Depression

Depression causes sadness and/or a loss of interest in activities once enjoyed. It can also decrease a person’s ability to function at work and at home.

• A depressive disorder is a mood disorder that is characterized by a sad, blue mood that goes above and beyond normal sadness or grief.
• A depressive disorder is a clinical syndrome, meaning a group of symptoms.
• Depressive disorders feature not only negative thoughts, moods, and behaviors but also specific changes in bodily functions (like, eating, sleeping, energy, and sexual activity, as well as potentially developing aches or pains).
• One in 10 people will have a depression in their lifetime.
• Because depression can lead to self-harm including suicide, it is important to note that one of every 25 suicide attempts results in death.
• Some types of depression, especially bipolar depression, run in families.
• While there are many social, psychological, and environmental risk factors for developing depression, some are particularly prevalent in one gender or the other, or a particular age or ethnic groups.
• There can be some differences in signs and symptoms of depression depending on age, gender, and ethnicity.
• Doctors clinically diagnose depression; there is no laboratory test or X-ray for depression. It is, therefore, crucial to see a health professional as soon as you notice symptoms of depression in yourself, your friends, or your family.
• The first step in getting appropriate treatment for a depressive disorder is a complete physical and psychological evaluation to determine whether the person, in fact, has a depressive disorder.
• Depression is not a weakness but a serious mental illness with biological, psychological, and social aspects to its cause, symptoms, and treatment. A person cannot will it away. Untreated or undertreated, it can worsen or return.
• There are many safe and effective medications, particularly the SSRI antidepressants, which can be of great help in the treatment of depression.
• For full recovery from a mood disorder, regardless of whether there is a precipitating factor or it seems to come out of the blue, treatments with medication, phototherapy, and/or brain stimulation therapies, like electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS), as well as psychotherapy and participation in support groups are often necessary.
• In the future, through depression research and education, we will continue to improve treatments, decrease society's burden, and hopefully improve the prevention of this illness.

Major depression is a period of sadness, irritability, or low motivation that occurs with other symptoms, lasts at least two weeks.

Depressive disorders are mood disorders that have been with mankind since the beginning of recorded history. In the Bible, King David, as well as Job, suffered from this affliction. Hippocrates referred to depression as melancholia, which literally means black bile. Black bile, along with blood, phlegm, and yellow bile were the four senses of humor (fluids) that described the basic medical physiology theory of that time. Literature and the arts have portrayed depression, also referred to as clinical depression, for hundreds of years, but what do we mean today when we refer to a depressive disorder? In the 19th century, people thought of depression as an inherited weakness of temperament. In the first half of the 20th century, Freud linked the development of depression to guilt and conflict. John Cheever, the author and a modern sufferer of depressive disorder, wrote of conflict and experiences with his parents as influencing his becoming clinically depressed.

In the 1950s and '60s, health care professionals divided depression into two types, endogenous and neurotic. Endogenous means that the depression comes from within the body, perhaps of genetic origin, or comes out of nowhere. Neurotic or reactive depression has a clear environmental precipitating factor, such as the death of a spouse, or other significant loss, such as the loss of a job. In the 1970s and '80s, the focus of attention shifted from the cause of depression to its effects on the afflicted people. That is to say, whatever the cause in a particular case, what are the symptoms and impaired functions that experts can agree make up a depressive illness? Although experts sometimes dispute these issues, most agree on the following:

1. A depressive disorder is a syndrome (a group of symptoms) characterized by sad and/or irritable mood exceeding normal sadness or grief. More specifically, the sadness of depression is characterized by a greater intensity and duration and by more severe symptoms and functional problems than is normal.
2. Depressive signs and symptoms not only include negative thoughts, moods, and behaviors but also specific changes in bodily functions (for example, excessive crying spells, body aches, low energy or libido, as well as problems with eating, weight, or sleeping). neurovegetative signs are the changes in functioning associated with clinical depression. This means that the nervous system changes in the brain are thought to cause many physical symptoms that result in a decreased or increased activity level and other problems with functioning.
3. People with certain depressive disorders, especially bipolar depression (manic depression), seem to have an inherited vulnerability to this condition.
4. Depressive illnesses are a huge public health problem, due to their affecting millions of people. Facts about depression include that about 10% of adults, up to 8% of teens, and 2% of preteen children experience some kind of depressive disorder. Postpartum depression is the most common mental health disorder to afflict women after childbirth.
   • The statistics on the costs due to depression in the United States include huge amounts of direct costs, which are for treatment, and indirect costs, such as lost productivity and absenteeism from work or school.
   • Adolescents who suffer from depression are at risk for developing and maintaining obesity.
   • In a major medical study, depression caused significant problems in the functioning (morbidity) of those affected more often than did arthritis, hypertension, chronic lung disease, diabetes, and in some ways as often as coronary artery disease.
   • Depression can increase the risks for developing coronary artery disease and asthma, contracting the human immunodeficiency virus (HIV), and many other medical illnesses. Other complications of depression include its tendency to increase the morbidity (illness/negative health effects) and mortality (death) from these and many other medical conditions.
   • Depression can coexist with virtually every other mental health condition, aggravating the status of those who suffer the combination of both depression and the other mental illness.
   • Depression in the elderly tends to be chronic, has a low rate of recovery, and is often undertreated. This is of particular concern given that elderly men, particularly elderly white men have the highest suicide rate.
5. Depression is usually first identified in a primary care setting, not in a mental health professional's office. Moreover, it often assumes various disguises, which causes depression to be frequently underdiagnosed.
6. In spite of clear research evidence and clinical guidelines regarding treatment, depression is often undertreated. Hopefully, this situation can change for the better.
7. For full recovery from a mood disorder, regardless of whether there is a precipitating factor or it seems to come out of the blue, treatment with medication, phototherapy, electroconvulsive therapy (ECT), and/or transcranial magnetic stimulation, (see discussion below), as well as psychotherapy and/or participation in a support group, is necessary.

Psychodynamic therapy helps the depression sufferer understand and come to terms with how issues from their past may unconsciously affect their current moods and actions.

The following are myths about depression and its treatment.

• It is a weakness rather than an illness.
• If the depression sufferer just tries hard enough, it will go away without treatment.
• If you ignore depression in yourself or a loved one, it will go away.
• Highly intelligent or highly accomplished people do not get depressed.
• Poor people do not get depressed.
• Minorities do not get depressed.
• People with developmental disabilities do not get depressed.
• People with depression are "crazy."
• Depression does not really exist.
• Children, teens, the elderly, or men do not get depressed.
• Depression cannot look like (present as) irritability.
• The symptoms of depression are the same for everyone who gets the illness.
• People who tell someone they are thinking about committing suicide are only trying to get attention and would never do it, especially if they have talked about it before.
• People with depression cannot have another mental or medical condition at the same time.
• Psychiatric medications are all addicting.
• Psychiatric medications do not work; any improvement felt is in the sufferer's imagination.
• Psychiatric medications are never necessary to treat depression.
• Medication is the only effective treatment for depression. People should never give children and teens antidepressant medication.

