Attention Deficit Hyperactivity Disorder (ADD/ADHD)
Coping with Chronic Illness
Child Behavior Disorders
Children Mental Health
Post-Traumatic Stress Disorder
Seasonal Affective Disorder
What Is Depression?
Everyone occasionally feels blue or sad, but these feelings
are usually fleeting and pass within a couple of days.
When a person has a depressive disorder, it interferes
with daily life, normal functioning, and causes pain for
both the person with the disorder and those who care about
him or her. Depression is a common but serious illness,
and most who experience it need treatment to get better.
Many people with a depressive illness never seek treatment.
But the vast majority, even those with the most severe depression,
can get better with treatment. Intensive research into the
illness has resulted in the development of medications, psychotherapies,
and other methods to treat people with this disabling disorder.
What are the different forms of depression?
There are several forms of depressive disorders. The most
common are major depressive disorder and dysthymic disorder.
Major depressive disorder, also called
major depression, is characterized by a combination of
symptoms that interfere with a person's ability to work,
sleep, study, eat, and enjoy once–pleasurable activities. Major
depression is disabling and prevents a person from functioning normally. An
episode of major depression may occur only once in a person's lifetime, but
more often, it recurs throughout a person's life.
also called dysthymia, is characterized by long–term
(two years or longer) but less severe symptoms that may not
disable a person but can prevent one from functioning normally
or feeling well. People with dysthymia may also experience
one or more episodes of major depression during their lifetimes.
Some forms of depressive disorder exhibit slightly different
characteristics than those described above, or they may develop
under unique circumstances. However, not all scientists agree
on how to characterize and define these forms of depression.
Psychotic depression, which occurs when
a severe depressive illness is accompanied by some form of
psychosis, such as a break with reality, hallucinations,
Postpartum depression, which is diagnosed
if a new mother develops a major depressive episode within
one month after delivery. It is estimated that 10 to 15 percent
of women experience postpartum depression after giving birth.1
Seasonal affective disorder (SAD), which
is characterized by the onset of a depressive illness 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 respond to light therapy alone. Antidepressant medication and
psychotherapy can reduce SAD symptoms, either alone or in combination with
Bipolar disorder, also called manic-depressive illness, is
not as common as major depression or dysthymia. Bipolar disorder
is characterized by cycling mood changes-from extreme highs
(e.g., mania) to extreme lows (e.g., depression). Visit the
NIMH website for more information about bipolar
What are the symptoms of depression?
People with depressive illnesses do not all experience the
same symptoms. The severity, frequency and duration of symptoms
will vary depending on the individual and his or her particular
illness. Symptoms include:
- Persistent sad, anxious
or "empty" feelings
- Feelings of hopelessness and/or pessimism
- Feelings of guilt, worthlessness and/or helplessness
- Irritability, restlessness
- Loss of interest in activities or hobbies once pleasurable,
- Fatigue and decreased energy
- Difficulty concentrating, remembering details and making
- Insomnia, early–morning
wakefulness, or excessive sleeping
- Overeating, or appetite loss
- Thoughts of suicide, suicide attempts
- Persistent aches or pains, headaches, cramps or digestive
problems that do not ease even with treatment
What illnesses often co-exist with depression?
often co–exists with other illnesses. Such
illnesses may precede the depression, cause it, and/or be
a consequence of it. It is likely that the mechanics behind
the intersection of depression and other illnesses differ
for every person and situation. Regardless, these other co–occurring
illnesses need to be diagnosed and treated.
such as post–traumatic stress disorder
(PTSD), obsessive–compulsive disorder, panic disorder,
social phobia and generalized anxiety disorder, often accompany
depression.3,4 People experiencing PTSD are especially prone
to having co-occurring depression. PTSD is a debilitating
condition that can result after a person experiences a terrifying
event or ordeal, such as a violent assault, a natural disaster,
an accident, terrorism or military combat.
People with PTSD
often re–live the traumatic event
in flashbacks, memories or nightmares. Other symptoms include
irritability, anger outbursts, intense guilt, and avoidance
of thinking or talking about the traumatic ordeal. In a National
Institute of Mental Health (NIMH)–funded study, researchers
found that more than 40 percent of people with PTSD also
had depression at one-month and four-month intervals after
the traumatic event.5
Alcohol and other substance
abuse or dependence may also co–occur with depression. In fact,
research has indicated that the co–existence of mood
disorders and substance abuse is pervasive among the U.S.
