Dolce Far Niente by John William Godward

Your place is a mess; laundry and dishes are piled up, mail is unopened, etc. (Assuming you usually stay on top of these things).

I hope these examples help to clarify things. Also see Reflections on Depression.

Young Man Nude by the Seashore by Flandrian Hippolyte

“It was not really alarming at first, since the change was subtle, but I did notice that my surroundings took on a different tone at certain times: the shadows of nightfall seemed more somber, my mornings were less buoyant, walks in the woods became less zestful, and there was a moment during my working hours in the late afternoon when a kind of panic and anxiety overtook me…” – William Styron, Darkness Visible

Sometimes the Depression Self-Screening Test is just too clinical, and the symptoms don’t really “click” with you. Some of the criteria are general, and if you’re suffering from depression, specifics are easier to understand. I know that I might not have diagnosed myself with depression just on the basis of those symptoms. I had no change in appetite, and no sleep problems (getting out of bed was what was difficult). Below are some un-clinical symptoms.

• Things just seem “off” or “wrong.”
• You don’t feel hopeful or happy about anything in your life.
• You’re crying a lot for no apparent reason, either at nothing, or something that normally would be insignificant.
• You feel like you’re moving (and thinking) in slow motion.
• Getting up in the morning requires a lot of effort.
• Carrying on a normal conversation is a struggle. You can’t seem to express yourself.
• You’re having trouble making simple decisions.
• Your friends and family really irritate you.
• You’re not sure if you still love your spouse/significant other.
• Smiling feels stiff and awkward. It’s like your smiling muscles are frozen.
• It seems like there’s a glass wall between you and the rest of the world.
• You’re forgetful, and it’s very difficult to concentrate on anything.
• You’re anxious and worried a lot.
• Everything seems hopeless.
• You feel like you can’t do anything right.
• You have recurring thoughts of death and/or suicidal impulses. Suicide seems like a welcome relief.
• You have a feeling of impending doom – you think something bad is going to happen, although you may not be sure what, and/or…
• …You have a very specific fear that torments you constantly.
• In your perception of the world around you, it’s always cloudy. Even on sunny days, it seems cloudy and gray.
• You feel as though you’re drowning or suffocating.
• You’re agitated, jumpy and and anxious much of the time.
• Your senses seem dulled; food tastes bland and uninteresting, music doesn’t seem to affect you, you don’t bother smelling flowers anymore.
• Incessantly and uncontrollably into your mind comes the memory of every failure, every bad or uncomfortable experience, interview or date, like a torrent of negativity.

Note: I wrote this a few years ago, and it has made its way around the Net uncredited. If you want to reproduce it in any way, please look at the terms of the Creative Commons license at the bottom of the page.

Also see How Depression May Affect Your Life. Archived comments in response to this article can be found here.

Please feel free to post your comment about what depression feels like. Don’t post:

• Questions about depression and how to handle it.
• Comments on how you think it should be managed, including finding God.
• Requests for other people to email you.
• Your depression “biography”.

Please note that comments are moderated – if you post a comment, it will not show up until it is approved, and this can take a few days. Also, this is not the best place to post if you would like responses. If you would, please post to our forum. Comments asking for responses will be edited accordingly.

“Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self…as to verge close to being beyond description.” William Styron, Darkness Visible

I was reminded recently, when I told the members of my forum for people with depression that we were moving back to a previous software platform, how any change can freak out someone with depression. Even though we were moving back to software that many members had complained about leaving in the first place when we changed last fall, many members (in some cases, the same ones) were now complaining about going “home,” as one member who was happy with the reversal put it.

I’ve run into this depression symptom many times during the ten or so years I’ve had my forum. But if you look on any of the depression symptoms lists, the ones many people use to self-diagnose, you wouldn’t see “strong resistance to changes.”

Read on

**Causes** (cont.)
- What initiates the alteration in brain chemistry?
- Is a tendency to depression inherited?

**Treatment**
- What sorts of psychotherapy are effective for depression?

**Medication**
- Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?
- How do you tell when a treatment is not working? How do you know when to switch treatments?
- How do antidepressants relieve depression?
- Are Antidepressants just “happy pills?”
- What percentage of depressed people will respond to antidepressants?
- What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?
- What are the major categories of anti-depressants?
- What are the side-effects of some of the commonly used antidepressants?
- What are some techniques that can be used by people taking antidepressants to make side effects more tolerable?
- Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?
- What should I do if my antidepressant does not work?

Causes (cont.)
————–

Q. What initiates the alteration in brain chemistry?

It can be either a psychological or a physical event. On the physical  side, a hormonal change may provide the initial trigger: some women dip into depression briefly each month during their premenstrual phase; some find that the hormone balance created by oral contraceptives disposes them to depression; pregnancy, the end of pregnancy, and menopause have also been cited. Men’s hormone levels fluctuate as deeply but less obviously.