Depressive disorders are mood disorders that come in different forms, just as do other illnesses, such as heart disease and diabetes. However, remember that within each of these types, there are variations in the number, timing, severity, and persistence of symptoms. There are sometimes also differences in how individuals express and/or experience depression based on age, gender, and culture.

The pattern of symptoms may fit a pattern within any type of depression. For example, a person who suffers from persistent depressive disorder, major depressive disorder, bipolar disorder, or any other illness that includes depression can have prominently anxious, melancholic, mixed, psychotic, or atypical features. Such features can have a significant impact on the approach to treatment that may be most effective. For example, for the person whose depression includes prominent anxiety, a focus of treatment is more likely to be effective if the sufferer's pattern of repeatedly going over thoughts is a major focus of treatment, versus an individual with melancholic features, who may need more intensive support in the morning when the intensity of depression tends to be worse, or versus a person with atypical features, whose tendency toward weight gain and excessive sleeping may require nutritional counseling to address dietary issues.

Major depressive disorder

Major depression, also often referred to as unipolar depression, is characterized by a combination of symptoms that lasts for at least two weeks in a row, including depressed and/or irritable mood (see symptom list), that interferes with the ability to work, sleep, eat, and enjoy once-pleasurable activities. Difficulties in sleeping or eating can take the form of excessive or insufficient of either behavior. Disabling episodes of depression can occur once, twice, or several times in a lifetime.

Persistent depressive disorder (dysthymia)

Persistent depressive disorder, formerly referred to as dysthymia, is a less severe but usually more long-lasting type of depression (dysphoric) compared to major depression. It involves long-term (chronic) symptoms that do not disable but prevent the affected person from functioning at "full steam" or from feeling good. Sometimes, people with persistent depressive disorder also experience episodes of major depression. Double-depression is the name for this combination of the two types of depression.

Bipolar disorder (manic depression)

Another type of depression is bipolar disorder, which encompasses a group of mood disorders formerly called manic-depressive illness or manic depression. These conditions often show a particular pattern of inheritance. Not nearly as common as the other types of depressive illnesses, bipolar disorders involve cycles of mood that include at least one episode of mania or hypomania and may include episodes of depression, as well. Bipolar disorders are often chronic and recurring. Sometimes, the mood switches are dramatic and rapid, but most often they are gradual, in that they usually take place over several days, weeks, or longer.

When in the depressed cycle, the person can experience any or all of the symptoms of a depressive condition. When in the manic cycle, any or all of the symptoms listed later in this article under mania may be experienced. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, indiscriminate or otherwise unsafe sexual practices or unwise business or financial decisions may be made when an individual is in a manic phase.

Bipolar II disorder is a significant variant of the bipolar disorders. (The usual form of bipolar disorder is referred to as bipolar I disorder.) Bipolar II disorder is a syndrome in which the affected person has repeated depressive episodes punctuated by hypomania (mini-highs). These euphoric states in bipolar II do not completely meet the criteria for the full manic episodes that occur in bipolar I.

Symptoms of depression and mania

Not everyone who is depressed or manic experiences every symptom. Some people suffer from a few symptoms and some many symptoms. The severity of symptoms also varies with individuals. Less severe symptoms that precede the more debilitating symptoms are often called warning signs.

Depressive symptoms of major depression or manic depression

• Persistent feelings of sadness, anxiety, anger, irritability, discontent, or "emptiness"
• Feelings of hopelessness or pessimism
• Feelings of worthlessness, helplessness, or excessive guilt
• Loss of interest or inability to feel pleasure in hobbies and activities that individuals once enjoyed, including sex
• Apathy/lack of motivation
• Social isolation, meaning the sufferer avoids interactions with family or friends
• Sleep changes, like insomnia, early morning awakening, restless sleep, excess sleepiness, or oversleeping
• Appetite changes, like loss of appetite and/or weight, or excessive hunger, overeating, and/or weight gain
• Fatigue/tiredness, decreased energy levels, slowness in activity or thought
• Crying spells
• Thoughts of death or suicide, suicide attempts
• Restlessness, agitation, irritability
• Inability to concentrate, remember things, make decisions, or to handle responsibilities
• Persistent physical symptoms that do not respond to treatment, such as repeated headaches, digestive disorders, and/or chronic pain

Mania symptoms of manic depression

• Inappropriate or excessive elation/expansive mood
• Inappropriate or excessive irritability or anger
• Severe insomnia or decreased need to sleep
• Grandiose notions, like having special powers or importance
• Increased talking speed and/or volume
• Disconnected/tangential thoughts or speech
• Racing thoughts
• Severely increased sexual desire and/or activity
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

The most prominent symptoms of depression are usually a sad or irritable mood and/or loss of interest in all or most activities that used to be pleasurable.

Compared to women, men with depression are more likely to experience low energy, irritability, and anger, sometimes to the point of inflicting pain on others. Men with depression are also more likely to exhibit sleep problems, a loss of interest in work or hobbies, and substance abuse. They may work excessively and engage in more risky behaviors when struggling with depression, committing suicide four times as often as women with this condition. Despite these difficulties, men tend to be much less likely to receive treatment for any condition, particularly depression.

Some individuals with depression experience an increase or decrease in appetite, which may lead to substantial loss or gain in weight.

In comparison to men, women tend to develop depression at an earlier age and have depressive episodes that last longer and tend to recur more often. Women may more often have a seasonal pattern to depression, as well as symptoms of atypical depression (for example, eating or sleeping too much, carbohydrate craving, weight gain, a heavy feeling in the arms and legs, mood worsening in the evenings, and trouble getting to sleep). Also, women with depression more often have anxiety, eating disorders, and dependent personality symptoms compared to men.

Perimenopause, which is the time of life immediately before and after menopause, can last as long as 10 years. While perimenopause and menopause are normal stages of life, perimenopause increases the risk of depression during that time. Also, women who have had depression in the past are five times more likely to develop major depression during perimenopause.

In addition to becoming more irritable, teens might lose interest in activities they formerly enjoyed, experience a change in their weight, and start abusing substances. They may also take more risks, show less concern for their safety, and they are more likely to complete suicide than their younger counterparts when depressed. Generally, acne increases the risk of teen depression.

Since babies, toddlers, and preschool children are usually unable to express their feelings in words, they tend to show sadness in their behaviors. For example, they may become withdrawn, resume old, younger behaviors (regress), or fail to thrive. School-age children might regress in their school performance, develop physical complaints, anxiety, or irritability. Interestingly, some children may try more, sometimes even excessively, to please others when depressed as a way of compensating for their low self-esteem. Therefore, their good grades and apparently good relationships with others may make depression harder to recognize.

