Who gets depressed?

Major depressive disorder often referred to as depression is a common illness that can affect anyone. About 1 in 20 Americans (over 11 million people) get depressed every year. Depression affects twice as many women as men.

What is depression?

Depression is not just "feeling blue" or "down in the dumps." It is more than being sad or feeling grief after a loss. Depression is a medical disorder (just like diabetes, high blood pressure, or heart disease are medical disorders) that day after day affects your thoughts, feelings, physical health, and behaviors.

Depression may be caused by many things, including:

• Family history and genetics.
• Other general medical illnesses.
• Certain medicines.
• Drugs or alcohol.
• Other psychiatric conditions.

Certain life conditions (such as extreme stress or grief), may bring on a depression or prevent a full recovery. In some people, depression occurs even when life is going well. Depression is not your fault. It is not a weakness. It is a medical illness. Depression is treatable.

How will I know if I am depressed?

People who have major depressive disorder have a number of symptoms nearly every day, all day, for at least 2 weeks. These always include at least one of the following:

• Loss of interest in things you used to enjoy.
• Feeling sad, blue, or down in the dumps.

You may also have at least three of the following symptoms:

• Feeling slowed down or restless and unable to sit still.
• Feeling worthless or guilty.
• Increase or decrease in appetite or weight.
• Thoughts of death or suicide.
• Problems concentrating, thinking, remembering, or making decisions.
• Trouble sleeping or sleeping too much.
• Loss of energy or feeling tired all of the time.

With depression, there are often other physical or psychological symptoms, including:

• Headaches.
• Other aches and pains.
• Digestive problems.
• Sexual problems.
• Feeling pessimistic or hopeless.
• Being anxious or worried.

What should I do if I have these symptoms?

Too often people do not get help for their depression because they don't recognize the symptoms, have trouble asking for help, blame themselves, or don't know that treatments are available.

Family practitioners, clinics, or health maintenance organizations are often the first places that people go for help. These health care providers will:

• Find out if there is a physical cause for your depression.
• Treat the depression.
• Refer you to a mental health specialist for further evaluation and treatment.

If you do not have a regular health care provider, contact your local health department, community mental health clinic, or hospital. University medical centers also provide treatment for depression.

How will treatment help me?

Treatment reduces the pain and suffering of depression. Successful treatment removes all of the symptoms of depression and returns you to your normal life. The earlier you get treatment for your depression, the sooner you will begin to feel better. As with other medical illnesses, the longer you have the depression before you seek treatment, the more difficult it can be to treat.

Most people who are treated for depression feel better and return to daily activities in several weeks. Because it takes several weeks for treatment to work fully, it is important to get treatment early before your depression gets worse.

As with any medical condition, you may have to try one or two treatments before finding the best one. It is important not to get discouraged if the first treatment does not work. In almost every case, there is a treatment for the depression that will work for you.

Information on where to get help for depression is found on the inside front cover of this booklet.

What type of treatment will I get?

The major treatments for depression are:

• Antidepressant medicine.
• Psychotherapy.
• Antidepressant medicine combined with psychotherapy.

In some cases of depression, other treatments, such as electroconvulsive therapy (ECT) and light therapy , are also useful.

Thoughts of suicide or death are often a part of depression. If you have these thoughts, tell someone you trust now. Ask them to help you find professional help right away. Once your depression is properly treated, these thoughts will go away.

Who should see a mental health specialist?

Many people with depression can be successfully treated by their general health care provider. However, some people need specialized treatment because the first treatment does not work, because they need a combination of treatments, or because the depression is severe or it lasts a long time. Many times, a second opinion or consultation is all that is needed. If the mental health specialist provides treatment, it is most often on an outpatient basis (not in the hospital). If you think you need to see a mental health specialist, tell your health care provider, or contact one of the mental health organizations listed on the inside front cover of this booklet. More information about people who treat depression is on page 6.

Section 2 of this booklet will tell you more about depression, its diagnosis, and its treatment.

People Who Treat Depression

The following health care providers can treat depression:

• General Health Care Provider

  • Physician --
  • A medical health care provider who has some training in treating mental or psychiatric disorders.
  • Physician Assistant --
  • An individual with medical training and some training in treating mental or psychiatric disorders.
  • Nurse Practitioner --
  • A registered nurse (R.N.) with additional nursing training and some training in treating mental or psychiatric disorders.

