Depression is one of the most common types of mental illness among Americans.
While everyone has experienced sadness, not everyone has experienced depression. In fact, if you’ve never been depressed, chances are that you don’t have a real grasp on what living with this complex mental illness is like.
Depression is insidious. It affects not only your mood, but also your ability to feel, think, and function. It blunts sensations of pleasure, closes off connectedness, stifles creativity, and, at its worst, shuts down hope. It also often causes deep emotional pain not only to the person experiencing it, but to that person’s close family and friends.
“It’s not what people think, an act of laziness or a lack of will for change,” says E. Mollie Kashuk, a 21-year-old college senior in Claremont, California. “Instead, it’s genuinely believing that change is not possible for you. It’s genuinely believing that you’re stuck in an overwhelming darkness that will never go away.”
Depression Statistics: Disturbing Trends, Helpful Treatment
Unfortunately, there are plenty of people who, like Kashuk, know exactly what it means to be depressed. An estimated 17.3 million, or 7 percent, of adults in the United States had at least one major depressive episode in the past year, according to the National Institute of Mental Health, making it one of the most common mental illnesses in the United States.
What’s more, a recent report from Mental Health America, a nonprofit founded in 1909, offers startling statistics pertaining to one of depression’s most disturbing symptoms: thoughts of suicide.
According to its 2021 State of Mental Health in America report, suicidal ideation among adults increased by 0.15 percent (an additional 460,000 people) between the 2016-2017 calendar year and the 2017-2018 calendar year, the most recent years for which statistics are available.
There is a bright side. Although there is no one-size-fits-all cure for depression, there are many effective treatment options, one of which is bound to help you heal if you’re struggling with the illness. This cannot be emphasized enough, given that roughly two-thirds of people living with depression do not receive the care they need, according to a report in the journal Neuropsychiatric Disease and Treatment, published online February 22, 2019.
Signs and Symptoms: How to Identify Depression
If sadness alone isn’t a good gauge of depression, what is? According to the American Psychiatric Association’s current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is the diagnostic guide used by most mental health professionals, if you’ve experienced at least five of the following symptoms most of the day, nearly every day, for at least two weeks, you may be diagnosed with major depressive disorder (MDD), also known as clinical depression.
- Constantly feel tearful, empty, or worthless?
- Have little interest or pleasure in your work, hobbies, friends, family, and other things you once enjoyed?
- Notice dramatic changes up or down in your appetite or your weight not related to dieting?
- Often feel listless or fatigued for no obvious reason?
- Have trouble concentrating or making decisions?
- Find yourself wringing your hands, pacing, or showing other signs of anxious restlessness — or the opposite, moving or speaking more slowly than usual?
- Struggle with insomnia or sleep too much?
- Have recurrent thoughts of suicide or death?
To be diagnosed with MDD, one of your symptoms must be a persistent low mood or a loss of interest or pleasure, the DSM-5 states. Your symptoms must also not be due to substance abuse or a medical condition, such as thyroid problems, a brain tumor, or a nutritional deficiency.
Of course, it’s normal to have any or all of these symptoms temporarily (for hours or even days) from time to time. The difference with depression is that the symptoms persist and make it difficult to function normally.
If you suspect you may be depressed, the best first step is to reach out to your primary care doctor, a psychiatrist, or a psychotherapist. If you’re reluctant to consult a professional, type “depression” or “clinical depression” into Google on your cell phone or computer and you’ll find links to a clinically validated depression test known as the PHQ-9 patient health questionnaire. Although designed to be administered by a healthcare professional, this test is short and straightforward. Take it and you can immediately see if your score indicates you may have depression.
Important: If you suspect you have depression, or if you’re feeling troubled by your symptoms, have suicidal thoughts, just need to talk, want some advice, or need a referral for treatment, call the National Suicide Prevention Lifeline at 800-273-8255 or the National Substance Abuse and Mental Health Services Administration Helpline at 800-662-4357. Both are free and available 24/7, 365 days a year.
What Are the Different Types of Depression?
In addition to MDD there are several other kinds of depression, including:
- Persistent depressive disorder (PDD) Previously known as dysthymia, PDD is diagnosed in people who have at least two of the symptoms of major depression for at least two years at a time. It’s possible to fluctuate between severe and less-severe symptoms, and to have both PDD and MDD at the same time, a condition called double depression.People with PDD are often perceived as cranky, sullen, changeable, or pessimistic rather than being recognized as having a treatable disorder.
- Bipolar disorder, formerly called manic depressive disease, is characterized by moods that cycle between extreme highs (mania) and lows (depression), often with periods of normal mood in between.Bipolar disorder affects 2.8 percent of U.S. adults, or more than 6 million people.