Children and adolescents with depression may also experience the classic symptoms as adults as described above, but they may exhibit other symptoms instead of or in addition to those symptoms, including the following:

• Poor school performance
• Persistent boredom or irritability
• Frequent complaints of physical problems such as headaches and stomachaches
• Some of the classic "adult" symptoms of depression may also be more or less obvious during childhood compared to the actual emotions of sadness, such as a change in eating or sleeping patterns. (Has the child or teen lost or gained weight or failed to gain appropriate weight for their age in recent weeks or months? Does he or she seem more tired than usual? Does the minor have a sense of low self-worth?)

Some types of depression run in families, indicating an inheritable biological vulnerability to depression. This seems to be the case, especially with bipolar disorder. Researchers have studied families in which members of each generation develop bipolar disorder. The investigators found that those with the illness have a somewhat different genetic makeup than those who do not become ill. However, the reverse is not true. That is, not everybody with the genetic makeup that causes vulnerability to bipolar disorder will develop the illness. Apparently, additional factors, like a stressful environment, are involved in its onset and protective factors, like good support from family and friends, are involved in its prevention.

Major depression also seems to occur in generation after generation in some families, although not as strongly as in bipolar I or II. Indeed, major depression can also occur in people who have no family history of depression.

An external event often seems to initiate an episode of depression. Thus, a serious loss, chronic illness, difficult relationship, exposure to abuse, neglect or community violence, financial problem, or any negative life events or unwelcome changes in life patterns can trigger a depressive episode and chronic exposure to such negative factors can result in persistent depression. People exposed to numerous and/or severe stressors as young children may develop changes in their brain structure that may make them prone to developing depression during adulthood.

Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Stressors that contribute to the development of depression sometimes affect some groups more than others. For example, minority groups who more often feel impacted by discrimination are disproportionately represented. Socioeconomically disadvantaged groups have higher rates of depression compared to their advantaged counterparts. Immigrants to the United States may be more vulnerable to developing depression, particularly when isolated by language.

Regardless of ethnicity, men appear to be particularly sensitive to the depressive effects of unemployment, divorce, low socioeconomic status, and having few good ways to cope with stress. Women who have been the victim of physical, emotional, or sexual abuse, either as a child or perpetrated by a romantic partner are vulnerable to developing a depressive disorder, as well. Men who engage in sex with other men seem to be particularly vulnerable to depression when they have no domestic partner, do not identify themselves as homosexual, or have been the victim of multiple episodes of antigay violence. However, it seems that men and women have similar risk factors for depression for the most part.

Nothing in the universe is as complex and fascinating as the human brain. Neurochemicals or neurotransmitters make up the 100-plus chemicals that circulate in the brain. Much of our research and knowledge, however, has focused on four of these neurochemical systems: norepinephrine, serotonin, dopamine, and acetylcholine.

Different neuropsychiatric illnesses seem to be associated with an overabundance or a lack of some of these neurochemicals in certain parts of the brain. For example, a lack of dopamine at the base of the brain causes Parkinson's disease. There appears to be a relation between Alzheimer's dementia and lower acetylcholine levels in the brain. The addictive disorders are under the influence of the neurochemical dopamine. That is to say, drugs of abuse and alcohol work by releasing dopamine in the brain. The dopamine causes euphoria, which is a pleasant sensation. Repeated use of drugs or alcohol, however, desensitizes the dopamine system, which means that the system gets used to the effects of drugs and alcohol. Therefore, a person needs more drugs or alcohol to achieve the same high feeling (builds up tolerance to the substance). Thus, the addicted person takes more substance but feels less and less high and increasingly depressed. There are also some drugs whose effects can include depression (these include alcohol, narcotics, and marijuana) and those for whom depression can be a symptom of withdrawal from the substance (including caffeine, cocaine, or amphetamines).

Certain medications used for a variety of medical conditions are more likely than others to cause depression as a side effect. Specifically, some medications that treat high blood pressure, cancer, seizures, extreme pain, and to achieve contraception can result in depression. Even some psychiatric medications, like some sleep aids and medications to treat alcoholism and anxiety, can contribute to the development of depression.

Many mental health conditions or developmental disabilities are associated with depression, as well. Individuals with anxiety, attention deficit hyperactivity disorder (ADHD), substance abuse, and developmental disabilities may be more vulnerable to developing depression.

Schizophrenia is associated with an imbalance of dopamine (too much) and serotonin (poorly regulated) in certain areas of the brain. Finally, the depressive disorders appear to be associated with altered brain serotonin and norepinephrine systems. Both of these neurochemicals may be lower in depressed people. Please note that depression is "associated with" instead of "caused by" abnormalities of these neurochemicals because we really don't know whether low levels of neurochemicals in the brain cause depression or whether depression causes low levels of neurochemicals in the brain.

What we do know is certain medications that alter the levels of norepinephrine or serotonin can alleviate the symptoms of depression. Some medicines that affect both of these neurochemical systems appear to perform even better or faster. Other medications that treat depression primarily affect the other neurochemical systems. One of the most powerful treatments for depression, electroconvulsive therapy (ECT), is certainly not specific to any particular neurotransmitter system. Rather, ECT, by causing a seizure, produces a generalized brain activity that probably releases massive amounts of all of the neurochemicals.

Women are twice as likely to become depressed as men. However, scientists do not know the reason for this difference. Psychological factors also contribute to a person's vulnerability to depression. Thus, persistent deprivation in infancy, physical or sexual abuse, exposure to community violence, clusters of certain personality traits, and inadequate ways of coping (maladaptive coping mechanisms) all can increase the frequency and severity of depressive disorders, with or without inherited vulnerability.

The presence of maternal-fetal stress is another risk factor for depression. It seems that maternal stress during pregnancy can increase the chance that the child will be prone to depression as an adult, particularly if there is a genetic vulnerability. Researchers believe that the mother's circulating stress hormones can influence the development of the fetus' brain during pregnancy. This altered fetal brain development occurs in ways that predispose the child to the risk of depression as an adult. Further research is still necessary to clarify how this happens. Again, this situation shows the complex interaction between genetic vulnerability and environmental stress, in this case, the stress of the mother on the fetus.

Postpartum depression (PPD) is a condition that describes a range of physical and emotional changes that many mothers can have after having a baby. PPD can be treated with medication and counseling. Talk with your health care provider right away if you think you have PPD that is interfering with your ability to function in any way.

