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Depression

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.  Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 2013.

The Center for Disease Control (CDC) characterized depression as:

A depressed or sad mood, diminished interest in activities which used to be pleasurable, weight gain or loss, psychomotor agitation or retardation, fatigue, inappropriate guilt, difficulties concentrating, as well as recurrent thoughts of death. But depression is more than a “bad day”; diagnostic criteria established by the American Psychiatric Association dictate that five or more of the above symptoms must be present for a continuous period of at least two weeks.1 As an illness, depression falls within the spectrum of affective disorders.

Depression symptoms can vary from mild to severe and can include:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in restless activity (e.g., hand-wringing or pacing) or slowed movements and speech
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

Symptoms must last at least two weeks for a diagnosis of depression.

Also, medical conditions (e.g., thyroid, a brain tumor or vitamin deficiency) can mimic symptoms of depression so it is important to rule out general medical causes.

Depression affects an estimated one in 15 adults (6.7%) in any given year. And one in six people (16.6%) will experience depression at some time in their life. Depression can strike at any time, but on average, first appears during the late teens to mid-20s. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a major depressive episode in their lifetime.

The death of a loved one, loss of a job or the ending of a relationship are difficult experiences for a person to endure. It is normal for feelings of sadness or grief to develop in response to such situations. Those experiencing loss often might describe themselves as being “depressed.”

But sadness and depression are not the same. The grieving process is natural and unique to each individual and shares some of the same features of depression. Both grief and depression may involve intense sadness and withdrawal from usual activities. They are also different in important ways:

  • In grief, painful feelings come in waves, often intermixed with positive memories of the deceased. In major depression, mood and/or interest (pleasure) are decreased for most of two weeks.
  • In grief, self-esteem is usually maintained. In major depression, feelings of worthlessness and self-loathing are common.
  • For some people, the death of a loved one can bring on major depression. Losing a job or being a victim of a physical assault or a major disaster can lead to depression for some people. When grief and depression co-exist, the grief is more severe and lasts longer than grief without depression. Despite some overlap between grief and depression, they are different. Distinguishing between them can help people get the help, support or treatment they need.

Depression can affect anyone—even a person who appears to live in relatively ideal circumstances.

Several factors can play a role in depression:

  • Biochemistry: Differences in certain chemicals in the brain may contribute to symptoms of depression.
  • Genetics: Depression can run in families. For example, if one identical twin has depression, the other has a 70 percent chance of having the illness sometime in life.
  • Personality: People with low self-esteem, who are easily overwhelmed by stress, or who are generally pessimistic appear to be more likely to experience depression.
  • Environmental factors: Continuous exposure to violence, neglect, abuse or poverty may make some people more vulnerable to depression.

Depression poses a substantial burden globally – and to the individual suffering from this disorder. As research has found that interpersonal relationships are particularly likely to suffer when someone is depressed, data suggest that few families or networks of friends are likely to remain unaffected by depression.

The urgency of the rate of depression to public health is likely compounded by the recognition that – if not effectively treated – depression is likely to lapse into a chronic disease. Just experiencing one episode of depression places the individual at a 50% risk for experiencing another, with subsequent episodes raising the likelihood of experiencing more episodes in the future.2

Major depression frequently goes unrecognized and untreated and may foster tragic consequences, such as suicide and impaired interpersonal relationships at work and at home. The use of medications and/or specific psychotherapeutic techniques has proven very effective in the treatment of major depression, but this disorder is still misconstrued as a sign of weakness, rather than being recognized as an illness.

Dysthymia, a depressive disorder characterized by low-grade mood impairment of at least two years, and, commonly, with an initial presentation in childhood or young adulthood.3 Dysthymia has been likened to a less severe major depression, but one more likely to assume a chronic course. Current thinking holds that aggressive treatment of dysthymia is warranted, as many suffering from this disorder develop major depression or may experience the two disorders concurrently.

Depression as a Correlate of Adverse Health Behaviors

In addition to being a chronic disease in its own right, the burden of depression is further increased as depression appears to be associated with behaviors linked to other chronic diseases. In most studies, it is difficult to determine whether depression is the result of an unhealthy behavior or whether depression causes the behavior.

