Depression

The evidence that stressful life events cause depression is less that overwhelming.
In, general, research suggest some relationship between stress and depressive
symptoms (Kessler, 1997). Chronic workplace stress is related to the development
of depression (Tennant, 2001). Illness is another type of stress that shows
relationship to depression. Experiencing health problems produces stress both for
the sick person and for caregivers. Heart disease (Guck, Navan, Elsasser, & Barone,
2001), cancer (Livneh, 2000) AIDS (Fleishman & Fogel, 1994), and Alzheimers
disease (Rabins, 1989) have all been realted to increase incidence of depression.

Brannon, L. & Feist, J. (2004). Health psychology: An introduction to behavior and

health. 5th Edition. USA: Thomson Learning Inc.

What is depression?
Everyone occasionally feels blue or sad. But these feelings are usually short-lived
and pass within a couple of days. When you have depression, it interferes with daily
life and causes pain for both you and those who care about you. Depression is a
common but serious illness. Many people with a depressive illness never seek
treatment. But the majority, even those with the most severe depression, can get
better with treatment. Medications, psychotherapies, and other methods can
effectively treat people with depression.

What are the different forms of depression?

There are several forms of depressive disorders.
Major depressive disorder, or major depression, is characterized by a
combination of symptoms that interfere with a persons ability to work, sleep, study,
eat, and enjoy oncepleasurable activities. Major depression is disabling and
prevents a person from functioning normally. Some people may experience only a
single episode within their lifetime, but more often a person may have multiple
episodes.
Dysthymic disorder, or dysthymia, is characterized by long-term (2 years or
longer) symptoms that may not be severe enough to disable a person but can
prevent normal functioning or feeling well. People with dysthymia may also
experience one or more episodes of major depression during their lifetimes.

Minor depression is characterized by having symptoms for 2 weeks or longer that

do not meet full criteria for major depression. Without treatment, people with minor
depression are at high risk for developing major depressive disorder. Some forms of
depression are slightly different, or they may develop under unique circumstances.
However, not everyone agrees on how to characterize and define these forms of
depression. They include:

Psychotic depression, which occurs when a person has severe depression

plus some form of psychosis, such as having disturbing false beliefs or a
break with reality (delusions), or hearing or seeing upsetting things that
others cannot hear or see (hallucinations).
Postpartum depression, which is much more serious than the baby blues
that many women experience after giving birth, when hormonal and physical
changes and the new responsibility of caring for a newborn can be
overwhelming. It is estimated that 10 to 15 percent of women experience
postpartum depression after giving birth.
Seasonal affective disorder (SAD), which is characterized by the onset of
depression during the winter months, when there is less natural sunlight. The
depression generally lifts during spring and summer. SAD may be effectively
treated with light therapy, but nearly half of those with SAD do not get better
with light therapy alone. Antidepressant medication and psychotherapy can
reduce SAD symptoms, either alone or in combination with light therapy

What are the signs and symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The
severity, frequency, and duration of symptoms vary depending on the individual
and his or her particular illness.
SIGNS AND SYMPTOMS INCLUDE:

Persistent sad, anxious, or empty feelings

Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, 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
Aches or pains, headaches, cramps, or digestive problems that do not ease
even with treatment.

What causes depression?

Most likely, depression is caused by a combination of genetic, biological,
environmental, and psychological factors.
Depressive illnesses are disorders of the brain. Longstanding theories about
depression suggest that important neurotransmitterschemicals that brain cells
use to communicateare out of balance in depression. But it has been difficult to
prove this.
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, think-ing, sleep,
appetite, and behavior appear different. But these images do not reveal why the
depression has occurred. They also cannot be used to diagnose depression.
Some types of depression tend to run in families. However, depression can occur in
people without family histories of depression too.9 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.10 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.
(Research indicates that depressive illnesses are disorders of the brain.)

How is depression diagnosed and treated?

