Coping with Depression: What You Need to Know

Major depressive disorder — often referred to as depression — is a common illness that can affect anyone. About one in 20 Americans (over 11 million people) get depressed every year. Depression affects twice as many women as men. Depression is not just feeling "blue" or "down in the dumps." It is more than being sad or feeling grief after a loss. Depression is a medical disorder (just like diabetes, high blood pressure, or heart disease) that day after day affects your thoughts, feelings, physical health, and behaviors. Depression may be caused by many sources, including family history and genetics, other general medical illnesses, certain medications, illegal drugs or alcohol, and other psychiatric conditions. Certain life conditions, such as extreme stress or grief, may bring on a depression or prevent a full recovery. In some people, depression occurs even when life is going well. Depression is not your fault. It is not a weakness. It is a medical illness. Depression is treatable.

Causes of depression

Major depressive disorder is not caused by any one factor. It is probably caused by a combination of biological, genetic, psychological, and other factors. Certain life conditions (such as extreme stress or grief) may bring out a natural psychological or biological tendency toward depression. In some people, depression occurs even when life is going well. Drinking too much alcohol or using drugs can sometimes cause depression. When drug and alcohol use is stopped, the depression usually goes away. Talk to your health care provider if you have a problem with drugs or alcohol. It can be treated. Remember, major depressive disorder is not caused by personal weakness, laziness, or lack of willpower. It is a medical illness that can be treated.

Diagnosing depression

Before depression can be treated, it must be accurately diagnosed. Your health care provider will ask about symptoms, general health, and family history of general medical health and mental disorders. You also will be given a physical examination and undergo some basic laboratory tests.

How will I know if I am depressed?

People who have major depressive disorder have a number of symptoms nearly every day, all day, for at least two weeks. The symptoms always include at least one of the following:

- Loss of interest in things you used to enjoy, including sex.*

- Feeling sad, blue, or down in the dumps.*

- Feeling slowed down or feeling restless and unable to sit still.

- Feeling worthless or guilty.

- Changes in appetite or weight loss or gain.

- Thoughts of death or suicide, suicide attempts.

- Problems concentrating, thinking, remembering, or making decisions.

- Trouble sleeping or sleeping too much.

- Loss of energy or feeling tired all the time.

Other symptoms include:

- Headaches.

- Other aches and pains.

- Digestive problems.

- Sexual problems.

- Feelings of pessimism or hopelessness.

- Being anxious or worried.

If you have had five or more of the symptoms including at least one of the symptoms marked with an asterisk (*) for at least two weeks, you may have major depressive disorder. See your health care provider for diagnosis. Sometimes a few symptoms can go on to become major depressive disorder. Other forms of depression are milder, but persistent or chronic. Chronic symptoms of depression also need treatment.

Another form of depression

Some people with depression have well-defined mood cycles. They have terrible "lows" (depression) and inappropriate "highs" (mania) that can last from several days to months. In between the highs and lows, they feel completely normal. This condition is called bipolar disorder or manic-depressive disorder. Bipolar disorder affects about one in 100 people. Just as eye or hair color are inherited, bipolar illness in most cases is inherited. It can also be caused by other general medical problems, such as head injury, or neurologic or other general medical conditions.

Use this list to learn the symptoms of mania and to check off any you might have.

- Feeling unusually "high," euphoric, or irritable.*

- Needing less sleep.

- Talking a lot or feeling that you can’t stop talking.

- Being easily distracted.

- Having lots of ideas go through your head very quickly at one time.

- Doing things that feel good but have bad effects (spending too much money, excessive sexual activity, foolish business investments).

- Having feelings of greatness.

- Making lots of plans for activities (at work, school, socially, or sexually) or feeling that you have to keep moving.

If you have had four of these symptoms at one time for at least one week, including the first symptom marked with an asterisk (*), you may have had a manic episode. Tell your health care provider about these episodes. There are effective treatments for this form of depression.

What should I do if I have the symptoms?

Too often people do not get help for their depression because they don’t recognize the symptoms, have trouble asking for help, blame themselves, or don’t know that treatments are available. Family practitioners, clinics, or HMOs are often the first places that people go for help. Those health care providers will help you find out if there is a physical cause for your depression, treat the depression, and refer you to a mental health specialist for further evaluation and treatment. If you do not have a regular health care provider, contact your local health department, community mental health clinic, or hospital. University medical centers also provide treatment for depression.

What type of treatment will I get?

The major treatments for depression are antidepressant medicine, psychotherapy, and antidepressant medicine combined with psychotherapy.

How will treatment help me?