Smoking: Previous research suggests depression is an established risk factor for smoking, with nicotine stimulating receptors in the brain which may improve mood in certain types of depression.4 The significance of nicotine use as a means of ameliorating depressive symptoms was supported by a longitudinal study examining smoking cessation. The study found that smokers with depressive symptoms in a control group continued to be highly symptomatic, while those who received nicotine replacement therapy did not have significantly higher depressive symptom scores relative to their non-depressed peers.5 Smokers have been found to be more likely than nonsmokers to experience daily symptoms of depression (29% vs. 19%).6 Notably as depressive symptom scores increase, the probability of smoking cessation decreases.7 Thus, depression is associated with an increased risk for smoking and, furthermore, may impede smoking cessation efforts.

Alcohol Consumption: Early onset of drinking has been reported to be associated with a range of problematic outcomes, including depressive symptoms.Assessing a clinical population, investigators reported a dynamic association between negative affect and lapses in sobriety following alcohol treatment.Specifically, these researchers found that changes in drinking following treatment were significantly associated with current and prior changes in negative affect, and, moreover, changes in negative affect were related to prior changes in drinking. These investigators concluded that negative affect and alcohol lapses were dynamically associated and indicate that assessing the relationship between negative affect and alcohol use could greatly decrease the probability of lapses from sobriety.9

Physical Inactivity: Physical inactivity and its strong correlate, obesity, have been identified as modifiable risk factors for depression.10  Researchers conducted a longitudinal, community-based study of depression and physical activity using data from the Canadian National Population Health Survey (NPHS), and found that, over time, major depression is associated with an increased risk of transition from an active to an inactive pattern of activity.11 These findings may have therapeutic implications, with physical activity reported to reduce depressive symptoms – even among individuals who are not clinically depressed.12

Sleep Disturbance: Depression appears to be associated with poor sleep throughout the lifespan.13, 14 In a cross-sectional study of 12- and 16-year old adolescents, after accounting for psychological comorbidity, sleep disturbance, such as nightmares, was associated with self-reported depression in adolescence (Coulombe et al. 2010). Some antidepressant agents are reported to commonly foster sleep disturbance.15

  • According to the World Health Organization, unipolar depression was the third most important cause of disease burden worldwide in 2004. Unipolar depression was in “eighth place in low-income countries, but at first place in middle- and high-income countries.”1
  • In a nationally representative face-to-face household survey, 6.7% of U.S. adults experienced a major depressive episode in the past 12 months.2
  • Significantly greater percentages of lifetime major depression have been reported among women (11.7%) than men (5.6%).3
  • Examining ethnic differences reveals lifetime percentages of depression of 6.52% among whites and 4.57% among blacks and 5.17% among Hispanics.4

How Is Depression Treated?

Depression is among the most treatable of mental disorders. Between 80 percent and 90 percent of people with depression eventually respond well to treatment. Almost all patients gain some relief from their symptoms.

Before a diagnosis or treatment a health professional should conduct a thorough diagnostic evaluation, including an interview and possibly a physical examination. In some cases, a blood test might be done to make sure the depression is not due to a medical condition like a thyroid problem. The evaluation is to identify specific symptoms, medical and family history, cultural factors and environmental factors to arrive at a diagnosis and plan a course of action.

Medication: Brain chemistry may contribute to an individual’s depression and may factor into their treatment. For this reason, antidepressants might be prescribed to help modify one’s brain chemistry. These medications are not sedatives, “uppers” or tranquilizers. They are not habit-forming. Generally antidepressant medications have no stimulating effect on people not experiencing depression.

Antidepressants may produce some improvement within the first week or two of use. Full benefits may not be seen for two to three months. If a patient feels little or no improvement after several weeks, his or her psychiatrist can alter the dose of the medication or add or substitute another antidepressant. It is important to let your doctor know if a medication does not work or if you experience side effects.

Psychiatrists usually recommend that patients continue to take medication for six or more months after symptoms have improved. Longer-term maintenance treatment may be suggested to decrease the risk of future episodes for certain people at high risk.

Psychotherapy: Psychotherapy, or “talk therapy,” is sometimes used alone for treatment of mild depression; for moderate to severe depression, psychotherapy is often used in along with antidepressant medications. Cognitive behavioral therapy (CBT) has been found to be effective in treating depression. CBT is a form of therapy focused on the present and problem solving. CBT helps a person to recognize distorted thinking and then change behaviors and thinking.

Psychotherapy may involve only the individual, but it can include others. For example, family or couples therapy can help address issues within these close relationships. Group therapy involves people with similar illnesses.

Depending on the severity of the depression, treatment can take a few weeks or much longer. In many cases, significant improvement can be made in 10 to 15 sessions.

