Depression

Overview

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.

Some forms of depression are slightly different, or they may develop under unique circumstances, such as:

• Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years to be considered persistent depressive disorder.
• Postpartum depression is much more serious than the “baby blues” (relatively mild depressive and anxiety symptoms that typically clear within two weeks after delivery) that many women experience after giving birth. Women with postpartum depression experience full-blown major depression during pregnancy or after delivery (postpartum depression). The feelings of extreme sadness, anxiety, and exhaustion that accompany postpartum depression may make it difficult for these new mothers to complete daily care activities for themselves and/or for their babies.
• Psychotic depression occurs when a person has severe depression plus some form of psychosis, such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations). The psychotic symptoms typically have a depressive “theme,” such as delusions of guilt, poverty, or illness.
• Seasonal affective disorder is characterized by the onset of depression during the winter months, when there is less natural sunlight. This depression generally lifts during spring and summer. Winter depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably returns every year in seasonal affective disorder.
• Bipolar disorder is different from depression, but it is included in this list is because someone with bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression (called “bipolar depression”). But a person with bipolar disorder also experiences extreme high – euphoric or irritable – moods called “mania” or a less severe form called “hypomania.”

Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-5 include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder (PMDD).

Risk Factors

Depression is one of the most common mental disorders in the U.S. Current research suggests that depression is caused by a combination of genetic, biological, environmental, and psychological factors.

Depression can happen at any age, but often begins in adulthood. Depression is now recognized as occurring in children and adolescents, although it sometimes presents with more prominent irritability than low mood. Many chronic mood and anxiety disorders in adults begin as high levels of anxiety in children.

Depression, especially in midlife or older adults, can co-occur with other serious medical illnesses, such as diabetes, cancer, heart disease, and Parkinson’s disease. These conditions are often worse when depression is present. Sometimes medications taken for these physical illnesses may cause side effects that contribute to depression. A doctor experienced in treating these complicated illnesses can help work out the best treatment strategy.

Risk factors include:
• Personal or family history of depression
• Major life changes, trauma, or stress
• Certain physical illnesses and medications

Depression: Introduction

Do you feel sad, empty, and hopeless most of the day, nearly every day? Have you lost interest or pleasure in your hobbies or being with friends and family? Are you having trouble sleeping, eating, and functioning? If you have felt this way for at least 2 weeks, you may have depression, a serious but treatable mood disorder.

What is depression?
Everyone feels sad or low sometimes, but these feelings usually pass with a little time. Depression—also called “clinical depression” or a “depressive disorder”—is a mood disorder that causes distressing symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, symptoms must be present most of the day, nearly every day for at least 2 weeks.

What are the different types of depression?
Two of the most common forms of depression are:
• Major depression — having symptoms of depression most of the day, nearly every day for at least 2 weeks that interfere with your ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person has several episodes.
• Persistent depressive disorder (dysthymia)—having symptoms of depression that last for at least 2 years. A person diagnosed with this form of depression may have episodes of major depression along with periods of less severe symptoms.

Some forms of depression are slightly different, or they may develop under unique circumstances, such as:
• Perinatal Depression: Women with perinatal depression experience full-blown major depression during pregnancy or after delivery (postpartum depression).
• Seasonal Affective Disorder (SAD): SAD is a type of depression that comes and goes with the seasons, typically starting in the late fall and early winter and going away during the spring and summer.
• Psychotic Depression: This type of depression occurs when a person has severe depression plus some form of psychosis, such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others cannot hear or see (hallucinations).

Other examples of depressive disorders include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder. Depression can also be one phase of bipolar disorder (formerly called manic-depression). But a person with bipolar disorder also experiences extreme high—euphoric or irritable —moods called “mania” or a less severe form called “hypomania.”

What causes depression?

Scientists at NIMH and across the country are studying the causes of depression. Research suggests that a combination of genetic, biological, environmental, and psychological factors play a role in depression.

Depression can occur along with other serious illnesses, such as diabetes, cancer, heart disease, and Parkinson’s disease. Depression can make these conditions worse and vice versa. Sometimes medications taken for these illnesses may cause side effects that contribute to depression symptoms.