Treatment reduces the pain and suffering of depression. Successful treatment removes all of the symptoms of depression and returns you to your normal life. The earlier you get treatment for your depression, the sooner you will begin to feel better. As with other medical illnesses, the longer you have the depression before you seek treatment, the more difficult it can be to treat. Most people who are treated for depression feel better and return to daily activities in several weeks. Because it takes several weeks for treatment to work fully, it is important to get treatment early before your depression gets worse. As with any medical condition, you may have to try one or two treatments before finding the best one. It is important not to get discouraged if the first treatment does not work. In almost every case, there is a treatment for the depression that will work for you.

Who should see a mental health specialist?

Many people with depression can be treated successfully by their general health care provider. However, some people need specialized treatment because the first treatment does not work, because they need a combination of treatments, or because the depression is severe or it lasts a long time. Many times, a second opinion or consultation is all that is needed. If the mental health specialist provides treatment, it is most often on an outpatient basis (not in the hospital).

People who treat depression

The following health care providers can treat depression:

General health care providers

— Physician: A medical health care provider who has some training in treating mental or psychiatric disorders.

— Physician assistant: An individual with medical training and some training in treating mental or psychiatric disorders.

— Nurse practitioner: A registered nurse with additional nursing training and some training in treating mental or psychiatric disorders.

The health care providers listed above can refer you to one of the health care providers specializing in mental health listed below:

Mental health specialists

— Psychiatrist: A physician who specializes in the diagnosis and treatment of mental or psychiatric disorders.

— Psychologist: A person with a doctoral degree (PhD or PsyD) in psychology and training in counseling, psychotherapy, and psychological testing.

— Social worker: A person with a degree in social work. A social worker with a master’s degree, often has specialized training in counseling.

— Psychiatric nurse specialist: A registered nurse, usually with a master’s degree in psychiatric nursing, who specializes in treating mental or psychiatric disorders.

(Note: The term "health care provider" is used to describe any general health care provider or mental health specialist listed above.)

Preparing for your first visit

You can help your health care provider diagnose and treat you by giving as much information as possible about your health. General medical history, physical examination, and basic laboratory tests can help your doctor learn if a general medical disorder is the cause of your depression. About 10% to 15% of all depressions are caused by general medical illness (such as thyroid disease, cancers, or neurologic diseases) or medicines. Once these conditions are treated, the depression usually will go away. If you have a general medical illness and feel depressed, it is important to tell your clinician. Sometimes depression is a reaction to a life-threatening condition. Getting help during a difficult time in your life may help you to cope with your general medical illness. An episode of depression begins when symptoms of depression start and ends when the symptoms are completely gone. If your first episode of major depressive disorder occurred after age 40, a thorough medical evaluation is important.

Severe? Moderate? Mild?

For each type of depression there is a treatment that works best. You should talk with your clinician about your depression and the best treatment for you. In general:

Severe depression is present when people have nearly all of the symptoms of depression, and the depression almost always keeps them from doing their regular day-to-day activities.

Moderate depression is present when a people have many symptoms of depression that often keep them from doing activities that they need to do.

Mild depression is present when people have some of the symptoms of depression and it takes extra effort to do the activities they need to do.

Treating depression

Depression is usually treated in two steps.

Acute treatment. The aim of acute treatment is to remove the symptoms of depression until you feel well.

Continuation treatment (continuing the treatment for some time even after you are well) is important because it keeps the episode of depression from coming back. Depending on the type of treatment you have, your chances of staying well for six months on continuation treatment are extremely good.

In cases of recurrent depression (three or more episodes), a third treatment, called maintenance treatment, is used. In maintenance treatment, you stay on the treatment for a longer period of time. The purpose of maintenance treatment is to prevent a recurrence of the depression. With maintenance treatment, the chances of staying well are also extremely good.

How treatment works

Treatment for depression works gradually over several weeks. With medicine, most people see some benefits by three or four weeks; with psychotherapy alone, it can sometimes take longer. There is a very good chance that your first treatment will work well for you. If treatment is not effective after a certain amount of time, it can be changed or adjusted. There are other treatments to try, and your chances for effective treatment are still very good.

Choosing a treatment

You and your clinician can work together to find the best treatment for you. In choosing which acute treatment is best for you, you should weigh the chances of getting better against the chances of possible harm, as well as the expense of the treatment offered and the costs of the depression (time from work, effect on personal relationships, etc.). Here are some questions you may want to ask when discussing treatment:

• What are the chances of getting better with this treatment?

• What are the possible risks and side effects of treatment?

• What are the costs of treatment?