Depression, even the most severe cases, can be effectively treated. The earlier that
treatment can begin, the more effective it is.
The first step to getting appropriate treatment is to visit a doctor or mental health
specialist. Certain medications, and some medical conditions such as viruses or a
thyroid disorder, can cause the same symptoms as depression. A doctor can rule out
these possibilities by doing a physical exam, interview, and lab tests. If the doctor can
find no medical condition that may be causing the depression, the next step is a
psychological evaluation.
The doctor may refer you to a mental health professional, who should discuss with you
any family history of depression or other mental disorder, and get a complete history of
your symptoms. You should discuss when your symptoms started, how long they have
lasted, how severe they are, and whether they have occurred before and if so, how they
were treated. The mental health professional may also ask if you are using alcohol or
drugs, and if you are thinking about death or suicide.
Once diagnosed, a person with depression can be treated in several ways. The most
common treatments are medication and psychotherapy.

Medication

All antidepressants must be taken for at least 4 to 6 weeks before they have a full
effect. You should continue to take the medication, even if you are feeling better, to
prevent the depression from returning.
Medication should be stopped only under a doctors supervision. Some medications
need to be gradually stopped to give the body time to adjust. Although antidepressants
are not habit-forming or addictive, suddenly ending an antidepressant can cause
withdrawal symptoms or lead to a relapse of the depression. Some individuals, such as
those with chronic or recurrent depression, may need to stay on the medication
indefinitely.
In addition, if one medication does not work, you should consider trying another. NIMHfunded research has shown that people who did not get well after taking a first
medication increased their chances of beating the depression after they switched to a
different medication or added another medication to their existing one.28,29
Sometimes stimulants, anti-anxiety medications, or other medications are used together
with an antidepressant, especially if a person has a co-existing illness. However, neither
anti-anxiety medications nor stimulants are effective against depression when taken
alone, and both should be taken only under a doctors close supervision.
More information about mental health medications is avail-able on the NIMH website at
http://www.nimh.nih.gov/ health/publications/mental-health-medications/index.shtml.
(Report

any unusual side effects to a doctor immediately.)

(Children, adolescents, and young adults taking
antidepressants should be closely monitored.)
Psychotherapy

Several types of psychotherapyor talk therapycan help people with depression.

Two main types of psychotherapiescognitive-behavioral therapy (CBT) and
interpersonal therapy (IPT)are effective in treating depression. CBT helps people with
depression restructure negative thought patterns. Doing so helps people interpret their
environment and interactions with others in a positive and realistic way. It may also help
you recognize things that may be contributing to the depression and help you change
behaviors that may be making the depression worse. IPT helps people understand and
work through troubled relationships that may cause their depression or make it worse.
For mild to moderate depression, psychotherapy may be the best option. However, for
severe depression or for certain people, psychotherapy may not be enough. For teens, a
combination of medication and psychotherapy may be the most effective approach to
treating major depression and reducing the chances of it coming back.27 Another study
looking at depression treatment among older adults found that people who responded
to initial treatment of medication and IPT were less likely to have recurring depression if
they continued their combination treatment for at least 2 years.23

More information on psychotherapy is available on the NIMH website at

http://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml.

How can I help a loved one who is depressed?

If you know someone who is depressed, it affects you too. The most important thing you
can do is help your friend or relative get a diagnosis and treatment. You may need to
make an appointment and go with him or her to see the doctor. Encourage your loved
one to stay in treatment, or to seek different treatment if no improvement occurs after 6
to 8 weeks.

(2011). National Institute of Mental Health: Depression. USA: NIH Publication

Understanding depression
If you are depressed, you may feel that nothing can help.
But this is untrue. Most people recover from bouts of
depression, and some even look back on it as a useful
experience, which forced them to take stock of their lives
and make changes in their lifestyle.
What is depression?
We often use the expression I feel depressed when were feeling sad or miserable
about life. Usually, these feelings pass in due course. But, if the feelings are
interfering with your life and don't go away after a couple of weeks, or if they come
back, over and over again, for a few days at a time, it could be a sign that you're
depressed in the medical sense of the term.
In its mildest form, depression can mean just being in low spirits. It doesnt stop you
leading your normal life, but makes everything harder to do and seem less
worthwhile. At its most severe, major depression (clinical depression) can be lifethreatening, because it can make you feel suicidal or simply give up the will to live.
There are also some specific forms of depression:
Seasonal affective disorder (SAD) this is seasonal depression which is
related to day length. It usually comes on in the autumn and winter, when
days are short and the sun is low in the sky, and gets better as the days get
longer and brighter. (See Minds booklet Understanding seasonal affective
disorder.)
Postnatal depression many mothers have the baby blues soon after the
birth of their baby, but it usually passes after a day or two. Postnatal
depression is a much more serious problem and can occur any time between

