What You Need To Know About This Medical Illness 

Like diabetes and heart disease, major depression is a serious medical illness, and it is quite common. Psychological, biological, environmental, and genetic factors contribute to its development. 

For many years, people suffering from depression and their families were blamed and stigmatized for their illness, partly because their illness was so poorly understood. During the last decade, however, scientific research has greatly expanded our understanding and firmly established that mental illnesses like major depression are biologically based brain diseases. 

Major depression affects about 9.9 million people in the United States alone in any six-month period. Nearly twice as many women (6.7 million) as men (3.2 million) suffer from major depression each year. More than half of those who experience a single episode of depression will go on to have episodes that occur as frequently as once or even twice a year. And without treatment the frequency of illness as well as the severity of symptoms tend to increase over time. 

Major depression is also known as major depressive illness, clinical depression, major affective disorder, or unipolar disorder. It involves periodic disturbances in mood, concentration, sleep, activity, appetite, and social behavior. Left untreated, it can lead to suicide, which is the eighth leading cause of death in the United States. Devastating as this disease may be, it is treatable. The availability of effective treatments and a better understanding of the biological basis for depression may lessen the stigma that can prevent early detection, accurate diagnosis, and the decision to seek medical treatment. 

Unfortunately, many cases of major depression go unrecognized and untreated. This web page is intended to answer your questions about depression and give you valuable, accurate information about this illness and how it is treated. You may need this information because you suspect you yourself have depression, or you may want to become knowledgeable because a family member or friend has the disorder. 

Major depression is only one form of depressive illness. Bipolar disorder-or manic-depressive illness-is another form, and it is characterized by symptoms such as mood swings, loss of sleep, extreme "highs," increased energy and activity, increased risk-taking and poor judgment, feelings of great pleasure or irritability, aggressiveness, and racing, disconnected thoughts as well as "low" periods very similar to those experienced by individuals with depressive illness.

What Is Major Depression? 

Major depression is a brain disorder that is much more than temporarily feeling sad or blue. It is a serious medical illness that affects one's thoughts, feelings, behavior, mood, and physical health. Major depression is the leading cause of disability in the U.S. and many other developed countries. 

Major depression can occur at any age - including childhood, adolescence, adulthood, and late adulthood. Some individuals may only have one episode of depression in a lifetime, but more often people have recurrent episodes. More than half of those who experience a first episode of depression will have at least one other episode in their lives. Some people may have several episodes in the course of a year, and others may have ongoing chronic symptoms. If untreated, episodes commonly last anywhere from six months to a year. 

The outward behavior of the person with depression often remains relatively stable-people with depression rarely behave in bizarre ways, almost never experience hallucinations, and only rarely experience delusions. The behavior of the depressed individual-although quite worrisome to family members and friends and even to him or herself-rarely disrupts the lives of others to the extent some other serious mental illnesses do. Depression may not appear to be a life-threatening illness, yet researchers believe that more than 60 percent of the people who succeed in committing suicide were suffering from depression. 

Major depression is an "affective disorder," which means there are changes in mood. The term affect refers to one's mood or spirits. The normal human emotion we sometimes call "depression" is a common response to a loss, failure, or disappointment. This booklet discusses a serious biological disease known as major depression, which-with a correct medical diagnosis-can typically be treated effectively and relatively quickly But because biological depression is frequently a life-long condition in which periods of wellness alternate with recurrences of illness, it may require long-term treatment to keep it under control just as any other chronic medical illness, such as diabetes, does. 

There is a somewhat milder form of affective disorder known as dysthymia, which is a chronic and persistent disturbance in mood that lasts for at least two years and is characterized by relatively typical depressive symptoms. Persons with dysthymia are chronically unhappy, and sometimes they develop the more severe major depressive syndrome. When the major depressive episode clears, they return to their chronic state of dysthymia. The coexistence of the milder and more severe forms of depression is referred to as double depression. 