Depression also often co–exists with
other serious medical illnesses such as heart disease, stroke,
cancer, hiv/aids, diabetes, and Parkinson's disease. Studies
have shown that people who have depression in addition to
another serious medical illness tend to have more severe
symptoms of both depression and the medical illness, more
difficulty adapting to their medical condition, and more
medical costs than those who do not have co–existing
depression.7 Research has yielded increasing evidence that
treating the depression can also help improve the outcome
of treating the co–occurring illness.8
What causes depression?
There is no single
known cause of depression. Rather, it likely results from
a combination of genetic, biochemical, environmental, and
Research indicates that depressive
illnesses are disorders of the brain. 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
responsible for regulating mood, thinking, sleep, appetite
and behavior appear to function abnormally. In addition,
that brain cells use to communicate–appear to be out
of balance. But these images do not reveal why the depression
Some types of depression tend to
run in families, suggesting a genetic link. However, depression
can occur in people without family histories of depression
as well.9 Genetics research indicates that risk for depression
results from the influence of multiple 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. Subsequent depressive
episodes may occur with or without an obvious trigger.
How do women experience depression?
is more common among women than among men. Biological, life
cycle, hormonal and psychosocial factors unique to women
may be linked to women's higher depression rate. Researchers
have shown that hormones directly affect brain chemistry
that controls emotions and mood. For example, women are particularly
vulnerable to depression after giving birth, when hormonal
and physical changes, along with the new responsibility of
caring for a newborn, can be overwhelming. Many new mothers
experience a brief episode of the "baby blues," but
some will develop postpartum depression, a much more serious
condition that requires active treatment and emotional support
for the new mother. Some studies suggest that women who experience
postpartum depression often have had prior depressive episodes.
women may also be susceptible to a severe form of premenstrual
syndrome (PMS), sometimes called premenstrual dysphoric disorder
(PMDD), a condition resulting from the hormonal changes that
typically occur around ovulation and before menstruation
begins. During the transition into menopause, some women
experience an increased risk for depression. Scientists are
exploring how the cyclical rise and fall of estrogen and
other hormones may affect the brain chemistry that is associated
with depressive illness.11
Finally, many women face the additional
stresses of work and home responsibilities, caring for children
and aging parents, abuse, poverty, and relationship strains.
It remains unclear why some women faced with enormous challenges
develop depression, while others with similar challenges
How do men experience depression?
experience depression differently than women and may have
different ways of coping with the symptoms. Men are more
likely to acknowledge having fatigue, irritability, loss
of interest in once–pleasurable activities, and
sleep disturbances, whereas women are more likely to admit
to feelings of sadness, worthlessness and/or excessive guilt.12,13
Men are more likely than women to turn to alcohol or drugs
when they are depressed, or become frustrated, discouraged,
irritable, angry and sometimes abusive. Some men throw themselves
into their work to avoid talking about their depression with
family or friends, or engage in reckless, risky behavior.
And even though more women attempt suicide, many more men
die by suicide in the United States.14
How do older adults experience depression?
is not a normal part of aging, and studies show that most
seniors feel satisfied with their lives, despite increased
physical ailments. However, when older adults do have depression,
it may be overlooked because seniors may show different,
less obvious symptoms, and may be less inclined to experience
or acknowledge feelings of sadness or grief.15
older adults may have more medical conditions such as heart
disease, stroke or cancer, which may cause depressive symptoms,
or they may be taking medications with side effects that
contribute to depression. Some older adults may experience
what some doctors call vascular depression, also called arteriosclerotic
depression or subcortical ischemic depression. Vascular depression
may result when blood vessels become less flexible and harden
over time, becoming constricted. Such hardening of vessels
prevents normal blood flow to the body's organs, including
the brain. Those with vascular depression may have, or be
at risk for, a co–existing cardiovascular
illness or stroke.16
Although many people assume that the
highest rates of suicide are among the young, older white
males age 85 and older actually have the highest suicide
rate. Many have a depressive illness that their doctors may
not detect, despite the fact that these suicide victims often
visit their doctors within one month of their deaths.17
majority of older adults with depression improve when they
receive treatment with an antidepressant, psychotherapy,
or a combination of both.18 Research has shown that medication
alone and combination treatment are both effective in reducing
the rate of depressive recurrences in older adults.19 Psychotherapy
alone also can be effective in prolonging periods free of
depression, especially for older adults with minor depression,
and it is particularly useful for those who are unable or
unwilling to take antidepressant medication.20, 21
How do children and adolescents experience depression?
and doctors have begun to take seriously the risk of depression
in children. Research has shown that childhood depression
often persists, recurs and continues into adulthood, especially
if it goes untreated. The presence of childhood depression
also tends to be a predictor of more severe illnesses in
A child with depression may pretend to be sick,
refuse to go to school, cling to a parent, or worry that
a parent may die. Older children may sulk, get into trouble
at school, be negative and irritable, and feel misunderstood.
