Depression

Depressive disorder, frequently referred to simply as depression, is more than just feeling sad or going through a rough patch. It’s a serious mental health condition that requires understanding and medical care. Left untreated, depression can be devastating for those who have it and their families. Fortunately, with early detection, diagnosis and a treatment plan consisting of medication, psychotherapy and healthy lifestyle choices, many people can and do get better.

Depression

Overview

Some will only experience one depressive episode in a lifetime, but for most, depressive disorder recurs. Without treatment, episodes may last a few months to several years.

More than 19 million U.S. adults—nearly 8% of the population—had at least one major depressive episode in the past year. People of all ages and all racial, ethnic and socioeconomic backgrounds experience depression, but it does affect some groups more than others.

Symptoms

Depression can present different symptoms, depending on the person. But for most people, depressive disorder changes how they function day-to-day, and typically for more than two weeks. Common symptoms include:

Changes in sleep
Changes in appetite
Lack of concentration
Loss of energy
Lack of interest in activities
Hopelessness or guilty thoughts
Changes in movement (less activity or agitation)
Physical aches and pains
Suicidal thoughts

Types of This Disorder

Major Depressive Disorder with a Seasonal Pattern (formerly known as seasonal affective disorder, or SAD) is characterized by recurrent episodes of depression in late fall and winter, alternating with periods of normal mood the rest of the year.

This disorder’s most common presentation is of an atypical depression. With classic depression, people tend to lose weight and sleep less. This condition is the kind of atypical depression often seen in bipolar disorder—people tend to gain weight and sleep more.

Although not everyone experiences all the following symptoms, the classic characteristics of Major Depressive Disorder with a Seasonal Pattern include:

Hypersomnia (or oversleeping)
Daytime fatigue
Overeating
Weight gain
Craving carbohydrates
Many people may experience other symptoms as well, including:

Decreased sexual interest
Lethargy
Hopelessness
Suicidal thoughts
Lack of interest in usual activities and decreased socialization



Major Depressive Disorder (MDD) with Peripartum Onset (also known as postpartum depression) is different than a temporary mood disturbance after childbirth. Up to 6% of women will experience a major depressive episode during pregnancy or in the first year following delivery. It is also estimated that 50% of all MDD episodes actually begin prior to delivery or postpartum. For this reason, all episodes are referred to collectively as “peripartum.”

Any woman can experience postpartum depression and it has no relationship to a woman's capacity to be a good mother. With treatment, she can feel better.

Postpartum depression can present different symptoms, depending on the person. But common symptoms include:

Extreme difficulty in day-to-day functioning
Feelings of guilt, anxiety and fear
Loss of pleasure in life
Insomnia
Bouts of crying
Thoughts of hurting oneself or the infant

Psychotic symptoms in the peripartum timeframe are less common after childbirth and are characterized by seeing things that don't exist, confusion, rapid mood swings and thoughts of harming oneself or the infant. These symptoms only occur in about 1 of every 1,000 births. Women who have bipolar disorder or schizoaffective disorder are at increased risk of having psychotic symptoms, but they can also occur in women with no prior history.

Causes

Depression does not have a single cause. It can be triggered by a life crisis, physical illness or something else—but it can also occur spontaneously. Scientists believe several factors can contribute to depression:

Trauma. When people experience trauma at an early age, it can cause long-term changes in how their brains respond to fear and stress. These changes may lead to depression.
Genetics. Mood disorders, such as depression, tend to run in families.
Life circumstances. Marital status, relationship changes, financial standing and where a person lives influence whether a person develops depression.
Brain changes. Imaging studies have shown that the frontal lobe of the brain becomes less active when a person is depressed. Depression is also associated with changes in how the pituitary gland and hypothalamus respond to hormone stimulation.
Other medical conditions. People who have a history of sleep disturbances, medical illness, chronic pain, anxiety and attention-deficit hyperactivity disorder (ADHD) are more likely to develop depression. Some medical syndromes (like hypothyroidism) can mimic depressive disorder. Some medications can also cause symptoms of depression.
Drug and alcohol misuse. 21% of adults with a subtance use disorder also experienced a major depressive episode in 2018. Co-occurring disorders require coordinated treatment for both conditions, as alcohol can worsen depressive symptoms.

Diagnosis

To be diagnosed with depressive disorder, a person must have experienced a depressive episode lasting longer than two weeks. The symptoms of a depressive episode include:

Loss of interest or loss of pleasure in all activities
Change in appetite or weight
Sleep disturbances
Feeling agitated or feeling slowed down
Fatigue
Feelings of low self-worth, guilt or shortcomings
Difficulty concentrating or making decisions
Suicidal thoughts or intentions

Treatments

Many treatment options are available for depression, but how well treatment works depends on the type of depression and its severity. For most people, psychotherapy and medications give better results together than either alone, but this is something to review with your mental health care provider.

Psychotherapy
Psychotherapy (or talk therapy) has an excellent track record of helping people with depressive disorder. While some psychotherapies have been researched more than others, many types can be helpful and effective. A good relationship with a therapist can help improve outcomes.

Many clinicians are trained in more than one kind of psychotherapy, so ask your clinician what kind of psychotherapy they practice and how it can help you. A few examples include:

Cognitive behavioral therapy (CBT) has a strong research base to show it helps with symptoms of depression. This therapy helps assess and change negative thinking patterns associated with depression. The goal of this structured therapy is to recognize negative thoughts and to teach coping strategies. CBT is often time-limited and may be limited to 8–16 sessions in some instances.