Why depression must be treated

Even though some people are able to struggle through an episode of depression without treatment, most find that it is much easier to get some help for their pain and suffering. It is important to get treatment for your depression because:

• Early treatment may help to keep the depression from becoming more severe, or chronic.

• Thoughts of suicide are common in depression, and the risk of suicide is increased when patients are not treated and the depression recurs. When depression is successfully treated, the thoughts of suicide will go away.

• Major depressive disorder usually comes in episodes lasting six to 12 months. In between the episodes, most people feel better or are completely well (without symptoms).

• Between episodes, about one out of four people with depression will still have some symptoms and trouble doing their daily activities. These people, if not treated, have a greater chance of having another episode of depression.

• Treatment can prevent recurrences of depression. The more episodes of depression you have had, the greater the chance that you will have another. About half of the people who have one episode of depression will have a second. Without treatment, after two episodes, the chances of having a third episode (recurrent depression) are even greater. After three episodes, the chances of having a fourth are 90%.

If you have concerns about your treatment

If at any time you are worried about your treatment or you don’t think that things are going well, tell someone about your concerns. You can talk to your clinician, ask for a second opinion, or talk to someone you trust. Health care providers and mental health specialists are interested in your concerns and will help you. This may mean getting a second opinion or even finding another clinician.

Taking care of yourself

When you are depressed, it is important to:

• Pace yourself. Do not expect to do all of the things you were able to do in the past. Set a schedule that is realistic for you.

• Remember that negative thinking (blaming yourself, feeling hopeless, expecting failure, and other such thoughts) is part of a depression. As the depression lifts, the negative thinking will go away, too.

• Avoid making major life decisions during a depression. If you must make a major decision about your life, ask your clinician or someone you trust to help you.

• Avoid drugs and alcohol. Research shows that drinking too much alcohol and use of drugs can cause or worsen a depression. It can also lower the effectiveness of antidepressant medicines or cause dangerous side effects.

• Understand that it took time for the depression to develop and it will take time for it to go away.

• There is some evidence in milder cases of depression that exercise can be helpful in reducing symptoms.

You can get information about other ways to help yourself during episodes of depression from the organizations listed on p. 105. Your public library also has books about depression.

Talking to others about depression

When people have major depressive disorder they often have difficulty at work, at school, and with family. With treatment, almost everyone returns to their normal life. Some jobs (where the safety of others is involved) require that you report treatment for medical illnesses (including depression). You and your clinician should talk about how and what to tell your supervisors, teachers, or friends.

Your family and friends

Ask your friends for their support, understanding, and patience during your depression. It may be helpful to talk to your friends about your feelings and treatment, and to spend time with friends in social activities. Keep the names and phone numbers of people that you can talk to and ask to help you. Some people find it difficult, almost a burden, to interact with people during this time. If you feel this way, do whatever lifts your mood and makes you feel better. If you find yourself alone and unable to interact with others, tell your clinician. Many people find that family members are very supportive and helpful, especially those who have received education about depression.

Your children

Parents often worry about whether depression is inherited. Most children of people with depression will not get this illness. Overall, research shows that only about one in seven children with one parent who has had several episodes of major depressive disorder or bipolar disorder will develop major depressive disorder. Another one in seven children with one parent who has bipolar disorder will develop bipolar disorder. If you have questions about your child’s mental health, talk to a clinician.

Finding Help

Depression is a serious illness, but it can be successfully treated with the help of a health professional. If you think you are depressed, there are many places to get the help you need. You can:

• Call your family physician or other health care provider.

• Call your local health department, community mental health center, hospital, or clinic. They can help you or tell you where else you can go for help.

• Contact a local university medical center (many have special programs for the treatment of depression).

• Contact one of the national mental health groups. (See box, p. 105.) They can refer you to a health professional where you live. They can also give you more information about depression, provide you with books and pamphlets, and tell you about support groups where you live.

Additional resources

In addition to the organizations listed on p. 105, the National Institute of Mental Health has free publications about depression for persons of all ages, including teenagers and the elderly. Write: Depression Awareness, Recognition, and Treatment (D/ART) Program, Department GL, Room 10-85, 5600 Fishers Lane, Rockville, MD 20857. Telephone: (80) 421-4211.

For more information

The information in this article was taken from the Clinical Practice Guideline on Depression in Primary Care, Vol. 1 and 2. The guideline was developed by a private, non-federal expert panel of physicians, psychologists, psychiatrists, social workers, nurses, counselors, and people who have depression. The development of the guideline was sponsored by the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Public Health Service.

To receive additional copies of this article in booklet form or the depression guidelines, call (800) 358-9295. Or write:

AHRQ Publications

Clearinghouse

P.O. Box 8547

Silver Spring, MD 20907