The health care providers listed above can refer you to one of the health care providers specializing in mental health listed below:

• Mental Health Specialists

  • Psychiatrist --
  • A physician who specializes in the diagnosis and treatment of mental or psychiatric disorders.
  • Psychologist
  • A person with a doctoral degree (Ph.D. or Psy.D.) in psychology and training in counseling, psychotherapy, and psychological testing.
  • Social Worker --
  • A person with a degree in social work. A social worker with a master's degree often has specialized training in counseling.
  • Psychiatric Nurse Specialist --
  • A registered nurse (R.N.) usually with a master's degree in psychiatric nursing who specializes in treating mental or psychiatric disorders.

Note: In this booklet, the term "health care provider" is used to describe any general health care provider or mental health specialist listed above.

Another Form of Depression

Some people with depression have mood cycles. They have terrible "lows" (depression) and inappropriate "highs" (mania) that can last from several days to months. In between the highs and lows, they feel completely normal. This condition is called bipolar disorder or manic-depressive disorder.

Bipolar disorder affects about 1 in 100 people. Just as eye or hair color are inherited, bipolar illness in most cases is inherited. It can also be caused by other general medical problems, such as head injury, or neurologic or other general medical conditions.

You can use this list to learn the symptoms of mania and to check ([X]) off any you might have.

• [ ] Feeling unusually "high," euphoric, or irritable.*
• [ ] Needing less sleep.
• [ ] Talking a lot or feeling that you can't stop talking.
• [ ] Being easily distracted.
• [ ] Having lots of ideas go through your head very quickly at one time.
• [ ] Doing things that feel good but have bad effects (spending too much money, excessive sexual activity, foolish business investments).
• [ ] Having feelings of greatness.
• [ ] Making lots of plans for activities (at work, school, socially, or sexually) or feeling that you have to keep moving.

If you have had four of these symptoms at one time for at least 1 week, including the first symptom marked with an *, you may have had a manic episode. Tell your health care provider about these episodes. There are effective treatments for this form of depression.

Preparing For Your First Visit

You can help your health care provider diagnose and treat you by giving as much information as possible about your health. You can use the chart on page 10 to write down some of that information. Information that you share with a health care provider is confidential.

If your depression is causing you to have a hard time talking and remembering, take a family member or friend along on your first visit to help.

The general medical history, physical examination, and basic laboratory tests can help your doctor learn if a general medical disorder is the cause of your depression. About 10 to 15 percent of all depressions are caused by general medical illness (such as thyroid disease, cancers, or neurologic diseases) or medicines. Once these conditions are treated, the depressions will usually go away.

If you have a general medical illness and feel depressed, it is important to tell your clinician. Sometimes depression is a reaction to a life-threatening condition. Getting help during a difficult time in your life may help you to cope with your general medical illness. An episode of depression begins when symptoms of depression start and ends when the symptoms are completely gone.

If your first episode of major depressive disorder occurred after age 40, a very thorough medical evaluation is important.

Severe? Moderate? Mild?

In the treatment section coming up, the terms severe, moderate, and mild depression are used. In general ...

• Severe depression is present when a person has nearly all of the symptoms of depression, and the depression almost always keep them from doing their regular day-to-day activities.
• Moderate depression is present when a person has many symptoms of depression that often keep them from doing things that they need to do.
• Mild depression is present when a person has some of the symptoms of depression and it takes extra effort to do the things they need to do.

For each type of depression there is a treatment that works best. You should talk with your clinician about your depression, and the best treatment for you.

Types of Treatment

The major types of treatment for depression are:

• Antidepressant medicine.
• Psychotherapy.
• Antidepressant medicine combined with psychotherapy.
• Other treatments including electroconvulsive therapy (ECT) and light therapy.

For severe depression, research studies show that medicine is very effective. Psychotherapy has not been well studied for the more severe forms of depression.

How Treatment Works

Treatment for depression works gradually over several weeks. With medicine, most people see some benefits by 3 or 4 weeks; with psychotherapy alone, it can sometimes take longer. There is a very good chance that your first treatment will work well for you. If treatment is not effective after a certain amount of time, it can be changed or adjusted. There are other treatments to try, and your chances for effective treatment are still very good.

Choosing a Treatment

You and your clinician can work together to find the best treatment for you. In choosing which acute treatment is best for you, you should weigh the chances of getting better (benefits) against the chances of possible harms, as well as the expense of the treatment offered and the costs of the depression (time from work, effect on personal relationships, etc.) Here are some questions you may want to ask when discussing treatment.

1. What are the chances of getting better with this treatment?
2. What are the possible risks and side effects of treatment?
3. What are the costs of treatment?