It is well known that certain chronic illnesses have depression as a frequent consequence: some forms of heart disease, for example, and Parkinsonism. This seems to be the result of a chemical effect rather than a purely psychological one, since other, equally traumatic and serious illnesses don’t show the same high risk of depression.

Q. Is a tendency to depression inherited?

It seems there are some people whose brain chemistry is predisposed to the depressive response, and others who are at much lower risk of depression even if exposed to the same physical or psychological triggers. The genetic relations of manic-depressives are at a higher risk for unipolar depression than the population at large or their adopted/by marriage relations. There seems to be a link between high creativity and the gene for manic-depression: artists and writers often are not manic-depressive themselves, but have a family member who is. Studies of families in which members of each generation  develop manic-depressive illness found that those with the illness have a somewhat different genetic make-up than those who do not get ill. However, the reverse is not true: not everybody with the genetic make-up that causes vulnerability to manic-depressive illness has the disorder. Apparently additional factors, possibly a stressful environment, are involved in its onset.

Major depression also seems to occur, generation after generation, in some families. However, depression can occur in people with no family history of any form of mental illness. And I would be reluctant to suggest that there is any human who is entirely immune to depression under all possible conditions.

Psychological triggers: many, if not most, people with depression can point to some incident or condition which they believe is responsible for their unhappiness. Of course, people with severe depression are prone to astonishingly virulent and inappropriate guilt and self-hatred.

The (genuine) life events that most often appear in connection with depression are various, but there is one distinguishing feature that appears in many cases, over and over: loss of self-determination, of empowerment, of self-confidence. More profoundly: a loss of self, of the abilities or activities that a person identifies with herself.  Stereotypically: a man loses the job that had defined him to himself and others, whether that definition was “executive” or “breadwinner”; a woman who had spent her whole life preparing for and living the role of wife, supporter, caretaker, is suddenly left alone by divorce or death. In general, any life change, often caused by events beyond  one’s control, which damages the structure that gave life meaning.

The ability of a person to respond to such an event will depend on many factors, including genetic predisposition, support from friends, physical health, even the weather. It can also depend on internal psychological factors which may best be explored in talk therapy: why is the person’s self-esteem so bound up in the position or state that has been lost? Can she find a new source of self-esteem? Therapy can be immensely helpful here.

Obviously, not everyone to whom this sort of event happens becomes depressed, and not every person who becomes depressed has had this sort of catastrophe befall them. In fact, if a person suffers a loss and then becomes depressed, it may well be that they weathered the loss in fine style and then succumbed to a much less obvious trigger, psychological or physical.

Some depressions may well be caused by a spontaneous aberration in brain chemistry, with no trigger that we can currently identify, just as a seizure or migraine may have an obvious trigger or be apparently spontaneous.

However, once the depressive state has set in, both physical and psychological problems will be generated in abundance. What faster way to lose a job or a spouse than to be too depressed to work or to communicate? What worse psychological state for coping with a blow to identity can there be than a chemically promoted, pathological self-hatred? And what can be worse for self-esteem than watching one’s appearance and household disintegrate as one loses the motivation to shower, straighten up, wash dishes or laundry, or choose attractive clothes? Health deteriorates as well: some depressed people can’t sleep or eat, others sleep constantly (a real help on the job!) and eat incessantly, sometimes in order to stay awake, sometimes because it’s the only thing that gives a little pleasure or comfort. (Carbohydrates induce production of serotonin, so there may be an element of self-medication here); almost no one has the impulse to exercise or get fresh air and sunshine. Most if not all of these effects form feedback loops, increasing in magnitude and becoming triggers for further depression.

The question, “Is depression mostly physical or psychological,” is rather beside the point. Depression may be triggered by either physical or psychological events. Most commonly, both seem to be involved, though it is often difficult to separate the two when one is talking about psychology and neurochemistry. But however it begins, depression quickly develops into a set of physical and psychological problems which feed on each other and grow. This is why a combination of physical and psychological intervention has been shown to give the best results for most patients, regardless of any classifications that doctors may have tried to impose on their depression and its cause.

Treatment
———

Q. What sorts of psychotherapy are effective for depression?

Two effective methods of psychotherapy for people with depressions are cognitive therapy and interpersonal therapy. Both psychoanalysis, and insight oriented psychotherapy have not been shown to be effective treatments for people with a depressive disorder. Cognitive (and cognitive-behavioral) therapists can be found in most major cities.

For a referral to a properly trained cognitive therapist practicing close to your location, contact:

Aaron T. Beck, MD.
The Center for Cognitive Therapy
3600 Market Street
Philadelphia, PA 19101
(215) 898-4100.