two weeks and two years after the birth. (See Understanding postnatal
depression.)
Bipolar disorder (manic depression) some people have major mood swings,
when periods of depression alternate with periods of mania. When manic,
they are in a state of high excitement, and may plan and may try to carry out
over-ambitious schemes and ideas. They often then have periods of severe
depression. (See Understanding bipolar disorder.)

What are the symptoms of depression?

Am I depressed?

The following are all symptoms of depression, and if you tick off five or more of any
of them you are probably depressed.
My feelings
I am low-spirited for much of the time, every day
I feel restless and agitated
I get tearful easily
I feel numb, empty and full of despair
I feel isolated and unable to relate to other people
I am unusually irritable or impatient
I find no pleasure in life or things I usually enjoy
I feel helpless
I have lost interest in sex
I am experiencing a sense of unreality
My behaviour
Im not doing activities I usually enjoy
I am avoiding social events
I usually enjoy
I have cut myself off from others and cant ask for help
I am self-harming
I find it difficult to speak
My thoughts
I am having difficulty remembering things
I find it hard to concentrate or make decisions
I blame myself a lot and feel guilty about things
I have no self-confidence or self-esteem
I am having a lot of negative thoughts
The future seems bleak
Whats the point?
I have been thinking about suicide
My physical symptoms
I have difficulty sleeping
I am sleeping much more than usual

I
I
I
I
I
I

feel tired and have no energy

have lost my appetite, and am losing weight
am eating a lot more than usual and putting on weight
have physical aches and pains with no obvious physical cause
am moving very slowly
am using more tobacco, alcohol or other drugs than usual

What causes depression?

Depression varies very much from person to person and can happen for one or
more reasons. Occasionally it may appear for no obvious reason.

Life events
In many cases, the first time someone becomes depressed, it has been triggered by
an unwelcome or traumatic event, such as being sacked, divorced, or physically or
sexually assaulted.

Loss
Often events or experiences that trigger depression can also be seen as a loss of
some kind. It could be following the actual death of someone close, a major life
change (such as moving house or changing jobs), or simply moving from one phase
of life into another, e.g. as you reach retirement, children leave home, or you come
to realize that you may never have a family of your own.
Its not just the negative experience that causes the depression, but how we deal
with it. If the feelings provoked are not expressed or explored at the time, they
fester and contribute towards depression.

Anger
In some cases some people call depression frozen anger. You may have
experienced something which left you feeling angry and helpless, and if you were
unable to express your feelings at the time perhaps because you were a child, or
your feelings were unacceptable to others the anger becomes internalized and is
expressed as depression.

Childhood experiences
If you experienced a traumatic event in childhood, or were abused physically or
emotionally, or were not helped to learn good coping skills as you grew up, this can
leave you less able to cope with difficulties as an adult.

Physical conditions
The following conditions may cause depression, but are sometimes overlooked
because of the focus on their physical symptoms:
conditions affecting the brain and nervous system
hormonal problems, especially thyroid and parathyroid problems; symptoms
relating to the menstrual cycle or the menopause
low blood sugar
sleep problems.

If you think any of the above conditions apply to you, make sure your doctor knows
about them. Some of these problems can be diagnosed by simple blood tests, and
your doctor may suggest that these are done to help make the right diagnosis, or
you can ask for blood tests if you think they might be relevant for you.

Side effects of medication

Depression is a side effect of a lot of different medicines; for example, many people
become depressed after a heart attack, and this may be more likely if they are
taking beta blocker medicines as part of their treatment.
If you are feeling depressed after starting any kind of medication, its worth looking
at the patient information leaflet that came with the drug to see if depression is
listed among the side effects. If you think a drug is causing your depression, you
could mention this to your doctor and see if there is an alternative you could take,
especially if you are expecting the,treatment to last some time.

