed, but point
out realities and offer hope. Do not ignore remarks about suicide.
Report them to the depressed person's therapist. Invite the
depressed person for walks, outings, to the movies, and other
activities. Be gently insistent if your invitation is refused.
Encourage participation in some activities that once gave
pleasure, such as hobbies, sports, religious or cultural
activities, but do not push the depressed person to undertake too
much too soon. The depressed person needs diversion and company,
but too many demands can increase feelings of failure.
Do not accuse the depressed person of faking
illness or of laziness, or expect him or her "to snap out of
it." Eventually, with treatment, most depressed people do get
better. Keep that in mind, and keep reassuring the depressed
person that, with time and help, he or she will feel better.