While many therapists call themselves cognitive therapists and interpersonal therapists, only a few have had proper training. To find an interpersonal therapist with the best training, contact:

Myrna Weissman, Ph.D.
New Your State Psychiatric Institute
722 West 168th Street
New York, NY 10032
(212) 996-6390

Medication
———-

Q. Do certain drugs work best with certain depressive illnesses? What are the guidelines for choosing a drug?

There are very few kinds of depression for which there are specific antidepressant treatments. When it comes to people with Bipolar Disorder who are depressed there are some major problems. Most importantly, with any antidepressant, there is a possibility that the antidepressant treatment will cause depressed bipolar people not just to come out of their depressions, but to develop manic episodes. The possibility of an antidepressant causing mania is least when the antidepressant is bupropion (Wellbutrin). The possibility of mania is greatly reduced if depressed bipolar folks are on a mood stabilizer such as lithium, Tegretol or Depakote when they are started on an antidepressant.

Q. How do you tell when a treatment is not working? How do you know when to switch treatments?

Antidepressant treatment is clearly not working when the individual receiving the treatment remains depressed or becomes depressed again. When a recently started antidepressant fails to cause improvement, the depressed individual often asks that the medication be stopped, and a new one started. It generally does not make sense to change antidepressants until 8-weeks at the maximum tolerated dose have elapsed. With some tricyclic antidepressants, it is important to check the blood level of the antidepressant before it is stopped. The blood test can tell if the amount in the blood has been adequate. Only after an adequate trial of one antidepressant should another be tried. To have been on four antidepressants in an 8-week period means that one has not had an adequate trial on any of them.

Q. How do antidepressants relieve depression?

There are several classes of antidepressants, all of which seem to work by increasing levels of certain neurotransmitters (most commonly serotonin, norepinephrine, and dopamine) in the brain. It is not entirely clear why increasing neurotransmitter levels should reduce the severity of a depression. One theory holds that the increased concentration of neurotransmitters causes changes in the brain’s concentration of molecules, receptors, to which these transmitters bind. In some unknown way it is the changes in the receptors that are thought responsible for improvement.

Q. Are Antidepressants just “happy pills?”

No matter what their exact mode of action may be, it is clear that antidepressants are not “happy pills.” There is no street-market in antidepressants, for unlike “speed” which will improve the mood of almost everybody, antidepressants only improve the mood of depressed people. Also unlike the almost instant effects of speed, the mood-improving effects of antidepressants develop slowly over a number of weeks. “Speed” induces a highly artificial state, antidepressants cause the brain to slowly increase its production of naturally occurring neurotransmitters.

Q. What percentage of depressed people will respond to antidepressants?

Generally, about 2/3 of depressed people will respond to any given antidepressant. People who do not respond to the first antidepressant they have taken, have an excellent chance of responding to another.

Q. What does it feel like to respond to an antidepressant? Will I feel euphoric if my depression responds to an antidepressant?

The most common description of the effects of antidepressants is that of feeling the depression gradually lift, and for the person to feel normal again. People who have responded to antidepressants are not euphoric. They are not unfeeling automatons. The are still able to feel sad when bad things happen, and they are able to feel very happy in response to happy events. The sadness they feel with disappointments is not depression, but is the sadness anyone feels when disappointed or when having experienced a loss. Antidepressants do not bring about happiness, they just relieve depression. Happiness is not something that can be had from a pill.

Q. What are the major categories of anti-depressants?

There are many classes of antidepressants. Two kinds of antidepressants have been around for over 30 years. These are the tricyclic antidepressants and the monoamine oxidase inhibitors. While there are newer antidepressants, many with fewer side-effects, none of the newer antidepressants has been shown to be more effective than these two classes of drugs. In fact, many people who have not responded to newer antidepressants have been successfully treated with one of these classes of drugs.

The tricyclic antidepressants (TCAs) include such drugs as imipramine (Tofranil, amitriptyline (Elavil), desipramine (Norpramin), nortriptyline (Aventyl and Pamelor).

The monoamine oxidase inhibitors (MAOIs) include tranylcypromine (Parnate), phenelzine (Nardil), and isocarboxazid (Marplan) which has recently been taken off the market in the U.S.A. for marketing rather than safety or efficacy reasons.

One of the popular new classes of antidepressants are the selective serotonin reuptake inhibitors (SSRIs). The first of these drugs to be marketed in the USA was fluoxetine (Prozac). Sertraline (Zoloft), and paroxetine (Paxil) soon followed, and fluvoxamine (Luvox) is scheduled to be marketed in late 1994, or early 1995.

Bupropion (Wellbutrin) is the only drug in its class, as is trazodone (Desyrel). The most recently marketed antidepressant (4/94) is venlafaxine (Effexor), the first drug in yet another class of drugs.