There are three types of PPD women can have after giving birth:

1. The so-called "baby blues" happen in many women in the days right after childbirth. A new mother can have sudden mood swings, such as feeling very happy and then feeling very sad or angry. She may cry for no reason and can feel impatient, irritable, restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long as one to two weeks after delivery. The baby blues do not always require treatment from a health care professional. Often, sharing childcare duties, maintaining contacts with loved ones, joining a support group of new moms, or talking with other moms helps.
2. Postpartum depression (PPD) can happen a few days or even months after childbirth. PPD can happen after the birth of any child, not just the first child. A woman can have feelings similar to the baby blues -- sadness, despair, anxiety, irritability -- but she feels them much more strongly than she would with the baby blues. PPD often keeps a woman from doing the things she needs to do every day. If PPD affects a woman's ability to function, this is a sure sign that she needs to see her health care professional right away. If a woman does not get treatment for PPD, symptoms can get worse and last for as long as one year. While PPD is a serious condition, it can be treated with medication and counseling.
3. Postpartum psychosis is a very serious mental illness that can affect new mothers. This illness can happen quickly, often within the first three months after childbirth. Women can experience psychotic depression, in that the depression causes them to lose touch with reality, have auditory hallucinations (hearing things that aren't actually happening, like a person talking when there is no one there), and delusions (interpreting things completely differently from what they are in reality). Visual hallucinations (seeing things that aren't there) are less common. Other symptoms include insomnia (not being able to sleep), feeling agitated (unsettled) and angry, strange feelings and behaviors, as well as less commonly having suicidal or homicidal thoughts. Women who have postpartum psychosis need treatment right away and almost always need medication. Sometimes doctors hospitalize women because they are at risk for hurting themselves or someone else, including their baby.

A variety of health care specialists evaluate and treat people with this condition, including the following:

• Primary care providers like family doctors, internal-medicine practitioners, gynecologists, or geriatricians (physicians who specialize in treating the elderly)
• Mental health specialists, such as psychiatrists, clinical psychologists, social workers, pastoral or mental health nurses, or other counselors
• Primary care or mental health prescribers, like physician assistants or nurse practitioners
• Health-maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Community support groups, often hospital affiliated
• University or medical school-affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

People who wonder if they should talk to their health professional about whether or not they have depression might consider taking a depression quiz or self-test, which asks questions about depressive symptoms that are included in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), the accepted diagnostic reference for mental illnesses. In thinking about when to seek medical advice about depression, the sufferer can benefit from considering if the sadness lasts more than two weeks or so or if the way they are feeling significantly interferes with their ability to function at home, school, work, or in their relationships with others. The first step to getting appropriate treatment is accurate diagnosis, which requires a complete physical and psychological evaluation to determine whether the person may have a depressive illness, and if so, what type. As previously mentioned, the side effects of certain medications, as well as some medical conditions and exposure to certain drugs of abuse, can include symptoms of depression. Therefore, the examining physician should rule out (exclude) these possibilities through a clinical interview, physical examination, and laboratory tests. Many primary care doctors use screening tools, which are symptom tests, for depression. Such tests are usually questionnaires that help identify people who have symptoms of depression and may need to receive a full mental health evaluation.

A thorough diagnostic evaluation includes a complete history of the patient's symptoms:

1. When did the symptoms start and under what circumstances/stressors?
2. How long have symptoms lasted?
3. How severe are the symptoms?
4. Have the symptoms occurred before, and if so, were they treated, what treatment was received, and was it effective?

The doctor usually asks about alcohol and drug use and whether the patient has had thoughts about death or suicide. Further, the history often includes questions about whether other family members have had a depressive illness, and if treated, what treatments they received and which were effective. Professionals are becoming increasingly aware of the importance of exploring potential cultural differences in how people with depression experience, understand, and express depression in order to appropriately assess and treat this condition.

A diagnostic evaluation also includes a mental-status examination to determine if the patient's speech, thought pattern, or memory has been affected, as often happens in the case of a depressive or manic-depressive illness.

As of today, there is no laboratory test, blood test, or X-ray that can diagnose a mental disorder. Even the powerful CT, MRI, SPECT, and PET scans, which can help diagnose other neurological disorders such as stroke or brain tumors, cannot detect the subtle and complex brain changes in psychiatric illness. However, these techniques are currently useful ruling out the presence of a number of physical disorders and in research on mental health and perhaps in the future they will be useful for the diagnosis of depression, as well.

Regardless of the medication that treats depression, practitioners have become more aware that both genders, each age group, and different ethnic groups may have different responses and have different risks for medication side effects than others. Also, while there are certainly treatment methods that have been determined to be effective across populations, given the individual variability of response to treatment, there should not be a one-size-fits-all approach to treatment.

Antidepressant medications

Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of the neurochemical serotonin in the brain. (Remember that brain serotonin levels often are low in depression.) As their name implies, the SSRIs work by selectively inhibiting (blocking) serotonin reuptake in the brain. This block occurs at the synapse, the place where brain cells (neurons) connect to each other. Serotonin is one of the chemicals in the brain that carries messages across these connections (synapses) from one neuron to another.

The SSRIs work by keeping serotonin present in high concentrations in the synapses. These drugs do this by preventing the reuptake of serotonin back into the sending nerve cell. The reuptake of serotonin is responsible for turning off the production of new serotonin. Therefore, the serotonin message keeps on coming through. This, in turn, helps arouse (activate) cells that have been deactivated by depression, thereby relieving the depressed person's symptoms. SSRIs have fewer side effects than the tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). SSRIs do not interact with the chemical tyramine in foods, as do the MAOIs, and therefore do not require the dietary restrictions of the MAOIs. Also, SSRIs do not cause orthostatic hypotension (sudden drop in blood pressure when sitting up or standing) and are less likely to predispose to heart-rhythm disturbances like the TCAs do. Therefore, SSRIs are often the first-line treatment for depression. Examples of SSRIs include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox), escitalopram (Lexapro), vortioxetine (Trintellix), and vilazodone (Viibryd).

Patients generally tolerate SSRIs well, and side effects are usually mild. The most common side effects are nausea and other stomach upset, diarrhea, agitation, insomnia, and headache. However, these side effects generally go away within the first month of SSRI use. Some patients experience sexual side effects, such as decreased sexual desire (decreased libido), delayed orgasm, or an inability to have an orgasm. Sexual side effects occur less often with newer SSRIs like vortioxetine and vilazodone, compared to the older medications in this category. For those patients, especially for whom anxiety is a prominent symptom of depression, the addition of buspirone may help enhance the effectiveness (augment) the effect of the SSRI while decreasing or eliminating sexual side effects. Uncommonly, some patients experience tremors, hair loss, or gradual weight gain with SSRIs. The so-called serotonergic (meaning caused by serotonin) syndrome is a serious neurologic condition associated with the use of SSRIs, usually when given in high doses or in combination with another SSRI. High fevers, seizures, and heart-rhythm disturbances characterize serotonergic syndrome. This condition is very rare and tends to occur only in very ill psychiatric patients taking multiple psychiatric medications.

All patients are unique biochemically. Therefore, the occurrence of side effects or the lack of a satisfactory result with one SSRI does not mean that another medication in this group will not be beneficial. However, if someone in the patient's family has had a positive response to a particular drug, that drug may be the preferable one to try first.