About Hospitalization

Most people with depression get their treatment through regular visits to a health care provider, therapist, or both. However, sometimes treatment in the hospital is needed. This is because other medical conditions could affect your treatment. Another reason is that people with severe depression may need hospital care (for example, to adjust medicine). Also, people who are at great risk for suicide are hospitalized until those feelings pass and treatment begins to work. If you must go to the hospital for treatment, it is often only for a few days or a week or two. Early treatment, before the depression becomes severe or chronic, can lower the chances of hospitalization.

Why Depression Must Be Treated

Without treatment, a major depressive episode can last 6 to 12 months. In between the episodes, most people feel better or are completely well (without symptoms).

Even though some people are able to struggle through an episode of depression without treatment, most find that it is much easier to get some help for their pain and suffering. It is important to get treatment for your depression because:

• Early treatment may help to keep the depression from becoming more severe, or chronic.
• Thoughts of suicide are common in depression, and the risk of suicide is increased when patients are not treated and the depression recurs. When depression is successfully treated, the thoughts of suicide will go away.
• Major depressive disorder usually comes in episodes lasting 6 to 12 months. In between the episodes most people feel better or are completely well (without symptoms).
• Between episodes, about 1 out of 4 people with depression will still have some symptoms and trouble doing their daily activities. These people, if not treated, have a greater chance of having another episode of depression.
• Treatment can prevent recurrences of depression. The more episodes of depression you have had, the greater the chance that you will have another. About half of the people who have one episode of depression will have a second. Without treatment, after two episodes, the chances of having a third episode (recurrent depression) are even greater. After three episodes, the chances of having a fourth are 90 percent.

If You Have Concerns About Your Treatment..

If at any time you are worried about your treatment or you don't think that things are going well, tell someone about your concerns. You can:

• Talk to your clinician.
• Ask for a second opinion.
• Talk to someone you trust.

Health care providers and mental health specialists are interested in your concerns and will help you. This may mean getting a second opinion or even finding another clinician.

Changing medicine is a complicated medical decision. It is dangerous to attempt to make changes in your medicine on your own!

Here are some common side effects of antidepressant medicines:

• Dry mouth.
• Dizziness.
• Constipation.
• Skin rash.
• Sleepiness.
• Trouble sleeping.
• Weight gain/loss.
• Restlessness.

More serious side effects are rare. As with minor side effects, they usually happen in the first few weeks of treatment. They include difficulty passing urine, heart trouble, sexual problems, seizures, fainting, or other effects. Both the common and rare side effects are nearly always.

If you are having side effects, call your clinician. Do not wait for the next appointment.

About 1 in 10 people who have a close relative with bipolar disorder can develop manic symptoms in the first few weeks of taking the medicine. Only a very small number (1 or 2 out of 100) of people without a relative with bipolar disorder experience manic symptoms on antidepressant medicine. An early sign that manic symptoms may be coming is that you may feel that you have a lot of energy or feel very "high" or euphoric. Tell your health care provider about these changes right away.

Tell your health care provider how the medicine is working. One way to know how the medicine is working is to keep a record of your symptoms. You can keep a record of your symptoms using the chart on page xx . If the medicine is not working for you (your symptoms are getting worse or not getting better), your clinician may recommend a blood test to see whether you are getting the right amount of medication in your body.

There are many things that your clinician can do if the medicine is not working. These are:

• Adjust the dose
• Change the medicine
• Add psychotherapy
• Add a medicine

Feeling Better

Continuation treatment. Once you are feeling better for awhile, you and your clinician will decide if this episode of depression has ended. In most cases, you should continue to take the antidepressant medicine for several months. Research clearly shows that continuation treatment with medicine helps prevent a relapse (a return) of the depressive episode.

After 4 to 9 months of continuation treatment, if you continue to feel good, you have recovered from this episode of depression. If you have had only a single episode of depression, continuation treatment can be stopped with a good chance that you will remain well. Nearly all patients who are on continuation treatment will stay well during that time.

Maintenance treatment. Some people with depression need maintenance (long-term) treatment. If you have had at least three episodes of depression or if you have bipolar disorder, you will need maintenance treatment to stay well. Research clearly shows that maintenance treatment with medicine prevents a new episode of depression. Some antidepressant medicines have been used by patients for 30 or more years with no bad effects.

Before starting maintenance treatment, you and your doctor should discuss its costs and benefits

Types of Psychotherapy

Psychotherapy can be individual (only you and a therapist); it can be group therapy (with a therapist, you, and other people with similar problems); or it can be family or marriage therapy (with a therapist, you, and family members, loved ones, or spouse).