Q. What are the side-effects of some of the commonly used antidepressants?

Below is a list of some of the more frequently prescribed antidepressants, and their most common side effects. The figure following each side effect is the percentage of people taking the medication who experience that side effect.

Aventyl (nortriptyline): Dry mouth (15); Constipation (15);
Weakness-fatigue (10); Tremor (10).

Effexor (venlafaxine) Nausea (35); Headache (25); Sleepiness (25);
Dry mouth (20); Insomnia (20); Constipation (15).

Elavil (amitriptyline): Dry mouth (40); Drowsiness (30); Weight gain
(30); Constipation (25); Sweating (20).

Nardil (phenelzine): dry mouth (30); insomnia (25); Increased heart
rate (25); Lowered blood pressure (20); Sedation (15); Over
stimulation (10);

Norpramin (desipramine): dry mouth (15); increased pulse (15);
constipation (10); reduced blood pressure (10).

Pamelor – see Aventyl

Parnate (tranylcypromine) Dry mouth (20); Insomnia (20); Increased
pulse rate (20); Lowered blood pressure (15); Over stimulation (15);
Sedation (15).

Paxil (paroxetine): Decreased sexual interest and/or problems
achieving orgasm (30); Nausea (25); Sedation (25); Dizziness (15)
Insomnia (15)

Prozac (fluoxetine): Decreased sexual interest and/or problems
achieving orgasm (30); Nausea (20); Headache (20); Nervousness (15);
Insomnia (15); Diarrhea (15).

Sinequan (doxepin): Dry mouth (40); Sedation (40); Weight gain (30);
Lowered blood pressure (25); Constipation (25); Sweating (20).

Tofranil (imipramine): Dry mouth (30), Reduced blood pressure (30),
Constipation (20), Difficulty with urination (15).

Wellbutrin (bupropion): Agitation (30); Weight loss (25), Dizziness
(20); Decreased appetite (20);

Zoloft (sertraline): Decreased sexual interest and/or problems
achieving orgasm (30);Nausea (25); Headache (20); Diarrhea (20);
Insomnia 15); Dry mouth (15); Sedation (15).

Q. What are some techniques that can be used by people taking antidepressants to make side effects more tolerable?

Listed below are some frequent side effects of antidepressants, and some techniques to reduce their severity:

Dry mouth: Drink lots of water, chew sugarless gum, clean teeth daily, ask the dentist to suggest a fluoride rinse to prevent cavities, visit the dentist more often than usual for tooth and gum hygiene

Constipation: Drink at least six 8-ounce glasses of water every day, eat bran cereals, eat salads twice a day, exercise daily (walk for at least 30 minutes a day), ask your doctor about taking a bulk producing agent such as Metamucil, also ask about taking a stool softener such as Colace, be sure to avoid laxatives such as Ex-Lax.

Bladder problems: The effects of some antidepressants, especially the tricyclic medications may make it difficult for you to start the stream of urine. There may be some hesitation between the time you try to urinate and the time your urine starts to flow. If it takes you over 5-minutes to start the stream, call your doctor.

Blurred vision: The tricyclic antidepressants may make it difficult for you to read. Distant vision is usually unaffected. If reading is important to you the effects of the antidepressant can be compensated for by a change in glasses. As you may compensate for the change in your vision, try to postpone getting new glasses as long as possible.

Dizziness: Dizziness when getting out of bed or when standing up from a chair, or when climbing stairs may be a problem when taking tricyclic antidepressants and monoamine oxidase inhibitors. Changing posture slowly may help prevent this kind of dizziness. Drinking adequate amounts of liquid and eating enough salt each day is important. Be sure to speak to your doctor if this side-effect is severe.

Drowsiness: This side effect often passes as you get used to taking the antidepressant that has been prescribed for you. Ask your doctor if it is safe for you to increase your intake of caffeine, and if so, by how much. If you are drowsy be sure not to drive or operate dangerous machinery.

Q. Many antidepressants seem to have sexual side effects. Can anything be done about those side-effects?

Both lowered sexual desire and difficulties having an orgasm, in both men and women, are particularly a problem with the selective serotonin re-uptake inhibitors (Prozac, Zoloft, Paxil and Luvox), and the monoamine oxidase inhibitors (Nardil and Parnate). There is no treatment for decreased sexual interest except lowering the dose or switching to a drug that does not have sexual side effects such as bupropion (Wellbutrin). Difficulty having orgasms may be treated by a number of medications. Among those medications are: Periactin, Urecholine, and Symmetrel. None of these are over-the-counter drugs and they must be prescribed by a physician. Unfortunately, many psychiatrists are not familiar with using these medications to treat the sexual side-effects of antidepressants.