Dual-action antidepressants: The biochemical reality is that all classes of medications that treat depression (MAOIs, SSRIs, TCAs, and atypical antidepressants) have some effect on both norepinephrine and serotonin, as well as on other neurotransmitters. However, the various medications affect the different neurotransmitters in varying degrees.

Some of the newer antidepressant drugs, however, appear to have particularly robust effects on both the norepinephrine and serotonin systems. These medications seem to be very promising, especially for the more severe and chronic cases of depression. (Psychiatrists and other mental health professionals, rather than family practitioners, see such cases most frequently.) Venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima) are four of these dual-action compounds. Effexor is a serotonin reuptake inhibitor that, at lower doses, shares many of the safety and low side-effect characteristics of the SSRIs. At higher doses, this drug appears to block the reuptake of norepinephrine. Thus, venlafaxine is an SNRI, a serotonin and norepinephrine reuptake inhibitor. Cymbalta and Pristiq tend to act as equally powerful serotonin reuptake inhibitors and norepinephrine reuptake inhibitors regardless of the dose, Fetzima even more so. They are, therefore, also SNRIs.

Mirtazapine (Remeron), another antidepressant, is a tetracyclic compound (four-ring chemical structure). It works at somewhat different biochemical sites and in different ways than the other medications. It affects serotonin but at a postsynaptic site (after the connection between nerve cells). It also increases histamine levels, which can cause drowsiness. For this reason, patients take mirtazapine at bedtime; physicians often prescribe mirtazapine for people who have trouble falling asleep. Like the SNRIs, it also works by increasing levels in the norepinephrine system. Other than causing sedation, this medication has side effects that are similar to those of the SSRIs.

Atypical antidepressants work in a variety of ways. Thus, atypical antidepressants are not TCAs, SSRIs, or SNRIs, but they can be effective in treating depression for many people nonetheless. More specifically, they increase the level of certain neurochemicals in the brain synapses (between nerves, where nerves communicate with each other). Examples of atypical antidepressants include nefazodone (Serzone), trazodone (Desyrel), and bupropion (Wellbutrin). Serzone has come under scrutiny due to rare cases of life-threatening liver failure that have occurred in some individuals while taking it. The United States Food and Drug Administration (FDA) has also approved bupropion (Zyban) for use in weaning from addiction to cigarettes. This drug is also being studied for treating attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). These problems affect many children and adults and restrict their ability to manage their impulses and activity level, focus, or concentrate on one thing at a time.

Lithium (Eskalith, Lithobid), valproate (Depakene, Depakote), carbamazepine (Epitol, Tegretol), and lamotrigine (Lamictal) are mood stabilizers and, except for lithium, are used to treat seizures (anticonvulsants). They treat bipolar depression. Certain antipsychotic medications, such as ziprasidone (Geodon), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), asenapine (Saphris), paliperidone (Invega), iloperidone (Fanapt), lurasidone (Latuda), and brexpiprazole (Rexulti), may treat psychotic depression. They have also been found to be effective mood stabilizers and are therefore sometimes been used to treat bipolar depression, usually in combination with other antidepressants.

Monoamine oxidase inhibitors (MAOIs) are the earliest developed antidepressants. Examples of MAOIs include phenelzine (Nardil) and tranylcypromine (Parnate). MAOIs elevate the levels of neurochemicals in the brain synapses by inhibiting monoamine oxidase. Monoamine oxidase is the main enzyme that breaks down neurochemicals, such as norepinephrine. When monoamine oxidase is inhibited, the norepinephrine is not broken down and, therefore, the amount of norepinephrine in the brain is increased.

MAOIs also impair the ability to break down tyramine, a substance found in aged cheese, wines, most nuts, chocolate, certain processed meats, and some other foods. Tyramine, like norepinephrine, can elevate blood pressure. Therefore, the consumption of tyramine-containing foods by a patient taking an MAOI drug can cause elevated blood levels of tyramine and dangerously high blood pressure. In addition, MAOIs can interact with over-the-counter cold and cough medications to cause dangerously high blood pressure. The reason for this is that these cold and cough medications often contain drugs that likewise can increase blood pressure. Because of these potentially serious drug and food interactions, MAOIs are usually only prescribed for people who are thought to be willing and able to manage the many dietary restrictions required by these medications and after other treatment options have failed.

Tricyclic antidepressants (TCAs) were developed in the 1950s and '60s to treat depression. They are called tricyclic antidepressants because their chemical structures consist of three chemical rings. TCAs work mainly by increasing the level of norepinephrine in the brain synapses, although they also may affect serotonin levels. Doctors often use TCAs to treat moderate to severe depression. Examples of tricyclic antidepressants are amitriptyline (Elavil), protriptyline (Vivactil), desipramine (Norpramin), nortriptyline (Aventyl, Pamelor), imipramine (Tofranil), trimipramine (Surmontil), and perphenazine (Triavil).

Tetracyclic antidepressants are similar in action to tricyclics, but their structure has four chemical rings. Examples of tetracyclics include maprotiline (Ludiomil) and mirtazapine (Remeron).

TCAs are safe and generally well tolerated when properly prescribed and administered. However, if taken in overdose, TCAs can cause life-threatening heart-rhythm disturbances. Some TCAs can also have anticholinergic side effects, which are due to the blocking of the activity of the nerves that are responsible for control of the heart rate, gut motion, visual focus, and saliva production. Thus, some TCAs can produce dry mouth, blurred vision, constipation, and dizziness upon standing. The dizziness results from low blood pressure that occurs upon standing (orthostatic hypotension). Anticholinergic side effects can also aggravate narrow-angle glaucoma, urinary obstruction due to benign prostate enlargement (hypertrophy), and cause delirium in the elderly. Patients with seizure disorders or a history of strokes should avoid TCAs.

Stimulants such as methylphenidate (Ritalin) or dextroamphetamine (Dexedrine), or their derivatives (for example, Concerta, Metadate or Focalin; Adderall or Vyvanse, or extended-release mixed salts of amphetamine [Mydayis] respectively), which are primarily used to treat attention deficit hyperactivity disorder (ADHD), are also used for the treatment of depression that is resistant to other medications. The stimulants are most commonly used along with other antidepressants or other medications, such as mood stabilizers, antipsychotics, or even thyroid hormone. They are sometimes used alone to treat depression but rarely. The reason they are usually used sparingly and with other medications for depression is that unlike the other medications, they may induce an emotional rush and a high in both depressed and nondepressed people, particularly if taken in doses or ways other than how they are prescribed. Therefore, the stimulants are potentially addictive drugs.

Phototherapy

Phototherapy, a particularly effective treatment for seasonal affective disorder, entails the individual with depression being exposed to cool-white florescent light at a strength of 10,000 lux for half an hour every day.