- Seasonal affective disorder (SAD) is depression that occurs at the same time each year, usually beginning in fall and persisting through winter. SAD is associated with changes in sunlight, and is often accompanied by increased sleep, weight gain, and cravings for foods high in carbohydrates.
- Premenstrual dysphoric disorder (PMDD) is a more serious form of premenstrual syndrome (PMS). PMDD usually develops a week or two before a woman’s period and passes two or three days after menstruation starts.
- Postpartum (or perinatal) depression (PPD) is diagnosed in mothers who experience symptoms of major depression shortly after giving birth.PPD is usually related to a combination of factors, including sharp changes in hormone levels following childbirth. Feelings of intense sadness, anxiety, or exhaustion are much stronger, and last longer, than the “baby blues” — the relatively mild symptoms of depression and anxiety that many new mothers experience.
Depression: Recognizing Unusual Symptoms
One reason depression can be hard to identify is that its signs can vary widely from person to person and sometimes be masked by atypical symptoms. For example, some people who are depressed may show it by acting disgruntled, resentful, or irritable. In fact, aggression — including outright acts of violence — can be indicative of “hidden” depression, according to a February 28, 2017, report in Psychiatric Times. Depression masquerading as anger may seem surprising at first, but not when you consider that several underlying factors, including alcohol or substance abuse and childhood trauma, have been linked to both.
Similarly, although it’s not clear why, a person who experiences anxiety is at high risk for developing depression, and vice versa. The National Alliance on Mental Illness reports that as many as 60 percent of people with anxiety will also have symptoms of depression; the same goes for people with depression having symptoms of anxiety. Experts say there is often a genetic predisposition for these co-occurring disorders.
Depression may also manifest psychosomatically, meaning that instead of presenting first and foremost as a mood disorder, the dominant symptom may be things like vague aches, dizziness, headaches, digestive problems, or back pain, according to the Journal of Clinical Psychiatry. Complicating matters is that it’s often hard to know whether depression is causing the physical symptoms, or if the physical symptoms are causing depression.
What Causes Depression?
No one knows for sure why some people become depressed and others do not. Depression can occur spontaneously, without any obvious cause. And it’s well documented that once you’ve had one depressive episode your risk of having another later in life increases. For example, a study in Psychological Medicine found that more than 13 percent of people who recover from their first episode of major depression go on to have another episode within five years; 23 percent within 10 years; and 42 percent within 20 years.
Psychiatrists today generally look at depression in “bio-psycho-social” terms, meaning that they see it as a complex disorder most likely triggered by overlapping biological, psychological, and social (also referred to as environmental) factors.
Among the potential contributors to depression are:
- Genetics Many studies suggest that depression can spring from a genetic predisposition, including one international study involving more than 2 million people, published in the February 2019 issue of the journal Nature Neuroscience, that linked 269 genes to depression.Genes alone are not believed to write your destiny, however. Scientists think that while some genes may increase risk, other factors are needed to trigger symptoms.
- Neurotransmitters The long-held idea that depression is caused by low levels of certain neurotransmitters (chemicals messengers that communicate between neurons) has been debunked. And yet it’s clear that neurotransmitters do play a role. The new thinking is that depression can sometimes be activated by nerve cell connections in the brain, nerve cell growth, or when the functioning of nerve circuits goes awry.
- Inflammation Multiple studies indicate that disease-related or stress-related inflammation may create chemical changes in the brain that can trigger or worsen depression in certain people and influence how a person responds to drug therapy.
- Hardship There’s growing evidence, according to the World Health Organization, that psychological and social factors like a history of abuse, poor health and nutrition, unemployment, social isolation or loneliness, low socioeconomic status, or stressful life events (divorce or money worries, for example) can play a decisive role in the onset of depression. For example, adults with MDD have double the rate of childhood trauma compared with people without MDD, a study published May 3, 2016, in the journal Translational Psychiatry found.
- Traumatic brain injury (TBI) Another all-too-common cause of depression is traumatic brain injury (TBI). Close to three million people each year are treated in U.S. emergency rooms for TBIs (aka concussions) following a bump or blow to the head from things like falls, assaults, car accidents, and workplace and sports-related injuries, according to the Centers for Disease Control and Prevention. And more than half of those patients will meet the criteria for major depression three months after their injury, suggests a study published November 30, 2017, in the journal Brain Injury.
Depression and Gender: Is It Different in Men and Women?
When it comes to depression, there is a distinct gender gap. Depression is nearly twice as common in women as in men, according to data from the National Center for Health Statistics. Hormonal and other biological factors play a role in this disparity. After all, only women can have premenstrual or postpartum depression. The same is true of antepartum (or perinatal) depression — depression during pregnancy — which the American College of Obstetricians and Gynecologists estimates affects one in seven women.