Signs and Symptoms

If you have been experiencing some of the following signs and symptoms most of the day, nearly every day, for at least two weeks, you may be suffering from depression:
• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, or pessimism
• Irritability
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities
• Decreased energy or fatigue
• Moving or talking more slowly
• Feeling restless or having trouble sitting still
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide, or suicide attempts
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Not everyone who is depressed experiences every symptom. Some people experience only a few symptoms while others may experience many. Several persistent symptoms in addition to low mood are required for a diagnosis of major depression, but people with only a few – but distressing – symptoms may benefit from treatment of their “subsyndromal” depression. The severity and frequency of symptoms and how long they last will vary depending on the individual and his or her particular illness. Symptoms may also vary depending on the stage of the illness.

What are the signs and symptoms of depression?

Sadness is only one small part of depression and some people with depression may not feel sadness at all. Different people have different symptoms. Some symptoms of depression include:
• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies or activities
• Decreased energy, fatigue, or being “slowed down”
• Difficulty concentrating, remembering, or making decisions
• Difficulty sleeping, early-morning awakening, or oversleeping
• Appetite and/or weight changes
• Thoughts of death or suicide or suicide attempts
• Restlessness or irritability
• Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment

Does depression look the same in everyone?
No. Depression affects different people in different ways. For example:
Women have depression more often than men. Biological, lifecycle, and hormonal factors that are unique to women may be linked to their higher depression rate. Women with depression typically have symptoms of sadness, worthlessness, and guilt.
Men with depression are more likely to be very tired, irritable, and sometimes angry. They may lose interest in work or activities they once enjoyed, have sleep problems, and behave recklessly, including the misuse of drugs or alcohol. Many men do not recognize their depression and fail to seek help.
Older adults with depression may have less obvious symptoms, or they may be less likely to admit to feelings of sadness or grief. They are also more likely to have medical conditions, such as heart disease, which may cause or contribute to depression.
Younger children 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 and teens with depression may get into trouble at school, sulk, and be irritable. Teens with depression may have symptoms of other disorders, such as anxiety, eating disorders, or substance abuse.

Treatment and Therapies

Depression, even the most severe cases, can be treated. The earlier that treatment can begin, the more effective it is. Depression is usually treated with medications, psychotherapy, or a combination of the two. If these treatments do not reduce symptoms, electroconvulsive therapy (ECT) and other brain stimulation therapies may be options to explore.

    Quick Tip: No two people are affected the same way by depression and there is no "one-size-fits-all" for treatment. It may take some trial and error to find the treatment that works best for you.

Medications

Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has manageable side effects. A medication that has helped you or a close family member in the past will often be considered.

Antidepressants take time – usually 2 to 4 weeks – to work, and often, symptoms such as sleep, appetite, and concentration problems improve before mood lifts, so it is important to give medication a chance before reaching a conclusion about its effectiveness. If you begin taking antidepressants, do not stop taking them without the help of a doctor. Sometimes people taking antidepressants feel better and then stop taking the medication on their own, and the depression returns. When you and your doctor have decided it is time to stop the medication, usually after a course of 6 to 12 months, the doctor will help you slowly and safely decrease your dose. Stopping them abruptly can cause withdrawal symptoms.

    Please Note: In some cases, children, teenagers, and young adults under 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. This warning from the U.S. Food and Drug Administration (FDA) also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

If you are considering taking an antidepressant and you are pregnant, planning to become pregnant, or breastfeeding, talk to your doctor about any increased health risks to you or your unborn or nursing child.

To find the latest information about antidepressants, talk to your doctor and visit www.fda.gov.

You may have heard about an herbal medicine called St. John's wort. Although it is a top-selling botanical product, the FDA has not approved its use as an over-the-counter or prescription medicine for depression, and there are serious concerns about its safety (it should never be combined with a prescription antidepressant) and effectiveness. Do not use St. John’s wort before talking to your health care provider. Other natural products sold as dietary supplements, including omega-3 fatty acids and S-adenosylmethionine (SAMe), remain under study but have not yet been proven safe and effective for routine use. For more information on herbal and other complementary approaches and current research, please visit the National Center for Complementary and Integrative Health website.

Psychotherapies

Several types of psychotherapy (also called “talk therapy” or, in a less specific form, counseling) can help people with depression. Examples of evidence-based approaches specific to the treatment of depression include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy. More information on psychotherapy is available on the NIMH website and in the NIMH publication Depression: What You Need to Know.