Electroconvulsive therapy (ECT)

With the ECT procedure, a brain stimulation therapy, a physician passes an electric current through the brain to produce controlled convulsions (seizures). ECT is useful for certain patients, particularly for those who cannot take or have not responded to a number of antidepressants, have severe depression, and/or are at a high risk for suicide. ECT often is effective in cases where trials of a number of antidepressant medications do not provide sufficient relief of symptoms. This procedure probably works, as previously mentioned, by a massive neurochemical release in the brain due to the controlled seizure. Often highly effective, ECT relieves depression within one to two weeks after beginning treatments in many people. After ECT, some patients will continue to have maintenance ECT, while others will return to antidepressant medications or have a combination of both treatments.

Over the years, the technique of ECT has improved from the procedure that still invokes stigma in the minds of many. Physicians administer the treatment in the hospital under anesthesia so that people receiving ECT do not hurt themselves or feel emotional or physical pain during the induced seizures or at any other time. Most patients undergo six to 10 treatments. A health care professional passes an electrical current through the brain to cause a controlled seizure, which typically lasts for 20-90 seconds. The patient is awake in five to 10 minutes. The most common side effect is short-term memory loss, which usually resolves quickly. Doctors safely perform ECT as an outpatient procedure.

Transcranial magnetic stimulation (TMS)

Another brain stimulation therapy, transcranial magnetic stimulation (TMS) involves a physician passing an electrical current through an insulated coil that is placed on the surface of the depression sufferer's scalp. That induces a brief magnetic field that can change the electrical flow of the brain that is effective in easing symptoms of depression or anxiety. TMS does not require anesthesia; doctors perform TMS for a few minutes per session, five times per week over the course of four to six weeks. Side effects are usually mild and fade quickly, including scalp discomfort or headaches. It is unusual for side effects to be severe enough to cause the recipient to stop treatment prematurely. Serious side effects are rare, including worsened depression, suicidal thoughts, or actions.

Transcranial magnetic stimulation is effective in alleviating depression or anxiety in people who did not respond to psychiatric medication.

Psychotherapies

Many forms of psychotherapy are effective at helping depressed individuals, including some short-term (10-20 weeks) therapies. Talking therapies (psychotherapies) help patients gain insight into their problems and resolve them through verbal give-and-take with the therapist. Behavioral therapists help patients learn how to obtain more satisfaction and rewards through their own actions. These therapists conduct behavior therapy to help patients to unlearn the behavioral patterns that may contribute to their depression.

Interpersonal and cognitive/behavioral therapies are two of the short-term psychotherapies that research has shown to be helpful for some forms of depression. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving that are often associated with depression. A form of cognitive behavioral therapy, dialectical behavior therapy (DBT) tends to focus on intensive, simultaneous acceptance of the depression sufferer's abilities, while motivating emotionally healthy changes using a highly structured approach. This form of therapy treats severely or chronically depressed people. Psychodynamic therapies sometimes treat depression. They focus on resolving the patient's internal psychological conflicts rooted in childhood. Long-term psychodynamic therapies are particularly important if there seems to be a lifelong history and pattern of inadequate ways of coping (maladaptive coping mechanisms) by using negative or self-injurious behavior.

Alternative medicine approaches to treatment

The future is very bright for the treatment of depression. In response to the customs and practices of their patients from a variety of cultures, physicians are becoming more sensitized to and knowledgeable about natural remedies. Vitamins and other nutritional supplements like vitamin D, folate, and vitamin B12 may be useful in alleviating mild depression when used alone or more severe degrees of depression when used in combination with an antidepressant medication. Another intervention from alternative medicine is St. John's wort (Hypericum perforatum). This herbal remedy is helpful for some individuals who suffer from mild depression. However, St. John's wort being an herbal remedy is no guarantee against developing complications. For example, its chemical similarity to many antidepressants disqualifies it from being given to people who are taking those medications.

In general, the severe depressive illnesses, particularly those that are recurrent, will require antidepressant medications, phototherapy for winter seasonal depression (or ECT or TMS in severe cases) along with psychotherapy for the best outcome. If a person suffers one major depressive episode, he or she has up to about a 75% chance of a second episode. If the individual suffers two major depressive episodes, the chance of a third episode is about 80%. If the person suffers three episodes, the likelihood of a fourth episode is 90%-95%. Therefore, after a first depressive episode, it may make sense for the patient to come off medication gradually. However, after a second and certainly after a third episode, most clinicians will have a patient remain on a maintenance dosage of the medication for an extended period of years, if not permanently.

Patience is required because the treatment of depression takes time. Sometimes, the doctor will need to try a variety of antidepressants before finding the medication or combination of medications that is most effective for the patient. Sometimes, it's necessary to increase the dosage to be effective or decrease the dosage to alleviate medication side effects.

In choosing an antidepressant, the doctor will take into account the patient's specific symptoms of depression, as well as his or her age, other medical conditions, and medication side effects. Of particular importance is that children and adolescents continue to use antidepressant medication with caution because of uncommon instances in which minors become acutely worse instead of better while receiving this treatment.

Doctors often use one of the SSRIs initially because of their lower severity of side effects compared to the other classes of antidepressants. It's possible to further minimize side effects of SSRI medications by starting them at low doses and gradually increasing the doses to achieve full therapeutic effects. For those patients who do not respond after taking a SSRI at full doses for six to eight weeks, doctors often switch to a different SSRI or another class of antidepressants. For patients whose depression failed to respond to full doses of one or two SSRIs or whom could not tolerate those medications, doctors will usually then try medications from another class of antidepressants. Some doctors believe that antidepressants with dual action (action on both serotonin and norepinephrine), such as duloxetine (Cymbalta), (Cymbalta), mirtazapine (Remeron), venlafaxine (Effexor), desvenlafaxine (Pristiq), and levomilnacipran (Fetzima), may be effective in treating patients with severe depression that is treatment resistant. Other options include bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban), which has action on dopamine (another neurotransmitter).

Increasingly, doctors may use a combination of antidepressants from different classes or add a medication from a completely different chemical class, such as Abilify or Seroquel, that are thought to enhance the effectiveness of antidepressant medication more rapidly than adding or switching to a second antidepressant. Also, new types of antidepressants are constantly being developed, and one of these may be the best for a particular patient.

If the depressed person is taking more than one medication for depression or medications for any other medical problem, each of the patient's doctors should be aware of the other prescriptions. Many of these medications clear from the body (metabolized) in the liver. This means that the multiple treatments can interact competitively with the liver's biochemical clearing systems. Therefore, the actual blood levels of the medications may be higher or lower than would be expected from the dosage. This information is especially important if the patient is taking anticoagulants (blood thinners), anticonvulsants (seizure medications), or heart medications, such as digitalis (Crystodigin). Although multiple medications do not necessarily pose a problem, all of the patient's doctors may need to be in close contact to adjust dosages accordingly.