Q. What should I do if my antidepressant does not work?

Many people decide that their antidepressant is not working prematurely. When one starts an antidepressant the hope is for rapid relief from depression. What must be remembered is that for an antidepressant to work, you must be on an adequate dose of the drug for an adequate length of time. A fair trial of any antidepressant is at least two months. Prior to a two month trial the only reason to abandon an antidepressant trial is if the medication is causing severe side effects. With many antidepressants the dose has to be increased at intervals far above the starting dose. Unfortunately, the two-month period mentioned above, refers to two months following the most recent increase in the dose, not the time from starting the particular antidepressant.

What Is Depression?

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder.

What are the different forms of depression?

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person’s ability to work, sleep, study, eat, and enjoy once–pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person’s lifetime, but more often, it recurs throughout a person’s life.

Dysthymic disorder, also called dysthymia, is characterized by long–term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.¹

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.²

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (e.g., mania) to extreme lows (e.g., depression). Visit the NIMH website for more information about bipolar disorder.

What are the signs and symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness.

Symptoms include:

• Persistent sad, anxious or “empty” feelings
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness and/or helplessness
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early–morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

What illnesses often co-exist with depression?

Depression often co–exists with other illnesses. Such illnesses may precede the depression, cause it, and/or be a consequence of it. It is likely that the mechanics behind the intersection of depression and other illnesses differ for every person and situation. Regardless, these other co–occurring illnesses need to be diagnosed and treated.

Anxiety disorders, such as post–traumatic stress disorder (PTSD), obsessive–compulsive disorder, panic disorder, social phobia and generalized anxiety disorder, often accompany depression.^3,4 People experiencing PTSD are especially prone to having co-occurring depression. PTSD is a debilitating condition that can result after a person experiences a terrifying event or ordeal, such as a violent assault, a natural disaster, an accident, terrorism or military combat.

People with PTSD often re–live the traumatic event in flashbacks, memories or nightmares. Other symptoms include irritability, anger outbursts, intense guilt, and avoidance of thinking or talking about the traumatic ordeal. In a National Institute of Mental Health (NIMH)–funded study, researchers found that more than 40 percent of people with PTSD also had depression at one-month and four-month intervals after the traumatic event.⁵

Alcohol and other substance abuse or dependence may also co–occur with depression. In fact, research has indicated that the co–existence of mood disorders and substance abuse is pervasive among the U.S. population. ⁶

Depression also often co–exists with other serious medical illnesses such as heart disease, stroke, cancer, hiv/aids, diabetes, and Parkinson’s disease. Studies have shown that people who have depression in addition to another serious medical illness tend to have more severe symptoms of both depression and the medical illness, more difficulty adapting to their medical condition, and more medical costs than those who do not have co–existing depression.⁷ Research has yielded increasing evidence that treating the depression can also help improve the outcome of treating the co–occurring illness.⁸

What causes depression?

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior appear to function abnormally. In addition, important neurotransmitters–chemicals that brain cells use to communicate–appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well.⁹ Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.¹⁰

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

How do women experience depression?

Depression is more common among women than among men. Biological, life cycle, hormonal and psychosocial factors unique to women may be linked to women’s higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the “baby blues,” but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression often have had prior depressive episodes.

Some women may also be susceptible to a severe form of premenstrual syndrome (PMS), sometimes called premenstrual dysphoric disorder (PMDD), a condition resulting from the hormonal changes that typically occur around ovulation and before menstruation begins. During the transition into menopause, some women experience an increased risk for depression. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.¹¹

Finally, many women face the additional stresses of work and home responsibilities, caring for children and aging parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

How do men experience depression?

Men often experience depression differently than women and may have different ways of coping with the symptoms. Men are more likely to acknowledge having fatigue, irritability, loss of interest in once–pleasurable activities, and sleep disturbances, whereas women are more likely to admit to feelings of sadness, worthlessness and/or excessive guilt.^12,13

Men are more likely than women to turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, irritable, angry and sometimes abusive. Some men throw themselves into their work to avoid talking about their depression with family or friends, or engage in reckless, risky behavior. And even though more women attempt suicide, many more men die by suicide in the United States.¹⁴

How do older adults experience depression?

Depression is not a normal part of aging, and studies show that most seniors feel satisfied with their lives, despite increased physical ailments. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.¹⁵

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what some doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body’s organs, including the brain. Those with vascular depression may have, or be at risk for, a co–existing cardiovascular illness or stroke.¹⁶

Although many people assume that the highest rates of suicide are among the young, older white males age 85 and older actually have the highest suicide rate. Many have a depressive illness that their doctors may not detect, despite the fact that these suicide victims often visit their doctors within one month of their deaths.¹⁷

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both.¹⁸ Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults.¹⁹ Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.^{20, 21}

How do children and adolescents experience depression?