Interpersonal therapy (IPT) focuses on improving problems in personal relationships and other changes in life that may be contributing to depressive disorder. Therapists teach individuals to evaluate their interactions and to improve how they relate to others. IPT is often time-limited like CBT.

Psychodynamic therapy is a therapeutic approach rooted in recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Looking at a person’s unconscious processes is another component of this psychotherapy. It can be done in short-term or longer-term modes.
Psychoeducation And Support Groups
Psychoeducation involves teaching individuals about their illness, how to treat it and how to recognize signs of relapse. Family psychoeducation is also helpful for family members who want to understand what their loved one is experiencing.

Support groups, meanwhile, provide participants an opportunity to share experiences and coping strategies. Support groups may be for the person with the mental health condition, for family/friends or a combination of both. Mental health professionals lead some support groups, but groups can also be peer-led.

Explore NAMI’s nationwide offerings of free educational programs and support groups that provide outstanding education, skills training and support.

Medications
For some people, antidepressant medications may help reduce or control symptoms. Antidepressants often take 2-4 weeks to begin having an effect and up to 12 weeks to reach full effect. Most people will have to try various doses or medications to find what works for them. Here are some antidepressants commonly used to treat depression:

Selective serotonin reuptake inhibitors (SSRIs) act on serotonin, a brain chemical. They are the most common medications prescribed for depression.

Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
​Serotonin and norepinephrine reuptake inhibitors (SNRIs) are the second most common antidepressants. These medications increase serotonin and norepinephrine.

Venlafazine (Effexor)
Desvenlafazine (Pristiq)
Duloxetine (Cymbalta)
Norepinephrine-dopamine reuptake inhibitors (NDRIs) increase dopamine and norepinephrine. Bupropion (Wellbutrin) is a popular NDRI medication, which causes fewer (and different) side effects than other antidepressants. For some people, bupropion causes anxiety symptoms, but for others it is an effective treatment for anxiety.

Mirtazapine (Remeron) targets specific serotonin and norepinephrine receptors in the brain, thus indirectly increasing the activity of several brain circuits. Mirtazapine is used less often than newer antidepressants (SSRIs, SNRIs and bupropion) because it is associated with more weight gain, sedation and sleepiness. However, it appears to be less likely to result in insomnia, sexual side effects and nausea than the SSRIs and SNRIs.

Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Second-generation antipsychotics (SGAs), or “atypical antipsychotics,” treat schizophrenia, acute mania, bipolar disorder and bipolar mania and other mental illnesses. SGAs can be used for treatment-resistant depression.

Aripiprazole (Abilify)
Quetiapine (Seroquel)
Tricyclic antidepressants (TCAs) are older medications, seldom used today as initial treatment for depression. They work similarly to SNRIs but have more side effects. They are sometimes used when other antidepressants have not worked. TCAs may also ease chronic pain.

Amitriptyline (Elavil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor, Avantyl)
Protriptyline (Vivactil)
Monoamine oxidase inhibitors (MAOIs) are less used today because newer, more effective medications with fewer side effects have been found. These medications can never be used in combination with SSRIs. MAOIs can sometimes be effective for people who do not respond to other medications.

Phenelzine (Nardil)
Isocarboxazid (Marplan)
Tranylcypromine Sulfate (Parnate)
Selegiline patch (Emsam)
Brain Stimulation Therapies
For some, brain stimulation therapies may be effective, typically after other treatments have not been effective.

Electroconvulsive Therapy (ECT) involves transmitting short electrical impulses into the brain. ECT does cause some side effects, including memory loss. Individuals should understand the risks and benefits of this intervention before beginning a treatment trial.

Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of an electrical current to activate the brain. It is not effective as a maintenance treatment.

Vagus Nerve Stimulation (VNS) has a complex history. For a fuller understanding of this treatment, read the NIMH summary of this and other brain stimulation interventions.
Complementary And Alternative Medicine (CAM)
Relying solely on CAM methods is not enough to treat depression, but they may be useful when combined with psychotherapy and medication. Discuss your ideas of CAM interventions with your health care professional to be sure they will not cause side effects or adverse reactions.

The National Center for Complementary and Integrative Health reviews research on complementary treatments. You can search for each intervention on their website.

Exercise. Studies show that aerobic exercise can help treat mild depression because it increases endorphins and stimulates norepinephrine, which can improve a person’s mood.

Folate. Some studies have shown that when people with depression lack folate (also called folic acid or vitamin B9), they may not be receiving the full benefit from any antidepressants they may be taking. Studies suggest that in some situations taking L-methylfolate (an active form of folate) can be an additional treatment with other psychiatric medications.

St John’s Wort. This supplement has similar chemical properties to some SSRIs. Risks of combining St John’s Wort with SSRIs and other medications are well-known and substantial.
Experimental Treatments
These following treatments are not FDA-approved but are being researched:

Ketamine. Ketamine, which may offer a new model in treating depression, may have potentially quick and short-term impact on depression and suicidal thoughts. Ketamine is an anesthetic with a street value (special K) that has not been studied for long-term use. It can make psychosis worse and is not an ideal choice for people with substance use disorders.

Deep Brain Stimulation. This treatment has been used to treat Parkinson’s disease. See the NIMH page on brain stimulation for more information.

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