Depression

People with major depressive disorder are depressed most days for at least 2 weeks. They may appear miserable. Their eyes may be full of tears, their brows may be furrowed, and the corners of the mouth may be turned down. They may slump and avoid eye contact. They may hardly move, show little facial expression, and speak in a monotone.

People with persistent depressive disorder have been depressed for most of the time for 2 years or more.

Symptoms begin gradually, often during adolescence, and may last for years or decades. How many symptoms are present at one time varies, and sometimes symptoms are less severe than those in major depression.

People with this disorder may be gloomy, pessimistic, skeptical, humorless, and incapable of having fun. Some are passive, lack energy, and keep to themselves. Some constantly complain and are quick to criticize others and reproach themselves. They may be preoccupied with inadequacy, failure, and negative events, sometimes to the point of morbid enjoyment of their own failures.

Severe symptoms occur before most menstrual periods and disappear after they end. Symptoms cause substantial distress and/or greatly interfere with functioning. Symptoms are similar to those of premenstrual syndrome Premenstrual Syndrome (PMS) Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that start several days before a menstrual period begins and usually end a few hours after the first day of a period... read more but are more severe, causing great distress and interfering with functioning at work and social interactions.

Premenstrual dysphoric disorder may first appear any time after the first menstrual period. It may worsen as women approach menopause but ends after menopause. It occurs in about 3 to 8% of women who are menstruating.

Women with premenstrual dysphoric disorder have mood swings, suddenly becoming sad and tearful. They are irritable and anger easily. They feel very depressed, hopeless, anxious, and on edge. They may feel overwhelmed or out of control.

As with other types of depression, women with this disorder may lose interest in their usual activities, have difficulty concentrating, and feel tired and without energy. They may eat too much and crave certain foods. They may sleep too little or too much.

Prolonged grief is persistent sadness following the loss of a loved one. It is different from depression in that the sadness relates specifically to the loss rather than the more general feelings of sadness and failure associated with depression.

Prolonged grief is considered present when grief (as shown by persistent longing or yearning and/or preoccupation with the deceased) is long-lasting (at least 12 months), experienced a great deal of the time, and is deeper than what a person's culture considers typical. It also must be accompanied by 3 or more of the following for at least 1 month to a degree that causes distress or disability:

Thoughts of death are among the most serious symptoms of depression. Many people with depression want to die or feel they are so worthless that they should die. As many as 15% of people with untreated depression end their life by suicide Suicidal Behavior Suicide is death caused by an act of self-harm that is intended to be lethal. Suicidal behavior includes completed suicide, attempted suicide, and suicidal ideation (thoughts and ideas). Suicide... read more .

A suicide threat is an emergency. When people threaten to kill themselves, a doctor may hospitalize them so that they can be supervised until treatment reduces the risk of suicide. The risk is especially high in the following situations:

People with depression are more likely to use alcohol or illicit drugs in an attempt to help them sleep or feel less anxious. However, depression leads to alcohol use disorder Alcohol Use Alcohol (ethanol) is a depressant (it slows down brain and nervous system functioning). Consuming large amounts rapidly or regularly can cause health problems, including organ damage, coma,... read more or other substance use disorders Illicit Drugs and Intoxicants less often than was once thought.

People are also more likely to smoke heavily and to neglect their health. Thus, the risk of developing or worsening other disorders, such as chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease is persistent narrowing (blocking, or obstruction) of the airways occurring with emphysema, chronic obstructive bronchitis, or both disorders. Cigarette... read more , is increased.

Depression may reduce the immune system's ability to respond to foreign or dangerous invaders, such as microorganisms or cancer cells. As a result, people with depression may be more likely to get infections.

Depression increases the risk of heart and blood vessel disorders (such as heart attacks) and stroke. The reason may be that depression causes certain physical changes that increase this risk. For example, the body produces more of the substances that help blood clot (clotting factors), and the heart is less able to change how fast it beats in response to different situations.

No test can confirm depression. However, laboratory tests may help a doctor determine whether depression is caused by a hormonal or other physical disorder. For example, blood tests are usually done to detect a thyroid disorder Overview of the Thyroid Gland The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that lies just under the skin below the Adam’s apple in the neck. The two halves (lobes) of the gland are connected... read more or vitamin deficiency Overview of Vitamins Vitamins are a vital part of a healthy diet. The recommended dietary allowance (RDA)—the amount most healthy people need each day to remain healthy—has been determined for most vitamins. A safe... read more . Tests may be done to detect illicit drug use.

A thorough neurologic examination Neurologic Examination When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the different parts of the nervous system. Examination... read more is done to check for Parkinson disease Parkinson Disease (PD) Parkinson disease is a slowly progressive degenerative disorder of specific areas of the brain. It is characterized by tremor when muscles are at rest (resting tremor), increased muscle tone... read more , which causes some of the same symptoms.