Use of alcohol-a central nervous system depressant-can be a serious complication for depressed individuals who use it to try to medicate themselves. Alcohol is especially dangerous for those with high levels of anxiety along with their other depressive symptoms. Too much alcohol or the use of illicit drugs-can cause or complicate a major depressive episode and lead to multiple psychiatric problems. All alcohol should be avoided during treatment for depression for several reasons. First, after its initial anti-anxiety effect, alcohol will produce increased feelings of depression. Second, in combination with many antidepressants, alcohol can make the drugs' side effects much worse, even dangerous. Third, the fact that alcohol releases inhibitions increases the risk of suicide. 

What Are the Symptoms? 

The onset of the first episode of major depression may not be obvious if it is brief or mild. Unrecognized or left untreated, however, it may recur with greater seriousness or progress to a syndrome that includes a profoundly sad or irritable mood lasting at least two weeks and accompanied by pronounced changes in sleep, appetite, energy, ability to concentrate and remember, a lack of interest in usual activities, and in a decreased ability to experience pleasure. Frequently, there are feelings of hopelessness, worthlessness, sadness, emptiness, or guilt. Very depressed persons cannot respond to the positive events or things in their lives. A depressive episode may develop gradually or affect a person quite suddenly, and it frequently is unrelated to current events in the person's life. 

The symptoms of clinical depression characteristically represent a significant change in how a person functioned before the illness. Often when all of these symptoms coexist at a severe level for a long time, individuals become so discouraged and hopeless that death seems preferable to life. These feelings can lead to passive suicidal wishes, suicidal plans, and even attempted and completed suicide. 
 
Changes in sleep

The changes in sleep can go in either direction. Typically, depressed individuals have difficulty falling asleep, wake throughout the night, and awaken an hour to several hours earlier than desired in the morning. But at least 20 percent of individuals experiencing depression sleep more than the usual amount. In all cases, individuals awaken without feeling rested. 

Changes in appetite

Most patients in a clinical depression experience a decrease in appetite and weight loss that is occasionally considerable; however, a substantial proportion will experience an increased desire to eat and will gain weight. Most of these people will still report that the food they are eating does not actually appeal to them. 

Impaired concentration and decision-making

The inability to concentrate and make decisions experienced by depressed individuals can be the most frightening aspect of the disorder. In the midst of a severe depression, individuals may find that they cannot follow the thread of a simple newspaper article or the story line of a half-hour comedy on television. Major decision-making is impossible. Even minor decisions such as which dress to wear or which brand of toothpaste to buy can seem overwhelming. This often leads depressed individuals to feel as though they are literally losing their minds. 

Loss of energy 

Equally distressing to a depressed person is the loss of energy and profound fatigue experienced by both those who sleep more and those who sleep less during their episodes. Mental speed and activity are usually lowered, as is the ability to perform normal daily routines. Ideas are fewer; there is a poverty of thought; and responses to the environment are painfully slowed. 

Loss of interest

Depressed persons feel sad and lose interest in their usual activities. They lose their capacity to experience pleasure. Even eating and sex are no longer enjoyable. Former activities seem boring or unrewarding, and the ability to feel and offer love may be diminished or lost. 

Low Self-Esteem

During periods of depression, individuals often dwell on memories of losses or failures, and they feel excessive guilt and helplessness. Negative thoughts such as "I am not worth much" or "The world is a terrible place" may take over. 

Feelings of Hopelessness

The symptoms of depression often come together in a strong feeling of hopelessness, a belief that nothing will ever improve. Periods of depression can lead to the wish to die or thoughts of killing oneself. 

Depression may be as disabling, in terms of time spent in bed and loss of work productivity, as hypertension and diabetes. It has been calculated that in 1989 the economy lost an estimated $27 billionn$17 billion in time lost from work-because of clinical depression. But although people never question the heart patient's need for medical treatment and time to recuperate, they generally assume that the depressed individual should be able to pick himself up by his own bootstraps. In fact, the depressed individual is no more capable of treating his own disorder than is the person with heart disease or diabetes. 

When several symptoms of depression occur and last longer than two weeks-or interfere with ordinary functioning-professional treatment is needed. 

Who Develops Major Depression? 

All age groups and all racial, ethnic, and socioeconomic groups suffer from depression. An estimated 9.9 million American adults are affected by major depression in a given year, but less than one-third of all people with the disorder are treated. 