Because these signs may be viewed as normal mood swings typical
of children as they move through developmental stages, it
may be difficult to accurately diagnose a young person with
Before puberty, boys and girls are equally likely
to develop depressive disorders. By age 15, however, girls
are twice as likely as boys to have experienced a major depressive
Depression in adolescence
comes at a time of great personal change–when boys and girls are forming an
identity distinct from their parents, grappling with gender
issues and emerging sexuality, and making decisions for the
first time in their lives. Depression in adolescence frequently
co–occurs with other disorders such as anxiety, disruptive
behavior, eating disorders or substance abuse. It can also
lead to increased risk for suicide. 22, 24
clinical trial of 439 adolescents with major depression found
that a combination of medication and psychotherapy was the
most effective treatment option.25 Other NIMH–funded
researchers are developing and testing ways to prevent suicide
in children and adolescents, including early diagnosis and
treatment, and a better understanding of suicidal thinking.
How is depression detected and treated?
Depression, even the most severe cases, is a highly treatable
disorder. As with many illnesses, the earlier that treatment
can begin, the more effective it is and the greater the likelihood
that recurrence can be prevented.
The first step to getting
appropriate treatment is to visit a doctor. 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 conducting a
physical examination, interview and lab tests. If the doctor
can eliminate a medical condition as a cause, he or she
should conduct a psychological evaluation or refer the
patient to a mental health professional.
The doctor or mental
health professional will conduct a complete diagnostic evaluation.
He or she should discuss any family history of depression,
and get a complete history of symptoms, e.g., when they started,
how long they have lasted, their severity, and whether they
have occurred before and if so, how they were treated. He
or she should also ask if the patient is using alcohol or
drugs, and whether the patient is thinking about death or
Once diagnosed, a person with depression can be treated
with a number of methods. The most common treatments are
medication and psychotherapy.
work to normalize naturally occurring brain chemicals called
neurotransmitters, notably serotonin and norepinephrine.
Other antidepressants work on the neurotransmitter dopamine.
Scientists studying depression have found that these particular
chemicals are involved in regulating mood, but they are unsure
of the exact ways in which they work.
The newest and most
popular types of antidepressant medications are called selective
serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine
(Prozac), citalopram (Celexa), sertraline (Zoloft) and several
others. Serotonin and norepinephrine reuptake inhibitors
(SNRIs) are similar to SSRIs and include venlafaxine (Effexor)
and duloxetine (Cymbalta). SSRIs and SNRIs are more popular
than the older classes of antidepressants, such as tricyclics–named
for their chemical structure–and
monoamine oxidase inhibitors (MAOIs) because they tend to
have fewer side effects. However, medications affect everyone
approach to medication exists. Therefore, for some people,
tricyclics or MAOIs may be the best choice.
MAOIs must adhere to significant food and medicinal restrictions
to avoid potentially serious interactions. They must avoid
certain foods that contain high levels of the chemical tyramine,
which is found in many cheeses, wines and pickles, and some
medications including decongestants. MAOIs interact with
tyramine in such a way that may cause a sharp increase in
blood pressure, which could lead to a stroke. A doctor should
give a patient taking an MAOI a complete list of prohibited
foods, medicines and substances.
For all classes of antidepressants,
patients must take regular doses for at least three to four
weeks before they are likely to experience a full therapeutic
effect. They should continue taking the medication for the
time specified by their doctor, even if they are feeling
better, in order to prevent a relapse of the depression.
Medication should be stopped only under a doctor's supervision.
Some medications need to be gradually stopped to give the
body time to adjust. Although antidepressants are not habit–forming
or addictive, abruptly ending an antidepressant can cause
withdrawal symptoms or lead to a relapse. 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, patients should be open to trying
another. NIMH–funded research has
shown that patients who did not get well after taking a first
medication increased their chances of becoming symptom–free
after they switched to a different medication or added another
medication to their existing one. 26,27
anti–anxiety medications, or
other medications are used in conjunction with an antidepressant,
especially if the patient has a co–existing mental
or physical disorder. However, neither anti–anxiety
medications nor stimulants are effective against depression
when taken alone, and both should be taken only under a doctor's
What are the side effects of antidepressants?
may cause mild and often temporary side effects in some people,
but they are usually not long–term.