Scientists and doctors have begun to take seriously the risk of depression in children. Research has shown that childhood depression often persists, recurs and continues into adulthood, especially if it goes untreated. The presence of childhood depression also tends to be a predictor of more severe illnesses in adulthood.²²

A child with depression may pretend to be sick, refuse to go to school, cling to a parent, or worry that a parent may die. Older children may sulk, get into trouble at school, be negative and irritable, and feel misunderstood. Because these signs may be viewed as normal mood swings typical of children as they move through developmental stages, it may be difficult to accurately diagnose a young person with depression.

Before puberty, boys and girls are equally likely to develop depressive disorders. By age 15, however, girls are twice as likely as boys to have experienced a major depressive episode.²³

Depression in adolescence comes at a time of great personal change–when boys and girls are forming an identity distinct from their parents, grappling with gender issues and emerging sexuality, and making decisions for the first time in their lives. Depression in adolescence frequently co–occurs with other disorders such as anxiety, disruptive behavior, eating disorders or substance abuse. It can also lead to increased risk for suicide. ^{22, 24}

An NIMH–funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy was the most effective treatment option.²⁵ Other NIMH–funded researchers are developing and testing ways to prevent suicide in children and adolescents, including early diagnosis and treatment, and a better understanding of suicidal thinking.

How is depression detected and treated?

Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.

The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out these possibilities by conducting a physical examination, interview and lab tests. If the doctor can eliminate a medical condition as a cause, he or she should conduct a psychological evaluation or refer the patient to a mental health professional.

The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression, and get a complete history of symptoms, e.g., when they started, how long they have lasted, their severity, and whether they have occurred before and if so, how they were treated. He or she should also ask if the patient is using alcohol or drugs, and whether the patient is thinking about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.

Medication

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics–named for their chemical structure–and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects. However, medications affect everyone differently–no one–size–fits–all approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice.

People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances.

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor’s supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit–forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, patients should be open to trying another. NIMH–funded research has shown that patients who did not get well after taking a first medication increased their chances of becoming symptom–free after they switched to a different medication or added another medication to their existing one. ^26,27

Sometimes stimulants, anti–anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co–existing mental or physical disorder. However, neither anti–anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor’s close supervision.

What are the side effects of antidepressants?

Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long–term. However, any unusual reactions or side effects that interfere with normal functioning should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache–usually temporary and will subside.
• Nausea–temporary and usually short–lived.
• Insomnia and nervousness (trouble falling asleep or waking often during the night)–may occur during the first few weeks but often subside over time or if the dose is reduced.
• Agitation (feeling jittery).
• Sexual problems–both men and women can experience sexual problems including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

Tricyclic antidepressants also can cause side effects including:

• Dry mouth-it is helpful to drink plenty of water, chew gum, and clean teeth daily.
• Constipation-it is helpful to eat more bran cereals, prunes, fruits, and vegetables.
• Bladder problems–emptying the bladder may be difficult, and the urine stream may not be as strong as usual. Older men with enlarged prostate conditions may be more affected. The doctor should be notified if it is painful to urinate.
• Sexual problems–sexual functioning may change, and side effects are similar to those from SSRIs.
• Blurred vision–often passes soon and usually will not require a new corrective lenses prescription.
• Drowsiness during the day–usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

FDA Warning on Antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a “black box” warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A “black box” warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used “triptan” medications for migraine headache could cause a life-threatening “serotonin syndrome,” marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.

What about St. John’s wort?

The extract from St. John’s wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is one of the top-selling botanical products.

To address increasing American interests in St. John’s wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John’s wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John’s wort was no more effective than the placebo in treating major depression.29 Another study is looking at the effectiveness of St. John’s wort for treating mild or minor depression.

Other research has shown that St. John’s wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapy

Several types of psychotherapy–or “talk therapy”–can help people with depression.

Some regimens are short–term (10 to 20 weeks) and other regimens are longer–term, depending on the needs of the individual. Two main types of psychotherapies–cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT)-have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence.²⁵ Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.²¹

Electroconvulsive Therapy

For cases in which medication and/or psychotherapy does not help alleviate a person’s treatment–resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as “shock therapy,” once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. A patient typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some patients will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.

ECT may cause some short-term side effects, including confusion, disorientation and memory loss. But these side effects typically clear soon after treatment. Research has indicated that after one year of ECT treatments, patients showed no adverse cognitive effects.³⁰

What efforts are underway to improve treatment?

Researchers are looking for ways to better understand, diagnose and treat depression among all groups of people. New potential treatments are being tested that give hope to those who live with depression that is particularly difficult to treat, and researchers are studying the risk factors for depression and how it affects the brain. NIMH continues to fund cutting–edge research into this debilitating disorder.