Brain Stimulation Therapies
If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an option to explore. Based on the latest research:
• ECT can provide relief for people with severe depression who have not been able to feel better with other treatments.
• Electroconvulsive therapy can be an effective treatment for depression. In some severe cases where a rapid response is necessary or medications cannot be used safely, ECT can even be a first-line intervention.
• Once strictly an inpatient procedure, today ECT is often performed on an outpatient basis. The treatment consists of a series of sessions, typically three times a week, for two to four weeks.
• ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually these side effects are short-term, but sometimes memory problems can linger, especially for the months around the time of the treatment course. Advances in ECT devices and methods have made modern ECT safe and effective for the vast majority of patients. Talk to your doctor and make sure you understand the potential benefits and risks of the treatment before giving your informed consent to undergoing ECT.
• ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, a patient is put under brief anesthesia and given a muscle relaxant. Within one hour after the treatment session, which takes only a few minutes, the patient is awake and alert.

Other more recently introduced types of brain stimulation therapies used to treat medicine-resistant depression include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). Other types of brain stimulation treatments are under study. You can learn more about these therapies on the NIMH Brain Stimulation Therapies webpage.

If you think you may have depression, start by making an appointment to see your doctor or health care provider. This could be your primary care practitioner or a health provider who specializes in diagnosing and treating mental health conditions. Visit the NIMH Find Help for Mental Illnesses if you are unsure of where to start.

Beyond Treatment: Things You Can Do

Here are other tips that may help you or a loved one during treatment for depression:
• Try to be active and exercise.
• Set realistic goals for yourself.
• 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.
• Expect your mood to improve gradually, not immediately.
• 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.
• Continue to educate yourself about depression.

How is depression treated?

The first step in getting the right treatment is to visit a health care provider or mental health professional, such as a psychiatrist or psychologist. Your health care provider can do an exam, interview, and lab tests to rule out other health conditions that may have the same symptoms as depression. Once diagnosed, depression can be treated with medications, psychotherapy, or a combination of the two. If these treatments do not reduce symptoms, brain stimulation therapy may be another treatment option to explore.

Medications

Medications called antidepressants can work well to treat depression. They can take 2 to 4 weeks to work. Antidepressants can have side effects, but many side effects may lessen over time. Talk to your health care provider about any side effects that you have. Do not stop taking your antidepressant without first talking to your health care provider.

    Please Note: Although antidepressants can be effective for many people, they may present serious risks to some, especially children, teens, and young adults. Antidepressants may cause some people, especially those who become agitated when they first start taking the medication and before it begins to work, to have suicidal thoughts or make suicide attempts. Anyone taking antidepressants should be monitored closely, especially when they first start taking them. For most people, though, the risks of untreated depression far outweigh those of antidepressant medications when they are used under a doctor’s careful supervision.

Information about medications changes frequently. Visit the U.S. Food and Drug Administration (FDA) website for the latest warnings, patient medication guides, or newly approved medications.

Psychotherapy

Psychotherapy helps by teaching new ways of thinking and behaving, and changing habits that may be contributing to depression. Therapy can help you understand and work through difficult relationships or situations that may be causing your depression or making it worse.

Brain Stimulation Therapies

Electroconvulsive therapy (ECT) and other brain stimulation therapies may be an option for people with severe depression who do not respond to antidepressant medications. ECT is the best studied brain stimulation therapy and has the longest history of use. Other stimulation therapies discussed here are newer, and in some cases still experimental methods.

How can I help myself if I am depressed?

As you continue treatment, you may start to feel better gradually. Remember that if you are taking an antidepressant, it may take 2 to 4 weeks to start working. Try to do things that you used to enjoy. Go easy on yourself. Other things that may help include:
• Trying to be active and exercise
• Breaking up large tasks into small ones, set priorities, and do what you can as you can
• Spending time with other people and confide in a trusted friend or relative
• Postponing important life decisions until you feel better. Discuss decisions with others who know you well
• Avoiding self-medication with alcohol or with drugs not prescribed for you

How can I help a loved one who is depressed?

If you know someone who has depression, first help him or her see a health care provider or mental health professional. You can also:
• Offer support, understanding, patience, and encouragement
• Never ignore comments about suicide, and report them to your loved one’s health care provider or therapist
• Invite him or her out for walks, outings, and other activities
• Help him or her adhere to the treatment plan, such as setting reminders to take prescribed medications
• Help him or her by ensuring that he or she has transportation to therapy appointments
• Remind him or her that, with time and treatment, the depression will lift

Where can I go for help?