But women also have higher rates of seasonal affective disorder, depressive symptoms in bipolar disorder, and persistent depressive disorder, note Harvard Health experts.The reasons for this are cause for speculation. Some researchers believe that environmental factors, such as the different stressors and expectations that society places on women, are an important factor. Others theorize that men and women actually have depression at similar rates, but that women are more likely to talk about their feelings and seek help.
Depression Treatment: Lifestyle Changes, Talk Therapy, Antidepressants
If you suspect that depression is interfering with your life, talking about what you’re experiencing and discussing treatment options with a medical professional is essential. As actress Taraji P. Henson, who describes her depression as “suffocating” darkness, recently explained in an interview with Self magazine, “When you’re quiet, things aren’t fixed. It gets worse.”
The good news is that there’s abundant evidence that people with depression who seek treatment will find significant relief from lifestyle changes, talk therapy (psychotherapy), medication, or a combination of all efforts, according to the Anxiety and Depression Association of America.
Lifestyle Changes for Depression
Lifestyle changes, such as making art, journaling, exercising more, and practicing yoga or mindfulness, can also alleviate depression and the stress that can heighten it. Alternative treatments like massage, acupuncture, and light therapy may also help.
Diet changes, too, can uplift your mood by reducing inflammation and helping to ensure your brain gets the nutrients it needs to function at its best.
One randomized controlled study, published October 9, 2019, in the journal PLoS One, found that self-reported symptoms of depression dropped significantly in just three weeks in young adults who changed from a highly processed, high-carbohydrate diet to a Mediterranean diet focused on vegetables, whole grains, lean proteins, unsweetened dairy, nuts and seeds, olive oil, and the spices turmeric and cinnamon. In contrast, the depression scores didn’t budge in a control group of people who didn’t change their diet.
Which Types of Talk Therapy Work Best for Depression?
The Society of Clinical Psychology rates several types of psychotherapy as highly effective treatments for depression:
- Behavioral activation therapy The aim of this type of therapy is to reverse the downward spiral of depression by encouraging you to seek out experiences and activities that give you joy.
- Cognitive behavioral therapy(CBT) CBT focuses on changing specific negative thought patterns so that you are able to better respond to challenging and stressful situations.
- Interpersonal therapy This very structured, time-limited form of therapy focuses on identifying and improving problematic personal relationships and circumstances directly related to your current depressive mood.
- Problem-solving therapy This therapy is a form CBT that teaches take-charge skills that help you solve the real-life problems and stressors, big and small, that contribute to depression.
- Self-management/self-control therapy This type of behavioral therapy trains you to lessen your negative reactions to events and reduce your self-punishing behaviors and thoughts.
What Are the Different Antidepressants and How Do They Work?
The most commonly prescribed antidepressants cause changes in brain chemistry that affect how neurons communicate. Exactly how this improves mood remains somewhat of a mystery, but the fact that they do often work is well-established.
- SSRIs(selective serotonin reuptake inhibitors) This category of drug includes Prozac (fluoxetine), Celexa (citalopram), and Zoloft (sertraline) and targets serotonin, a neurotransmitter that helps control mood, appetite, and sleep.
- SNRIs(serotonin and norepinephrine reuptake inhibitors) SNRIs include drugs like Cymbalta (duloxetine), Pristiq (desvenlafaxine), and Effexor XR (venlafaxine), which block the reabsorption of both serotonin and another neurotransmitter, norepinephrine.
- NDRIs(norepinephrine–dopamine reuptake inhibitors) This class of medications includes bupropion.
- TCAs (tricyclic antidepressants)TCAs include such drugs as Tofranil (imipramine) and Pamelor (nortriptyline). These drugs were among the earliest antidepressants to come on the market. These days, doctors generally only turn to them when treatment with SSRIs, SNRIs, and NDRIs has failed.
- MAOIs(monoamine oxidase inhibitors) MAOIs, including Nardil (phenelzine) and Marplan (isocarboxazid), were the first antidepressants developed. They’re rarely used today, in part because people who take them require careful monitoring to prevent negative interactions with certain foods and other medications.
All antidepressants can have side effects, but some may be more problematic than others. You may need to try several different medications, or a combination, guided by your doctor, before you find what works best for you.
In addition, it may take some patience before you see results. The full benefits of the drugs may not be realized until you’ve taken them for as long as three months, according to the the STAR*D trial, the largest, longest study on antidepressant treatment, which ended in 2006.