For more information on NIMH-funded research on depression, visit the NIMH website.

How can I help a friend or relative who is depressed?

If you know someone who is depressed, it affects you too. The first and most important thing you can do to help a friend or relative who has depression is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with him or her to see the doctor. Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

To help a friend or relative:

• Offer emotional support, understanding, patience and encouragement.
• Engage your friend or relative in conversation, and listen carefully.
• Never disparage feelings your friend or relative expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend’s or relative’s therapist or doctor.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if he or she declines, but don’t push him or her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind your friend or relative that with time and treatment, the depression will lift.

How can I help myself if I am depressed?

If you have depression, you may feel exhausted, helpless and hopeless. It may be extremely difficult to take any action to help yourself. But it is important to realize that these feelings are part of the depression and do not accurately reflect actual circumstances. As you begin to recognize your depression and begin treatment, negative thinking will fade.

To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed. Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly “snap out of” your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are listed below.

Mental Health Resources:

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• Mental health programs at universities or medical schools
• State hospital outpatient clinics
• Family services, social agencies or clergy
• Peer support groups
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies
• You can also check the phone book under “mental health,” “health,” “social services,” “hotlines,” or “physicians” for phone numbers and addresses. An emergency room doctor also can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

• Call your doctor.
• Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
• Make sure you or the suicidal person is not left alone.

For More Information

• Visit the National Library of Medicine’s MedlinePlus and En Español
• For information on clinical trials for depression
• National Library of Medicine Clinical Trials Database

Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order paper brochures through the mail. If you would like to have NIMH publications, you can order them online at www.nimh.nih.gov. If you do not have Internet access and wish to have information that supplements this publication, please contact the NIMH Information Center at the numbers listed below.

Please check the NIMH Web site for the most up-to-date information on this topic.

National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
1-866-615-NIMH (6464) toll-free
TTY: 301-443-8431
TTY: 866-415-8051
FAX: 301-443-4279
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov

If you want to copy this booklet…

This publication is in the public domain and may be reproduced or copied without permission from NIMH. We encourage you to reproduce it and use it in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines:

• NIMH does not endorse or recommend any commercial products, processes, or services, and our publications may not be used for advertising or endorsement purposes.
• NIMH does not provide specific medical advice or treatment recommendations or referrals; our materials may not be used in a manner that has the appearance of such information.
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If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or e-mail at nimhinfo@nih.gov.

Citations

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8. Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. Journal of Psychosomatic Research, 2002; 53: 859-863.

9. Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.

10. Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.

11. Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: implications for affective regulation. Biological Psychiatry, 1998; 44(9): 839-850.

12. Pollack W. Mourning, melancholia and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147-166.

13. Cochran SV, Rabinowitz FE. Men and Depression: clinical and empirical perspectives. San Diego: Academic Press, 2000.

14. Kochanek KD, Murphy SL, Anderson RN, Scott C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.

15. Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. American Family Physician, 1999; 60(3): 820-826.

16. Krishnan KRR, Taylor WD, et al. Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry, 2004; 55: 390-397.

17. Conwell Y. Suicide in later life: a review and recommendations for prevention. Suicide and Life Threatening Behavior, 2001; 31(Suppl.): 32-47.

18. Little JT, Reynolds CF III, Dew MA, Frank E, Begley AE, Miller MD, Cornes C, Mazumdar S, Perel JM, Kupfer DJ. How common is resistance to treatment in recurrent, nonpsychotic geriatric depression? American Journal of Psychiatry, 1998; 155(8): 1035-1038.

19. Reynolds CF III, Frank E, Perel JM, Imber SD, Cornes C, Miller MD, Mazumdar S, Houck PR, Dew MA, Stack JA, Pollock BG, Kupfer DJ. Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. Journal of the American Medical Association, 1999; 281(1): 39-45.

20. Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278(14): 1186-1190.

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22. Weissman MM, Wolk S, Goldstein RB, Moreau D, Adams P, Greenwald S, Klier CM, Ryan ND, Dahl RE, Wichramaratne P. Depressed adolescents grown up. Journal of the American Medical Association, 1999; 281(18): 1701-1713.

23. Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 2000; 57: 21-27.

24. Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339-348.

25. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807-820.

26. Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1231-1242.

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28. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association, 2007; 297(15): 1683-1696.

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30. Rami L, Bernardo M, Boget T, Ferrer J, Portella M, Gil-Verona JA, Salamero M. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study. The Journal of Neuropsychiatry and Clinical Neurosciences, 2004; 16: 465-471.

A. Presence of a single Major Depressive Episode.

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Flora by Lawrence Alma-Tadema

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Major Depressive Disorder, Recurrent

A. Presence of a two or more Major Depressive Episodes.

B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode. Note:This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or are due to the direct physiological effects of a general medical condition.

