What is depression?
Depression symptoms
can vary from mild to severe and can include:
- Feeling sad or having a
depressed mood
- Loss of interest or pleasure
in activities once enjoyed
- Changes in appetite — weight
loss or gain unrelated to dieting
- Trouble sleeping or sleeping
too much
- Loss of energy or increased
fatigue
- Increase in purposeless
physical activity (e.g., inability to sit still, pacing, handwringing) or
slowed movements or speech (these actions must be severe enough to be
observable by others)
- Feeling worthless or guilty
- Difficulty thinking,
concentrating or making decisions
- Thoughts of death or suicide
Symptoms must last
at least two weeks and must represent a change in your previous level of
functioning for a diagnosis of depression.
Also, medical
conditions (e.g., thyroid problems, a brain tumor or vitamin deficiency) can
mimic symptoms of depression so it is important to rule out general medical
causes.
Depression affects
an estimated one in 15 adults (6.7%) in any given year. And one in six people
(16.6%) will experience depression at some time in their life. Depression can
occur at any time, but on average, first appears during the late teens to
mid-20s. Women are more likely than men to experience depression. Some studies
show that one-third of women will experience a major depressive episode in
their lifetime. There is a high degree of heritability (approximately 40%) when
first-degree relatives (parents/children/siblings) have depression.
The death of a
loved one, loss of a job or the ending of a relationship are difficult
experiences for a person to endure. It is normal for feelings of sadness or
grief to develop in response to such situations. Those experiencing loss often
might describe themselves as being “depressed.”
But being sad is
not the same as having depression. The grieving process is natural and unique
to each individual and shares some of the same features of depression. Both
grief and depression may involve intense sadness and withdrawal from usual
activities. They are also different in important ways:
- In grief, painful feelings
come in waves, often intermixed with positive memories of the deceased. In
major depression, mood and/or interest (pleasure) are decreased for most
of two weeks.
- In grief, self-esteem is
usually maintained. In major depression, feelings of worthlessness and
self-loathing are common.
- In grief, thoughts of death
may surface when thinking of or fantasizing about “joining” the deceased
loved one. In major depression, thoughts are focused on ending one’s life
due to feeling worthless or undeserving of living or being unable to cope
with the pain of depression.
Grief and
depression can co-exist For some people, the death of a loved one, losing a job
or being a victim of a physical assault or a major disaster can lead to
depression. When grief and depression co-occur, the grief is more severe and
lasts longer than grief without depression.
Distinguishing
between grief and depression is important and can assist people in getting the
help, support or treatment they need.
Depression can
affect anyone—even a person who appears to live in relatively ideal
circumstances.
Several factors can
play a role in depression:
- Biochemistry: Differences in
certain chemicals in the brain may contribute to symptoms of depression.
- Genetics: Depression can run
in families. For example, if one identical twin has depression, the other
has a 70 percent chance of having the illness sometime in life.
- Personality: People with low
self-esteem, who are easily overwhelmed by stress, or who are generally
pessimistic appear to be more likely to experience depression.
- Environmental factors:
Continuous exposure to violence, neglect, abuse or poverty may make some
people more vulnerable to depression.
Depression is among
the most treatable of mental disorders. Between 80% and 90% percent of people
with depression eventually respond well to treatment. Almost all patients gain
some relief from their symptoms.
Before a diagnosis
or treatment, a health professional should conduct a thorough diagnostic
evaluation, including an interview and a physical examination. In some cases, a
blood test might be done to make sure the depression is not due to a medical
condition like a thyroid problem or a vitamin deficiency (reversing the medical
cause would alleviate the depression-like symptoms). The evaluation will
identify specific symptoms and explore medical and family histories as well as
cultural and environmental factors with the goal of arriving at a diagnosis and
planning a course of action.
Brain chemistry may
contribute to an individual’s depression and may factor into their treatment.
For this reason, antidepressants might be prescribed to help modify one’s brain
chemistry. These medications are not sedatives, “uppers” or tranquilizers. They
are not habit-forming. Generally antidepressant medications have no stimulating
effect on people not experiencing depression.
Antidepressants may
produce some improvement within the first week or two of use yet full benefits
may not be seen for two to three months. If a patient feels little or no
improvement after several weeks, his or her psychiatrist can alter the dose of
the medication or add or substitute another antidepressant. In some situations
other psychotropic medications may be helpful. It is important to let your
doctor know if a medication does not work or if you experience side effects.
Psychiatrists
usually recommend that patients continue to take medication for six or more
months after the symptoms have improved. Longer-term maintenance treatment may
be suggested to decrease the risk of future episodes for certain people at high
risk.
Psychotherapy, or “talk therapy,” is sometimes used alone for
treatment of mild depression; for moderate to severe depression, psychotherapy
is often used along with antidepressant medications. Cognitive behavioral
therapy (CBT) has been found to be effective in treating depression. CBT is a
form of therapy focused on the problem solving in the present. CBT helps a
person to recognize distorted/negative thinking with the goal of changing
thoughts and behaviors to respond to challenges in a more positive manner.