However, any unusual reactions or side effects that interfere
with normal functioning should be reported to a doctor immediately.
The most common side effects associated with SSRIs and SNRIs
- Headache–usually temporary
and will subside.
- Nausea–temporary and usually short–lived.
- Insomnia and nervousness
(trouble falling asleep or waking often during the night)–may
occur during the first few weeks but often subside over
time or if the dose is reduced.
- Agitation (feeling jittery).
- Sexual problems–both
men and women can experience sexual problems including
reduced sex drive, erectile dysfunction, delayed ejaculation,
or inability to have an orgasm.
Tricyclic antidepressants also can cause side effects including:
- Dry mouth-it is helpful to drink plenty of water, chew
gum, and clean teeth daily.
- Constipation-it is helpful to eat more bran cereals,
prunes, fruits, and vegetables.
- Bladder problems–emptying
the bladder may be difficult, and the urine stream may
not be as strong as usual. Older men with enlarged prostate
conditions may be more affected. The doctor should be
notified if it is painful to urinate.
- Sexual problems–sexual
functioning may change, and side effects are similar
to those from SSRIs.
- Blurred vision–often
passes soon and usually will not require a new corrective
- Drowsiness during the day–usually
passes soon, but driving or operating heavy machinery
should be avoided while drowsiness occurs. The more sedating
antidepressants are generally taken at bedtime to help
sleep and minimize daytime drowsiness.
FDA Warning on antidepressants
Despite the relative safety and popularity of SSRIs and
other antidepressants, some studies have suggested that they
may have unintentional effects on some people, especially
adolescents and young adults. In 2004, the Food and Drug
Administration (FDA) conducted a thorough review of published
and unpublished controlled clinical trials of antidepressants
that involved nearly 4,400 children and adolescents. The
review revealed that 4% of those taking antidepressants
thought about or attempted suicide (although no suicides
occurred), compared to 2% of those receiving placebos.
information prompted the FDA, in 2005, to adopt a "black
box" warning label on all antidepressant medications
to alert the public about the potential increased risk of
suicidal thinking or attempts in children and adolescents
taking antidepressants. In 2007, the FDA proposed that makers
of all antidepressant medications extend the warning to include
young adults up through age 24. A "black box" warning
is the most serious type of warning on prescription drug
The warning emphasizes that children, adolescents
and young adults taking antidepressants should be closely
monitored, especially during the initial weeks of treatment.
Possible side effects to look for are worsening depression,
suicidal thinking or behavior, or any unusual changes in
behavior such as sleeplessness, agitation, or withdrawal
from normal social situations.
Results of a comprehensive
review of pediatric trials conducted between 1988 and 2006
suggested that the benefits of antidepressant medications
likely outweigh their risks to children and adolescents with
major depression and anxiety disorders.28 The study was funded
in part by the National Institute of Mental Health.
What about St. John's wort?
from St. John's wort (Hypericum perforatum), a bushy, wild-growing
plant with yellow flowers, has been used for centuries in
many folk and herbal remedies. Today in Europe, it is used
extensively to treat mild to moderate depression. In the
United States, it is one of the top–selling
To address increasing American
interests in St. John's wort, the National Institutes of
Health conducted a clinical trial to determine the effectiveness
of the herb in treating adults who have major depression.
Involving 340 patients diagnosed with major depression,
trial randomly assigned one-third of them to a uniform dose
of St. John's wort, one–third to a commonly prescribed
SSRI, and one–third to a placebo. The trial found that
St. John's wort was no more effective than the placebo in
treating major depression.29 Another study is looking at
the effectiveness of St. John's wort for treating mild or
Other research has shown that St. John's
wort can interact unfavorably with other medications, including
those used to control HIV infection. On February 10, 2000,
the FDA issued a Public Health Advisory letter stating that
the herb appears to interfere with certain medications used
to treat heart disease, depression, seizures, certain cancers,
and organ transplant rejection. The herb also may interfere
with the effectiveness of oral contraceptives. Because of
these potential interactions, patients should always consult
with their doctors before taking any herbal supplement.
Several types of psychotherapy–or "talk therapy"–can
help people with depression.