Youth

Some symptoms of depression in children and adolescents are similar to those in other age groups, but depressed young people may also "act out" by showing anger, becoming aggressive, abusing drugs or alcohol, doing poorly in school, or running away. They may feel isolated, empty, and hopeless. The number of suicides among children and adolescents has dramatically increased during the last three decades. Suicide is currently the fourth-leading cause of death among children ages 10 to 14 and the third-leading cause of death among people between the ages of 15 and 25. Therefore, it is essential for young people with severe symptoms or symptoms lasting for several weeks to be evaluated by a doctor. 

Adults Age 65 & Over

An estimated 6 percent of American adults age 65 and older (2 million of the 34 million people in this age group) have a diagnosable depressive disorder including major depression, bipolar disorder (manic-depression), and dysthymia. Yet, major depression is a widely under-recognized and under-treated medical illness in older adults. Depression can be difficult to recognize in older people because certain problems associated with aging such as backaches, headaches, joint pain, or stomach problems are also frequently signs of depression in this population. Older adults and their family members and physicians do not always recognize these problems as being caused by depression, especially when older persons do not talk about their lack of interest in daily activities and their feelings of anxiety or sadness that accompany their physical symptoms. 

Contrary to popular belief, depression is not a normal part of aging. It can be successfully treated when recognized and diagnosed by a physician. 

What Causes Major Depression?

Most likely there is not one single cause of major depression. Many depressions occur spontaneously and are not associated with any life crisis, physical illness, or other risks described in this booklet. Others seem connected to various factors described below. 

Functional studies of the brain-which are done by brain imaging or brain mapping-indicate a possible chemical dysfunction among depressed people, and genetics may playa role. Life events such as the death of a loved one, a major loss or change, or chronic stress-may trigger depression, too. And alcohol or drug abuse, certain medications, and even an individual's general outlook on life may contribute to the development of the disorder. With all the major advances in scientific knowledge about major depression, there is still no single, definitive answer to the question of cause. 

There is a risk for developing depression when there is a family history of the illness, which means there may be a biological vulnerability that is inherited. Not everyone with a genetic vulnerability develops depression, but some people probably have a biological make-up that leaves them particularly vulnerable. Scientists have found that family members who have the illness have genes in a specific chromosomal region that are different from genes of those who do not get depression. 

Certain personality traits - such as being overly dependent, a lack of self-esteem, consistent pessimism, or being easily overwhelmed by stress may make one prone to depression. Social conditioning is a possible influencing factor in some cases of depressive illness. Some illnesses such as hypertension and some medications may also trigger a depressive episode. 

Norepinephrine, serotonin, and dopamine are three neurotransmitters (chemical messengers that help transmit electrical signals between brain cells) thought to be involved with major depression. Antidepressant medications may work by changing the level of receptor sensitivity to these neurotransmitters, which must be available between nerve cells to transmit the brain impulses affecting mood and function. Scientists believe that if neurotransmitters are insufficiently available, clinical states of depression are the result. 

Scientific knowledge about depression has become astonishingly more sophisticated over the last ten years, and we hope that an exponential increase in our understanding of the causes of the illness over the next decade will lead to more and better treatments. 

How Is Major Depression Treated? 

Of all the mental illnesses, depressive disorders are among the most'responsive to treatment. Although major depression can be a devastating illness, it is highly treatable. Between 80 percent and 90 percent of those suffering from serious depression can be effectively treated and can return to their routine daily activities and experience relief from their feelings of depression. Many types of treatment are available, and the type chosen depends on the individual and the severity and patterns of the illness. There are three basic types of treatment for depression: medications, psychotherapy, and electroconvulsive therapy (ECT). They may be used singly or in combination. 

Medications

It often takes three to four weeks of treatment with antidepressants for people to notice an improvement in their symptoms, and they may have to try various doses and different types of antidepressants before finding the one - or combination - that is most effective for them. Antidepressant medications are not habit-forming. Four groups of antidepressant medications are most often prescribed for depression: 

Medications often effectively control the symptoms of severe depression, but people with this disorder must learn to recognize their individual patterns of illness and learn ways to cope with them. Taking medications prescribed by a doctor is just one way to manage major depression. Psychotherapy is another way to help manage depression, and often a combination of medication and psychotherapy is the most effective treatment. 