Psychotherapy may
involve only the individual, but it can include others. For example, family or
couples therapy can help address issues within these close relationships. Group
therapy brings people with similar illnesses together in a supportive
environment, and can assist the participant to learn how others cope in similar
situations.
Depending on the
severity of the depression, treatment can take a few weeks or much longer. In
many cases, significant improvement can be made in 10 to 15 sessions.
ECT is a medical
treatment that has been most commonly reserved for patients with severe major
depression who have not responded to other treatments. It involves a brief
electrical stimulation of the brain while the patient is under anesthesia. A
patient typically receives ECT two to three times a week for a total of six to
12 treatments. It is usually managed by a team of trained medical professionals
including a psychiatrist, an anesthesiologist and a nurse or physician
assistant. ECT has been used since the 1940s, and many years of research have
led to major improvements and the recognition of its effectiveness as a
mainstream rather than a "last resort" treatment.
There are a number
of things people can do to help reduce the symptoms of depression. For many
people, regular exercise helps create positive feeling and improves mood.
Getting enough quality sleep on a regular basis, eating a healthy diet and
avoiding alcohol (a depressant) can also help reduce symptoms of depression.
Depression is a
real illness and help is available. With proper diagnosis and treatment, the
vast majority of people with depression will overcome it. If you are
experiencing symptoms of depression, a first step is to see your family
physician or psychiatrist. Talk about your concerns and request a thorough
evaluation. This is a start to addressing your mental health needs.
PMDD was added to
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. A
woman with PMDD has severe symptoms of depression, irritability, and tension
about a week before menstruation begins.
Common symptoms
include mood swings, irritability or anger, depressed mood, and marked anxiety
or tension. Other symptoms may include decreased interest in usual activities,
difficulty concentrating, lack of energy or easy fatigue, changes in appetite
with specific food cravings, trouble sleeping or sleeping too much, or a sense
of being overwhelmed or out of control. Physical symptoms may include breast
tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or
weight gain.
These symptoms
begin a week to 10 days before the start of menstruation and improve or stop
around the onset of menses. The symptoms lead to significant distress and
problems with regular functioning or social interactions.
For a diagnosis of
PMDD, symptoms must have occurred in most of the menstrual cycles during the
past year and must have an adverse effect on work or social functioning.
Premenstrual dysphoric disorder is estimated to affect between 1.8% to 5.8% of
menstruating women every year.
PMDD can be treated
with antidepressants, birth control pills, or nutritional supplements. Diet and
lifestyle changes, such as reducing caffeine and alcohol, getting enough sleep
and exercise, and practicing relaxations techniques, can help.
Premenstrual
syndrome (PMS) is similar to PMDD in that symptoms occur seven to 10 days
before a woman’s period begins. However, PMS involves fewer and less severe
symptoms than PMDD.
Disruptive mood
dysregulation disorder is a condition that occurs in children and youth ages 6
to 18. It involves a chronic and severe irritability resulting in severe and
frequent temper outbursts. The temper outbursts can be verbal or can involve
behavior such as physical aggression toward people or property. These outbursts
are significantly out of proportion to the situation and are not consistent
with the child’s developmental age. They must occur frequently (three or more
times per week on average) and typically in response to frustration. In between
the outbursts, the child’s mood is persistently irritable or angry most of the
day, nearly every day. This mood is noticeable by others, such as parents,
teachers, and peers.
In order for a
diagnosis of disruptive mood dysregulation disorder to be made, symptoms must
be present for at least one year in at least two settings (such as at home, at
school, with peers) and the condition must begin before age 10. Disruptive mood
dysregulation disorder is much more common in males than females. It may occur
along with other disorders, including major depressive, attention-deficit/hyperactivity,
anxiety, and conduct disorders.
Disruptive mood
dysregulation disorder can have a significant impact on the child’s ability to
function and a significant impact on the family. Chronic, severe irritability
and temper outbursts can disrupt family life, make it difficult for the
child/youth to make or keep friendships, and cause difficulties at school.
Treatment typically
involves psychotherapy (cognitive behavior therapy) and/or
medications.
A person with
persistent depressive disorder (previously referred to as dysthymic disorder)
has a depressed mood for most of the day, for more days than not, for at least
two years. In children and adolescents, the mood can be irritable or depressed,
and must continue for at least one year.
In addition to
depressed mood, symptoms include:
- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self-esteem
- Poor concentration or
difficulty making decisions
- Feelings of hopelessness
Persistent
depressive disorder often begins in childhood, adolescence, or early adulthood
and affects an estimated 0.5% of adults in the United States every year.
Individuals with persistent depressive disorder often describe their mood as
sad or “down in the dumps.” Because these symptoms have become a part of the
individual’s day-to-day experience, they may not seek help, just assuming that
“I’ve always been this way.”
The symptoms cause
significant distress or difficulty in work, social activities, or other
important areas of functioning. While the impact of persistent depressive
disorder on work, relationships and daily life can vary widely, its effects can
be as great as or greater than those of major depressive disorder.
A major depressive
episode may precede the onset of persistent depressive disorder but may also
arise during (and be superimposed on) a previous diagnosis of persistent
depressive disorder.
Felix Torres, M.D., MBA, DFAPA
October 2020
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