Diet

Poor diet and general lack of fitness can both contribute to depression.
In addition, anecdotal evidence suggests that occasionally people become very
depressed in response to some specific foods. Such a reaction is very individual, and
people are often not aware of the particular food substance or drink that is causing
the problem. But if you suddenly feel depressed for no apparent reason, it may be
worth considering whether you have eaten or drunk something new, and whether
this might have caused your sudden change of mood. If this is the cause, your mood
should lift very quickly, so long as you dont consume any more of the particular
item. (See the 'Food and mood' pages on the Mind website.)

Street drugs and alcohol

Although you may be very tempted to have a drink to cheer you up, alcohol is a
depressant, and will tend to make you feel worse overall. Some street drugs can
also make you depressed, especially if used repeatedly. (For more information, see
Understanding the mental health effects of street drugs.)

Genetics

Although no specific genes for depression have been identified, it does seem to run
in families to some extent, and some of us are more prone to depression than
others. This could also be because we learn behavior and ways of responding from
our relatives, as well as inheriting our genes from them.

Chemical changes in the brain

Because antidepressants work by changing brain chemistry, many people have

assumed that depression must be caused by changes in brain chemistry that are
then corrected by the drugs. Some doctors may tell you that you have a chemical
imbalance and need medication to correct it. But the evidence for this, apart from
the effects of medication, is very weak, and if changes to brain chemistry occur, we
dont know whether these are the result of the depression or its cause. Although
there are physical tests which are occasionally used in research on depression, they
are not very accurate or consistent, and there are none that are done routinely to
help make a diagnosis.

What treatments are available?

At a time when you may find making decisions difficult, it can also seem like an
added burden to try and choose between a range of treatment options.
The National Institute for Health and Clinical Excellence (NICE) guidelines on the
treatment of depression recommend:
active monitoring this is for mild depression and means keeping an eye on
you while waiting to see if your depression goes away without treatment,
which mild depression often does
cognitive behaviour therapy (CBT), including self-help books, computerized
CBT for mild depression; a series of sessions with a therapist for more severe
depression
mindfulness-based cognitive therapy
behavioural activation
other forms of talking treatment, such as counselling or interpersonal
psychotherapy.
medication for severe depression, but not for mild to moderate depression
unless other treatments have not helped. This should be combined with CBT
or psychotherapy
exercise.
Cognitive behaviour therapy (CBT) helps to identify and change negative
thoughts and feelings affecting your behaviour and, although often a short-term
treatment, may last up to 12 months. For mild depression you may be offered
computerised CBT, which uses a programme you can follow either by yourself or in
addition to sessions with a therapist.
Mindfulness-based cognitive therapy is an approach to wellbeing that involves
accepting life, and living and paying attention to the present moment. It includes
taking time to see what is happening around you in a non-judgmental way, rather
than going over your problems again and again. Mindfulness-based cognitive
therapy is usually done in groups.
Behavioural activation makes you look at the simple everyday tasks you may be
avoiding and start doing them. Activity helps you to feel better, and once you have
conquered some everyday tasks, you may feel ready to tackle some bigger ones.
For example, you may have felt too depressed to do the washing up and let it pile
up in the kitchen. The bigger the pile, the less you feel like doing it. Behavioural
activation would encourage you to tackle it, even if you start by only doing some of
it. As you do it, the dishes get clean, your kitchen gets tidier, and you feel a bit
better about everything. Behavioural activation usually forms part of a CBT
programme, but may be offered on its own.
Guided self-help delivers a 6-8 week therapy programme through selfhelp books,
under the guidance of a healthcare professional.
Interpersonal psychotherapy focuses on relationships. Therapy can continue for
6 to 12 months.

Counselling, which can be short- or long-term. This involves talking with someone
who is trained to listen with empathy and acceptance. It allows you to express your
feelings and helps you to find your own solutions to your problems.
Psychodynamic counselling and psychotherapy focus on how past experiences
may be contributing to experiences and feelings in the present. Therapy can be
short- or long-term. It may be more frequent and intensive than counselling, and
may go deeply into childhood experience and significant relationships. It may not be
available on the NHS.
Group therapy allows a group of people to work together on their problems, with a
therapist. You may find it easier to talk with others who have similar experiences,
and that the insights of others help you to understand yourself better; you may also
learn about relationships with others.