Electroconvulsive Therapy (ECT) is a medical treatment most commonly used for patients with severe major depression or bipolar disorder who have not responded to other treatments. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. A patient typically receives ECT two to three times a week for a total of six to 12 treatments. ECT has been used since the 1940s, and many years of research have led to major improvements. It is usually managed by a team of trained medical professionals including a psychiatrist, an anesthesiologist and a nurse or physician assistant.

Self-help and Coping

There are a number of things people can do to help reduce the symptoms of depression. For many people, regular exercise helps create positive feeling and improve mood. Getting enough sleep on a regular basis, eating a healthy diet and avoiding alcohol can also help reduce symptoms of depression.

Depression is a real illness and help is available. With proper diagnosis and treatment, the vast majority of people with depression will overcome it. If you are experiencing symptoms of depression, a first step is to see your family physician or psychiatrist. Talk about your concerns and request a thorough evaluation. This is a start to addressing mental health needs.

Related Conditions

  • Postpartum depression
  • Seasonal affective disorder (Seasonal depression)
  • Persistent depressive disorder
  • Premenstrual dysphoric disorder
  • Disruptive mood dysregulation disorder
  • Bipolar disorders

More detail on mental health/mental illnesses may be found at: http://www.nimh.nih.gov/health/index.shtml or www.samhsa.gov/


References:

  1. American Psychiatric Association. Quick Reference to the Diagnostic Criteria from DSM-IV. Washington, DC. American Psychiatric Press, Inc. 1994.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. 2013.
  3. Kessler, RC, et al. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593602.http://archpsyc.jamanetwork.com/article.aspx?articleid=208678
  4. National Institute of Mental Health. (Data from 2013 National Survey on Drug Use and Health.) www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml
  5. NIMH Consensus Development Conference Statement. Mood disorders: pharmacologic prevention of recurrences. Am J Psychiatry. 1985;142:469-476.
  6. Sadock BJ & Sadock VA. Kaplan & Sadock’s Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. (10th ed.).Philadelphia, PA: Lippincott, Williams, & Williams, 2007.
  7. Balfour DJ, Ridley DL. The effects of nicotine on neural pathways implicated in depression: a factor in nicotine addiction? Pharmacol Biochem Behav. 2000 May;66(1):79-85 (NIMH 1985)
  8. Korhonen T, Kinnunen TH, Garvey AJ. Impact of nicotine replacement therapy on post-cessation mood profile by pre-cessation depressive symptoms.Tob Induc Dis 2008;3:58.
  9. Sanderson Cox L, Feng S, Canar J, McGlichey Ford, M, Tercyak KP. Social and behavioral correlates of cigarette smoking among mid-Atlanta Latino primary care patients. Cancer Epidemiol, Biomark & Prev 2005;14:1976.
  10. Wiecha J, Lee V, Hodgkins J. Patterns of smoking, risk factors for smoking, and smoking cessation among Vietnamese men in Massachusetts (United States). Tob Control 1998;7:27-34.
  11. Trim RS, Schuckit MA, Smith TL. Predicting drinking onset with discrete-time survival analysis in offspring from the San Diego prospective study. Drug Alcohol Depend 2010;107:215-220.
  12. Witkiewitz K, Villarroel NA. Dynamic association between negative affect and alcohol lapses following alcohol treatment. J Consult Clin Psychol2009;77:633-644.
  13. Ten Hacken NH. Physical inactivity and obesity: Relation to asthma and chronic obstructive pulmonary disease? Proc Am Thorac Soc 2009;6:663-667.
  14. Patten SB, Williams JV, Lavorato DH, Eliasziw M. A longitudinal community study of major depression and physical activity. Gen Hosp Psychiatry2009;31:571-575.
  15. Conn VS. Depressive symptom outcomes of physical activity interventions: Meta-analysis findings. Ann Behav Med 2010;[Epub ahead of print].
  16. Coulombe JA, Reid GJ, Boyle MH, Racine Y. Sleep problems, tiredness, and psychological symptoms among healthy adolescents. J Pediatr Psychol2010;[Epub ahead of print].
  17. Moreh E, Jacobs JM, Stessman J. Fatigue, function, and mortality in older adults. J Gerontol A Biol Sci Med Sci 2010 [Epub ahead of print].
  18. Bostwick JM. A generalist’s guide to treating patients with depression with an emphasis on using side effects to tailor antidepressant therapy. Mayo Clin Proc 2010{Epub ahead of print]
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