Patients often are tempted to stop their medication too soon, especially when they begin feeling better. It is important to keep taking medication therapy until the doctor says to stop, even if the patient feels better beforehand. Doctors often will continue the antidepressant medications for at least six to 12 months after symptoms are alleviated because the risk of depression quickly returning when treatment is stopped decreases after that period of time in those people experiencing their first depressive episode. Patients must stop some medications gradually to give the body time to adjust (see discontinuation of antidepressants below). For individuals with bipolar disorder, recurrent or chronic major depression, medication may have to become a part of everyday life for an extended period of years in order to avoid disabling symptoms.

Antidepressant medications are not habit-forming, so there need not be concern about that. However, as is the case with any type of medication prescribed for more than a few days, physicians must carefully monitor antidepressant use to ensure that the patient is getting the correct dosage. The doctor will want to check the dosage and its effectiveness regularly.

If the patient is taking MAOIs, he or she must avoid certain aged, fermented, or pickled foods, like many wines, processed meats, and cheeses. The patient should obtain a complete list of prohibited foods from the doctor and keep it available at all times. The other types of antidepressants require no food restrictions. It is also important to note that some over-the-counter cold and cough medicines can also cause problems when taken with MAOIs.

People should try to avoid mixing medications of any kind (prescribed, over the counter, or borrowed) without consulting their doctor. Patients should inform their dentist or any other medical specialist who prescribes a drug that he or she is taking antidepressants. Some medications that are harmless when taken alone can cause severe and dangerous side effects when taken with other medications. This may also be the case for individuals taking supplements or herbal remedies. Some addictive substances, like alcohol (including wine, beer, and liquor), tranquilizers, narcotics or marijuana, reduce the effectiveness of antidepressants and can cause mental health and/or physical symptoms. Patients should avoid these. These and other drugs can be dangerous when the person's body is either intoxicated with or withdrawing from their effects due to increasing the risk of seizure or heart problems in combination with antidepressants medications.

Antianxiety drugs such as diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan) are not antidepressants, but doctors occasionally prescribe these alone or with antidepressants for a brief period of anxiety. However, patients should not  take these alone for depressive disorder. Due to their addiction potential, patients should phase out the antianxiety drugs as soon as the antidepressant and antianxiety effects of the antidepressant medications begin to work, which is usually in four to six weeks.

Finally, patients should consult their doctor concerning any questions about a medication or problem that the patient believes is medication related.

The SSRI antidepressants can cause sexual dysfunction. SSRIs reportedly decrease sex drive (libido) in both men and women. SSRIs reportedly cause inability to achieve orgasm or delay in achieving orgasm (anorgasmia) in women and difficulty with ejaculation (delay in ejaculating or loss of ability to ejaculate) and erections in men. Sexual dysfunction with SSRIs is common though the exact incidence is unknown. Newer SSRIs like vortioxetine and vilazodone have little to no negative impact on sexual functioning. Furthermore, patients have reported sexual side effects with the use of other antidepressant classes such a MAOIs, TCAs, and dual-action antidepressants.

Management of sexual dysfunction due to SSRIs includes the following options:

• Decrease the SSRI dose. This option may be appropriate if the patient is on high doses of an SSRI. However, reducing the SSRI dose may also diminish the antidepressant effect. Remember, patients should never change medications and medication doses on their own without permission and monitoring by his/her doctor.
• Switch to another SSRI. Newer SSRIs like vortioxetine (Trintellix) and vilazodone (Viibryd) cause sexual dysfunction less than the older SSRIs.
• Trial of sildenafil (Viagra) or other sexual-enhancement medication. Studies in men whose depression has responded to SSRI but have developed sexual dysfunction showed improvement in sexual function with Viagra. Men taking Viagra reported significant improvements in arousal, erection, ejaculation, and orgasm as compared to men who were taking placebo, although Viagra generally does not increase one's libido.
• For men who do not respond to Viagra (and for women with sexual dysfunction due to SSRI), switching to a newer SSRI or to another class of antidepressants may be helpful. For example, bupropion, mirtazapine, and duloxetine may have no sexual side effects or significantly less sexual side effects than SSRIs.
• For patients who are unable to switch from an older SSRI to either a newer SSRI or to another class of antidepressants either because of lack of tolerance or lack of therapeutic response, the doctor may consider adding another medication to the SSRI. For example, some doctors have reported success by adding bupropion to SSRIs to improve sexual function.
• Some doctors also may use buspirone (BuSpar) to improve sexual function in patients treated with SSRIs. More clinical studies may determine whether this strategy works.

Patients gradually should taper antidepressants and should not be abruptly discontinued. Abruptly stopping an antidepressant in some patients can cause discontinuation syndrome.

For example, abruptly stopping an SSRI such as paroxetine can cause dizziness, nausea, flu-like symptoms, body aches, anxiety, irritability, fatigue, and vivid dreams. These symptoms typically occur within days of abrupt cessation, and can last one to two weeks (up to 21 days). Among the SSRIs, paroxetine and fluvoxamine cause more pronounced discontinuation symptoms than fluoxetine, sertraline, citalopram, escitalopram, vortioxetine, and vilazodone. Some patients experience discontinuation symptoms despite gradual tapering of the SSRI. Abrupt cessation of venlafaxine, duloxetine, desvenlafaxine, or levomilnacipran can cause discontinuation symptoms similar to those of SSRIs.

Abruptly stopping MAOIs can lead to irritability, agitation, and delirium. Similarly, abruptly stopping a TCA can cause agitation, irritability, and abnormal heart rhythms.

Depression can have a significant impact on the structure and function of many parts of the brain. This can result in many negative consequences. For example, people with severe depression are at higher risk of suffering from anxiety, chronic depression, other emotional issues, or having more medical problems or chronic pain. The trouble thinking (cognitive problems) that depression sufferers may experience can persist even after the illness resolves. People with a chronic illness, such as diabetes and heart disease, who also have depression tend to have worse outcome of their medical illness.

Even though clinical depression tends to occur in episodes, most people who experience one such episode will eventually have another one. Also, it seems that any subsequent episodes of depression are more easily triggered than the first one. However, most depression sufferers recover from the episode. In fact, individuals who have mild depression and receive treatment with medication tend to respond equally as well to sugar pill (placebo). Those with more severe depression seem to be less likely to get better when taking placebo versus taking antidepressant medication. Other encouraging information is that research shows that even people from teenage through adulthood who do not improve when treated with a first medication trial can improve when switched to another medication or given another medication in addition to psychotherapy. For individuals who experience thoughts of suicide, preventing access to firearms and other highly lethal means of committing suicide are important ways to improve their safety and that of those around them.

Programs that use mental health professionals to teach thinking skills (cognitive techniques) that assist in coping with stress seem to be effective in preventing depression. Key aspects in the prevention of postpartum depression include helping new mothers decrease those specific aspects of their lives that may contribute to depression, like having little social support and poor adjustment to their marriage or other domestic union. Engaging in religious or spiritual practices can often prevent depression, thought to be the result of decreasing stress, increasing a sense of hope, and providing a sense of community. On the other hand, people who feel they are unable to live up to the standards set by their family, societal, religious, or spiritual practices may feel a sense of guilt that becomes a risk factor for depression.