Dysthymic Disorder

A. Depressed mood for most of the day, for more days than not, as
indicated either by subjective account or observation by others, for at
least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:

• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be give when the criteria are met for a Major Depressive Episode

E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.

F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.

G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Early Onset. This specifier should be used if the onset of the dysthymic symptoms occurs before age 21 years. Such individuals are more likely to develop subsequent Major Depressive Episodes.

Late Onset. This specifier should be used if the onset of the dysthymic symptoms occurs at age 21 or older.

Detail from The Women of Amphissa by Sir Lawrence Alma-Tadema

“People who don’t know [what depression is], who say it’s self-indulgence, sound callous, but it’s not callousness born of indifference; I think it’s callousness born of ignorance. That kind of ignorance we’ve got to get rid of, and little by little I suppose, we will. You say to them, ‘It’s a pity you don’t know. I’m sure that if you knew, I’m sure that if you knew, not only wouldn’t you say that, you’d try to help in one way or another.”- Mike Wallace, On the Edge of Darkness

Note:I wrote this a few years ago, and it has made its way around the Net uncredited. If you want to reprint it, please make sure you credit Wing of Madness.

What Depression Is:

• Depression is an illness, in the same way that diabetes or heart disease are illnesses.
• Depression is an illness that affects the entire body, not just the mind.
• Depression is an illness that one in five people will suffer during their lifetime.

• Depression is the leading cause of alcoholism, drug abuse and other addictions.
• Depression is an illness that can be successfully treated in more than eighty percent of the people who have it.
• Depression is an equal-opportunity illness – it affects all ages, all races, all economic groups and both genders. Women, however, suffer from depression almost twice as much as men do.
• At least half of the people suffering from depression do not get proper treatment.
• Untreated depression is the number one cause of suicide.
• Depression is second only to heart disease in causing lost work days in America.
• Unipolar major depression is the leading cause of disability.

What Depression Is Not:

• Depression is not something to be ashamed of.
• Depression is not the same thing as feeling “blue” or “down.”
• Depression is not a character flaw or the sign of a weak personality.
• Depression is not a “mood” someone can “snap out of.” (Would you ask someone to “snap out of” diabetes or high blood pressure?)
• Depression is not fully recognized as an illness by most health care insurance providers. Most will only pay 50% of treatment costs for out-patient care, as well as limiting the number of visits.

Also see What Does Depression Feel Like?

“I am the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be a cheerful face on earth. Whether I shall ever be better I cannot tell; I awfully forbode I shall not. To remain as I am is impossible. I must die or be better.” – Abraham Lincoln

The Sorceress by John William Waterhouse

If five or more of the following symptoms have been present in either you or someone you know for more than two weeks, please talk to your doctor about the possibility of depression being present. Keep in mind that these symptoms could indicate a medical condition other than depression.

Depression Symptoms

• Feelings of sadness and/or irritability
• Loss of interest or pleasure in activities normally enjoyed
• Changes in weight or appetite
• Changes in sleeping pattern
• Feelings of guilt, hopelessness, or worthlessness
• Inability to concentrate, remember things, or make decisions
• Constant fatigue or loss of energy
• Observable restlessness or decreased activity
• Recurrent thoughts of suicide or death

In addition, look for at least three of the following symptoms, which could indicate the manic phase of manic-depression:

• Inflated ego, envisioning of grand schemes
• Increased energy and decreased need for sleep
• Inappropriate excitement or irritability
• Increased talking and/or moving
• Sexual promiscuity
• Disconnected and racing thoughts
• Impulsive behavior and poor judgment

For a more detailed screening, look at the Goldberg Mania Quiz.

Other self-screening tests are at:

• Depression Self Assessment
• depression-screening.org
• Depression Self Test

If you’re still not sure, look at What Does Depression Feel Like?.

Boreas by John William Waterhouse

Most people know the risk factors for illnesses such as heart disease or high blood pressure, but not many people realize that clinical depression has risk factors associated with it also. Having these risk factors doesn’t mean you will suffer from depression, only that you may be predisposed to it. Below, in no particular order, are listed some of these risk factors.

• There is a history of mental illness in your family.
• You are a woman. One in four women suffers from depression at some point in her life.
• You were sexually abused as a child.
• Someone close to you is depressed (depression can be “contagious”).
• You have a chronic illness or are in chronic pain.
• You lost a parent at an early age, either through death or abandonment.
• You have heart disease. One in five heart patients has severe depression.
• Someone close to you has recently died, or you are experiencing another stressful life event such as divorce or financial problems.
• You are taking a medication that can cause depression as a side-effect.

Related Links

• Grief and Loss
• GriefNet
• Who Becomes Depressed? – WebMD
• Lives of Women of Color Create Risk for Depression