Sometimes, other medications may be added to your regimen. These might include a mood stabilizer, such as lithium (sold under several brand names) or valproic acid (Depakene, Depakote). If psychotic symptoms (having delusions or seeing or hearing voices that are not real, for example) are present, a doctor may prescribe an antipsychotic medication, such as Haldol (haloperidol), Risperdal (risperidone), Geodon (ziprasidone), Abilify (aripiprazole), and Zyprexa (olanzapine).
Should You Worry About Antidepressant Withdrawal?
No, but it’s easy to see why some people might think so, because of a medical condition called antidepressant discontinuation syndrome (ADS), which can occur if you abruptly stop taking medication rather than tapering off as is generally advised. ADS is marked by a wide range of responses, including but not limited to flu-like symptoms, insomnia, worsening mood, and stomach distress, according to a March 11, 2019, report in Psychiatric Times.
Current estimates are that about 20 percent of patients who’ve taken an antidepressant for at least a month will experience ADS symptoms if they abruptly stop their medication instead of lowering their dose gradually. (Conversely, more than 60 percent of patients who stop taking an SSRI will have no significant symptoms.) Tapering under the care of a doctor can prevent ADS by allowing the brain to adjust to changes in neurotransmitter levels.
More to the point, while you should slowly stop your antidepressant with the help of your doctor, antidepressants do not cause dependence and withdrawal like other substances. Unlike substances that are known to cause addiction, such as alcohol, opioids, and barbiturates, people don’t crave antidepressants. You don’t get “high” from them, and they aren’t intentionally or compulsively overused. Serious reactions like the seizures and agitation that can follow sudden withdrawal from addictive substances are “unheard of when these antidepressants are tapered gradually,” note the authors of the Psychiatric Times report.
What Is Treatment Resistant Depression and Is There Any Help for It?
If you’ve tried at least two different antidepressants and your depression hasn’t improved, you may be diagnosed with treatment resistant depression (TRD). TRD is a serious condition that has been highly associated with suicidal ideation and suicide attempts. Nearly 33 percent of people with TRD attempt suicide in their lifetime, more than double the rate of their treatment-responsive peers, according to a recent report in Psychiatry Advisor. It is not, however, a hopeless condition. A number of alternative treatment approaches are available, including:
- Esketamine A nasal spray marketed under the name Spravato, esketamine won FDA approval on March 5, 2019, as a new treatment for TRD. It is derived from ketamine, a veterinary anesthetic best known as the street drug Special K. Because of safety concerns, Spravato must be administered in a medical office and should be taken along with an oral antidepressant.
- Electroconvulsive therapy (ECT) ECT is the modern-day version of electroshock therapy. It involves a brief electrical stimulation of the brain while the patient is under anesthesia. According to the American Psychiatric Association (APA), ECT rapidly provides substantial improvement in approximately 80 percent of patients with severe, uncomplicated major depression. Like any medical procedure, ECT is associated with side effects — most commonly, issues with memory. In most cases, this is short-term; however, some people can experience permanent gaps in memory. Nevertheless, current ECT has far fewer side effects than electroshock therapy of the past.
- Transcranial magnetic stimulation(TMS) TMS uses rapidly alternating magnetic fields to change activity in specific areas of the brain. When properly targeted, TMS can immediately improve mood in depressed patients, according to research in the November 29, 2018, issue of the journal Current Biology.
- Vagus nerve stimulation This therapy involves implanting a tiny device in the chest that provides regular mild electrical pulses to the longest of the nerves that arise from the brain. A study in the August 21, 2018, issue of the Journal of Clinical Psychiatry involving nearly 600 patients with TRD found that vagus nerve stimulation significantly improved quality of life for many patients.
- Psychedelic drugs While not yet FDA approved, microdosing with psychedelic drugs to produce more a positive mood in the chronically depressed is the focus of a flurry of research worldwide, including at the new Johns Hopkins Center for Psychedelic and Consciousness Research. The possibilities appear vast and promising. For example, one of the latest Johns Hopkins studies, published March 1, 2019, in the American Journal of Drug and Alcohol Abuse, found that a synthetic form of a psychedelic derived from the venom of certain toads provided fast-acting relief from depression and anxiety.
What’s the Difference Between Grief and Depression?
Given that the primary symptom associated with depression is sadness, it can be easy to think of grief or bereavement as depression. But grief is a natural response to specific experiences, such as the end of a relationship or the death of a loved one. While you might feel regret or remorse, and you might withdraw from usual activities if you are experiencing grief, you’re unlikely to feel the overwhelming sense of worthlessness, thoughts of self-harm or suicide, and other symptoms of depression. Another important difference is that in grief, painful feelings usually come in waves and are often mixed with positive memories.
In some cases, however, grief and depression do coexist, or grief can trigger depression, according to experts writing in the journal American Family Physician. Having a mental health professional help you distinguish between them can ensure you get the support you need.
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