If you are unsure where to go for help, ask your health provider or check out the NIMH Help for Mental Illnesses webpage at www.nimh.nih.gov/findhelp. Another Federal health agency, the Substance Abuse and Mental Health Services Administration (SAMHSA), maintains an online Behavioral Health Treatment Services Locator at https://findtreatment.samhsa.gov/. You can also check online for mental health professionals; contact your community health center, local mental health association, or insurance plan to find a mental health professional. Hospital doctors can help in an emergency.

If you or someone you know is in crisis, get help quickly.

• Call your or your loved one’s health professional.
• Call 911 for emergency services.
• Go to the nearest hospital emergency room.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TYY: 1-800-799-4TTY (4889).

Medications

Antidepressants are medicines that treat depression. They may help improve the way your brain uses certain chemicals that control mood or stress.

There are several types of antidepressants:
• Selective serotonin reuptake inhibitors (SSRI)
• Serotonin and norepinephrine reuptake inhibitors (SNRI)
• Tricyclic antidepressants (TCA)
• Monoamine oxidase inhibitors (MAOI)
There are other antidepressants that don’t fall into any of these categories and are considered unique, such as Mirtazapine and Bupropion.

Although all antidepressants can cause side effects, some are more likely to cause certain side effects than others. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has side effects that you can manage.

Most antidepressants are generally safe, but the U.S. Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers, and young adults under age 25 may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed. The warning also says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

Common side effects listed by the FDA for antidepressants are:
• Nausea and vomiting
• Weight gain
• Diarrhea
• Sleepiness
• Sexual problems

Other more serious but much less common side effects listed by the FDA for antidepressant medicines can include seizures, heart problems, and an imbalance of salt in your blood, liver damage, suicidal thoughts, or serotonin syndrome (a life-threatening reaction where your body makes too much serotonin). Serotonin syndrome can cause shivering, diarrhea, fever, seizures, and stiff or rigid muscles.

Your doctor may have you see a talk therapist in addition to taking medicine. Ask your doctor about the benefits and risks of adding talk therapy to your treatment. Sometimes talk therapy alone may be the best treatment for you.

If you are having suicidal thoughts or other serious side effects like seizures or heart problems while taking antidepressant medicines, contact your doctor immediately.

The National Suicide Prevention Lifeline is available at 1-800-273-TALK (8255), or you can visit www.suicidepreventionlifeline.org.

Medication

Antidepressants primarily work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways that they work. Te latest information on medications for treating depression is available on the U.S. Food and Drug Administration (FDA) website at http://www.fda.gov.

Popular newer antidepressants
Some of the newest and most popular antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloſt), escitalopram (Lexapro), paroxetine (Paxil), and citalopram (Celexa) are some of the most commonly prescribed SSRIs for depression. Most are available in generic versions. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs tend to have fewer side effects than older antidepressants, but they sometimes produce headaches, nausea, jitters, or insomnia when people first start to take them. Tese symptoms tend to fade with time. Some people also experience sexual problems with SSRIs or SNRIs, which may be helped by adjusting the dosage or switching to another medication.

One popular antidepressant that works on dopamine is bupropion (Wellbutrin). Bupropion tends to have similar side effects as SSRIs and SNRIs, but it is less likely to cause sexual side effects. However, it can increase a person’s risk for seizures.

Tricyclics
Tricyclics are older antidepressants. Tricyclics are powerful, but they are not used as much today because their potential side effects are more serious. They may affect the heart in people with heart conditions. Tey sometimes cause dizziness, especially in older adults. Tey also may cause drowsiness, dry mouth, and weight gain. These side effects can usually be corrected by changing the dosage or switching to another medication. However, tricyclics may be especially dangerous if taken in overdose. Tricyclics include imipramine and nortriptyline.

MAOIs
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. Tey can be especially effective in cases of “atypical” depression, such as when a person experiences increased appetite and the need for more sleep rather than decreased appetite and sleep. Tey also may help with anxious feelings or panic and other specific symptoms. However, people who take MAOIs must avoid certain foods and beverages (including cheese and red wine) that contain a substance called tyramine. Certain medications, including some types of birth control pills, prescription pain relievers, cold and allergy medications, and herbal supplements, also should be avoided while taking an MAOI. Tese substances can interact with MAOIs to cause dangerous increases in blood pressure. Te development of a new MAOI skin patch may help reduce these risks. If you are taking an MAOI, your doctor should give you a complete list of foods, medicines, and substances to avoid.

MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions. MAOIs should not be taken with SSRIs.