Psychotherapy

There are several types of psychotherapy that have been shown to be effective for depression, including cognitive-behavioral therapy (CBT) and interpersonal therapy OPT). In general, these two types of therapies are short -term; treatments usually last only 10 to 20 weeks. Research has shown that mild to moderate depression can often be treated successfully with either medication or psychotherapy alone. However, severe depression appears more likely to respond to a combination of these two treatments. 

Electroconvulsive Therapy (ECT) 

ECT is a highly effective treatment for severe depressive episodes. When medication, psychotheraapy, or a combination of the two is not effective, or if treatments are too slow to relieve severe symptoms such as psychosis or thoughts of suicide, or if a person cannot take antidepressants, ECT may be considered. 

How Successful Are Treatments For A Person With Major Depression? 

How well treatment works depends on the type of depression, its severity, how long it has been going on, and how an individual responds to the medical and psychological interventions offered. 

The development over the past 20 years of antidepressants and mood-stabilizing drugs has revolutionized the treatment of clinical depression, particularly for those with more serious or recurrent forms of the disorder. Biological treatments are dramatically effective, and between 80 percent and 90 percent of people with biological depression will get significant relief from medication-whether the depression is mild or severe, recent or long-term. Left untreated, however, depression can become more serious or go on indefinitely and become chronic. Treatment is important because it can prevent recurrences of depression. More than half of those who experience a first episode of depression will have at least one other episode in their lives; and, without treatment, after two episodes the chances of having a third episode are even greater. 

More extended treatment is needed when depression recurs often or continues for many weeks. Those with recurrent depression may need to stay on medication to prevent or lessen further episodes. Although most depressed people can be treated successfully as outpatients, severe episodes and episodes accompanied by suicidal thinking may require brief hospitalization for careful evaluation, protection, and initiation of treatment. In combined treatment, medications are used to treat the symptoms of depression while psychotherapy is used to help alleviate the problems depression causes in daily living. 

What Are The Possible Side Effects Of Drugs Used To Treat Major Depression? 

Different medications produce different side effects, and people differ in the type and severity of side effects they experience. About 50 percent of people who take antidepressant medications usually experience some side effects during the first weeks of treatment, but these problems are usually temporary and mild. Side effects that are particularly bothersome can often be treated by changing the dose of the medication, switching to a different medication, or treating the side effect directly with an additional medication. Rarely, serious side effects such as fainting, heart problems, or seizures may occur, but they are almost always treatable. For a small number of people, side effects are troublesome enough that they cannot take antidepressants.

What Type Of Help Does A Person With Major Depression Need? 

Above all, people with major depression need accurate diagnosis and early treatment. Family, friends, or coworkers should encourage a depressed person to seek expert evaluation. But those who are ill need understanding, compassion, patience, and respect as well. Family, friends, the community, and healthcare professionals are important sources of support. 

Family physicians, clinics, and managed care organizations (e.g., HMOs, PPOs, etc.) all may refer individuals to mental health specialists, who provide therapy for depression. A variety of mental health professionals including psychiatrists, psychologists, psychiatric social workers, psychiatric nurses, and some mental health counselors are trained in the diagnosis of depression. A psychiatrist is a medical doctor who specializes in mental disorders and, as a physician, is the only one of the mental health professionals who can prescribe medication (although in some states, psychiatric nurses may also prescribe medication). A clinical psychologist conducts psychotherapy and works with individuals, couples, and families to resolve problems associated with depression. Psychiatric or clinical social workers have advanced degrees in social work and are trained in counseling and psychotherapy: They are also trained in client-centered advocacy including information, referral, and direct intervention with governmental and civic agencies. Mental health counselors provide professional counseling services that involve psychotherapy, human development, learning theory, and group dynamics. Their main goal is the promotion and enhancement of healthy, satisfying lifestyles. These counselors can be found in mental health centers, private practice, or other community agencies. 

Many persons who are depressed or are trying to help a depressed friend or family member begin by seeking help from a family doctor. Because the symptoms of depression can be similar to those of other illnesses, a complete physical examination is essential for an accurate diagnosis.