Some regimens are short–term
(10 to 20 weeks) and other regimens are longer–term,
depending on the needs of the individual. Two main types
therapy (CBT) and interpersonal therapy (IPT)-have been shown
to be effective in treating depression. By teaching new ways
of thinking and behaving, CBT helps people change negative
styles of thinking and behaving that may contribute to their
depression. IPT helps people understand and work through
troubled personal relationships that may cause their depression
or make it worse.
For mild to moderate depression, psychotherapy
may be the best treatment option. However, for major depression
or for certain people, psychotherapy may not be enough. Studies
have indicated that for adolescents, a combination of medication
and psychotherapy may be the most effective approach to treating
major depression and reducing the likelihood for recurrence.25
Similarly, a study examining depression treatment among older
adults found that patients 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 two years.21
For cases in which
medication and/or psychotherapy does not help alleviate a
person's treatment–resistant depression,
electroconvulsive therapy (ECT) may be useful. ECT, formerly
known as "shock therapy," once had a bad reputation.
But in recent years, it has greatly improved and can provide
relief for people with severe depression who have not been
able to feel better with other treatments.
Before ECT is administered,
a patient takes a muscle relaxant and is put under brief
anesthesia. He or she does not consciously feel the electrical
impulse administered in ECT. A patient typically will undergo
ECT several times a week, and often will need to take an
antidepressant or mood stabilizing medication to supplement
the ECT treatments and prevent relapse. Although some patients
will need only a few courses of ECT, others may need maintenance
ECT, usually once a week at first, then gradually decreasing
to monthly treatments for up to one year.
ECT may cause some
short-term side effects, including confusion, disorientation
and memory loss. But these side effects typically clear soon
after treatment. Research has indicated that after one year
of ECT treatments, patients showed no adverse cognitive effects.30
How can I help a friend or relative who is depressed?
you know someone who is depressed, it affects you too. The
first and most important thing you can do to help a friend
or relative who has depression is to help him or her get
an appropriate diagnosis and treatment. You may need to make
an appointment on behalf of your friend or relative and go
with him or her to see the doctor. Encourage him or her to
stay in treatment, or to seek different treatment if no improvement
occurs after six to eight weeks.
To help a friend or relative:
- Offer emotional support, understanding, patience and
- Engage your friend or relative in conversation, and listen
- Never disparage feelings your friend or relative expresses,
but point out realities and offer hope.
- Never ignore comments about suicide, and report them
to your friend's or relative's therapist or doctor.
- Invite your friend or relative out for walks, outings
and other activities. Keep trying if he or she declines,
but don't push him or her to take on too much too soon.
Although diversions and company are needed, too many demands
may increase feelings of failure.
- Remind your friend or relative that with time and treatment,
the depression will lift.
How can I help myself if I am depressed?
you have depression, you may feel exhausted, helpless and
hopeless. It may be extremely difficult to take any action
to help yourself. But it is important to realize that these
feelings are part of the depression and do not accurately
reflect actual circumstances. As you begin to recognize your
depression and begin treatment, negative thinking will fade.
- Engage in mild activity or exercise. Go to a movie, a
ballgame, or another event or activity that you once enjoyed.
Participate in religious, social or other activities.
- 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.
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
- 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.
Where can I go for help?
If you are unsure
where to go for help, ask your family doctor. Others who
can help are listed below.
Mental Health Resources:
- Mental health specialists, such as psychiatrists, psychologists,
social workers, or mental health counselors
- Health maintenance organizations
- Community mental health centers
- Hospital psychiatry departments and outpatient clinics
- Mental health programs at universities or medical schools
- State hospital outpatient clinics
- Family services, social agencies or clergy
- Peer support groups
- Private clinics and facilities
- Employee assistance programs
- Local medical and/or psychiatric societies
- You can also check the phone
book under "mental
health," "health," "social services," "hotlines," or "physicians" for
phone numbers and addresses. An emergency room doctor also
can provide temporary help and can tell you where and how
to get further help.
What if I or someone I know is in crisis?
you are thinking about harming yourself, or know someone
who is, tell someone who can help immediately.
- Call your doctor.
- Call 911 or go to a hospital emergency room to get immediate
help or ask a friend or family member to help you do these
- Call the toll-free, 24-hour hotline of the National Suicide
Prevention Lifeline at 1-800-273-TALK (1-800-273-8255);
TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
- Make sure you or the suicidal person is not left alone.
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