People who have severely disturbed sleep may need to have sleep testing (polysomnography Testing ) to distinguish sleep disorders Insomnia and Excessive Daytime Sleepiness (EDS) The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in... read more from depression.

Doctors explain to people with depression and their family members that depression has physical causes and requires specific treatment, which is usually effective. Doctors reassure them that depression does not reflect a character flaw, such as weakness. It is important for family members to understand the disorder, be involved in treatment, and provide support.

Learning about depression can help people understand and deal with the disorder. For example, people learn that the path to recovery is often bumpy and that episodes of sadness and dark thoughts may recur but they will stop. Thus, people can put any setbacks in perspective and are more likely to continue their treatment and not give up.

Becoming more active—taking walks and exercising regularly—can help, as can interacting more with others.

Support groups (such as the Depression and Bipolar Support Alliance—DBSA) can help by providing a forum to share common experiences and feelings.

Psychotherapy alone may be just as effective as medications for mild depression. When used with medications, psychotherapy can be useful for severe depression.

Individual or group psychotherapy can help people with depression gradually resume former responsibilities and adapt to the normal pressures of life. Interpersonal therapy focuses on the person's past and present social roles, identifies problems with how the person interacts with other people, and provides guidance as the person adjusts to changes in life roles. Cognitive-behavioral therapy can help change hopelessness and negative thinking.

Several types of antidepressants Medications for Treatment of Depression Several types of medications can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Norepinephrine-dopamine reuptake inhibitors, serotonin modulators, and serotonin-norepinephrine... read more are available (see table ). They include the following:

Psychostimulants Drug therapy Attention-deficit/hyperactivity disorder (ADHD) is poor or short attention span and/or excessive activity and impulsiveness inappropriate for the child’s age that interferes with functioning... read more , such as dextroamphetamine and methylphenidate, as well as other medications, are sometimes used, often with antidepressants. Psychostimulants are used to increase mental alertness and awareness.

St. John’s wort St. John’s Wort The reddish substance in the flowers of St. John’s wort contains numerous biologically active compounds, including hypericin and hyperforin. (See also Overview of Dietary Supplements.) People... read more , an herbal dietary supplement, is sometimes used to relieve mild depression, although its effectiveness is not proven. Due to potentially harmful interactions between St. John’s wort and many prescription medications, people interested in taking this herbal supplement need to discuss possible drug interactions with their doctor.

Electroconvulsive therapy (in the past sometimes called shock therapy) is sometimes used to treat people with severe depression, including people who have psychosis, are threatening suicide, or are refusing to eat. It is also used to treat depression during pregnancy when medications are ineffective.

This type of therapy is usually very effective and can relieve depression quickly, unlike most antidepressants, which can take up to several weeks. The speed with which it takes effect can save lives. After electroconvulsive therapy is stopped, episodes of depression can recur. To help prevent them, doctors often prescribe antidepressants.

For electroconvulsive therapy, electrodes are placed on the head, and an electrical current is applied to induce a seizure in the brain. For reasons that are not understood, the seizures relieve depression. Usually, at least 5 to 7 treatments (one treatment every other day) are given.

Because the electrical current can cause muscle contractions and pain, general anesthesia is required during treatments. Electroconvulsive therapy may cause some temporary memory loss and, rarely, permanent memory loss.

Phototherapy using a light therapy box is the most effective treatment for seasonal depression but may be helpful for other types of depressive disorders.

Phototherapy involves sitting a specific distance from a light box that provides light with the necessary intensity. People are instructed not to look directly at the light and to remain in front of the light for 30 to 60 minutes a day. Phototherapy can be done at home.

If people go to sleep and get up late, phototherapy is most effective in the morning. If people go to sleep and get up early, phototherapy is most effective between the late afternoon and early evening.

Other therapies that stimulate the brain may be tried when initial treatments are ineffective. They include

The stimulated cells are thought to release chemical messengers (neurotransmitters), which help regulate mood and may thus relieve symptoms of depression. These therapies may help people with severe depression that does not respond to medications or psychotherapy.

For repetitive transcranial magnetic stimulation, an electromagnetic coil is placed against the forehead near an area of the brain thought to be involved in regulating mood. The electromagnet produces painless magnetic pulses that doctors think stimulate nerve cells in the targeted area of the brain. The most common side effects are headaches and discomfort near where the coil was placed.

For vagus nerve stimulation, a device that looks like a heart pacemaker (vagus nerve stimulator) is implanted under the left collarbone and is connected to the vagus nerve in the neck with a wire that runs under the skin. (The pair of vagus nerves run from the brain stem, located near the base of the skull, through the neck and down each side of the chest and abdomen to organs, such as the heart and lungs.) The device is programmed to periodically stimulate the vagus nerve with a painless electrical signal. It may be useful for depression when other treatments are ineffective, but it usually takes 3 to 6 months to take effect. Side effects of vagus nerve stimulation include hoarseness, cough, and deepening of the voice when the nerve is stimulated.