Depressive disorders can make those afflicted feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depressive illness and typically do not accurately reflect the actual situation. Negative thinking fades as treatment begins to take effect. In the meantime, the following are helpful tips for how to fight depression:

• Eat healthy foods and stay hydrated. The frequent lack of adequate nutrients, including water, and presence of excessive fats, sugars, and sodium in fast foods can further sap the energy of depression sufferers.
• Many may find that folate and vitamin D food supplements help coping with depression.
• Make time to get enough rest to promote improvement in your mood.
• Express your feelings, either to friends, in a journal, or using art to help release some negative feelings.
• Do not set difficult goals for yourself or take on a great deal of responsibility while dealing with depression.
• Break large tasks into small ones, set some priorities, and do what you can when you can.
• Do not expect too much from yourself too soon as this will only increase feelings of failure.
• Try to be with other people, which is usually better than being alone.
• Participate in activities that may make you feel better.
• You might try exercising, going to a movie or a ball game, or participating in religious or social activities.
• Don't rush or overdo it. Don't get upset if you do not feel "cured" right away. Feeling better takes time.
• Do not make major life decisions, such as changing jobs or getting married or divorced until your depression has improved without consulting others who know you well. These people often can have a more objective view of your situation.
• Remember, do not accept your negative thinking. It is part of the depression and will disappear as your depression responds to treatment.
• Plan how you would get help for yourself in an emergency, like calling friends, family, your physical or mental health professional, a local emergency room, or mental health crisis center if you were to develop thoughts of harming yourself or someone else.
• Limit your access to things that could hurt yourself or others (for example, do not keep excess medication of any kind, firearms, or other weapons in the home).

Family and friends can help! Since depression can make the affected person feel exhausted and helpless, he or she will want and probably need help from others. However, people who have never had a depressive disorder may not fully understand its effects. Although unintentional, friends and loved ones may unknowingly say and do things that may be hurtful to the depressed person. If you are struggling with depression, it may help to share the information in this article with those you most care about so they can better understand and help you.

The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This help may involve encouraging the individual to stay with treatment until symptoms begin to go away (usually several weeks) or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication for several months after symptoms have improved. Always report a worsening depression to the patient's physician or therapist.

The second most important way to help someone with depression is to offer emotional support. This support involves understanding, patience, affection, and encouragement to the depression sufferer. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Always take them seriously and report them to the depressed person's therapist.

Invite the depressed person for walks, outings, and to the movies and other activities. Be gently insistent if the depressed individual refuses your invitation. Encourage participation in activities that once gave pleasure, such as hobbies, sports, or religious or cultural activities. However, do not push the depressed person to undertake too much too soon. The depressed person needs company and diversion, but too many demands can increase feelings of failure and exhaustion.

Do not accuse the depressed person of faking illness or of laziness. Do not expect him or her "to snap out of it." Eventually, with treatment, most depressed people do get better. Keep that in mind. Moreover, keep reassuring the depressed person that, with time and help, it is highly likely that he or she will feel better.

A complete physical and psychological diagnostic evaluation by professionals will help the depressed person decide the type of treatment that might be best for him or her, including if they are in need of treatment for a physical condition that is causing or contributing to their depressed mood. However, if the situation is urgent because a suicide seems possible, having loved ones take the person to the emergency room for evaluation by an emergency-room doctor is essential. If the patient makes a suicide gesture or attempt, call 911. The patient might not realize how much help he or she needs. In fact, he or she might feel undeserving of help because of the negativity and helplessness that is a part of depressive illness.

We are close to having genetic markers for bipolar disorder. Soon after, we hope to have them for major depression. That way, we can know of a child's vulnerability to depression from birth and try to create preventive strategies. For example, we can teach parents the added importance of providing a supportive and otherwise healthy environment given their child's vulnerability. Parents can also be taught the early warning signs of depression so that they can get treatment for their children, if necessary, to ward off future problems.

The new world of pharmacogenetics holds the promise of actually keeping the genes responsible for depression turned off so as to avoid the illnesses completely. Also, by studying genes, we are learning more about the matching of patients with treatment. This kind of information can tell us which patients do well on which types of drugs and psychotherapy regimens.

We are learning more about the interactions of the neurochemicals, the chemical messengers in the brain, and their influence on depression. Moreover, researchers now study new categories of neurochemicals, such as neuropeptides and substance P. As a result, we will soon be able to develop new drugs that should be more effective with fewer side effects. We are also learning startling things about how maternal stress early in pregnancy can profoundly affect the developing fetus. For example, we now know that maternal stress can greatly increase the risk for the fetus to develop depression as an adult.

Physicians continue to investigate how to most effectively make treatment of depression available and acceptable to all who need it. This is particularly important for children and adolescents, minorities, individuals who are economically disadvantaged or live in rural areas, the elderly and for people with developmental disabilities, who suffer from lack of adequate access to mental health treatment that is knowledgeable and respectful of what may be their unique needs and preferences. While sadness will always be part of the human condition, hopefully we will be able to lessen or eradicate the more severe mood disorders from the world to the benefit of all of us.

For further information about depression, please visit the following sites:
Suicide Awareness Voices of Education (SAVE)
http://www.save.org/

APA: Women and Depression (American Psychological Association)
http://www.apa.org/pi/women/
programs/depression/index.aspx

For additional information and help, you can write or call the following organizations:

D/ART/Public Inquiries; National Institute of Mental Health
Room 15C-05
5600 Fishers Lane
Rockville, MD 20857

National Foundation for Depressive Illness
20 Charles Street
New York, NY 10014

National Depressive and Manic Depressive Association
730 N. Franklin, Suite 501
Chicago, IL 60601
Phone: 800-826-3632
Phone: 312-642-0049
Fax: 312-642-72433
http://www.ndmda.org/

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
800-969-NMHA (6642)
http://www.nmha.org/

National Alliance for the Mentally Ill
2101 Wilson Boulevard
Suite 302
Arlington, VA 22201
HelpLine: 800-950-NAMI [6264]
http://www.nami.org/

National Alliance for Research on Schizophrenia and Affective Disorders (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021 USA
Infoline: 800-829-8289
http://www.narsad.org/

National Suicide Prevention Lifeline
800-273-8255

Substance Abuse and Mental Health Services Administration (SAMHSA)
5600 Fishers Lane
Rockville, MD 20857
http://www.samhsa.gov

Suicide.org (for a suicide hotline near you)

Surgeon General's Report on Mental Illness
To receive a copy of this report, write or call:
Mental Health
Pueblo, Co 81009
800-789-2647

The National Institute of Mental Health (NIMH) for the Depression Awareness, Recognition, and Treatment (DART) program furnished a portion of the foregoing information.