Your health care provider will help you decide if psychotherapy is the right treatment for your depression.

Psychotherapy alone is not recommended as the only treatment for severe depression or for bipolar (manic-depressive) illness. Medicine is needed for these types of depression.

Three psychotherapies have been most well studied for their effectiveness in reducing symptoms of major depressive disorder. They are:

• Behavioral therapy -- focuses on current behaviors.
• Cognitive therapy -- focuses on thoughts and thinking patterns.
• Interpersonal therapy -- focuses on current relationships.

Choosing Psychotherapy

If you choose psychotherapy you need to:

• Keep your appointments.
• Be honest and open with your clinician.
• Do the tasks if assigned to you by your clinician.
• Tell your clinician how the treatment is working.

You can use the weekly record at the back of this booklet to keep track of your appointments, activities, and symptoms.

The cognitive, behavioral, and interpersonal therapies usually work gradually. Although psychotherapy may begin to work right away, it may take 8 to 10 weeks to show a full effect for some people. More than half of the patients with mild to moderate forms of major depression respond well to psychotherapy.

As with medicine, it is important to remember that people can react differently to similar treatments. While many people find psychotherapy effective, others do not. This usually means that another treatment is needed.

If you do not feel any better at all after 6 weeks, or if you are not completely well by 12 weeks, talk to your clinician about other treatments.

Continuation psychotherapy. If your depression gets better with psychotherapy, you and your clinician can decide if your therapy should continue and for how long.

Maintenance psychotherapy. In general, maintenance (long-term) psychotherapy by itself is not recommended unless there are reasons, such as pregnancy, or severe side effects, that keep you from taking medicine. While maintenance psychotherapy does not prevent another episode of depression, some research suggests that it can delay a recurrence.

Electroconvulsive Therapy

Most depressions, even severe depressions, can be treated completely with medicine, psychotherapy, or the combination of both. Electroconvulsive therapy, (ECT) works to remove the symptoms of depression. It is mostly used for severely depressed patients who have not responded to antidepressant medicines. It can also be used for patients who are severely depressed and have other severe general medical illnesses. ECT is much safer than in years past. General anesthesia and special muscle relaxing medicines are used to prevent physical harm and pain during the ECT. The choice of ECT as a treatment and the possible side effects should be discussed with a psychiatrist. As with other treatments, the psychiatrist will monitor the ECT treatment and check for side effects.

Light Therapy

In light therapy, a special kind of light called broad-spectrum light is used to give people the effect of having a few extra hours of daylight each day. Specially made light boxes or light visors are used to provide this light. Light therapy may help people who have mild or moderate seasonal depression. This treatment should only be given by a specialist until it has been studied more thoroughly.

Taking Care of Yourself

When you are depressed, it is important to:

• Pace yourself. Do not expect to do all of the things you were able to do in the past. Set a schedule that is realistic for you.
• Remember that negative thinking (blaming yourself, feeling hopeless, expecting failure, and other such thoughts) is part of a depression. As the depression lifts, the negative thinking will go away, too.
• Avoid making major life decisions during a depression. If you must make a major decision about your life, ask your clinician or someone you trust to help you.
• Avoid drugs and alcohol. Research shows that drinking too much alcohol and use of drugs can cause or worsen a depression. It can also lower the effectiveness of antidepressant medicines or cause dangerous side effects.
• Understand that it took time for the depression to develop and it will take time for it to go away.

There is some evidence in milder cases of depression that exercise can be helpful in reducing symptoms.

You can get information about other ways to help yourself during treatment is available from the organizations listed on the inside front cover of this booklet. Your public library also has books about depression.

Your Family and Friends

Ask your friends for their support, understanding, and patience during your depression. It may be helpful to talk to your friends about your feelings and treatment, and to spend time with friends in social activities. Keep the name and phone number of people that you can talk to and to ask to help you. Some people find it difficult, almost a burden, to interact with people during this time. If you feel this way, do whatever lifts your mood and makes you feel better. If you find yourself alone and unable to interact with others, tell your clinician. Many people find that family members are very supportive and helpful, especially those who have received education about depression.

Your children

Parents often worry about whether depression is inherited. Most children of people with depression will not get this illness. Overall, research shows that only about 1 in 7 children with one parent who has had several episodes of major depressive disorder or bipolar disorder will develop major depressive disorder. Another 1 in 7 children with one parent who has bipolar disorder will develop bipolar disorder. If you have questions about your child's mental health talk to a clinician.