Medication

Antidepressants
Antidepressant drugs work on brain chemicals (such as serotonin and
noradrenaline) to lift your mood. It often takes between two to six weeks before the
drugs take effect. They dont cure depression, but they can make you feel better so
that you may feel able to take action to deal with the problems causing your
depression.
The NICE guidelines suggest that, for mild depression, antidepressants are not
appropriate because the risk of side effects outweighs the chance of benefit, but
they are recommended for severe depression, or moderate depression that has
gone on for a long time.
If you do take antidepressants, the usual recommendation is that you stay on them
for six months after you feel better in order to stop the depression coming back.
Many people find them helpful, although they dont work for everyone.
Antidepressants can cause unpleasant side effects, some of which are worse to
begin with. Some can be dangerous when used with other drugs. Of the various
types available, SSRIs (selective serotonin reuptake inhibitors, such as Cipramil or
Prozac) are usually the preferred first choice because, they are usually better
tolerated than some of the other antidepressants. But if these do not suit you for
any reason, there are other types to try, which work in slightly different ways (see
Making sense of antidepressants).
Other medication
If you are having psychotic symptoms (see p.6), your GP may refer you to a
psychiatrist who may prescribe an antipsychotic drug, such as quetiapine
(Seroquel). (See Making sense of antipsychotics for more information).

Exercise

Although exercise is something you can do for yourself (see pp.10-11), it is also
recommended as a treatment for depression in the NICE guidelines, and some GPs

will give you a prescription for exercise, referring you to a programme at a local
gym or health centre.
Darton, K. (2014). Understanding depression. London: Mind

What is depression?
Depression is a common mental disorder that presents with depressed mood,
loss of interest or pleasure, decreased energy, feelings of guilt or low selfworth, disturbed sleep or appetite, and poor concentration. Moreover,
depression often comes with symptoms of anxiety. These problems can
become chronic or recurrent and lead to substantial impairments in an
individuals ability to take care of his or her everyday responsibilities. At its
worst, depression can lead to suicide. Almost 1 million lives are lost yearly
due to suicide, which translates to 3000 suicide deaths every day. For every
person who completes a suicide, 20 or more may attempt to end his or her
life (WHO, 2012).
There are multiple variations of depression that a person can suffer from,
with the most general distinction being depression in people who have or do
not have a history of manic episodes.

Depressive episode involves symptoms such as depressed mood, loss

of interest and enjoyment, and increased fatigability. Depending on the
number and severity of symptoms, a depressive episode can be
categorized as mild, moderate, or severe. An individual with a mild
depressive episode will have some difficulty in continuing with ordinary
work and social activities, but will probably not cease to function
completely. During a severe depressive episode, on the other hand, it
is very unlikely that the sufferer will be able to continue with social,
work, or domestic activities, except to a very limited extent.
Bipolar affective disorder typically consists of both manic and
depressive episodes separated by periods of normal mood. Manic
episodes involve elevated mood and increased energy, resulting in
over-activity, pressure of speech and decreased need for sleep.

While depression is the leading cause of disability for both males and
females, the burden of depression is 50% higher for females than males
(WHO,
2008). In fact, depression is the leading cause of disease burden for women
in both high-income and low- and middle-income countries (WHO, 2008).
Research in developing countries suggests that maternal depression may be
a risk factor for poor growth in young children (Rahman et al, 2008). This risk
factor could mean that maternal mental health in low-income countries may
have a substantial influence on growth during childhood, with the effects of
depression affecting not only this generation but also the next.

Conclusion
Depression is a mental disorder that is pervasive in the world and affects us
all. Unlike many largescale international problems, a solution for depression
is at hand. Efficacious and cost-effective treatments are available to improve
the health and the lives of the millions of people around the world suffering
from depression. On an individual, community, and national level, it is time
to educate ourselves about depression and support those who are suffering
from this mental disorder.
Marcus. M. et. al. (2012). Depression: A global public health concern.